A successful 25-year-old software designer sorts a stack of obsolete programs into exact chronological order, then labels, wraps and packs them — so he can toss them into the trash. A craving for rectilinearity drives him to type all his bank checks. If his receipts from the cash machine don’t print out on the quarter hour, he’ll wait another 15 minutes and try again. And again.
A young father can’t mail a letter without checking to make sure his daughter isn’t sealed inside. A woman has to save everything — fuzz from the carpet included — although she has no idea why. A teenager has to shower for an hour before and after riding his beloved motorcycle. A happening actor spends five hours a day in the bathroom scrubbing himself and his toilet.
Perhaps the craziest thing is that these people aren’t crazy. They are otherwise normal individuals who have obsessive-compulsive disorder (OCD), an illness that, despite its psychological symptoms, is thought to have a biological source in most cases. In fact, they seem so regular that close friends and relatives are often unaware of their agonizing secret lives, ruled by obsessions — repetitive, repellent thoughts — and compulsions, the behaviors that assuage them. A wedge of guilt and anxiety separates their deep-seated urge to perform compulsive rituals from their conscious desire to resist doing so and adds its own weight to their burden. Until recently, most of them could not be helped.
Now, two medical breakthroughs have reversed the obsessive-compulsive’s bleak prognosis. After treatment with an experimental drug or with actions-speak-louder-than-words behavioral therapy, most can lead normal lives, many for the first time in years. As the good news spreads, obsessive-compulsives are coming out of the closet at such a clip that some psychiatrists have seen more of them in the past year than in their entire previous practice.
Moreover, recent studies shows that there are at least ten times more Americans with OCD than previously estimated — two to three out of every 100 adults in an even male-female ratio and one in every 200 adolescents in a two to one ratio of boys to girls.
“Everyone has occasional disturbing, intrusive thoughts, say, that he’s going to swerve his car into oncoming traffic or harm a child or push someone off a subway platform,” says Dr. Wayne Goodman, assistant professor of psychiatry at Yale and director of the university’s obsessive-compulsive clinic. “The guy with normal brain chemistry just turns these ideas off and thinks about something else. Our patients helplessly play them over and over again. It’s like they were having an allergic reaction to a thought.”
That doesn’t mean that all the behaviors or persons casually described as compulsive or obsessive have OCD. Everyone occasionally gets carried away with door locking, stove checking or hand washing, especially when anxious. Successful people in demanding fields often show signs of what psychiatrists call the obsessive-compulsive personality type. “Dirt, time and money are the preoccupations of the personality,” says Dr. Michael Liebowitz, director of the Anxiety Disorders Clinic at the New York State Psychiatric Institute. This type of person is inclined to be emotionally tight, miserly, workaholic and perfectionist but is only somewhat more likely to have obsessive-compulsive disorder than others, despite the similar names. Both terms are often misapplied to addictive behaviors like drinking, gambling and sex binging, which all include an element of real enjoyment. In contrast, the obsessive-compulsive gets no pleasure from the dreary, often-despised rituals he’s senselessly driven to perform.
The impulses that fuel obsessive-compulsives and the general kinds of behaviors they elicit are so predictable that patients often think psychiatrists are reading their minds during the first consultation. OCD symptoms can appear suddenly, but they usually develop over months and last for years — or occur off and on for a lifetime. Most obsessions concern violence, doubt or contamination by germs or dirt, and the most common compulsions are checking, counting and washing.
One woman obsessed with violent thoughts feared she would stab her children: she checked the house to make sure there were no sharp pencils or knives and eventually banned not only steak knives but steaks — just in case. A 14-year-old boy could only be sure he’d done a thing right, whether it was checking his homework or crossing a threshold, if he’d done it four times — three times was no good, he explained, because three strikes and you’re out. Doctors and nurses obsessed with AIDS contamination have given up their professions or adopted elaborate washing rituals that, like Lady Macbeth’s, are addressed to spots that aren’t there.
There are no distinguishing differences in the personalities of checkers, counters and washers, and some patients fit into two or even all three categories. In contrast with the specificity of the details of their rituals, their rationales for performing them seem vague — guesses at how to palliate some merciless abstract demon: “I just feel sort of dirty somehow,” says one washer; “I have to get it right, because if it’s wrong, something bad will happen,” says a counter-checker.
Intriguingly, the severity of OCD — even the diagnosis of it — is gauged not by the oddness of the behavior but by the degree to which the patient resists it and to which he thinks it interferes with his life. You-could-eat-off-her-floors cleanliness might have been a reasonable goal for Grandma, whose career was her home, but if her granddaughter is chronically late for work at the law firm because of her endless scrubbing, what was once a cultural kink has become a sickness.
Dr. Thomas Insel, a psychiatrist at the National Institute of Mental Health (NIMH) and a pioneering OCD researcher, recalls the time the father of a hospitalized child came to visit but wouldn’t stay in the nearby antiseptic Holiday Inn because “it was too dirty and it might burn down.” Like many people who consider repeated checking of locks, lights and gas pilots and avoiding of public restrooms to be sensible and prudent, he didn’t think his obsessions about cleanliness and safety interfered with his day and spent no energy in resisting them. “He may have scored higher on tests for obsessive-compulsive symptoms than his child,” Insel says, “but he didn’t have the disorder, because dealing with the symptoms hadn’t taken over his life.”
For most of medical history, pretty much all doctors could do about OCD was to talk about it. Over the past decade, spurred by advances in neuroscience and the fact that talk therapy didn’t help most patients, researchers began to hunt for biological causes for OCD, just as they do for “real” diseases, like diabetes.
Several arrows pointed them in the direction of a brain dysfunction. After the 1918 epidemic of viral sleeping sickness swept through Europe, many victims were left with obsessive-compulsive symptoms, suggesting an organic cause for their odd new problems. Before less drastic treatments were available, brain surgery helped severe obsessive-compulsives. People afflicted with Tourette syndrome — a psychobiological disorder once thought to be possession by the devil, and manifested by compulsive tics, grunts, barks, yelps or blurting of obscenities — often have OCD symptoms too, as do 12 percent of their close relatives. The combination of OCD and Tourette can be devastating: a talented linguist with a very responsible position had obsessive-compulsive problems based on the fear that she would give certain Chinese words the wrong inflection, thus turning them into obscenities, and would lose her job; in addition, she compulsively grunted, clicked and grimaced — Tourette symptoms. By the time she sought treatment, she had attempted suicide several times.
OCD’s genesis from a glitch in the brain was also suggested by studies in animal behavior. Obsessive-compulsive behavior reminded researchers of the routine movements animals make during grooming, nesting rituals and displays of aggression. Dr. Judith Rapoport, chief of child psychiatry at NIMH and an expert on OCD in adolescents, recalls her first obsessive-compulsive patient, “a very nice man who felt compelled to pick up all the trash in town. Now, all animals with fur or feathers have grooming and nesting rituals, and as I studied this man, it struck me that he was nesting – instinctively picking up bits of things just like a bird building a home.”
These intuitions got some high-tech support from brain scans of obsessive-compulsives done by Dr. Lewis Baxter, a psychiatrist at UCLA’s Neuropsychiatric Institute. These maps of energy use in the brains of OCD victims show an irregularity in the caudate nucleus, an area in the primitive part of the human brain analogous to the one that controls repetitive movements in animals. Baxter thinks that in people the caudate nucleus may regulate repetitive thoughts as well as movements.
Liebowitz suggests there may be a mechanism in this unintellectual brain zone that’s responsible for checking things, making sure everything’s okay: “The key to the disorder is that the patients have an inability to be sure. They regard the minuscule possibility that they might stab someone as an imminent probability — as if the ‘certainty mechanism’ in the brain that allows a normal person to say, ‘That’s ridiculous,’ and dismiss the thought were faulty.”
Of all the indications of a biological cause of OCD, however, the strongest is the efficacy of biological treatment. Clomipramine, an antidepressant now being tested on volunteers at 21 research centers around the nation, alters the activity of serotonin, one of the brain’s chemical tools for handling information. In a matter of weeks, up to 75 percent of the patients who get the drug are able to cut their ritualizing time by as much as 80 percent. Although there can be side effects, for someone who has been washing or checking for five hours a day, this is an improvement that’s hard to overstate. One relieved patient describes life with clomipramine this way: “I still get the thoughts, but they’re much easier to resist.” The good results from the drugs certainly imply that serotonin is involved in the disorder’s neurochemistry, but there’s probably more to the biochemical picture. For example, the anxiety of obsessive-compulsives suggests to Dr. Joseph Zohar, a research psychiatrist at NIMH, that “the brain’s opiate system – the one that says to you, ‘Relax, it’s fine, don’t worry’ – goes awry in OCD as well.”
Exciting research done on the brain chemistry of murderers, suicides and violent criminals shows that serotonin is closely associated with aggression and dominance — the very urges Freud himself thought caused OCD. The two-bit psychoanalytical explanation for the disorder is that it’s caused by the patient’s repression of hostile pre-Oedipal feelings over control, particularly over that old standby, toilet training. Freud figured that the person obsessed with fears of stabbing others really wanted to do just that, just as the one who dreaded toilets really wanted to show Mom who was boss by playing with feces, and so on.
Postmodern psychiatrists, while reluctant to endorse these colorful particulars, are interested in this apparent link between aggression and OCD. Zohar sees a reverse connection: he recalls that when he accidentally jostled one patient’s arm, she repeatedly apologized for hurting him. To Goodman, patients like the devoted mother who feared she’d stab her children seem unable to permit themselves normal spurts of anger and annoyance. “I think what obsessive-compulsives have is a low tolerance for aggressive feelings, rather than a surplus of them,” he says. “They find any negative feeling about something that’s important to them — like their children — intolerable.”
Although he didn’t seem to have problems expressing aggression, Napoleon couldn’t pass a large building without stopping to count all the windows. The reasons behind such wacky behavior may never be clear to others, but obsessive-compulsives attempt to reassure themselves about their irrational fears through eerily rational actions. One federal employee obsessed with a fear of giving secrets to enemy spies checked newspapers compulsively to prove to himself that he hadn’t. This lucid response to what he knew was a crazy, self-generated stimulus distinguishes his thought from that of a schizophrenic, who might believe such actions were ordered by men from Mars or the CIA. As Goodman says, “In one sense, part of their tragedy is that obsessive-compulsives recognize as well as anyone the dichotomy between their rationality and their irrational behavior.”
The father who feared he’d post his daughter confessed to his doctor that if he passed a billboard that had a picture of a little girl on it, he had to go back and make sure it wasn’t his kid trapped up there. He explained with great embarrassment, “I knew she couldn’t be in a sign — but I’d have to check.” Shame over OCD and the secrecy it inspires seem almost like symptoms of the disease. The secrecy can be so well maintained that even the parents of young obsessive-compulsives can be unaware of their child’s double life. Dr. Henrietta Leonard, a child psychiatrist at NIMH, describes a handsome, popular 18-year-old jock, a counter-checker driven to perform actions in sets: he had to wash his face eight times, flick the light switch eight times, fold a sweater eight times. Despite the complexity of his rituals, he successfully concealed them for ten years, until he was finally hospitalized for drug abuse – a benighted attempt to escape from his secret numerical nightmare.
When the opposite dynamic prevails, relatives sometimes conspire in an obsessive-compulsive’s ritualizing — which can be harder to grasp than their obliviousness to it. One family out for Sunday dinner agreed to enter a restaurant three times rather than prolong a child’s distress by resisting her compulsion for threesies. Leonard recalls a kid who would say to her mother, “You know it takes me hours to brush my teeth, so just help me, okay?” Not surprisingly, it’s the exhausted and bewildered family that often demands that the obsessive-compulsive seek help. Many relationships can’t withstand the stress: the young actor with the extensive washing compulsions lost his live-in lover, who was not only perturbed by the rituals but virtually barred from the bathroom.
Giving up all pretense to a normal life can make OCD worse: Howard Hughes is an often-cited example of an obsessive-compulsive freed by privilege from any restraint on his ritualizations. He could afford to let his fear of contamination become the focus of his life, to the degree that he refused to touch things with his bare hands and rarely left his specially purified quarters.
People for whom rituals are part of normal life — such as members of religious sects with strict rules about morals, food and cleanliness — are apparently no more prone to OCD than other people. Dr. Zohar, an Israeli, says that while a very observant group of Jews living in Jerusalem had no more OCD than the norm, those who had it were inclined to be obsessed by religious issues, such as dietary regulations.
Looking for potential psychological causes for obsession-compulsion is not a high priority of researchers, because chewing over the possibilities with a therapist doesn’t help the sufferer. What does is behavioral therapy, based on doing scary things instead of talking about them. “Insight therapy doesn’t especially help any of the anxieties, because it doesn’t reduce fear — Freud himself knew this,” says Edna Foa, a psychologist at the Medical College of Pennsylvania and an expert in behavioral therapy for OCD.
The behavioral therapist makes the patient confront what he fears over and over again while preventing him from responding with ritualization, thus breaking the circuit between obsession and compulsion. “Feces contamination is the commonest underlying fear,” says Foa, “so the therapist would start out by having such a patient, a washer, touch doorknobs or use a public bathroom. By the fifth or sixth day, he’ll actually touch feces and see for himself that nothing terrible happens.” After three weeks of treatment, which includes “homework” and imposes strict limits on such rituals as washing and bathing, 75 percent of her patients, Foa says, show long-term improvement, in most cases without drugs. Jane, a young mother, is one of her success stories.
Jane felt contaminated by anything from her hometown — from hand-me-down Christmas ornaments from her parents’ attic to her parents themselves. A trip to the market meant hours of cleaning rituals to decontaminate herself and her groceries from contact with a popular candy made back home and sold in most stores. When her beloved grandmother got sick and Jane realized she was unable to visit, she finally sought help. First, her therapist took Jane shopping and got her to handle products near the candy. She then had Jane buy the candy, “contaminate” her home with it and finally eat it. Soon Jane was able to use clothes and objects sent from home, and she eventually went back for a visit, accompanied by her therapist. Because behavior therapy works by stopping compulsions, not obsessions, after her last session Jane was told to reinforce what she’d learned by going home every two weeks for three months. Several years after treatment, she’s still doing well.
That both drug and behavioral approaches yield rosy results is not as contradictory as it might seem at first. Thoughts and obsessions, and emotions like fear and anxiety, are neurochemical as well as psychological events. As Insel says, “Behavioral therapy reduces the patient’s fear through repeated exposure to his obsession, and the drug reduces it chemically.” Rather than being competitive about whose way is best, he and the researchers who treat obsessive-compulsives seem glad there are two effective remedies available to people in pain who were not long ago considered beyond the pale of medicine.