"Out, Damned Spot! Out, I Say!": Wrestling With the Demons of Obsessive-Compulsive Disorder

"It is an accustomed action with her, to seem thus washing her hands: I have known her continues with this a quarter of an hour."

---MacBeth, Act V, Scene 1

Did I remember to lock the door? Is the oven off? Many of us think of these questions in the car; or worse, just after we get on a plane. But people with obsessive-compulsive disorder never forget to ask. In fact, the questions and the worry and the fretting about them can overtake their lives. So they go back to check the door or the oven, over and over. In extreme cases, an OCD sufferer never makes it to the car at all. He or she keeps going back to see if the door is locked or inside to look at the oven dial. Or they think their hands aren't really clean, so they keep washing them, sometimes for hours every day, just like Lady MacBeth. And if they get dressed out of order, they have to start all over again.

To some degree, the tendency is present in many people. OCD is an anxiety disorder that affects over 2 percent of the entire human population, and in America, about 2.2 million adults. People with OCD experience persistent and unstoppable upsetting thoughts or obsessions, which tend to be thematic, but we'll talk about that in a minute.

In order to control the anxiety these thoughts produce, sufferers develop rituals, or compulsions, to control the discomfort. Unfortunately, the rituals can end up controlling them. They'll check things repeatedly, or count things. Or they have to touch certain objects, especially in a particular sequence. Sometimes, they'll just avoid the triggers for their anxiety altogether, which can make the situation much worse. They aren't able to get on the bus they take to work. They can't go into an elevator or even a car. In extreme cases this avoidance leads to agoraphobia, where a person can't leave the house at all. One of the best portrayals of this was Jack Nicholson's Academy Award-winning performance of an author with OCD in the movie As Good as it Gets.

OCD obsessions tend to fall into generalized categories that include a fear of contamination from germs, a need for orderliness and symmetry, or persistent visions of horrific situations, like hurting another person in a car accident. The fears don't have to be real to be terrifying or dangerous. As the disorder progresses, a person's ritualized responses to the anxiety become more involved and time consuming.

Scientists still don't know a great deal about the biological roots of OCD. Speculation has ranged from a genetic predisposition to insufficient levels of serotonin (a chemical messenger in the brain). In some children, OCD has been found to begin following a throat infection with a specific strain of streptococcus, which leads to the formation of antibodies against nerve cells. Another factor in OCD, which is now being considered and is leading to new kinds of imaging-guided surgical treatments, is the presence of a distinctive, overactive neurological circuitry that contributes to heightened anxiety.

New treatments. New hope.

Although OCD has been treated effectively with medications like selective serotonin, "reuptake inhibitors" like Prozac, Paxil and Zoloft, and trycyclic antidepressants like Anafranil, as well as behavioral therapies like cognitive behavioral therapy, there are patients for whom no amount of medication or therapy has worked. Their OCD is so resistant to medication that their lives have ceased to be their own. In these cases, new surgical techniques might provide an answer. Nevertheless, they're highly experimental so the screening process is very strict. An OCD patient must have exhausted all standard treatment, and must be suffering at a disabling level.

Here are several new surgical procedures that are being used for treatment of severe OCD:

Deep brain stimulation. Deep brain stimulation, or DBS, was approved by the FDA last year and is the first psychiatric application of the procedure. But again, it's only for the most severe cases. The treatment involves removable electrodes that are implanted in the part of the brain where the circuits involving anxiety have shown themselves to be over-active. A device similar to a pacemaker is then implanted near the collarbone, and sends a current that blocks the overactive circuits. Depending on the activity of the circuits, the current can be adjusted.

In a clinical trial of patients with severe OCD, those who underwent deep brain stimulation for a year showed an average of 40 percent reduction in symptoms. The treatment has a lower risk of permanent changes in the brain, and its adjustability allows for greater precision and tailoring of treatment.

Gamma Knife. Another new treatment is Gamma Knife radiosurgery, which uses an M.R.I.-like machine to send beams of radiation through the brain while minimizing damage to surrounding healthy tissue. Despite its name, no incision is ever made. The converging radiation waves then burn out spots of tissue from OCD-related circuits.

Cingulotomy. In cingulotomy, surgeons thread wires into an area of the brain called the anterior cingulate. The wires destroy tissue along a circuit that connects emotional centers in the brain to parts of the frontal cortex, where conscious planning is centered. This area tends to be hyperactive in people with severe OCD. Follow-up imaging studies suggest this surgery quiets the activity.

Capsulotomy. In this treatment, surgeons go deeper in the brain than in a cingulotomy, into an area called the internal capsule, and burn out spots in a circuit that are also thought to be overactive.

As innovative as these surgeries are, though, I can't stress enough that they are still considered experimental. Even if an outcome is positive, the results can take months to become apparent and the recovery is long. On the upside, these new techniques have been met with some success and are providing hope, not only for OCD sufferers, but for patients with a variety of brain disorders, including epilepsy and depression. For anyone who suffers from any of these debilitating conditions, hope is always good news.