Tormenting Thoughts and Secret Rituals

Not my real cube, but not far from the truth.

This weekend I took some much needed time away from the funnybook cubical of power. Naturally since I don’t hunt or fish, I instead spent quite a few hours tracking down new treasures as a “book scout.” Among other titles, I picked up a new book on OCD, Tormenting Thoughts and Secret Rituals by Ian Osborn, M. D.

You might think as many books as I’ve already read on the subject, this was a bit redundant -- that I’d already “caught my limit.” Ah, but herein lies the beauty of the cheap book score. When I collected “how to” art books, I found that if I could garner even only one or two new approaches or techniques out of a book, it was a terrific way to build up my overall knowledge base. But, the books do have to be cheap -- or you might go broke.

Books, books, books!

Ian Osborn’s title is a first-rate book about OCD, and he suffers from the condition himself. I particularly applaud his lucid explanations of the biological basis of the illness and for me, the sometimes-nettlesome topic of medication. He challenges the complete, anti-drug stance of celebrated psychiatric critic Dr. Peter Breggin whose contrarian views often provoke uncertainty in me. I think it’s worth excerpting a few passages from Dr. Osborn’s book on the topic of OCD and medication.

“The medications that are most useful for OCD are the SSRIs. These drugs which had previously been known to have anti-depressant effects, have now been discovered to have distinct, specific anti-OCD effects as well. Over a hundred well-controlled research studies involving thousands of patients have now conclusively proven that SSRIs are both safe and effective in the treatment of OCD.

In the treatment of OCD the SSRIs have their major therapeutic activity in one small area of the brain. Brain-imaging techniques, able to show the brain at work, reveal that OCD is caused by a hyperactive circuit of nerve cells running from the basal ganglia to the orbital frontal area of the brain. SSRI medications decrease the firing of nerve impulses in this circuit.

Basal Ganglia -- lizard brain type stuff all squished into the center of the brain.

From a practical standpoint, what patients report is that the SSRIs allow them to let go of obsessions more easily and to resist the urge to do compulsions more readily. They are classified as anti-depressants because even before their anti-OCD effect was discovered, all had been show to reverse the severe states of depression characterized by loss of energy, interests, appetite, and sleep. The anti-depressant effect appears to be unrelated to the anti-OCD effect.

What is clear is that these medications help 60-70% of patients with OCD – a figure remarkably similar to the percentage helped by behavior therapy. They bring the symptoms under control, but do not eliminate the underlying disorder. Typically, what SSRIs do when they work is to free a person from being disabled by obsessions and compulsions, allowing a return to a relatively normal life. Although this is a great boon to the OCD sufferer, it is not a complete cure.

An important consideration in prescribing for OCD is whether a second, distinct psychiatric disorder is present along with OCD. If so, it is imperative that this second condition be treated as well. Severe depression, panic disorder, bipolar disorder, and tics all occur with an increased frequency among OCD sufferers. OCD often will not respond to treatment until after these accompanying disorders have been addressed.

Many people think that medications are a cop-out; that taking them is to shrink from a personal challenge that should be met. This view is even promoted by some psychiatrists, notably Peter Breggin, author of Talking Back to Prozac and Toxic Psychiatry. Dr. Breggin, who rails against the use of all psychiatric medicines, including those that are used to treat very serious disorders such as schizophrenia, views all drugs that affect the mind as escapes from feeling the suffering of intense feelings, suffering that should be dealt with as a means of personal growth. What people should do, Dr. Breggin says, is try to understand the roots of their problems, not escape them through drugs.

The error in this reasoning is the assumption that OCD has deep psychological “roots.” It is now widely believed that OCD has little or nothing to do with unconscious conflicts or hidden hang-ups. Research has now proven OCD is a discrete, partially genetic, brain disorder. OCD is often brought on by life stresses, and they should be addressed in therapy. But far from being an escape, medications are used to treat the direct physiologic cause of OCD so that those afflicted can get back on their feet and begin meeting life’s real challenges.

Antiobsessional medications take more than two months to reach their full effect, a delay that has puzzled researchers, since the direct action of these medications on serotonin at the nerve synapses takes place in hours. Researchers have long concluded that secondary changes in the brain are responsible for the SSRIs’ therapeutic effects. A similar delay in therapeutic action is observed with behavioral therapy.

Behavioral therapy and medication, when effective, produce identical changes in the brains of OCD patients: specifically, decreased activity in a small part of the brain known as the orbital frontal area. Each treatment shares some sort of a final, common biochemical pathway -- changes in the concentration of neurotransmitters at the brain cell junctures. All life events affect us by causing synaptic changes (Don’s note here: e.g. Hebbian learning, and the connectome).

It is hypothesized that “secondary messengers” may subsequently carry the chemical changes to the genes. It may be by altering the information transcribed from the genes that these two therapies are able to alter many different and far-reaching aspects of brain functioning, including those generally considered to be “psychological,” such as memories, attitudes, and motivation.”

Medications, especially the SSRIs, are an indispensable part of therapy for the majority of OCD sufferers. These medications, now conclusively proven to be a specific treatment for OCD, represent a truly remarkable advance in the treatment of brain disorders. Relatively free of side effects, easy to take, and apparently safe for long-term use, these drugs can offer dramatic relief from crippling suffering, OCD patients should not hesitate to make use of them, nor should they feel guilty when they do.”

Ian Osborn, M. D.

Tormenting Thoughts and Secret Rituals: The Hidden Epidemic of Obsessive-Compulsive Disorder by Ian Osborn, M. D.

As many as six million Americans may suffer from obsessive-compulsive disorder (OCD), making it one of the most common mental diseases. Osborn had a bout with it while in medical training, and he narrates the unfolding understanding of the disease and its treatment informatively and readably. In medieval times, many felt that the disorder had a religious basis. Later, puritanism imputed it to sinning, and psychoanalysis "proved" that it had deep psychological roots. Osborn shows that OCD is caused by a chemical imbalance in the brain and that behavior therapy and drugs, preferably together, can take care of it for most patients; Osborn personalizes this part of the discussion with case histories of individuals rather than stick-figure textbook abstractions. He also mentions new research, such as that which finds a possible link between OCD and childhood streptococcal infections; brain injury and stress may also play causative roles. He concludes with a long list of OCD support groups and other helpful information.

"A truly wonderful, compassionate book."

--James W. Broatch, executive director, Obsessive-Compulsive Foundation

"A splendid book on OCD--lively, lucid, informative, and scholarly."

--Ronald Pies, M.D., clinical professor of psychiatry, Tufts University School of Medicine

"A marvelous achievement--an excellent and very practical overview of OCD and its treatment."

--Jeffrey Schwartz, M.D., associate professor, UCLA School of Medicine