What is Obsessive Compulsive Disorder?

(OCD) has seen a huge increase in understanding over the last 10 years! Many of these gains have come about as we began to understand its primarily biologic and usually genetic origin and as the first really effective treatments have become available. These have included, mainly, the SSRI's (Prozac, Zoloft, Paxil, Luvox, Celexa, Anafranil) and the cognitive therapies developed from principles of exposure and response prevention. It is important to remember that just because something has a primarily biologic basis it still can be effectively treated by certain psychotherapeutic techniques. This fits with our understanding that purely environmental events such as the death of a loved one can trigger a grief reaction that may become a biologic major depression. Obsessions are thoughts or images (eg, of illness, violent or sexual events that may or will occur) that are persistent and repetitive which greatly bother the person who experiences them usually as unwanted, distasteful, and foreign. Compulsions are repetitive behaviors (eg, hand washing, cleaning, ordering, checking, making symmetrical, etc) or mental acts (eg, counting, praying, repeating things silently, etc) that the person feels driven to do in response to an obsession or according to rules that must be followed rigidly. There is a fair amount of overlap between obsessions and compulsions as well as a considerable range in what individuals experience. There is also at times some overlap between obsessions, compulsions and tics. Tics are semi-involuntary motor (muscle) movements, usually twitch-like, and/or vocal (usually sounds, rarely words) sounds which may occur along with anxiety and/or attention symptoms especially in Tourette's Syndrome.

OCD affects about 2% of people and is often associated with other forms of anxiety or depression. It may also be complicated by substance abuse, Attention Deficit Disorder, or tics (see the article on Tourette's Syndrome in this Medical Memo). OCD is caused by faulty processing in the brain, especially the thalamus, basal ganglia, and related connections. OCD is most commonly inherited but may also occur after some brain injuries, tumors, or seizures.

Obsessive Compulsive Disorder can be disabling because of the intensity of the upsetting thoughts or images that can run through the victim's head like a horrifying video and the need to perform odd or illogical rituals that may take minutes to hours, especially when persons become "stuck". Even now, and especially in years past, persons with OCD were certain they were crazy and would be locked up because of their thoughts and rituals if they ever revealed them to even their closest loved ones, doctors or therapists each of whom often knew little about the disorder. No reliable treatments were available until the last decade. Most persons with OCD hid it or were ineffectively treated, if treated at all. We thought OCD was rare until public knowledge of the new treatments brought patients in to clinicians who had kept up with the new advances in knowledge. Now we know OCD is as common as one in every hundred people (which is the same rate as manic-depression and schizophrenia) and often begins as early as childhood. Many others have features of OCD as part of their anxiety or depression symptoms and we even increasingly suspect certain other patterns as being part of the OCD spectrum of conditions. These may include compulsive patterns of gambling, shopping, sexual behaviors, jealousy, hoarding, eating disorders, some substance abuse, self mutilation, some stealing, and persistent distorted views of body appearance. OCD, due to its potentially huge personal, social, and occupational costs, can often be complicated by depression or alcohol abuse which also may need direct treatment. The risk of suicide can be elevated in this situation especially when panic attacks also occur.

OCD, as is true of almost all psychiatric conditions, can be traced back hundreds or thousands of years. We can also guess at certain evolutionary advantages traits of OCD may have had. Reportedly, in the middle ages the Church recognized that some people were too saintly (too much self denial - asceticism, felt too much responsibility for things beyond their doing, felt too guilty about everything, were way too conscientious) to the point of being psychologically unhealthy. This was labeled "Scrupulosity" and is the extreme opposite of unscrupulous. This was, and is, a form of OCD.

The Spring 1999 Medical Memo will continue the discussion of Anxiety Disorders with an article on Post Traumatic Stress Disorder.

Effexor XR is the brand name of the extended release version of the previously available medicine Venlafaxine. The XR version is more convenient in that it is usually taken only once a day, usually in the morning. It also seems to be even more easily tolerated than the regular form of Effexor. Effexor XR is unique in that it not only increases the neurotransmitter serotonin (via reuptake inhibition) at low doses (like other SRI's such as Prozac, Zoloft, Paxil, Luvox, and Celexa) but it also increases norepinephrine (via reuptake inhibition). At the higher doses it even increases dopamine. Effexor XR is useful in treating both depression and anxiety. It and other medicines with dual action (Serzone, Remeron, combining a SRI with Wellbutrin, or the older tricyclic antidepressants) may work better for severe depressions than single action medicines.

Remeron also increases serotonin and norepinephrine to treat both depression and anxiety but by different mechanisms than other medicines. Remeron, the brand name of Mirtazapine, brings dual action and a unique combination of sedation and possible appetite increase that can be very helpful for certain patients. The sedation and appetite increase usually lessens with increased dose as the norepinephrine effect kicks in. Remeron does not typically interfere with sex drive or function as the SRI medicines may. Serzone and Wellbutrin share this desirable property and each, especially Wellbutrin, have been used to counteract this decrease in libido occurring in about 25-33% of patients taking SRI's.

Celexa is the newest antidepressant and antianxiety medicine to be approved for use in the US. It is the most specific Serotonin Reuptake Inhibitor (SRI) available and thus, at least theoretically, may have the least side effects of this group. SRI's are so widely prescribed both due to their broad benefits and their very low side effects as well as being generally very easy and safe to use. In fact, all of the newer medicines share, in varying ways, this advantage. As with the other SRI's, it is likely Celexa will prove to be effective for Obsessive Compulsive Disorder. Although only available in the US since 9/98, Celexa has been used in Europe for over 8 years and has reportedly been a top seller there.

None of these 3 newest medicines have been as well studied in children and adolescents as I would like. The FDA does not require testing in youth before medicine approval unless the company is seeking a specific "indication" in youth. However, they are all useful in this age group when one is mindful of the adjustments for age, size, and development.

More on these and other psychiatric medications can be found on my web site at www.leeheymd.com . You will see charts that talk about the dosages, effects, side effects, advantages and disadvantages of each medicine. Of course, these charts are intended only to provide information for you to consider and discuss with your psychiatrist.

Georges Gilles De La Tourette first described this group of signs and symptoms, which was soon named after him, in 1885.

The core feature, which must be present for the diagnosis of Tourette's, is the presence for at least a year of at least two motor and one vocal tic, not necessarily at the same time. The diagnosis, and any treatment, is only appropriate if the tics cause social, emotional, and/or physical problems. Tourette's occurs in up to 1% of the population, is 3 to 4 times more common in boys, almost always begins before the age of 18 and usually begins in elementary school age children. Transient or Chronic tic disorders are more common (up to 15% of people at some time in their lives) and do not meet the criteria for the more significant Tourette's disorder. The cause of Tourette's is clearly a biologic dysfunction in certain parts of the brain, particularly connections involving the basal ganglia, and is usually inherited. Tourette's may be very mild, very severe, or anywhere in between.

It is often easiest to think about Tourette's Syndrome diagramed (see below) as an equilateral triangle where tics are on the top (required for the diagnosis), Attention Deficit Hyperactivity Disorder at the front or leading corner (ADHD often presents first or along with the tics), and anxiety or Obsessive Compulsive Disorder at the back corner (anxiety and/or OCD often present after or along with the tics). Inside the triangle, as part of or associated with Tourette's, but not diagnostic of Tourette's, are the too often pronounced problems with impulsivity, temper, and/or inappropriate sexual judgment. Persons with Tourette's may have unusual preoccupations, learning disorders, and/or the full range of symptoms seen in ADHD or OCD. The life course of the tics is that they frequently begin in elementary school or even earlier, increase to a peak in frequency and intensity around puberty, and then decrease again and become easier to control as the youth moves through adolescence and into adulthood.

Tics are best described as quick, twitching semi-involuntary, repetitive movements of individual muscle groups. Tics typically occur in "bouts" where one or several types of tics will occur repeatedly over minutes to hours, days, or weeks. Tics are sometimes preceded by an uncomfortable feeling in that body area that the movement or sound makes "just right". Tics can be simple or complex and affect motor or vocal areas. Motor tics are observable muscle movements. Vocal tics are sounds emitted when small muscle groups twitch in the area of the nose, mouth, and/or throat thereby producing a sound. in the Simple tics are the movements of small muscles or groups usually in the face, throat, head, neck or shoulders and typically not seen as having a purpose. Examples of simple motor tics are eye blinking, squinting, forehead furrowing, nose wrinkling, lip pursing, gaping, grimacing, head nods or shakes, arm jerking, kicking without purpose, jaw twitches, teeth clicking, muscle tensing, and shoulder shrugs. Examples of simple vocal tics may be sniffs, coughs, throat clearing, spitting, screeching, barking, grunting,whistles, hissing, and monosyllabic non word sounds. You can see how some of these can be confused with allergy symptoms. Complex tics are bigger more purposeful seeming movements or sounds that often involve more muscle groups or combining sounds. Examples of complex tics may include gyrating, twisting, hopping, uttering or repeating words, touching, throwing, biting oneself, picking scabs, biting fingernails, repeating short phrases like, "oh boy", "all right" , " you're fat", etc. Coprolalia is the use of obscene or other socially inappropriate words or phrases in a complex tic. Persons with the coprolalia of Tourette's generally try to avoid such expressions or bury them in hidden ways.

It is important to remember that most nail biting, name calling, and cussing have nothing to do with Tourette's. In fact, I do not count possible complex tics toward the diagnosis of Tourette's unless I am convinced of the presence of simple tics, as well.

Tics are semi involuntary. This is confusing to many parents before they understand Tourette's. When told to stop that irritating repetitive grimace, squint, sniff, cough, etc their child can do so..... for a while, minutes, even hours. But it comes back. Parents may note the child has more tics when stressed or when nervous or anxious or excited. Frequently the child suppresses the tic at the doctor's office or at school, seeming to release it with a vengeance later or at home. The type or muscle group affected by a tic often changes with time.

Recent studies have shown that at least a few cases of Tourette's and OCD are caused or worsened indirectly by certain strep infections. These are known as PANDAS. An infection by beta hemolytic group A streptococcus (most commonly "strep throat") causes the body to develop an antibody auto immune response to attack the strep bacteria. A few weeks later, these antibodies may attack certain cells in the body they confuse with strep, thereby causing illness. This occurs in Scarlet Fever, Rheumatic Fever, post-streptococcal Glomerulonephritis, and Sydeham's Chorea depending on whether the skin, heart, kidney, or brain are affected, respectively. When certain areas of the brain are affected tics and/or obsessions and compulsions can result, usually temporarily. Certain severely or repetitively affected individuals may benefit from continually taking penicillin for prevention or using certain other more radical means to decrease the problematic antibodies.

Treatment for Tourette's requires first considering whether the tics or associated problems are currently causing enough distress to warrant treatment. Then, one must consider what is the target symptom(s) and how might treating that symptom (eg, tics or attention or impulsivity or compulsions, etc.) affect others. For example, if we treat attention deficit symptoms with Ritalin we may worsen tics while not affecting obsessions at all. Treatment may require multiple interventions as described in the Four Point Treatment Plan I laid out in my ADHD information packet. The most commonly used first line medicines to treat tics are Tenex (guanfacine) or clonidine, with Tenex having better duration, less sedation, and equal benefit for impulsivity and attention. The Catapres skin patch provides clonidine without a pill and often works quite well but often irritates the skin excessively. The more powerful anti tic medicines are all relatives of the anti psychotics, though they are not used that way in Tourette's. Orap (pimozide) has been shown in a good recent study to be better than the prior first choice Haldol (haloperidol) with Risperdal (Risperidone) seeming a good third choice. Each of these last three are very good for tics, impulsivity, and rage but do little for ADHD or OCD. These last 3 are usually monitored for reversible parkinson's like side effects and possibly irreversible Tardive Dyskinesia, if they are kept for years. Orap may be monitored for the unlikely advent of heart rhythm effects. When problematic tics, ADHD, and OCD occur together in more severe Tourette's a combination of medicines and other treatments, as in my 4 point plan, is often best. This can generally be done quite safely and with good benefit.

It is not unusual to have OCD occur along with tics in Tourette's Syndrome. The brain pathways and genetic mechanisms that produce tics seem to overlap substantially with those that lead to ADHD and OCD. It can at times be difficult to sort out certain tics from an obsession or compulsion. Please refer to my article on OCD in this issue. Please refer to my information packet on ADHD on my web site. There are also excellent internet links to the local and national Tourette's Association from my web site in the Mental Health Links section.

Concern about the privacy of medical records has been increasing of late, sometimes for good reasons. We all assume our medical records are private and confidential. There are many laws and standards to protect us. There are some pitfalls to watch out for.

Technically our records cannot be shared with anyone else without our permission. Permission is often given by either a written or verbal release of information (ROI). When you sign up with some HMO's or when your insurance company uses a third party managed care company to review and authorize payments for health or mental health services you may not realize you have often given written permission to these other parties to review your records without another ROI being needed. The same happens when you apply for health, life, or disability insurance. Many professionals, including myself, are concerned about these intrusions most people are little aware of. My advice is to consider privacy, as well as other factors when you select insurers and be specific about what you want released when authorizing a company or anyone to have your records. Be sure you know what is in the records being sent and that it is accurate. This is one reason I share records and give the initial report to each patient (or to the parent in the case of a child).

Another area of potential concern is the computerization of records. Secure computerized files are difficult to ensure and expensive. So far, the main health providers changing from paper to electronic records are those in large or very large group practices. Along with the advantages in communication a computerized record provides by being accessible to all or many in a big group of clinicians and staff, the record is obviously not very private at least within that group. Although concerns exist about internal privacy the biggest concern is about external persons, companies, and agencies obtaining access to the computer files without your permission. Congress has been debating without finalizing a "Patient Protection Act" which does some good in some areas but worsens medical records protections by repealing good state laws and allowing interested health promotion parties access to records with little restriction. Certainly, these intrusions are easier in these large group and corporate, often multi-city or multi-state, practices than in solo private practice settings not dominated by managed care. (A verbal or written permission is required for me to discuss a patient's care with even another professional at the office I share since each of us has a fully separate solo private practice.) The recent campaign for a Universal Patient Identifier is another potential intrusion into privacy. Hopefully, there will be enough of an outcry that ways can be found to promote public health research without opening records to the many companies that would love to get at our records for business purposes.

Other potential concerns can arise from the use of fax and e-mail. As long as the fax number is correct fax transmission is secure. Fax has become a standard way to send records quickly and therefore is often an advantage. E-mail is less secure and reliable encryption is expensive. Thus, I do not currently use e-mail for patient purposes.