What You Can Change _. And What You Can't - Martin E. Seligman [46]
Sometimes OCD begins with epilepsy, and after the great sleeping-sickness (a viral brain infection) epidemic of 1916–18 in Europe, there was an apparent rise in the number of OCD patients. There is also some marginal evidence for a genetic factor in OCD. It runs in families: 30 percent of all adolescents with OCD have a parent or sibling with OCD.
The second line of biological evidence comes from brain-scan studies of patients with OCD. Two areas of the brain show higher activity in OCD patients: These two areas are related to filtering out irrelevant information and perseveration of behavior. When patients improve with drugs or behavior therapy, activity in these areas diminishes.6
The third line of evidence concerns the specific content of the OCD jingle channel. What goes on there is not arbitrary. Like the content of phobias, which is mostly objects that were once dangerous to the human species, the content of obsessions and of the compulsive rituals is also narrow and selective. The vast majority of OCD patients are obsessed with germs or with violent accidents, and they wash or they check in response. Why such specific and peculiar themes? Why not obsessions about particular shapes, like triangles, or about socializing only with people of the same height? Why no compulsions about push-ups, or about handclapping, or about crossword puzzles? Why germs and violence; why washing and checking?
During the course of evolution, washing and checking have been very important and adaptive. The grooming and physical security of one’s self and one’s children are constant primate concerns. Perhaps the brain areas that kept our ancestors grooming and checking are the areas gone awry in OCD. Perhaps the recurrent thoughts and the rituals in OCD are deep vestiges of primate habits, run amok.7 This would mean, as it does for phobias, that it would not be easy to get rid of OCD, that we would not be able to talk people out of their obsessions and compulsions. This is true: Neither psychoanalysis nor cognitive therapy appears to work on OCD.
Effective therapy is, indeed, the final line of evidence for the biological theory. Anafranil (clomipramine) is a drug that has been used successfully with thousands of OCD sufferers, in more than a dozen controlled studies. Anafranil is a potent antidepressant drug, a serotonin-reuptake inhibitor. When OCD victims take Anafranil, the obsessions wane and the compulsions can be more easily resisted.
It is not a perfect drug. A large minority of patients (almost half) taking Anafranil do not get better, or they cannot take it because of side effects including drowsiness, constipation, and loss of sexual interest. Those who benefit are rarely cured: Their symptoms are dampened, but the obsessive thoughts are usually lurking and the temptation to ritualize remains. When those who do benefit go off the drug, many—perhaps most—of them relapse completely. But Anafranil is decidedly better than nothing.8
The Behavioral Viewpoint
There is something magnetic about horrible thoughts and images (the popularity of horror films testifies to this). Some of us are better than others at dismissing these thoughts or distracting ourselves from them. When we are depressed or anxious (as most people inclined to OCD are), such thoughts are even more difficult to stop. Indeed, when people are shown films of, for instance, gruesome woodworking accidents, those viewers who are most upset are the ones who have the most trouble discarding the images.9
Behavior therapists argue that people who are not very good at distracting themselves or dismissing thoughts are most prone to OCD. Once a horrible thought starts, if you cannot dismiss it, it makes you upset. The more upset you get, the harder it is to dismiss the thought. You get even more anxious, and a vicious circle is under way. If thought stopping by ordinary means doesn’t work for you, you can perform a ritual, a compulsion, that relieves the anxiety. So if you have mounting horrible thoughts about germs, you can wash your hands thoroughly;