AsianScientist (July 14, 2017) – By Lim Ting Wei – Beads of perspiration roll down his forehead. His hands are clammy as he grasps the door handle of his car for the 47th time. It doesn’t budge, assuring him that the door is firmly locked. Yet the man finds it impossible to walk away because as soon as he lets go of the handle, a kernel of doubt starts to loom large within his mind, eventually growing into something monstrous.
A distressing thought hijacks his brain, ‘What if the door was not properly locked? My child will die as a result.’ He knows that is not true—his children are safe away in school, and an unlocked handle would never imperil them. Nevertheless, the idea has become firmly embedded within his mind, sticking like freshly chewed gum.
Consumed with fear and anxiety, he returns to check the door handles again. However, it only provides temporary relief—the doubts quickly return and the compulsive need to check his door handle has to be answered again, and again, and again. He is already three hours late for his job; his boss will fire him if he is late again. But the only way to relieve himself from the anxiety is this ridiculous, irrational ritual of checking his door handle over and over again.
A debilitating disorder
Forget the caricatures of obsessive compulsive disorder (OCD) in films and novels. Forget the glamorized representations of OCD in popular media. This is the grim reality of OCD, an anxiety disorder characterized by persistent anxiety and ritualistic irrational actions to combat it. This crippling disease results in a daily impairment of at least one hour.
On the surface, OCD may resemble addiction, except that a gambling addict is driven to gamble repeatedly because of the pleasure he derives from the action, but patients suffering from OCD do not find their compulsive ritual pleasurable. Instead they experience intrusive, distressing thoughts that result in persistent anxieties. They are then compelled to engage in repetitive behavior to relieve it.
But the anxiety does not go away and sufferers end up trapped in an unending loop of misery which sucks away much of their time and energy. Sometimes, it can be severe enough to require medical intervention. A Brazilian man named Marcus who was suffering from OCD had obsessive thoughts about the shape of his eye sockets, so much so that he was compelled to feel them constantly with his own fingers. The constant touching eventually left him blind.
The World Health Organization has recognized OCD as one of the top ten most disabling disorders in terms of its effect on quality of life. Many of us may be unaware of it, but the problem is much closer to home than expected.
In 2011, the Singapore Mental Health Study found that Singapore was the OCD capital of the world, with OCD rates three times as high as that of Europe. Latest figures from the Institute of Mental Health (IMH) showed that 1 in 33 Singaporeans suffer from this anxiety disorder, yet only 1 in 10 patients seek any form of treatment. Even when they do, effective therapy is often stymied by a misdiagnosis of depression or anxiety.
Dozens of drugs have been tried and tested for OCD: LSD, lithium, fluoxetine, sertraline hydrochloride, amphetamines, nicotine patches and even the horse tranquilizer ketamine. Treatment is more like playing Russian roulette, because a given treatment might work like a miracle drug for some but aggravate the situation for others. There is no unequivocal opinion concerning the treatment of OCD because its neurobiological basis is still poorly understood.
Causes and consequences
For many years, people have sought to unravel the etiology of this illness. In the past, many wrongly ascribed it to possession by an evil spirit. As the field of psychiatry progressed, the explanation for OCD shifted from a religious view to a medical one.
At first, doctors attributed it to manifestation of melancholy, then as a psychological problem in the 20th century, implying that it was caused by life events, such as a traumatic childhood. By the 21st century, emerging evidence showed that OCD is caused by an interplay between physical and chemical abnormalities in the brain itself. Today, we understand it as a medical condition rather than a psychological one.
It’s been said that all behavioral disorders stem from the misfiring of an otherwise adaptive pursuit. Evolutionary biologists believe that OCD is a side effect of our evolved capacity to anticipate future threats. It is theorized that the brain randomly generates risk scenarios to allow individuals to develop harm avoidance behaviors without actually being exposed to these dangers in real life. While this neurological system conferred a clear advantage on those who possessed this trait over others, it also renders us vulnerable to developing OCD should this brain circuit go awry.
For example, it is perfectly normal for a person to wash their hands after touching something dirty because there is a risk of bacterial infection. A healthy person would stop washing their hands upon recognizing that they are clean, and is able to move on. This control is deficient in OCD patients. Instead of moving on, the act of washing their hands mutate into an obsession as their consciousness clings resolutely onto these scenarios and refuses to adapt to external changes.
Hunting down faulty circuits
Despite its severity and prevalence, there is still a paucity of data concerning the pathogenesis and treatment of OCD.
What we do know is that OCD involves dysfunction in the fronto-striato-thalamic brain circuit, a network that allows us to change our behavior according to environmental demands. This neuronal circuit starts in the orbitofrontal lobe, moves to the cingulate gyrus then into the caudate nucleus and the thalamus before going back to the orbitofrontal lobe. The question we want to answer is: where, in this circuit, has something gone wrong?
In 2004, neuroscientist David Mataix-Cols and colleagues at the Karolinska Institutet in Sweden reported that patients with different OCD symptoms exhibit abnormalities in distinct components of the fronto-striato-thalamic circuits.
Unlike previous neuroimaging studies of OCD that grouped together patients with mixed symptoms, they separated the patients according to the different symptoms they exhibited, namely washing-related, checking-related and hoarding-related. The researchers then exposed these patients to pictures of dirty bathrooms, open car doors and old newspapers respectively.
Patients who exhibited excessive washing behaviors demonstrated greater activation than healthy controls in bilateral ventromedial prefrontal regions and the caudate nucleus, suggesting that washing-related anxiety is associated with regions involved in the processing of emotions, specifically disgust.
As for checking-related anxiety, patients showed greater activation in the thalamus, globus pallidus and the cortical motor strip. In contrast to washing-related anxiety, there was a stronger association with dysfunction in a circuit that is essential for paying attention and reflective bodily movement as well as the inhibition of unwanted impulses rather than emotion processing.
The results were more complex for hoarders, as researchers observed hyper-metabolism in a variety of frontal regions. This suggests that it may be a different disease entirely as hinted by the fact that these patients often respond poorly to common OCD treatments.
Mataix-Cols’ study suggests that conceptualizing OCD as a spectrum of syndromes rather than a single entity may help doctors make better treatment decisions.
Even more recently, researchers from Central South University of Changsha in China reported widespread small-scale defects in the brain’s white matter in patients with OCD. These white matter tracts act like bridges that allow information to be exchanged between different parts of the brain. These findings suggest that OCD may involve abnormalities affecting a broader network of regions than commonly believed.
No laughing matter
All these findings point towards the fact that OCD is much more complicated than originally thought. Further research will continue to shed light on this devastating illness.
For now, we will need to confront the stigmatization and trivialization of mental illness in Asian culture. While many countries in Asia are beginning to take progressive strides to address mental health issues, mental health programs tend to revolve around more ‘threatening’ mental illnesses such as schizophrenia, ignoring common but disabling mental illnesses such as OCD. Also, there are fewer studies on the psychopathology of OCD in East Asian than in Western countries, with studies predominantly done only in Japan or Singapore.
Once relatively obscure, OCD has been catapulted into the limelight with the rise of TV series like Monk, popular threads like #ObsessiveChristmasDisorder and coffee mugs with one-liners that read “Obsessive Coffee Disorder.” Despite the way that it has been popularized, we ought to recognize that it is much more complex than a clean bathroom, color-organized markers or a clever one-liner on your coffee mug.
This article won third place in the Science Centre Singapore Youth Writing Prize at the Asian Scientist Writing Prize 2017.
Click here to see photos of the the prize presentation ceremony held on July 7, 2017.
Also, look out for the other winning entries to be published in a compilation coming out later this year.
Copyright: Asian Scientist Magazine; Photo: Shutterstock.
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