Obsessions

So when I was in training later as a psychiatrist, in addition to screening myself regularly for bipolar (manic-depressive) illness, which I knew damned well ran in my family for many generations before I appeared on this earth,  I also screened myself regularly for OCD — obsessive compulsive disorder — which, thank God, is one problem I don’t have. People can worry about things so much that their abilities to function both personally and professionally and/or in education. I actually helped perform neurological surgery on one severe case in France that failed totally to respond to the best medication then available, one of the tricyclic antidepressants, clomipramine (brand name “Anafranil”). He worried, curiously enough, about putting his clothes on properly.  His family had to spend time with him every day and every evening holding his clothes up to the light, making sure everything was clean and straight, and multiple related details.  This took so much time that his family lost the farm.

We severed some fibers going to his frontal lobe on first one side and then the other, with only brief improvements each time. I remember leaving him in the hands of psychotherapists, for a “behavioral” treatment he found difficult and onerous. In the U.S.A. I treated lots of patients with this as a psychiatrist.  First, when I was working on developing SSRIs — Selective Serotonin Reuptake Inhibitors — I worked on the initial studies that showed that instead of the dose it took to get a response to depression in 4 or 5 weeks, a dose 2 or 3 times higher, taken for 6 weeks, will often do the trick by itself, although I sometimes resorted to a technique known as “exposure with response prevention.” This would mean making someone, for example, obsessed with cleanliness, stare at something beneath their standards of cleanliness and deep breathe or relax a bit.  This is not particularly comfortable for anyone involved, so I generally asked folks to buy a particularly useful self-help book, “Stop Obsessing,” by Edna Foa and Reid Wilson. I don’t even remember how many editions it has been through. I remember seeing back then that studies if the population said 3% of all folks had this.  Now, our beloved government says 2.3 to 3% of the population.  Does anybody actually believe we treated and cured it?  Rubbish, I say, and double rubbish.

People with this disorder are motivated, like most folks everywhere, a lot by shame.  The young French guy whose family lost the farm — well, you don’t actually think he thought anything was wrong with him, do you? Sometimes a spouse or parent brings someone in against their will.  Rare indeed are the folks who bring themselves in — usually it takes years of suffering in secret before people come. These are the people to whom I have to swear to on the nearest sacred thing available, that I will never tell anyone about their problem, and if I ”forget” and do, they can sue me a lot. The prognosis is actually pretty good.  It usually happens for spells of maybe several months when someone is under stress and gets less bad when they either learn to deal with the stress or it ends. I saw a person, one of the earliest with whom I started using natural substances, who could not take any Serotonin Reuptake Inhibitors.  The Prozacs, Zolofts, and Paxils of the world all gave him urological symptoms.  We started him on a natural supplement —  5HTP, a serotonin precursor. Easiest way to start is usually 50 to 100 mg at night;  People can go up a bit.  As with many natural treatments there is no lethal human dose, but nobody really should take more than 500 mg. daily.  200mg. in divided daily doses does it usually, and if you get too sleepy during the day, please don’t be stupid enough to drive.

Does anyone actually believe anymore in the serotonin hypothesis for depression or obsessionality?  The brain is such a complicated interplay of neurotransmitters that raising the concentration of one, like serotonin, does just that.  It gives you a high serotonin brain.  Nobody ever said it gives you a normal brain. Recently another receptor system, the glutamate receptor, has been implicated in a subset of OCD.  Several kinds of body-picking — like picking at scars and picking at and twisting hair, often a severe enough behavior to create bald spots (tricotillomania) for example. There was a wonderfully designed study.  They found 50 people on whom to perform it — nowhere near as many as you usually get in drug studies, but I think the treatment is safe enough and good enough to use on folks, and I have. It is reasonable to infer it may work in similar complaints — a subset of OCD.  It seems safe enough to use even on something like nail biting, as suggested here. I believe the cautions voiced in the article to be real.  Liquid 5HTP available in pharmacies seems to have side effects.  I have had no problems with the regular-type supplement pills.  600mg. does not usually help much.  600 mg. twice daily helps more often. If you have both kinds of OCD symptoms, well, they work on different receptors and I cannot find any clinical reason to suspect interaction.  But be good and tell your doctor what you want to do before you do it, and run a check for drug-drug interactions, for LOTS of drugs work on these same receptors. So I have written and so it must be done.

As for me, Auntie Charlotte’s little “worrier,”  although I do not have obsessive-compulsive disorder, I do have an obsessive personality trait. I certainly have a little “workaholic” around the edges.  I flunk “personality disorder” as I can achieve and have wonderfully satisfying relationships.  I remember finding an article in the “New England Journal of Medicine” years ago saying that doctors who had both obsessional traits and paranoid traits had a higher stand of practice.  I walked around with a copy of it for years, while insisting (as I still do) on telling patients all that could go wrong, and well, worrying a bit about them. This is not necessarily a bad thing. I love you guys, and I really do worry about you.