Explaining Obsessions and Compulsions - OCD

Excerpted from the book: The Brain That Changes Itself

Stories of Personal Triumph from the Frontiers of Brain Science

By Norman Doidge, MD, Penguin Publishing, December, 2007

Normally, when we make a mistake, three things happen. First, we get a "mistake feeling," that nagging sense that something is wrong. Second, we become anxious, and that anxiety drives us to correct the mistake. Third, when we have corrected the mistake, an automatic gearshift in our brain allows us to move on to the next thought or activity. Then both the "mistake feeling" and the anxiety disappear.

But the brain of the obsessive-compulsive does not move on or "turn the page." Even though he has corrected his spelling mistake, washed the germs off his hands, or apologized for forgetting his friend's birthday, he continues to obsess. His automatic gearshift does not work, and the mistake feeling and its pursuant anxiety build in intensity.

We now know, from brain scans, that three parts of the brain are involved in obsessions.

We detect mistakes with our orbital frontal cortex, part of the frontal lobe, on the underside of the brain, just behind our eyes. Scans show that the more obsessive a person is, the more activated the orbital frontal cortex is. Once the orbital frontal cortex has fired the "mistake feeling," it sends a signal to the cingulate gyrus, located in the deepest part of the cortex.

The cingulate triggers the dreadful anxiety that something bad is going to happen unless we correct the mistake and sends signals to both the gut and the heart, causing the physical sensations we associate with dread.

The "automatic gearshift," the caudate nucleus, sits deep in the center of the brain and allows our thoughts to flow from one to the next unless, as happens in OCD, the caudate becomes extremely "sticky."

Brain scans of OCD patients show that all three brain areas are hyperactive. The orbital frontal cortex and the cingulate turn on and stay on as though locked in the "on position" together — one reason that Schwartz calls OCD "brain lock." Because the caudate doesn't "shift the gear" automatically, the orbital frontal cortex and the cingulate continue to fire off their signals, increasing the mistake feeling and the anxiety. Because the person has already corrected the mistake, these are, of course, false alarms. The malfunctioning caudate is probably overactive because it is stuck and is still being inundated with signals from the orbital frontal cortex.

The causes of severe OCD brain lock vary.

The UCLA psychiatrist Jeffrey M. Schwartz set out to develop a treatment that would change the OCD circuit by unlocking the link between the orbital cortex and the cingulate and normalizing the functioning of the caudate. Schwartz wondered whether patients could shift the caudate "manually" by paying constant, effortful attention and actively focusing on something besides the worry, such as a new, pleasurable activity. This approach makes plastic sense because it "grows" a new brain circuit that gives pleasure and triggers dopamine release which, as we have seen, rewards the new activity and consolidates and grows new neuronal connections. This new circuit can eventually compete with the older one, and according to use it or lose it, the pathological networks will weaken. With this treatment we don't so much "break" bad habits as replace bad behaviors with better ones.

Schwartz divides the therapy into a number of steps, of which two are key. The first step is for a person having an OCD attack to relabel what is happening to him, so that he realizes that what he is experiencing is not an attack of germs, AIDS, or battery acid but an episode of OCD. He should remember that brain lock occurs in the three parts of the brain.

The OCD patient should also remind himself that the reason the attack doesn't go away immediately is the faulty circuit.

After a patient has acknowledged that the worry is a symptom of OCD, the next crucial step is to refocus on a positive, wholesome, ideally pleasure-giving activity the moment he becomes aware he is having an OCD attack. The activity could be gardening, helping someone, working on a hobby, playing a musical instrument, listening to music, working out, or shooting baskets. An activity that involves another person helps keep the patient focused. If OCD strikes while the patient is driving a car, he should be ready with an activity like a book on tape or a CD. It is essential to do something, to "shift" the gear manually.

This may seem like an obvious course of action, and may sound simple, but it is not for people with OCD. Schwartz assures his patients that though their "manual transmission" is sticky, with hard work it can be shifted using their cerebral cortex, one effortful thought or action at a time. Of course, the gearshift is a machine metaphor, and the brain is not a machine; it is plastic and living. Each time patients try to shift gears, they begin fixing their "transmission" by growing new circuits and altering the caudate. By refocusing, the patient is learning not to get sucked in by the content of an obsession but to work around it.

One can see that Schwartz's technique with OCD has parallels with Taub's CI approach to strokes. By forcing the patients to "change the channel" and refocus on a new activity, Schwartz is imposing a constraint like Taub's mitt. By getting his patients to concentrate on the new behavior intensively, in thirty-minute segments, he is giving them massed practice.

Two key laws of plasticity that also underlie this treatment. The first is that Neurons that fire together wire together. By doing something pleasurable in place of the compulsion, patients form a new circuit that is gradually reinforced instead of the compulsion. The second law is that Neurons that fire apart wire apart. By not acting on their compulsions, patients weaken the link between the compulsion and the idea it will ease their anxiety. This delinking is crucial because, as we've seen, while acting on a compulsion eases anxiety in the short term, it worsens OCD in the long term.

When Schwartz and his team scanned the brains of their improved patients, they found that the three parts of the brain that had been "locked" and, firing together in a hyperactive way, had begun to fire separately in a normal way. The brain lock was being relieved.

"it's not that I'm crazy. It's just that my brain wasn't turning the page."

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If this post strikes a chord with you, we take brain plasticity possibilities a step further in Impossible Dream, the extraordinary story of triumph over disability told from the first-person perspective of a young woman living with autism.