Roger was a successful vice president of a bank, unremarkable in every respect, except one. Before starting a task, he had to pull his socks up and down five times. Exactly five.
Roger (not his real name) had obsessive-compulsive disorder (OCD). Like a skipping record, OCD patients repeat an act or repeatedly think about a phrase, number, or concept. "Most of us are able to switch things off," says Hopkins professor of psychiatry Rudolf Hoehn-Saric. "In obsessive-compulsive disorder, the person can't."
Roger had a relatively mild case of OCD, and eventually through medication was able to reduce his sock adjusting and other compulsive symptoms. But severe untreatable OCD makes normal life impossible. One of Hoehn-Saric's patients arose at 4 a.m. so she could count her silverware. Another was so obsessed with cleanliness that nurses had to pry her off the plumbing fixtures when she refused to stop washing her hands. OCD occurs in about 1 percent of the population, according to Hoehn-Saric.
Though these acts may seem like habits people could stop if they tried hard enough, mounting evidence indicates that a brain malfunction is at their root, says Hoehn-Saric. Recently, he, along with professor of psychiatry Godfrey Pearlson and Gordon Harris, formerly an instructor in psychiatry at Hopkins and now at Tufts University, visualized the brains of OCD patients with an imaging technique known as SPECT (single photon emission-computed tomography). The researchers fine-tuned the technique to be able to see differences between OCD patients and healthy people more clearly. The images show that OCD patients have unusually high rates of brain activity in two key areas: the frontal lobe and the cerebellum.
The frontal lobe helps people make decisions, time their activities, and switch from one activity to another. The fact that it appears to be involved in OCD is not surprising and confirms earlier studies, says Hoehn-Saric. He says his group is the first to suggest the cerebellum plays a role as well. The cerebellum controls motor functions and possibly some cognitive activities and the timing of motions.
In SPECT, which reveals the rate of blood flow in the brain, regions that are working harder have a higher rate of blood flow. (In the color-coded images on the next page, white areas represent the greatest rate of blood flow, red the next highest, followed by orange, yellow, green, purple, and black.) You'll see that the frontal lobe is a hard-working white in an OCD patient, a less active red in a control subject.
SPECT is also helping to test the effect and the effectiveness of medications for OCD, says Hoehn-Saric. For example, through SPECT imaging he observed that fluoxetine, a drug commonly used for OCD, reduces activity in the frontal lobe of OCD patients.
Clearly, says Hoehn-Saric, there is a need for new medicines for OCD. Antidepressant drugs, which are most commonly used for the disorder, can jar some patients out of their obsessions or compulsions, like nudging the stereo needle over to the next track on a skipping record. But current medications (often used in conjunction with behavior therapy) eliminate symptoms in only about 20 percent of patients, according to Hoehn-Saric. About 25 percent of patients do not improve on medication. The remainder improve to some extent. (A patient who pulled up his socks every five minutes might now pull them up every half hour.)
For patients with severe OCD who do not respond to treatment, the only alternative is surgery, in which the tracts connecting the frontal lobe to the thalamus are cut.
Melissa Hendricks is the magazine's senior science writer.
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