Diagnosis and Treatment of Obsessive-Compulsive Disorder Across the Lifespan

Tue, 05/02/2006 - 12:04pm

When: March 24, 2010 at the Downtown Library: Multi-Purpose Room

Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). This event will cover current trends and treatments in OCD, and what is being discovered through research. There will be ample time for audience questions. Speakers include Jim Abelson, MD, PhD, Professor, UM Dept. of Psychiatry, Director, UM Dept. of Psychiatry Anxiety Disorders Program, and Co-Director of the Trauma, Stress and Anxiety Research Group, UM; Gregory Lynn Hanna, MD, Assoc. Professor of Psychiatry, UM, and Director, Anxiety and Tic Disorders Program; and Joseph Himle, PhD, Assoc. Professor of Social Work and Assoc. Professor of Psychiatry, UM.This event is made possible through Partners In Research grants R03 NS065493 and R03 NS065491-0 and is co-sponsored by the Michigan Institute for Clinical and Health Research and the UM Taubman Health Sciences Library.For more information on obsessive-compulsive disorder take a look at our books on the subject. Articles and current research can be explored in our research databases MEDLINE and Health and Wellness Resource Center.

Transcript

[00:00:00.00] CELESTE CHOATE: Good evening everyone. Welcome to the Ann Arbor District Library. Thanks for coming out on such a beautiful evening where we could be outside getting ice cream at Washtenaw Dairy and walking around in town. We appreciate you coming. Am I buying? No, I'm sorry. I shouldn't make an offer to share food unless I want to really share food, huh? So, I've got a couple of housekeeping things we want to talk about first. Then I'll introduce one of my colleagues with the grants that brought us here tonight. And she will introduce our fine panel of speakers. If you have a cellphone with you tonight, please turn the ringer to off. The event tonight will be filmed, which is one of the reasons we're checking the lighting and making sure everything looks good. We will have a question and answer period at the end, and we will ask that if you're going to ask a question that you speak into the microphone and you wait until the microphone comes around, so that we can today hear your question and the answer. And that when the video is up live on our website later, the people who are watching online can also hear the question and answer equally. So, thank you very much for waiting with that. We also have cards in case you would prefer not to ask the question aloud. We'll be passing those out. You can flag us down for either the microphone or the cards later at the end of the session. And we can read the cards ourselves.
[00:01:41.77] This series of programs we have is available to us here at the Ann Arbor District Library, to our public, through a grant that we received with the University of Michigan through the National Institutes of Health. And we have, in order to support the grant, evaluation forms that we would like you to take a moment and complete. There a pre- and post-evaluation. So if you haven't taken a look at it, please complete the pre- part now. And then after the evening is over, fill out the post- part. This helps us collect data that we pass along to the to the National Institutes of Health as to how helpful it is to talk about health issues and clinical research issues in this type of library forum setting. If this is something that seems to work well, then we can talk to other libraries across the state and across the country about doing these kinds of things well in partnership with local universities. If it looks like this is not the best way to get information out there, then we will go down other paths. Thank you. We'll see how that works out. I'll center myself differently.
[00:02:53.07] And the next thing I'm going to say is, there's two evaluations. There's the evaluation for the grant which is on yellow or white pieces of paper. Then the library has the blue form, which helps us determine which programs work well for you coming to the library. How did you find out about us, what are good ways we can advertise so you hear about programs. So if you have a moment, please fill those out for us to make your future experiences even better. My name is Celeste Choate. I'm one of the associate directors and one of the principal investigators on the grant. With the help of Dorene Markel at MICHR. And I'm going to let you have her talk about her title in a moment.
[00:03:29.60] We've had a great relationship working together with MICHR and the University health libraries on campus and pulling together these programs and bringing them to you. It's important for us to talk about how clinical research can be important and valuable in your everyday life. Whether it's because of drugs that you take that have come to pass through FDA testing that's done through clinical research. Whether it's your involvement in research that helps move projects ahead. A lot of people don't know about clinical research, and it's important for us to get the word out. So that's why we're here today. If you have any questions, generally or specifically, we have these great speakers who will talk to you later tonight. And I'll turn the floor over to Dorene, to make the introductions.
[00:04:10.54] DORENE MARKEL: Thanks, Celeste. And, again, welcome everyone to the Ann Arbor District Library this evening. On behalf of the library and the University of Michigan. And MICHR, that Celeste referred to, is the Michigan Institute for Clinical and Health Research. An institute at the University of Michigan that actually provides infrastructure support and education to all of our health sciences schools and colleges around research that involves human participants from our community. And I think most of you are probably aware that every significant finding, therapy, improvement in healthcare, comes from the participation of folks in the community. Folks with various disorders partnering with us. And without the involvement of the community members, our patients, their families, healthcare research and healthcare improvements would stop. So, this engage website is our electronic tool to help the community be informed about the type of research that goes on at the University of Michigan. And it has two components to it. One is the list of all the studies that are looking for research participants. And the other part's a registry where you can go in and provide whatever information about yourself you're comfortable with to be matched with whatever study may come down the pipe in the future to be contacted. No obligation whatsoever, and it's completely secure and private.
[00:05:36.07] So, I am the associate director at the Michigan Institute for Clinical and Health Research. And also the managing director of the Brehm Center, which is focused on diabetes research. Which is unrelated to our topic tonight. And it is my pleasure to introduce three colleagues of mine from the University of Michigan, who are going to be our speakers tonight. We are really, really pleased that each of them will be able to represent a different, very important component of the topic of obsessive-compulsive disorders that we're going to be exploring this evening.
[00:06:09.15] So, let me introduce the three of them Dr. Greg Hanna is the Associate Professor of Psychiatry at the University of Michigan, where he has been the director of the pediatric anxiety and tic disorder program since 1991. He is the co-author of the APA practice guidelines for the treatment of patients with obsessive-compulsive disorder. He has conducted a systematic search to identify genetic factors involved in OCD and related disorders. And actually, Greg and I met years and years ago when I was working in the field of genetic counseling. So I know he has been working as an expert in this area for a very long time.
[00:06:44.09] Dr. Jim Abelson is the Director of the University of Michigan Health System Department of Psychiatry anxiety disorders program. He also co-directs a research group studying trauma stress and anxiety. He's been the co-investigator on the National Institute for Mental Health funded neuroimaging studies of OCD. And other research interests of his include stress, stress hormones, and trauma.
[00:07:08.61] Dr. Joseph Himle is our third speaker. And he's an associate professor at the University of Michigan School of Social Work and also in the Department of Psychiatry. He is also the associate director of the University of Michigan Anxiety Disorders Program. His current research focuses on understanding and intervening with underserved populations who are experiencing mental illness. So, I'll ask each of our speakers to just give their name when they come to the podium so that you can identify their names with their faces. And I'll turn the evening over to them. Thank you. So, this is Dr. Abelson.
[00:07:43.96] DR. ABELSON: And now we'll find out if whoever put the slides together knew what order we were going to go in. Yes, they did. OK. Very good.
[00:08:00.36] So, as she said, I'm Dr. Abelson, and I direct our adult anxiety disorders program. And we really think that conversation is the most effective way to learn about this sort of stuff. So, there's three of us. We all like to talk. But we made a lot of effort to try and keep our talks short, so that we'll have as much time as possible for question and answers. So, if this feels a little cursory and a little quick, forgive us. And you can fill in the details to more directly address the specific things that you're interested in. Hopefully with a big long question and answer period.
[00:08:32.10] So I'm going to give an introduction and overview. And then Dr. Hanna's going to talk about genetics and about children. And Dr. Himle's going to talk about cognitive behavioral therapy. So, I'm going to start with just some of the basics. The diagnostic criteria. The official diagnostic manual criteria. Which gives a fairly good summary of what the disorder's really about. But it doesn't make a lot of sense unless you've seen it. But it has two components. Obsessions is the first component. And these are intrusive thoughts, recurrent, persistent thoughts, or images, that are experienced as intrusive and cause distress. So these are things that come into people's heads. They generally don't like them. They are often distressing, distasteful kinds of thoughts. But they keep pressing on the mind of the patient. They aren't just excessive worries about normal sorts of things. And people usually are trying actively to get rid of them or neutralize them. And people are aware that this is a product of their own thought process at the same time that they feel like it's kind of a foreign intrusion that they don't like.
[00:09:37.97] Compulsions are the behavioral side of the disorder. And these are defined as repetitive behaviors, though they can sometimes be mental acts. And they're usually performed in response to an obsession and according to certain rules. And the goal of the compulsion usually is to somehow neutralize or prevent discomfort, or to somehow counteract the fear generated by the obsession.
[00:10:02.25] For those of you know a little bit about OCD and have seen people with it, or have it yourself, you know exactly what I'm talking about here. It'll become clearer as I talk about some of the specific manifestations. And to be a disorder, it has to cause marked distress. They're often very time-consuming kinds of compulsions. It disrupts normal routines and overall functions.
[00:10:26.57] In evaluating and screening people, to determine whether or not they have OCD, these are some of the kinds of questions that we ask. Do you have thoughts that make no sense to you? Do you have thoughts that keep coming back, even when you try not to have them. Do you have fears about being contaminated by germs or dirt? Do you have fears about harming someone that you care about? Somebody that you don't want to harm, but somehow the thought about harming them keeps intruding in your mind. Do you have intrusive thoughts about other kinds of distasteful, violent, sexual, or blasphemous things. Do you try hard to get rid of these thoughts? And if so, how is it that you try and get rid of them? And are there things that you have to do over and over again, like washing your hands. Checking locks. Are you spending lots of time dealing with these thoughts or repetitive behaviors? So, these are the kinds of questions that help us ferret out OCD when it exists. And then to further illuminate these various manifestations, I'm going to walk through these various categories in which we've divided people up. And the boundaries are not clean-cut but I'll just use this as an example to give you some examples.
[00:11:36.25] So, starting up here, washers and cleaners. These are probably the most classic, most commonly talked about, heard about, sorts of obsessive compulsive people. People who are washing their hands over and over and over again, 25 a day or a hundred times a day. Spending hours in the bathroom. Often driven by a fear of germs, fear of contamination, fear that if they don't get themselves clean enough they're going to get sick in some way. Although sometimes it's a different kind of fear. That just, it doesn't feel right. It feels yucky. Their hands feel greasy. And then they're working forever to get rid of that feeling.
[00:12:07.58] It isn't always just hands. There are people in this category who have very specific rituals about different aspects of personal hygiene. Who have to take showers in very specific ways. Sometimes those specific ways can lean to very elaborate shower rituals that can take hours. And, actually, some of the people in this category, you would be surprised are obsessive washers and cleaners. Because they're actually very dirty and they never shower. And some people get to that point because they discover that if they get in the shower they're stuck there. Sometimes all day long. Trying to complete their rituals, trying to get clean enough. And then rather than have to spend the whole day in the shower, they shower every eight days.
[00:12:52.88] There are also people in this category who are washing and cleaning other things. Compulsive vacuumers. Vacuuming their floors multiple hours every day of the week. People, sometimes, who fear contamination from the outside getting into their homes. So they'll have different sets of clothing for outdoors and indoors. And when they get home they have to go through elaborate rituals to get rid of the contaminated stuff from the outside, decontaminate themselves, and get into uncontaminated things on the inside.
[00:13:24.31] Harmers and checkers is another big category. And these are probably two of the most common categories here. Checkers are people who are repeatedly checking things. They're afraid that, often driven by this fear that they're going to somehow be the cause of harm coming to somebody. And so, they left the iron on. And it's going to burn the house down. And the pets are going to be killed. Checking door locks, for fear that somebody's going to break into the house. At night, sometimes going through an elaborate ritual to make sure all the doors and all the windows are locked. And then often having some sense of doubt. You know, did I really get it right? Are they all locked? And having to do it again. And sometimes having to do it again and again and again. This is an example of how these categories sort of lead into each other, the doubters. I'm not talking about the doubting aspect of the disorder. And that's a common component of it. It's the sense of, I'm not sure. I know that I just checked the lock, and I know that it's locked. Or I know that the stove is off. But the doubt creeps into their mind. And the doubt just nags and nags and nags. And in order to settle the doubt, they feel compelled to go back and check again. And they can check again. And five minutes later, the doubt's back. They've got to go check yet again. And they can get locked into repeating that kind of thing over and over and over again.
[00:14:48.42] And the centers refer to the people who have these intrusive thoughts. And it's interesting that people who get obsessional thoughts, intrusive thoughts that they don't like but they can't get rid of, tend to have thoughts in these three particular thematic arenas. And it's violence, sexual thoughts and blasphemous thoughts. And people feeling like they somehow have sinned and they have to undo it. They have to repent, they have to repair. People who compulsively pray, who can end up spending hours a day praying. For a perceived sin, or to avoid the possibility of sin. Then over here, orderers and arrangers. People who need everything always just so. Perfectly ordered. Particular arrangements. Coffee table has to be perfectly arranged, the pictures on the wall have to be perfectly straight. By the way, has anybody checked the pictures here? They do a pretty good job. And can get very tied up in distress when things seem out of order, the rows aren't just perfect. If we had one of those people arranging the chairs in this room it could've taken many hours as they attempted to get all the chairs just perfect. And I see that there's a chair and that row that doesn't match the others. And that would be very disturbing to somebody with this kind of OCD.
[00:16:12.46] And then there's various other types. Hoarders is an interesting category. It's receiving more publicity; it's much more common than ever suspected. This debate about whether it really belongs in the same category as the rest of OCD. But people who have this problem come to us for treatment. And we're the right place for them to go for treatment. So, for now, we continue to include it in the category. These are the people who can't get rid of anything. Collect things, save things, and do so to the point where their houses are overflowing with things, the children are on the streets because there's no room in the bedroom. They're at risk of being evicted. In the extreme form.
[00:16:52.78] Counters is another common manifestation. Often associated with some of the others. People who are obsessed with numbers, have to do things a certain number of times in order to feel comfortable. Have preferred numbers, and sometimes can walk into a room and have to count every corner. And if it's not the right, an even number or an odd number, they get very distressed and they have to count again.
[00:17:16.21] So there are all sorts of ways in which the mind can get tied in knots. All of them with some kind of similar process in the brain probably making the contribution. So these are just two quick classic presentations. A twenty year old college student. Good grades, conscientious, has never been in trouble. Now suddenly in college, struggling with failing grades, getting into fights with his roommates. And on evaluation, reveals that he's become obsessively afraid of catching a sexually transmitted disease. This is a young person in college. Who has perhaps had his first sexual experience. And gotten frightened about the possibility of disease. And now has escalating worries about what he knows are irrational sources. He knows that he can't get AIDS from touching the doorknob or using the public restroom. But is obsessed with the fear that maybe somehow he's going to be an exception. And is burning more and more hours trying to protect himself from this contamination. Decontaminate himself. Clean himself, et cetera. And it's interfering with his ability to function in school.
[00:18:19.05] Another example, twenty-five year old woman, churchgoing administrative assistant, new mother. Suddenly unable, unwilling to care for her baby. Asking her husband to stay home from work. On evaluation, reveals that she's been now tormented since the birth of the baby, with horrendous thoughts that she might harm her own baby. Knows she doesn't want to. Desperately afraid of these thoughts. Has never harmed anything in her life. Though she remembers that as a child that she had some terrible blasphemous thoughts about God that she never revealed to anyone because it seemed so scary to her.
[00:18:50.31] It's an illness that often starts early. A third of the cases begin before the age of 15. It's pretty common. And this is the most graphic illustration. 100 to 200 kids in Ann Arbor high schools right now are significantly afflicted with this disorder. It's disabling, and one of the top ten most disabling conditions. It doesn't go away. Kids who develop it tend to still have it, as they grow up. It leads to other problems. Most kids with OCD get additional problems as they mature. It can destroy lives. And it's often associated with severe disruption in function. And it often remains hidden.
[00:19:27.52] And it remains hidden for various reasons. Sometimes we don't hear about it because the people who have it think that the behavior's normal. They think everybody should keep their houses this clean. Everybody should spend multiple hours per day vacuuming. And they think that the problem is in those around them who are raising concerns. It often, as you can imagine, leads to marital conflict. When one person has it and another person doesn't. It also remains hidden by people who are aware that this is weird stuff. And they don't like it, but they think it's so strange, they don't want to embarrass themselves by revealing it to anyone. And it's often overlooked by physicians and even mental health professionals. In people coming in for other complaints. Because people with this disorder can be severely afflicted. But they're very high-functioning. And maintain high levels of success. Sometimes despite the disorders. Though other people can really have their potential undermined by it.
[00:20:22.79] The good news about it is that we're pretty good at helping people get better. And you'll hear more about that. Increasingly, as a result of modern neuroscience and research, we're learning more about its foundations and discovering that it really is a disorder of the brain. And a quite fascinating disorder of the brain. This is just some of the relevant information. There are clear cases that have definite biological causes. People with a movement disorder in neurology. And this is a kind of another, both of these are kind of autoimmune diseases. In which one's own immune system attacks one's own tissues. And it can cause a movement disorder. And other kinds of syndromes. And apparently, the immune system can attack particular areas in the brain and cause OCD symptoms. There are clear genetic factors which you'll hear more about. We now know, through neuroimaging research, that it involves a very particular circuit within the brain. This name is complicated and probably not necessary to really know. But there are particular circuits that are affected in people have this disorder. We don't know exactly what's wrong in those circuits, exactly where the problem lies, but we're honing in on that through research. And it's also helped by a very specific type of medication.
[00:21:41.90] It can also be helped by a very specific type of psychotherapy. And intriguingly, that psychotherapy can have an impact on these brain abnormalities that I've been talking about. This is just an illustration of some of the brain structures that are relevant to this. So this, I don't know if you can see this well, this is a head. Kind of a cartoon head with the top cut off so you're looking down on the top of a brain. And this is the same brain sort of with the head cut down the middle, and you're looking on the side of it.
[00:22:14.90] And in general, in terms of brain structure, the older, more primitive, parts of the brain are buried deeper within it. That run more basic functions. And the thalamus here is basically the brain's post office. It's where all the mail comes in and then gets distributed from. So, all sensory stimuli, as you learn about your world, the information is flowing through this and then being sent from the thalamus to the various parts of the brain that need to process the information. It also passes the information coming from within our own bodies.
[00:22:48.44] Here in the red is something called the striatum. It has multiple components. And that's sort of an intermediary level in the brain. And it has kind of an intermediary level function. So it participates in certain kinds of learning. And one example that's relevant is that it participates in the kind of learning that's relevant to the development of habits. So when you develop a habit, it's because you've done something the same way multiple times. Brushing your teeth is a good example. You don't think much about it, you don't think about how to do it. And you do it pretty much the same way every time that you do it. And the brain has put that behavior on autopilot. So it's not a cognitive function any longer. It's an automatic motor function. And this part of the brain plays a role in the type of learning that allows you to do that. And so you can see how this might well be involved in a disorder that involves repetitive kinds of behaviors.
[00:23:42.30] And then up here, the prefrontal cortex. Which is the real thinking part of our brain. That's where the higher order processing takes place. Some of the higher order processing takes place. Where we integrate various types of cognitive and emotional information, and we make decisions about what to do. And this part of the brain is also very important in inhibiting some of the more primitive functions that are taking place down here. So it's good and useful to put behavior on automatic pilot. But it's really important that if you put some kind of behavior on automatic pilot, that you know how to turn the automatic pilot off when you need to. So, you're brushing your teeth just like you always have and suddenly something really hurts that never hut before. And your brain automatically shuts off the automatic system, and starts thinking about what can it be, and do I want to touch that again with the toothbrush. And it shifts behavioral control from autopilot to cognitive control. And this part of the brain is important in that top-down inhibition.
[00:24:41.87] And the anterior cingulate is kind of in between. And I think one of its many roles is to help in that switching between automatic pilot and cognitive control. And people with OCD show increased activity in this anterior cingulate, in the prefrontal cortex, and in the caudate. And it's in the loops that connect these parts of the brain that the abnormality lies. And, again, we don't know exactly what it is. But it's somewhere in there.
[00:25:06.47] So this is just an old illustration. This is from a more than ten-year old article. And it was one of the first publications to look through brain imaging, at people before and after treatment. And in this case it was treatment of an OCD patient with a cognitive behavioral therapy. So this is a therapy that just involved talking, homework exercises into behavior. And this is the patient's brain beforehand. And this is the caudate here. And this is the thalamus on both sides. This is another picture of the caudate from a different angle. And you can see that from before to after treatment there's a pretty dramatic change in the level of activity in the caudate, in the thalamus, in the caudate down here. And this was a revolutionary study demonstrating that we could actually change the brain through a purely psychological intervention.
[00:25:58.77] So, summary. It's an important, common, impairing brain disorder. It has genetic biological causes, though it can be worsened and triggered by environmental factors. It starts early. It can cause impairment throughout life. We can't cure it, but current treatments are highly effective. And can restore patients to very successful functioning. And it can be treated effectively with both medication and psychotherapy, or a combination of the two. And I will stop there. And we'll let Greg take it.
[00:26:27.69] DR. HANNA: I'm Greg Hanna. Thank you for the turnout tonight. Dr. Abelson has already given a overview of this very important and fascinating disorder. I'll show you a few slides, and provide more clinical information about the disorder. And then also a few slides to describe some of the research that we've done over the past ten to fifteen years.
[00:26:53.48] You've already heard about many of the common obsessions and compulsions. It's important to recognize that these are unwanted thoughts and behaviors. There's nothing that's appealing, gratifying, interesting or pleasurable about these thoughts and behaviors. So we're not talking about the Calvin Klein obsession. We're not talking about anything that's mysterious or attractive. Instead, these thoughts and behaviors have all the appeal of being covered in leeches. Most of the kids that we see can tell us that they clearly would like to get rid of these thoughts and behaviors by any means possible.
[00:27:30.02] You've heard about how some of these obsessions, compulsions, are interrelated. And one of the factor analyses that was done with child and adolescent data, there were four factors, replicating what's often been demonstrated in adult factor analyses. There are also a few adult studies describing either three or four factors.
[00:27:52.80] Again, in this one, the first factor consisted of harm and aggression obsessions. Concerns about moral or sexual behavior. And checking rituals. Often in the children we see, if they start off with concerns about harm coming to themselves or others, or concerns about them doing something impulsively that might harm a brother, a sister, a parent. They often will at some point develop moral or religious scrupulosity obsessions or sexual obsessions. Again, picking up on the idea that they could do something impulsy. That's completely out of character, and completely unwanted. And yet they can't get rid of that concern that that's what might happen.
[00:28:37.77] The second factor that stood out in this factor analysis consisted of symmetry and exactness worries. And a variety of compulsions. Including counting, ordering, repeating and arranging. These behaviors often occur early in childhood. And they seem to be correlated with the familiarity of the disorder. That is, kids who have exactness and symmetry rituals tend to have multiple relatives with OCD.
[00:29:12.17] The third factor in this particular study consisted of contamination worries and washing rituals. And the fourth factor, as Dr. Abelson had mentioned, is hoarding. Which is somewhat different from these other behaviors. And it can be difficult to treat. Perhaps more resistant to treatment than all of the other behaviors listed on this slide. Hoarding, of course, can occur in children and adolescents. It tends to be capped in kids. Because they have both parents and teachers who are pushing them to get rid of the stuff. Get rid of the junk. So we don't see the sort of hoarding in kids that you might see on TV or in another public arenas.
[00:29:58.09] OCD is a heterogeneous disorder. I think we were all first attracted to studying this because it seemed fairly discrete and well-defined. It seemed more substantial than some of the other disorders that we study. And yet we have to acknowledge at this point that it's heterogeneous. There's a broad mix of behaviors. A person may meet criteria, for example, for OCD with contamination worries and washing rituals. And that may be the extent of their disorder. The next person that we see may have everything but washing and cleaning. And so, obviously, it's possible for two different people to qualify for the disorder. And yet they have no symptoms in common.
[00:30:41.77] This is the anxiety disorder with the highest percentage of serious cases. The median age of onset in one large, recent study, the national comorbidity survey, was nineteen years. That is, nineteen divided the sample in half. Half had an onset before nineteen and half later in life. 21% of the cases started by age ten. So a substantial number. About a fifth of all cases start by age ten. Males generally have an earlier age of onset. Up until about age fifteen, males predominate. That's different from what we see with other anxiety disorders. And usually there's a female predominance. Especially in adolescence and adulthood. Childhood OCD is often associated with tics. Tics in early onset OCD are like two sides of the same coin. Childhood OCD is also occasionally associated with ADHD, separation anxiety disorder, and a variety of phobias.
[00:31:37.80] Early onset OCD may be a more persistent form of the disorder. In one meta-analysis of follow-up studies done by Evelyn Stewart, she found that about 40% percent on follow-up still met criteria for OCD. And about 60% either met criteria for OCD, full-blown OCD, or sub-threshold OCD. However, the lengths of follow-up vary greatly among the various studies that are analyzed, from one to fifteen years. And many of these patients were still in treatment. So they may have looked good. They may have been relatively symptom-free but still, they may have been receiving both medication and therapy.
[00:32:17.76] This slide from a French group shows this age of onset curve in a different way. Again, OCD is rare before the age of five. But it does occur. It increases exponentially up until the late teens. In this [INAUDIBLE], many of these cases are male. Obviously it can occur in females, in childhood and adolescence. But the males are making up the bulk of our clinic. With a 2:1 to 3:1 ratio. After age twenty, there's more onset in females, with some of these cases starting during pregnancy or after pregnancy.
[00:33:01.93] Concerning the family genetic studies that have been done over the years, there are a variety of studies indicating that this a complex genetic trait. Twin family and segregation analyses all show that there's something going on that results in the transmission of the disorder from one generation to the next. In one child study, the heritability estimates for obsessive compulsive symptoms range for about 45-65%. This is a twin study comparing monozygotic with dizygotic twins.
[00:33:33.50] There are a variety of family studies showing that the prevalence of OCD is significantly higher in cases compared with control first degree relatives. So, by first degree relatives I'm referring to parents or children. Again, I'll show you a slide that gives some actual numbers. That will give you a more graphic illustration of how familiar the disorder can be. There are also a variety of studies showing that an early age of onset is associated with a more familiar form of the disorder.
[00:34:11.18] So I've shown data from some of the recent family studies that have been published since 1995. The rate of OCD in the first degree relatives in those studies that used adult cases, in which the family's study started off with an adult with OCD. And then the first degree relatives were interviewed. The rate of OCD varied from roughly 6.2% to 11.7%. So, compare that to a population rate of about 2% and you can see that there is a significant increase among these relatives.
[00:34:47.50] In the two child studies, the rate of OCD in the first degree relatives ranged, and I use that somewhat tongue in cheek, ranged from 22.5% to 22.7%. So this study was done here at the University of Michigan. The other study was done at Yale University. And I suspect that if we redid these studies we wouldn't come up with figures that matched so closely.
[00:35:17.84] So, again, if we start off with kids with OCD, a fairly high rate. About one out of five of the first degree relatives have OCD. About half of that, though, in the studies with adult [? probients. ?]
[00:35:32.68] OCD is treated in children and adolescents with both cognitive behavior therapy and with medication. Dr. Himle will review cognitive behavior therapy as is done with those children and adolescents. In our clinic, we often start off with cognitive behavior therapy. Especially in those cases that have a more mild presentation. There are four drugs approved by the FDA for the treatment of OCD. And there are also several other drugs that haven't been adequately studied but are used occasionally in treating this disorder. I didn't put a disclosure slide up here, but I received no money from the pharmaceutical companies. All of these drugs that have been approved have been done. Either received their approval because they've been shown to be better than placebo in least two randomized controlled trials.
[00:36:26.87] I can say, it's fairly easy compared to other psychiatric disorders, to show that these drugs are better than placebo. OCD seems to have little or no placebo response. And it's actually rather painful to do these sorts of studies, because we all want the kids to be randomized to active drug. But, obviously, half of them are not. And then you have to go through the study for about ten to twelve weeks with them taking placebo and receiving nothing else.
[00:36:56.43] There are also other drugs that are used to augment the response to standard treatments. These include antipsychotics. Other antidepressants. Amphetamine is actually used occasionally. And drugs that modulate glutamate. Glutamate is a different neurotransmitter in the brain. All of these drugs work by blocking the serotonin transporter. But there's a new group of medication that appear promising, that modulate glutamate. I mention this because the next few slides will show why we think glutamate's important.
[00:37:35.41] So, with this slide I'm going back to our earliest linkage study. We did a linkage study of kids and their families with OCD in the 1990s. In such a study we're looking at about 400 different markers that are scattered throughout the genome. And we're looking to see if those markers co-segregate, or correlate, with the illness. We found evidence at the tip of Chromosome 9 for linkage. That is, we have some evidence that there might be a gene, right out here at the very tip of the short arm of Chromosome 9. We knew that there was an interesting gene in that region, the glutamate transporter gene. And that is, the particular transporter that's expressed in neurons. There are other glutamate transporters but they're expressed in glial cells and in the retina. We also knew that at that point that there had been one case report of an individual with those both OCD and Tourette's who is missing the tip of that chromosome. So we thought there might be something there.
[00:38:41.27] Our colleagues at Johns Hopkins took this information and did a linkage analysis with families that they had collected in a family study. They used only thirteen markers. So, in a sense it was a cold shot. We told them where to look, we told which markers to use. And they came up with a linkage peak that overlapped our linkage peak and had about the same level of statistical evidence for linkage in that area. So that's somewhat unusual. All too often in psychiatric genetics, we have an interesting finding but we struggle to replicate it. At least in this instance, we even go that long before we hit a replication.
[00:39:21.87] Since that time, there have been four family-based association studies that have shown association with this glutamate transporter gene. It also has this code number, SLC1A1. So it refers to the first transporter in that group.
[00:39:41.17] In this study, we 71 trios from our various families. And we examined an array of markers in and around the transporter gene. I won't go through them all, but I could say that this has been a marker that has held up nicely in several different studies. And there's also a marker way out here beyond the gene. Sort of next door, That also appears quite promising.
[00:40:09.11] I shows this slide to give you some sense as to what some of these families look like. And, again, I can't emphasize too much that a long list of families here in Michigan have contributed much of what we know about the genetics of OCD. In this family, our largest family, we start off with a young boy with OCD and tics. He has several other affected relatives in his family. So all these people with yellow coloring have OCD. They were all directly interviewed. And, in fact, we had two sources of information. We interviewed each person directly and then we also had information from a relative about that person to confirm our findings. So, again, extensive amounts of OCD occurring in this family. The red dots refer to a deletion that's sitting right next to the glutamate transporter gene in this family. This deletion has not been noted in other family at this point. So this an eleven base pair deletion, a tiny deletion. But it seems to co-segregate with the illness. There are some individuals in this family who have the deletion. But who don't have the illness. And that's probably what occurs in complex traits. A person they carry the gene, but for a variety of other reasons they don't express the illness.
[00:41:33.39] There's also one person here who was diagnosed with OCD but does not have the deletion. And this is someone who was reviewed extensively. I reviewed all the records that we had. I bundled it up, gave it to Dr. Himle. He reviewed it all. Bundled it up, didn't tell us what he thought. And then it went to Dr. Curtis, a senior colleague in the department. We all agreed that this person had OCD. But, to some extent, where our evidence for linkage started to fall apart. There are two members here who are not characterized. But I will mention because it's, I think, part of the continuing story in this illness. Both of these offspring, two sons, had autism and pervasive developmental disorder. So, in this instance, we'd extended our pedigree until we ran into another genetic study. We ran into a genetic study being conducted by Stanford University. We have reasons to think that OCD overlaps, within some families, with autism. And that glutamate transporter gene that I mentioned to you has already been implicated in two studies of autism.
[00:42:46.70] So, to summarize the results from five different association studies. We don't have a perfect overlap in our market data. We have evidence in this column for association with this one marker, RS301430. It's currently my favorite snip marker. There's also evidence for this marker distil, to the far right-hand side of the glutamate transporter gene. This marker had a very large, substantial finding in the study that was organized by the group at Johns Hopkins. Curiously, this is the market that we couldn't analyze in our largest family. Because we had a deletion in that area.
[00:43:29.55] So, again, if I had to bet any money, 5c or 10c, I think there might be something going on right here. And way out here. And this particular marker RS301430, has also been shown to have an influence upon expression of this gene in the brain.
[00:43:48.76] You've already seen this slide. Dr. Abelson has already walked you through various brain regions that appear to be implicated in OCD. In some of our work we're very focused upon the anterior singulate, this part of the brain that's like a way station between the frontal cortex and lower brain centers. It's a part of the brain that's involved in error detection and performance monitoring. So, when a person makes a mistake, there is a signal that goes off in this brain, in this part of the brain, that tells the person to wake up, actually sends a message here to the frontal cortex saying wake up, slow down, pay attention. This region of the brain has been investigated with a simple reaction time task, that involves measuring to brainwaves. Dr. Himle was involved in the first study with Dr. Gehring. A study in which these two ways were examined in adults with OCD.
[00:44:46.13] The first wave is referred to as error-related negativity. Occurs about 50 milliseconds after a person makes a mistake. A simple reaction time task. There's another brainwave that pops out about 300-400 milliseconds later. So, with these waves, I'm showing you data from about 54 kids with OCD, controls and unaffected sibs of kids with OCD. This is a simple reaction time test in which a person is indicating which direction an arrowhead is pointing. The computer screen is flashing five arrowheads. Sometimes that middle arrow's pointing the same direction as all the others. The other half of the time it's pointing in the opposite way. And we expect people to make mistakes about 10% of the time. But we're assuming that with anxiety disorders have a part of the brain, this anterior singulate cortex, that's overreacting to making a simple trivial mistake.
[00:45:44.45] So, again, we've got with our OCD kids they have a higher peak here than do the controls. And with error positivity. They also bottom out way down here. So it's like a big rollercoaster effect. These kids are spending too much electrical, or brain energy, in processing a simple nonconsequential mistake. They can tell us that anyway. They know they're already spending far too much time thinking about these things and processing things that have no importance. As an example, I tried to explain this experiment to one boy. Told him that we were interested in how the brain reacts to making mistakes. He then told me that since I told him the point of the experiment, his brain would be biased. And so it wouldn't react in the way that I expected it to, and all the data that he's going to give me was a mistake. And so I'd have to throw it out. Fortunately, with a little bit more treatment, he was able to do this experiment.
[00:46:40.28] So this is my plug. We have a variety of studies at the University of Michigan, Wayne State University, and the University of Toronto. We have a brain imaging study being done here at the U of M in Wayne State. This involves kids with both anxiety or OCD and tick disorders. Eight to nineteen, involves an extensive interview. A blood or saliva sample. And then brain imaging, currently at Wayne State. It's not a bad study. Not to twist any arms, but a lot of the adolescents show up early Saturday morning. They're tired, they stayed up too late. And they can sleep in the scanner. They make $100 for that. So, it's good money for a nap. We have the EEG study that I just showed you. We also need normal controls. We've done quite well with older adolescents, because they can make $200-300 by doing these experiments. For further information, please contact Shannon Harbin. I also have flyers out there on the table. And Jenna also has consents. So we're prepared to talk to you about these things. So I'll let Dr. Himle take it from there.
[00:47:49.70] DR. HIMLE: All right. Let's see if we can get this moving here. We have a little time left to talk about psychosocial treatment. My name is Joe Himle, I work in the Department of Psychiatry in the school of social work. And I'm going talk to you a little bit about the psychotherapy part of obsessive compulsive disorder. There are two main elements to the behavioral treatment of obsessive compulsive disorder. They're called exposure and response prevention. They certainly do require some effort, but they're very durable treatment. This behavior therapy called exposure and response prevention. And it seems to be effective both for the obsessions, the thinking, and the compulsion part of obsessive compulsive disorder.
[00:48:36.95] So let's talk a little bit about exposure therapy and what it is. So, exposure therapy involves doing the exact opposite of what a person with OCD feels kind of most naturally driven to do. So if you had intrusive thoughts about dirt, germs and contamination, the natural strategy for you would be what? Let's avoid it. I'll just stay away from dirty things. I won't shake people's hands, I'll avoid the door handle. And in behavioral exposure therapy, we do the opposite. We try to go toward it. So we're trying to find contaminated things and help our clients, our patients, who are afraid of dirt, germs and contamination, we ask them to actually go toward it.
[00:49:15.62] If we have someone whose concern was symmetry, exactness or to order, we'll ask people to knock things out of order. Starting with just a little bit and then maybe working up to having a picture hung upside down. Or a chair tipped over in their living room. If we have someone who avoids using the stove, because they have to check it again and again, they're very concerned about burning down the house, we might ask them to turn it off by feel. As opposed to looking to see that the flame has gone down.
[00:49:40.99] So, with exposure therapy we have a common goal. And that is, can we activate the obsessions. Can we make the thoughts occur and make the distress occur. It's the exact opposite of what most of our patients with OCD are doing. They're trying to sidestep trouble, and they're trying to neutralize those thoughts as quickly as possible.
[00:49:58.75] So, obviously, you might expect it takes a little urging to get people going. And we help people get started by starting with little exposures. Things that most of us would seem very easy to do. Like touching a remote corner of the wall. And then working up to more challenging exercises that most of us would be a little concerned about like touching restroom surfaces or the floor, or the bottom of your shoe.
[00:50:21.29] So the idea is, one way we help people with OCD get the courage to face what they're afraid of, or what they're anxious about, is to start small. So we try to use what we call a graded hierarchy from easier to more difficult. And if we do behavior therapy well, we try to incorporate the exposure in your day to day life. So that throughout the day you're continuously getting practice. So it's one thing to touch a door handle. It's another thing to carry a door handle around in your purse. Maybe one from an architectural salvage area, for instance. So then the exposure is at ready hand. So we have people touch rags that are contaminated. Knock things out of order at home and take a quick picture of it on their cellphone. So they can check it or take a look at it during the day. So, we're doing as much as we can to make the exposures easy to more difficult. And also convenient to do. So, exposure therapy is meant to activate the stress.
[00:51:14.87] Now. Exposure therapy doesn't do you much good unless you stick with the distress. Anybody who's found themselves uncomfortable doing just about any task knows that if you're nervous about it, and you get really afraid and you walk away, you're just as afraid as you were. That exercise, that practice, didn't do much good for you. So if Dr. Hanna was very afraid of a dog and we put a dog in front of him and we pulled it away very quickly, we wouldn't do much for him as far as a therapeutic effect. He'd still be just as afraid of dogs. If, however, we coaxed him to come to a room. And we set him across from a big dog and we kept him there long enough, gradually his body would begin to slow down. And that's why we're trying to capitalize in this response prevention half of obsessive compulsive disorder treatment, or this cognitive behavioral therapy. We're trying to activate the OCD like touching a contaminated surface. And then try to avoid washing afterward. That's the response prevention part. We try to use the stove. That might be the exposure. And then we try to keep from going back and checking it again. Live with that distress and let the distress decay. Knock something out of order. Feel the tension, and then let it decay on its own. We all have some built-in capacity as people that if we're anxious about something and we stay in contact with it long enough, our bodies start to slow down. Gets a little boring. And that's really what we're trying to capitalize in this behavior therapy intervention that we use in OCD.
[00:52:46.67] Now, that's a simple, straightforward kind of idea. Anybody here who has a family member with OCD, or has obsessive compulsive problems themselves, knows that it's a huge amount easier, much easier, for me to describe the basics of treatment then it is to actually get it done. And I think we have several motivational strategies. And particular ways that we designed the exposure and response prevention treatment to make it such that people with OCD are willing to do it.
[00:53:19.62] And it's interesting. You know, a lot of folks come in. Very hesitant. But we have one thing on our side in the exposure and response prevention treatment. The psychosocial, psychotherapy treatment of obsessive compulsive disorder. And we've got very strong research data to support that this is helpful. And if it's designed right, it helps almost everyone who tries hard. Occasionally we have some people who try hard and it doesn't make much benefit in their life. Doesn't lead much benefit in their life. But for most folks, people do very well. And they get a big portion of their life back.
[00:53:53.66] So, our work in behavior therapy is design exercises that people can follow through with. Both exposure, so activating the OCD, like touching contamination. And response prevention, not washing afterward. Exposure, knocking things out of order. Response prevention, not straightening them out. Exposure, throwing away something. Maybe starting with one of a series of endless butter tubs that are stacked up in a hoarder's room or house, or newspapers. Starting with easy things. And then working up to more challenging items that you throw out. That's an exposure. Response prevention is not retrieving it from the trash. So, relatively straightforward concept.
[00:54:28.11] There are lots of different strategies. We have particular activities for contamination. Like, we ask people to use portable or wearable contaminants, carry things with them in their pocket like we talked about. Spreading the contamination down your body. So you get some more durable exposures throughout the day. We sometimes transfer contamination to other surfaces around a person's home. So we have strategies to help with contamination. Checking problems. One of our big things that we do for checking problems is try to compromise a person's sensory input. Like, look away when they turn off the stove like we talked about. Or, lock the door by feel. Or turn down the thermostat without looking closely at it.
[00:55:06.91] So we have a whole series of specific techniques and strategies that we use to make this general concept come to life as a person tries to overcome their OCD problems. I won't go through them in detail, but I will just bring this slide up. And that is, we also know that exposure and response prevention work quite well for people who have primarily obsessions. So, when people have terrible thoughts about hurting others. Or terrible blasphemous thoughts. We have them practice those thoughts as opposed to driving them out of their head. And try to block reassurance and other routines that they might do to kind of neutralize those thoughts. So, we can design exposure and response prevention for OCD of the type you'd think of, like contamination and checking. And also for people with primary obsessional thoughts.
[00:55:54.61] I should just say that we have a lot of empirical support. A lot of scientific support to suggest that this general concept of exposure and response prevention works well in both children and adolescents, as well as in adults with OCD. We have meta-analyses. These are these grand studies that pool together research subjects from multiple projects all over the world. And, without question, obsessive compulsive disorder treatment using exposure and response prevention has very large what we call effect sizes. In that the amount of improvement that people get is significant. It's hard work, but it's durable. And it's highly compatible with medication. Behavior therapy of the sort that we're talking about, exposure and response prevention, works very well with all the listed medications that Dr. Hanna talked about earlier. So it's compatible treatment. And we can talk in the discussion about some of the specifics of how it might apply to a particular person's situation. So, we look forward to the question and answer period.
[00:56:58.26] We're coming up on the half an hour, so we should probably take our little break. We'll step up. We'll pull up this screen. And we'll have a chance for some give and take. And the give and take can be delivered to us via some cards, if you write your question on. But it'd be really nice to hear from you, too. And remember to use the microphone. Thanks.
[00:57:14.60] AUDIENCE MEMBER: I'm wondering what would be the most helpful approach for parents of a teenager who has OCD. And what would be approaches that would be helpful in interacting with them.
[00:57:29.59] UNIDENTIFIED SPEAKER: I think we'll have Greg answer this.
[00:57:30.60] UNIDENTIFIED SPEAKER: Start at this end and go down the row.
[00:57:33.83] DR. GREG HANNA: I think that it's most important to avoid accommodating any rituals. So I think parents, early on, want to try to relieve the distress of their children. They'll often reassure them. Maybe even help them carry out the ritual. But, unfortunately, that process only reinforces the behavior. So if they ask you, did I touch that, will I get sick, am I going to die. And if you say no, you're fine. That's not going to take it very far. Instead it's probably going to lead them to ask you that again. So the family accommodation is important to disrupt. Beyond that, it would involve encouraging the person to approach those situations that they are trying to avoid. As Dr. Himley outlines. Beyond that, if it's a significant problem, if it really is taking more than an hour a day or causing significant distress or impairment, it does make sense to get an evaluation and pursue treatment.
[00:58:37.16] DR. JOSEPH HIMLE: I think one of the things that's interesting about adolescents and children and obsessive compulsive disorder, especially when you think about taking a medicine to try to help, or using exposure and response prevention, kids are sometimes motivated by what we call externalizing the OCD. Beginning to talk about it as sort of an enemy or a bully, or intruder in their life. There's some interesting research done by a guy named John March years ago. And it's been carried forward many other projects with children and adolescents, where they work with children and adolescents to start thinking about just that. That OCD is like an invader on their land. That's interfering with their birthright, right? And what's your birthright? To have some fun with your friends. To go to school. To spend some time at home. To feel relaxed and happy. And that OCD gradually has kind of marched on their territory. And the idea is, hey, how do we turn back this OCD? We can push it off of our land. And fight back to the bully. If you give money to the bully in the lunch line every day, he's going to be back. The idea is, you've got to stand up to it. And we can use exposure and response prevention and medications, or both, to begin to push back against this bully. And I think it makes a big difference. Not only for kids, but we use it a lot in adults, too.
[00:59:52.69] DR. JIM ABELSON: The first and most catalyzing step, whether it's kids or adults, is often getting people to buy into the idea that this is a problem that could be treated, that could be helped. And getting them into our offices is sometimes the hardest part. Often, once they get there, they're kind of amazed. Because they're sitting there talking to somebody who really seems to understand the way their brain works. In a way nobody else has ever previously understood. Because we've spent thousands of hours talking to people with OCD. Getting them in depends on who they are. And a lot of people are really into the internet, and if you get them on to the right internet sites and they read about other people and suddenly they see themselves, and they see this person who's had this problem and has been helped. And you have to figure out what's going to help that person be comfortable coming to talk to a professional about it. But they're going to be surprised once they get there. At how comfortable they can be, because they can really be understood.
[01:00:45.46] UNIDENTIFIED SPEAKER: I'm going to read a question from the audience. How do you treat tics or movement disorders?
[01:00:55.53] DR. GREG HANNA: Tics, including Tourette's disorder, are often treated with medications. A variety of medications have been tried over the years. The oldest one that was shown to be better than placebo was Haldol. And it's still a drug that's used at this point. So it's one of several older antipsychotic medications that's used. There are also some newer antipsychotics that are effective. We tend, in our clinic, to use a different set of drugs initially. One of them is called Guanfacine or Tenex. It's actually an older antihypertensive medication. It's not used that often, now, to treat hypertension. But it's generally well-tolerated by kids. It has fewer side-effects than some of the older but more potent medications. And it often has a fairly even, steady effect through the day. So it's a treatment that is used for both tic disorders as well as ADHD. And the two tend to run together. Often what parents notice with such a medication early on is that, parents will say the kid feels smoother. Meaning that, they don't overreact. They don't blow up. They can change the day's events or the schedule with less stress. It doesn't completely eliminate the tics, but we think we're doing well if we decrease them by half. Especially if we can help the kid get through most of the schoolday with few tics. Beyond that, habit reversal therapy and exposure and response prevention are also under investigation for treating tics.
[01:02:36.36] DR. JOSEPH HIMLE: I think that the behavioral treatment called habit reversal therapy is the one that is being studied most. But one of the big issues that we face is that there are very few clinicians who are prepared to deliver that treatment in the US currently. It's not typically taught in a lot of training centers where therapists learn their craft. And it's very difficult to disseminate new treatments out into the community when people have already earned their licensure and they're out practicing. So there's a big barrier between what might be helpful for tics, namely, this treatment called habit reversal therapy, and its availability.
[01:03:13.65] DR. JIM ABELSON: I think it's important to understand the relationship between tics and OCD. The vast majority of people with OCD do not have tics, and the vast majority of people with tics do not have OCD. They're separate disorders. But in a fascinating way, they are connected to each other. And there's clearly a higher incidence of OCD in kids and families in which there are tics. And vice versa. And from a biologist's, brain scientist's, point of view it's extremely interesting that there's a relationship between a disorder in which the problem is repetitive motor behavior that person can't stop, and a disorder in which there's repetitive cognitive behavior that a person can't stop. And they seem to involve these circuits that I had up there on my slide. And so, scientifically, it's fascinating that they're related to each other.
[01:03:57.52] UNIDENTIFIED SPEAKER: If you could raise your hand if you'd like a piece of paper handed to you?
[01:04:04.52] UNIDENTIFIED SPEAKER: Looks like we might have a live comment here, or?
[01:04:06.96] UNIDENTIFIED SPEAKER: We're going to go to live comments. And then I've got three in my hand to read.
[01:04:10.67] UNIDENTIFIED SPEAKER: Oh, great.
[01:04:13.97] AUDIENCE MEMBER: I have a very severe hoarding problem. And I believe that in the talk, you said there were some effective treatments for that. And you listed four medications, I think, that were approved for OCD. Were they ordered in, by effectiveness, is Zoloft a good one, or is one of the other ones on there would be better?
[01:04:49.42] DR. JIM ABELSON: They're probably all equally good. There aren't clear differences between them in terms of effectiveness. So, any medication in that class has some chance of being helpful. The medications are not as consistently helpful for hoarding as they are for other types of OCD. They can provide some benefit. I really think, and in our experience in the adult clinic, combining medications with serious cognitive behavioral therapy is really the only way to most effectively get that problem under control. And the key to success there is level of motivation. It's a very tough problem. If somebody is sufficiently motivated, and they have enough reason want to beat it, they don't want to leave the legacy to their children to be the house that has to be cleaned out, they want to be remembered in other ways, then we can have an impact. It's involved real teamwork. And serious effort. But we can help.
[01:05:50.56] DR. JOSEPH HIMLE: Our behavior therapy is relatively straightforward an idea. And that is, we make kind of a list of progressively more challenging items to get rid of. And then practice keeping them in the trash and not retrieving them. And try to work hard to keep the flow of new things coming out. So it's relatively straightforward in thought. But there's often a lot of preparation work that goes into working with people who have hoarding problems. To help them to build a legacy that can continue to focus on a legacy that's service-based and interpersonally based, and to try to begin to treat their possessions as if they don't matter. And that's not easy. But if we can make a little headway, then sometimes we can really get the ball rolling. I do think that people are sometimes overly pessimistic about outcomes for hoarders. But I will say that we've had some very good successes over the last several years as we've begun to be more open to a broader range of technique in helping people with hoarding problems.
[01:06:50.95] DR. JIM ABELSON: A key word that we haven't mentioned yet is desensitization. And that's a description of what happens with exposure. That if you're afraid of germs, and you're afraid you're going to get sick, and you repeatedly force yourself to come into contact with what you perceive as contaminating germ kind of substances, over time your brain gets desensitized and reacts less strongly to it. With hoarders, we have to desensitize them to the distress of letting go of things. And so they have to just practice making themselves feel uncomfortable by letting go, over and over and over again. Until the distress gets desensitized. And over time it becomes easier. And then it becomes possible to empty the house that's completely filled. When you have a house that's completely filled and you're starting out by throwing away some cups, it feels like you're never going to get there. But that desensitization to the distress has to occur.
[01:07:42.53] AUDIENCE MEMBER: Hi. My son, at approximately aged ten, was diagnosed at the U of M clinic with OCD. And he actually, at that time, referred to it obsessive compulsive disaster. But he's twenty now and, unfortunately, he's refusing treatment. But, my question's actually twofold. One, do you see medications that target more of the obsession; depending on what the obsession is, are there medications that target that better? And, do you see new medications coming down the pike that maybe perhaps have less side-effects and that will be treating OCD more efficiently then what is out now?
[01:08:23.64] DR. GREG HANNA: I think, of the medications that I showed you at the top of that list, they seem to be equally effective for obsessions and compulsions. And even in those who do behavior therapy along with the medication, I think often the medication allows them to take on certain obsessions, compulsions that they otherwise might avoid dealing with in the therapy. With the newer medications of, I showed you a partial list. It's a fairly long list of drugs under investigation. I don't think of any of them as necessarily having fewer side-effects then the standards. But the usual progression is to try at least two of the SSRIs, like Prozac and Zoloft. And then to go to Anafranil. If one of these newer drugs doesn't work. Anafranil's thought to be as good or perhaps better than the others. But it's a little bit harder to tolerate. And then it's a progression going through various augmenting agents. And I think our rate of success with those various augmentation strategies is roughly a third to a half. But from my perspective, it's important to keep moving. To try systematic trials. If something doesn't work after eight to ten weeks move on.
[01:09:43.78] DR. JIM ABELSON: The key to successful medication treatment is finding the best medicine for a given person. And none of the big studies can tell us that. So we have to do individual studies with the person. Trial and error process. The nice thing about having a list of multiple medications that are effective is that we have choices. And they're all equally effective in aggregate. For a specific individual one might be better than another. One might be more tolerable than another. So, we systematically walk through the various options, trying to find the one that works. Fits best for a given individual.
[01:10:15.03] DR. JOSEPH HIMLE: You said something I thought was interesting. And that is, you mentioned for a particular obsession. I don't know what this is like for your son. And I'm certainly not asking you to say so. But I think a lot of people feel that if the condition is mainly obsessional, the thinking part, that we have not much to offer from a behavior therapy point of view. But, actually, if we have somebody who has fearful, intrusive, obsessions, and that's sort of the core of their problem, we would love to be able to treat someone like that. Because our interventions are particularly good in that arena. I think we've really defined ways to use this desensitization approach to help people with that problem. So I think there's definitely hope for people with primary obsessions. Medication's a great starting point. And behavior therapy can be helpful.
[01:11:03.19] DR. JIM ABELSON: Dr. Himle has really pioneered the use of exposure and response prevention for pure obsessions. And so somebody who's reluctant to get help, perhaps, can be enticed by offering them an opportunity to see one of the world's experts for an evaluation.
[01:11:18.47] DR. JOSEPH HIMLE: Thanks very much.
[01:11:20.98] UNIDENTIFIED SPEAKER: We're going to go. I have a few here from the audience that I've been holding for some time. One of the audience members says, she would like to hear your thoughts on perpetually problematic songs, dance steps, numbers that get stuck in his or her mind.
[01:11:40.09] DR. JOSEPH HIMLE: I could answer this one. I think that comes under the annoying obsessions part. I mean, there's two different kinds of obsessional thoughts. One are fear-inducing. Like, I'm going to stab someone. And the other is just sort of annoying. Like, phrases, songs, et cetera. And it's a little harder to approach it from a behavior therapy perspective. But let me say a little bit about how we've done that. We try to find the most succulent triggers. Those things that are most likely to get stuck in someone's mind. And try to flood their day with reminders of those songs, or phrases. So we put them in their office. Put them in their car. Put them in their wallet. Such that wherever they turn, they're reminded of this. And we find that if you, because usually people try to push it away or avoid it, so if people stop trying to put the brakes on these thoughts or songs, and actually welcome them, and invite them to stay, we call it an acceptance and commitment approach. I'll let this song stay. In fact, I'll welcome it; but I've got other things to do. So I'm going to get to work on my major life aims. Song, if you want to continue to play, that's fine. Sort of turning the tables on the song. We've had some success in that area.
[01:12:49.50] UNIDENTIFIED SPEAKER: Another question, in my own experience, this is written by someone in the audience. Caffeine significantly exacerbates symptoms. Today's kids get Coke, Pepsi, Mountain Dew, in liter sizes. Has anyone studied this effect?
[01:13:04.36] DR. JIM ABELSON: Actually, the few years ago retired chairman of our department of psychiatry, he was our chair for twenty-two years, and was one of the pioneers in studying the impact of caffeine on psychiatric disorders. And he began with a case study, I think, of his wife. Who didn't have a psychiatric disorder. But it was his observation of the impact of caffeine on her behavior that suggested that there might be a problem. And it's a particular problem for people who are anxious. And so caffeine is a big bugaboo in our clinic. And it's something that we always ask about. Because we know that utilization of caffeine is going to make anxiety worse in whatever way, shape or form it takes. So, we start there. Before introducing new drugs we will work hard to help people get caffeine out of their lives. And a lot of our patients come in having already reduced it on their own. Because they've noticed that it tends to make them worse. And it definitely exacerbates anxiety in a general sense. And it will impact any the anxiety disorders.
[01:14:02.98] UNIDENTIFIED SPEAKER: I'm going to do one more written, and then we'll go back to the audience for live questions. The question is, how do you help kids buy into treatment when they don't consider the rituals unreasonable or distressing?
[01:14:16.15] DR. GREG HANNA: That is a difficult one. I think, often, there some element in their array of obsessions or compulsions that they find unwanted or distressing. They may argue or rationalize some of these symptoms. But I think with many that we see, there is at least some piece of it that they're willing to take on. It can be a problem with having no insight. And we have struggled with such cases over the years. I remember one that we treated perhaps for about five years. And when he hit about fifteen, he was ready to say it was a real problem and he wanted rid of it. But up until that time, he was seeing a very gifted behavior therapist. And he argued with him every week. Something bad really could happen, or all of this really was necessary. So it's quite difficult, I think. We often wait for a kernel of insight to occur. I know that parents always want that to happen earlier in life rather than later.
[01:15:24.57] DR. JIM ABELSON: And this isn't a problem that's limited to the kids. We regularly see people in the adult clinic who come in because their marriage has fallen apart. And they've agreed, finally, before divorce papers are filed, to come in for an evaluation. And the tack I take with them wouldn't necessarily work with a kid. But it has to do with the idea of freedom. And it's the idea that, I say to them, if you could stop doing this tomorrow, I wouldn't say you need treatment. But if you can't stop doing this tomorrow, you are a slave to your obsessions. If I treat you successfully, and you're no longer a slave, and you decide that you still want to spend three hours a day in your hygiene routines, I won't have any argument with you. But, right now, you're not free. And my goal is to give you that freedom to make a choice. And I don't want to argue with the choices that you make. Just convince me that you've liberated yourself from the enslavement of your obsessions. And sometimes that grabs them, they're going to prove to me that they can be free and still obsess. But most of them, once free, decide it's more fun to live without the obsession.
[01:16:43.75] UNIDENTIFIED SPEAKER: I have a question that is kind of linked to her question earlier. I have a friend who's in her early thirties. And she's been diagnosed with OCD. And about ten, fifteen years ago I think she went through the full regimen of drugs and behavioral therapy. And she also does hair pulling. I don't know if you guys have talked about that very much. And she pretty much just gave up. And has adapted as best she can to the situation. And I guess I'm wondering two things. One, is about hair pulling in particular as part of either a tic or an OCD thing. And the other is, is the approach, she was on Paxil and a lot of these things. Is the approach significantly different than it was ten, fifteen years ago. So would it be worth it recommending her try over, all over again. And, I guess that's kind of my question. What should I say to her? And she's just like, they can't help me, they tried.
[01:17:29.10] DR. JOSEPH HIMLE: Wow. I'd be happy to sort of entertain both the trichtotillomania side. Maybe we could hold that aside. Maybe someone would like to answer the first half.
[01:17:38.84] UNIDENTIFIED SPEAKER: Joe, why don't you comment that that's the --
[01:17:41.35] DR. JOSEPH HIMLE: The hair pulling problem, I'm sorry.
[01:17:43.38] DR. JIM ABELSON: So, Joe, we'll come back to the hair pulling in a minute. And Joe will address that. Two things. One is, there are some medications available now that weren't available then. You mentioned Paxil, and of the list of medications that Greg showed up, Paxil's probably my least favorite for treating OCD. For a variety of reasons that I won't go into now. So, there may be medications that weren't tried that could be helpful. There are some advances, certainly in the last ten years. I think we're better at treating OCD, kind of, behaviorally now than we were ten years ago. Thirdly, I don't know if you came to see us. But we're better at, cognitive behavioral therapy for OCD than anybody else. And that's just a matter of experience. We've been doing this for 30 years. And we've just seen thousands and thousands of people. And I'm generally a pretty humble guy. But we really are better at it than most people. And, finally, her brain is different now than it was ten years ago. And to me that's the most important part. Because brains change. How old did you say she was? So the brain does not finish developing until the mid- to late-twenties. So our final full development of our cognitive capacities does not occur until then. And the last thing to develop is what's called the myelination, which is a sheath that grows over the nerve fibers. Specifically of those fibers that travel from the frontal cortex to lower centers in the brain. And allow us to inhibit the automatic behaviors that are being generated lower in the brain. So at twenty-three she didn't have the same kind of transmission in those critical circuits to the effectiveness of the CBT that she has at thirty-three. And to me, that would be the strongest argument.
[01:19:40.92] DR. JOSEPH HIMLE: I'll say just a little something about the hair pulling problems, or trichotillomania. There are clearly some people who pull their hair out again and again. And they have bald spots and other impairments, and a lot of self-loathing connected to it. Because they have such trouble stopping. There is a technique, a behavioral technique, called habit reversal therapy. Which is actually similar, in some ways, to the psychosocial treatment we use for tick disorders. And it involves a whole range of different procedures. From relaxation to learning when pulling it is likely to occur. And doing opposite behaviors, behaviors that are incompatible with pulling. So, it's a slightly different behavioral treatment. But there's certainly great opportunities for these impulse control disorders. We actually have an impulse control disorder treatment group in our clinic. And there is a real hope for people with hair-pulling problems. It's a difficult struggle sometimes. And there's some on and off that occurs. So if there's a waxing and waning course, that's typical for hair-pulling problems. But we can certainly help people, often, get a handle on it. Or get ahead of it.
[01:20:51.82] DR. JIM ABELSON: And on the topic of research, which is part of the theme here, Dr. Himle also is participating in, he just got a grant approved, and is developing some technologies that will help. Because a lot of these are very automatic behaviors. It becomes habitual. People aren't even aware that they're doing it. And he's working on a technology that will allow them, every time the hand moves to the head, a signal will occur. And then they won't be able to do it unconsciously. And he will at some point, not in the too distant future, be recruiting people for that study.
[01:21:20.70] DR. JOSEPH HIMLE: Thank you. Thanks very much.
[01:21:22.08] DR. GREG HANNA: One other comment about medications. There are newer medications available that are showing promise. There was a nice study published last summer that compared a medication called N-acetylcysteine to placebo. It's available over the counter at GNC and health food stores. It's a powerful antioxidant. It's often used to help people with drug overdoses. Anyway, in this study, it was effective in helping adults with hair-pulling. And the people on the placebo actually complained more about side effects than those on N-acetylcysteine. Which is unusual. So, that's probably the easiest one available without prescription.
[01:22:03.99] DR. JIM ABELSON: I-N-O-S-I-T-O-L.
[01:22:08.02] DR. GREG HANNA: No, N-acetylcysteine. N-A-C.
[01:22:10.13] DR. JIM ABELSON: Oh, not enough.
[01:22:11.13] DR. GREG HANNA: Yeah. So it's actually used every day in ICUs for Tylenol overdoses. It's given as Mucomyst. But it's available in pill form. There are other adult studies being done, and there's one active study with kids at Yale with that compound.
[01:22:29.89] DR. JOSEPH HIMLE: And that is the first compound that's ever been shown to be effective in treating trichotillomania in a double-blind placebo-controlled trial. Which is really interesting. DR. GREG HANNA: I learned early on, after trying standard [INAUDIBLE] depressants for kids with trichotillomania that I just needed to refer them to a very skilled behavior therapist. Because I don't think we've had drugs that helped significantly in that area until recently.
[01:22:53.48] DR. JIM ABELSON: And the one that I got it mixed up with is another over the counter health-food store kind of drug that has evidence to suggest that it helps OCD in general. It's the only thing other than the medications he listed that has any evidence to show value.
[01:23:08.33] UNIDENTIFIED SPEAKER: Greg, we have a request for you to spell the name of that over the counter drug again.
[01:23:14.02] DR. GREG HANNA: OK. N, just capital N. acetyl, A-C-E-T-Y-L hyphen, cysteine, C-Y-S-T-E-I-N-E. And it affects glutamate and glutathione. And it gets into that glutamate pathway that I was speaking about.
[01:23:37.52] UNIDENTIFIED SPEAKER: You were talking about the combination therapy of the SSRIs and side effects and stuff. My question is, the side-effects that they have. And you say you just change the drug after so many weeks because it's not working. Well, what if one of them works and the other doesn't? How do you taper them off if you don't know which one works? Do you start with one for a couple of weeks, and then add the second one? Oh, how do you do that?
[01:24:06.39] DR. JIM ABELSON: It it's a slow, systematic process. The drugs work slowly. It takes time to taper up to a full dose. And with these medications, you don't see the full benefit until you've been on it for three months. So what we do is, we start slowly. We try and get up to a relatively high dose that can be tolerated. And we ask people to wait and watch for weeks. For a month, for six weeks. If we see nothing happening at four weeks, at six weeks, we may be starting to think about switching. But it takes a while. So it's a systematic, slow process. And if a first one doesn't work, we will usually taper them off of it and start a different one. And we --
[01:24:50.68] UNIDENTIFIED SPEAKER: Persistenly having, like, a side-effect that doesn't go away after a month on that drug, you'll just taper them off of it.
[01:24:57.34] DR. JIM ABELSON: If somebody's having a significant side-effect that's making it hard for them to stay on it, we will stop after a week or two.
[01:25:04.37] UNIDENTIFIED SPEAKER: I see.
[01:25:05.98] DR. JIM ABELSON: So we titrate up according to side-effects and to tolerability. If it's tolerable, then we'll give it time to see if it works. If it's not tolerable, we will move to something else sooner.
[01:25:31.22] UNIDENTIFIED SPEAKER: Could you elaborate a little more about the glutamate pathways and how that would affect OCD?
[01:25:38.77] DR. GREG HANNA: Briefly, we think that that one brain region, the anterior cingulate cortex is overactive. There is evidence from the studies done, in particular, by David Rosenberg at Wayne State that that brain region is actually enlarged in kids. It's as if that region has grown too rapidly, and it's out of balance with the rest of the brain. And the glutamate concentrations in that region are decreased. Whereas they appear to be increased in the caudate. So, at this point, at a research level, we're trying to connect the dots between various glutamate genes, brain structure, brain volume, glutamate concentration, and various measures of functional activity in those regions.
[01:26:31.54] UNIDENTIFIED SPEAKER: And what is glutamate?
[01:26:34.15] DR. GREG HANNA: It's an amino acid. We all have it in our bodies. But it functions, in the brain, as a very common neurotransmitter.
[01:26:46.21] DR. JIM ABELSON: Two of the most common neurotransmitters within the brain are glutamate and one called GABA, which is an initials, an abbreviation. And glutamate is the most common activating neurotransmitter. And GABA is the most common inhibiting neurotransmitter. And they seem to both play a role in anxiety disorders. And it probably is a function of where it is, in too high a concentration. So it's activating some kind of circuitry that shouldn't be so active.
[01:27:14.57] UNIDENTIFIED SPEAKER: This is our last question from the audience, because, believe it or not, we are already past time. And our speakers can remain for probably about ten minutes after we conclude, if someone didn't get to ask a question and wanted to come forward and ask them at the front of the room. But the last question is also on the glutamate theme. It says, my son and I, and my grandsons, are all very sensitive to monosodium glutamate. We all have anxiety or OCD. Any connection?
[01:27:43.64] DR. GREG HANNA: It's a great question. I don't have an answer. That is I don't know of any reports linking monosodiu, glutamate to OCD or anxiety in general.
[01:27:54.01] UNIDENTIFIED SPEAKER: Monosodium glutamate is like, it's a preservative that's used in a lot of foods and things for people, if you're not familiar.
[01:27:58.14] DR. JIM ABELSON: It enhances flavor in a general sense. It used to be used much more commonly. It's very common in Asian food restaurants.
[01:28:06.77] UNIDENTIFIED SPEAKER: MSG?
[01:28:08.86] DR. JIM ABELSON: Yes. And whether, a lot of amino acids that you ingest are broken down in the digestive process. And don't really enter the bloodstream in their active form. And I don't know about glutamate. We do see patients with other anxiety disorders who have learned to avoid certain Asian restaurants because they do seem to feel sensitive to it. But I'm not aware of any data about OCD.
[01:28:35.42] One more comment about research. We do have an active research program on adult OCD in our clinic right now. We're in a window between grants where we're not actively recruiting at the moment. But we do neuroimaging studies to produce those pretty colored pictures of people's brains. And trying to help us dissect the circuitry that's involved and show how it's working. And so, if you register on that engage site, it's a good way to keep track of what we're doing. And announcements will be up there when we're recruiting people for new studies.
[01:29:06.59] UNIDENTIFIED SPEAKER: That website address is um, for the University of Michigan engage.org. And you're free to see what studies are posted up there. And all different spectrums of disorders. Anything that you could possibly think of is there. And then, new studies as they come online. You'll be matched to if you express interest in being contacted. Can we have a round of applause for our speakers this evening?
[01:29:39.16] [APPLAUSE]

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March 24, 2010 at the Downtown Library: Multi-Purpose Room

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