Last updated: Mar 09, 2009
Anne Coulter, 45, of Evanston, Illinois, knew her stove burners were off. She knew it. And, yet, before she left the house she sometimes checked them three or four times, just to make sure. Was being a little "OCD" okay or was this behavior a sign of severe Obsessive-Compulsive Disorder?


We all have our little rituals that give us comfort and help us cope—especially amid worries about a sinking economy, tainted peanut butter, and the rising cost of health care. Some women count to 10 before driving on when the light turns green, arent comfortable unless they have hand sanitizer in their purse (car, desk drawer), or kiss their children on the forehead three times every night before bed.

Its even trendy these days for anyone whos a neat freak or a little worried about germs to say, “Im sooo OCD”—shorthand for obsessive compulsive disorder, the mental illness we all know about (and think we have) thanks to TVs Monk. If youve alphabetized your CD collection or have a morning ritual like Coulters, you know what were talking about—and youre not alone.

Nearly half of us do engage in some of the rituals associated with OCD, and some of us have a subclinical version of the disorder. “Almost everyone washes their hands sometimes when they dont need to,” says Jonathan Abramowitz, PhD, director of the University of North Carolina Anxiety Disorders Clinic. It would be hard to find someone who hasnt had an occasional obsession or compulsive urge, he says: unwanted thoughts of something bad happening or the need to check the locked door.

“For most of us, those things dont cause lots of distress, interfere with our jobs or relationships, or take an inordinate amount of time—and thats what differentiates people with clinical OCD from everyone else,” Abramowitz says.Life with OCD
For those who do have OCD (about 2 million people in the United States), it can be a hugely disabling illness. Sufferers are less likely than other people to get married and more likely to be unemployed and depressed. “People often keep their OCD secret because they feel ashamed of their unusual behavior, so it can take years for them to seek treatment,” says Michael Jenike, MD, professor of psychiatry at Harvard Medical School and the director of the Obsessive Compulsive Disorders Institute at McLean Hospital in Belmont, Massachusetts. Just going through the elaborate rituals that help someone with OCD get out the door can be exhausting.

Take Hilary Zurbuch, a 29-year-old from Pittsburgh. Each morning she used to make her bed, muss it, remake it, shower, and pick out perfectly matching clothes—similar colors, same brand, head to toe. Shed check the lock on her door five times before climbing into her immaculate Jeep to drive to work. On the way shed listen to the same song, “April Showers” by Sugarland. “If I didnt follow the same routine every day, I worried that something bad would happen,” she says.

Sheila Cavanaugh, 42, of Brownville Junction, Maine, may not make it out of the house at all. Even though she isnt sick, shes so concerned shell infect someone else with her germs that she rarely ventures out.

But theres good news, whatever your level of obsessive compulsive behavior: Over the last decade or so, a flurry of research (some with high-tech imaging tools that let doctors peer into the brains of people with OCD) has yielded a better understanding of why some peoples disturbing thoughts and odd habits spin out of control. Heres the latest thinking on obsessive compulsive behavior, and how to manage it.

When is a habit an illness?
Most people would never guess that Anne Coulter has struggled with OCD. A freelance writer with lots of friends and an active social life, she rarely checks her stove these days—but it wasnt always so. Like many women with the illness, her symptoms have waxed and waned over the years, often in response to stress.

Coulters problems began in her early 20s, which is typical. Most people with OCD and similar disorders develop symptoms before age 36. And the earlier the illness crops up (one-third to one-half of sufferers show signs in childhood), the tougher it may be to treat. Why the illness appears earlier in some is a mystery, but there is evidence that some children (1 in 1,000) may develop the disorder after a strep infection, when an antibody generated to fight the bacteria mistakenly turns against a brain enzyme and disrupts communication between neurons.

Some OCD sufferers think a stressful event precipitated the onset of symptoms, but for Coulter they came out of the blue. At the time, she had a good job as a communications specialist with a consulting firm and was in a happy, relatively calm phase of her life.

“When it first started, Id check the locks and stove a few times. As time went by, I started checking more and more things—the iron, the hair dryer, the window-screen locks—and Id check them each dozens of times before leaving for work and before going to bed. At its worst, the checking and re-checking took three to four hours a day. It became difficult to socialize, because it was exhausting, physically and emotionally.”

OCD is sometimes called the doubting disease, and its easy to see why. “I would look at a gas burner and see it was off, but the second I looked away a flicker of doubt would enter my brain, and Id think, Is it really off? Maybe I accidentally bumped it and turned it back on. I wouldnt feel safe until I checked it again,” Coulter says.

“People with OCD have intrusive, upsetting thoughts that make them feel anxious. And they use their compulsions, whether its checking the stove or washing their hands, to relieve the anxiety—so the illness becomes self-perpetuating,” says Elna Yadin, PhD, director of the OCD Open Clinic at the University of Pennsylvania Center for the Treatment and Study of Anxiety. “Anxiety relief feels good, so that fuels the compulsive behavior, even though they realize that the behavior is either irrational or excessive.”

Understanding the OCD brain
“When I was 4 years old, Id brush the carpet in my room a certain way so Id know if anyone walked in, and I was always straightening the dolls on my shelf,” Zurbuch recalls. “Everything was perfectly clean and nothing ever moved.”

Worse than her fear of disorder was her long-standing worry that harm would come to someone she loves. “I had daily rituals to protect loved ones. I knew intellectually that those rituals wouldnt protect my family, but OCD isnt an intellectual process,” she says. “I dont know how to explain it except that the rituals were something I felt like I had to do.”

Although its tempting to think of OCD as a character flaw or eccentricity, experts say its a brain-based disorder. And more studies are starting to reveal the neurological underpinnings of the insistent thoughts, fears, and behaviors that besiege sufferers.

In a 2007 study, for instance, University of Cambridge researchers found that people with OCD have less gray matter in regions of the brain that play an important role in suppressing responses and habits. This “may contribute to the compulsive and repetitive behaviors,” Lara Menzies, the lead author of the study and a researcher in the universitys Brain Mapping Unit, has said.

Likewise, when researchers at the University of California, Los Angeles used positron emission tomography (PET) to look at the brains of people with OCD, they found a pattern of hyperactivity in particular circuits involved in habit formation, says Sanjaya Saxena, MD, who participated in the UCLA research and is now director of the Obsessive Compulsive Disorders Program at the University of California, San Diego. The affected brain areas identify danger, generate worry signals, and dictate how we respond to those emotional red flags.

Whether the brain abnormalities are the cause or result of OCD is unclear, but studies show that the disorder has a strong genetic component. Having a first-degree relative with OCD increases your risk of developing it fivefold. OCD probably involves malfunctions in several genes—glitches that researchers are starting to identify.

In fact, last year National Institutes of Mental Health researchers reported that several variations within a certain gene, known as the serotonin transporter gene, act together to increase the risk of OCD. The gene produces a protein that helps make serotonin, the brain chemical affected by Prozac and many other antidepressants, more available to brain cells. When the gene is overactive (as it seems to be in some people with OCD), too much serotonin is taken out between cells, leaving too little for the brain to use.

Not surprisingly, selective serotonin reuptake inhibitors (SSRIs) such as Prozac improve the symptoms for many people. “About 50 to 60% of patients respond to SSRIs, but it usually takes about 10 weeks and requires a higher dose than the treatment of depression,” says Elias Aboujaoude, MD, director of the Impulse Control Disorders Clinic at Stanford University and author of Compulsive Acts: A Psychiatrists Tales of Ritual and Obsession. Medications can improve symptoms substantially, but it may take trials of several drugs to find the one that works best, Dr. Aboujaoude says.

How to get better
Cavanaugh, who believes shes had OCD her whole life, didnt improve with SSRIs. But shes found some relief with a combination of three medications and an intensive in-patient treatment program at McLean Hospital, one of two in the country. There she did a form of cognitive behavior therapy known as exposure and response prevention (ERP). Patients list all of the triggers that produce fears and anxieties and then, starting with the least distressing, tackle them one at a time in order to break the stranglehold their fear and anxiety have on them.

“Every time you do something that causes distress and face your discomfort without performing a ritual, the easier it gets,” Yadin says. “The goal is habituation—getting used to the thoughts so they lose their power to cause anxiety.”

Exposure and response prevention (ERP) seems to really work: In January 2008, researchers from the University of California, Los Angeles, reported that just four weeks of intensive ERP not only improved OCD symptoms and daily functioning but also caused changes in the brain that correlated with symptom improvement. Results are similar with drug treatment (medication causes some brain changes, too), but doctors say the effects of therapy are more long-lasting. “To get the best response, most doctors recommend a combination of drugs and therapy,” Dr. Saxena says.

Pittsburghs Hilary Zurbuch, who has a masters degree in counseling and is currently working as a therapist, has tried a number of medications and completed an 18-month ERP program. Zurbuch says that she is “virtually symptom-free” now. “I can actually think about bad things happening to my family without performing a ritual afterward. It has been a process of learning to live with the discomfort.”

ERP has been life-changing for Anne Coulter, too. She did an intensive, three-week outpatient treatment. “The therapist would come to my house and have me turn on the stove, then turn it off and leave the room,” Coulter says. “It doesnt sound traumatic, but for me it was. After three weeks, though, I saw a dramatic improvement.” Coulter no longer has to take medication, and her symptoms are mild and sporadic—“more like an allergy than a full-blown illness. I sometimes have a flare-up, but I can usually get myself back on track thanks to what I learned in therapy. Therapy gave me my life back. It helped me learn to not only live with doubt but to live happily with it.”