The high point of my graduation from medical school was a dinner celebration on Princess Island off the coast of Istanbul as cheers and toasts were finally fading. I was surrounded by happy faces and watery eyes in all directions when my cousin Joe, a skinny, tall man known to us as “Nervous Joe,” spoke loudly on a Friday evening some 25-plus years ago. “Come on Alen, now that you are a real doctor, tell me, what can you do for my hands?” with both of his hands and arms extended, over half-filled wine glasses, we all stared at his red, chapped hands.

Hmm! What help could I offer? There were too many possibilities. “Hey, Joe, you need a dermatologist!” I offered.

A phone call, a visit, and a few weeks later, cousin Joe shared with me his diagnosis: Compulsive hand washing secondary to obsessive-compulsive disorder (OCD).

There was a time not many centuries ago when OCD was viewed as a satanic possession treatable with exorcism. Not until the mid 1980s did we discover that OCD was not a rare disease. The Epidemiologic Catchment Area Study that the National Institute of Mental Health sponsored identified a lifetime prevalence rate of OCD in about 2.5% of the general population, greater than the rate of panic disorder or schizophrenia.

Increasingly, the profession is recognizing that for most patients OCD is a lifelong illness. Approximately 65% of patients develop OCD before age 25 and less than 15% of patients will develop the disorder after age 36.

Postulated Causes

The past century has witnessed a gradual transformation of the theories explaining the underlying causes of OCD. No longer can Freudian psychodynamic explanations of OCD survive scientific scrutiny. Still, the exact causes of OCD are not known. Yet, there seems to be increasing evidence that biological factors play an important role and that genetic and environmental factors may contribute to particular symptoms.

Serotonergic dysregulation has been proposed as the basis of OCD. And not surprisingly, the most efficacious agents for OCD have been SSRIs or medications that have potent effects on selective serotonin reuptake inhibition such as clomipramine. A number of studies suggest a genetic link to OCD. Some report that about 25% of OCD patients have a first-degree relative with OCD.

Comorbidity

Statistics strongly suggest that patients with OCD may present with other psychiatric disorders. At the time of OCD diagnosis, 31% of patients suffer from major depression, and the prevalence of depression in OCD patients ranges from 67% to 78%. Similarly, the lifetime prevalence of a core existing anxiety disorder is also high, ranging from 22% to 28% for simple phobias and 12% to 15% for panic disorder.

Treatment Strategies

During the past several decades, various treatment strategies including pharmacotherapy, behavior therapy, and psychosurgery emerged as somewhat effective in treating OCD.

Pharmacotherapy

Approximately 65% to 75% of patients with OCD report moderate improvements with serotonergic agents. In spite of the relatively dirty effect profile (i.e., dizziness, weight gain, constipation, somnolence and dry mouth), many clinicians still view clomipramine (Anafranil) as the gold standard of OCD treatment. Understandably, because of their more favorable side effect profiles, SSRIs (fluoxetine, fluvoxamine, sertraline, paroxetine) should be considered first.

Two factors, inadequate dosage and inadequate duration of treatment, have often been linked to treatment failures. A 12-week trial with dosages up to 300 mg of clomipramine, 200 mg with sertraline, 80 mg with fluoxetine, 300 mg with fluvoxamine, and 60 mg with paroxetine are necessary prior to a realistic evaluation of medication efficacy. In spite of early disappointing results with various psychological treatments such as psychoanalytic psychotherapy, relaxation therapy, hypnosis, and biofeedback, the past decade also witnessed the positive outcome of behavior therapy for patients with OCD.

Electroconvulsive Treatment

How about electroconvulsive treatment (ECT) or augmentation strategies? To date, there has not been any convincing evidence to support using ECT for OCD patients. And unlike treatment-resistant depressed patients who may respond favorably to adjunct lithium, liothyronine, methylphenidate or buspirone, the current psychiatric literature remains, at best, controversial about the efficacy of augmenting agents for OCD when monotherapy fails.

Psychosurgery

What about psychosurgery? Ever since its introduction, psychosurgery has offered hope and triggered apprehension for patients with OCD. And rarely has a medical approach been vilified as much as psychosurgery has. Yet, few people know much about the recent reports indicative of moderate success for treatment-resistant patients with OCD.

Even though using very conservative outcome criteria, different studies suggest a 41% to 56% moderate improvement; the current psychiatric consensus remains unchanged. Consider psychosurgery only for severely incapacitated patients for whom all other treatments failed.

More on OCD from DSM-IV

According to the DSM-IV, OCD is classified as one of the anxiety disorders. OCD may be diagnosed if the patient demonstrates obsessions or compulsions that cause marked distress, are time consuming (generally an hour or more per day), or significantly interfere with social or role functioning.

Obsessions are defined by:
-Recurrent and persistent thoughts, impulses or images that are experienced, at some point during the disturbance, as intrusive and inappropriate, and cause marked anxiety or distress.
-The thoughts, impulses, or images are not simply excessive worries about real-life problems.
-The person attempts to ignore or suppress such thoughts or impulses or neutralizes them with some other thought or action.
-The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion).

Compulsions are defined by:
-Repetitive behaviors (e.g., handwashing, ordering, or checking) or mental acts (e.g., praying, counting or repeating words silently) that are performed in response to an obsession, or according to rules that might be applied rigidly.
-The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

Hoarding as a result of Obsessive-Compulsive Disorder (OCD) is a psychobiological symptom that is treatable.

A few months ago I was talking with a friend who was concerned about her aunt who was about to be evicted from her apartment due to “hazardous conditions” deemed by the Fire Department. Her aunt, Kay, at the time lived amongst mountainous piles (of what most would call trash) as high as the ceilings, with barely passable tunnels to the bathroom, kitchen, and doorway. She described her aunt as a “serious pack rat”. As we continued the discussion, it sounded familiar.

For several years, I have worked with people plagued by hoarding as a result of obsessive compulsive disorder (OCD), a potentially debilitating illness. After explaining the genetic psychobiological nature of OCD to Audra – a deficiency in the system regulating the neurotransmitter serotonin – she decided to intervene with my help. After some family discussion and gentle persuasion, Aunt Kay (who was adamantly opposed to psychiatric medications) agreed to come and see me for cognitive behavioral psychotherapy in order to gain control of her hoarding.

I completed a full assessment which included Kay’s family history which revealed genetic markers for anxiety and OCD in her family. Kay described her mother as a “neurotic” woman who “collected” so many things in the attic that it had started to cave. She also spoke of her paternal grandfather who “washed the dishes three to four times after each meal until his hands peeled and bled.”

After completing the assessment, we developed a treatment plan including weekly cognitive-behavioral therapy to reduce the frequency and intensity of Kay’s fears about throwing things away. After two months of intense work, to my disappointment there was only mild improvement – she had learned to identify main sources of her clutter (junk mail, newspapers, and magazines) and brought them to a halt by canceling subscriptions. However, she was still raptured by intense worry about older more “sentimental” items.

That is when Kay and I stepped up our work and began splitting the sessions – with a portion dedicated to psychoeducation in the hopes that she would understand the biological component of what she was dealing with and agree to meet with a psychiatrist. After a month of psychoeducation Kay agreed to receive a psychiatric evaluation. The doctor diagnosed Kay with Obsessive-Compulsive Disorder and prescribed the medication Paxil.

She reluctantly took the medication and I began visiting her at her home to assist in processing irrational fears and psychological hurdles, as well as aiding in the development of an organized system to reduce feelings of being overwhelmed and assist her in managing her time and items in an emotionally and logistically efficient manner.

During Kay’s third month taking Paxil, I went to her home for a visit after a two week hiatus. I was astonished. Her apartment was relatively clear and organized. As I collected my tongue from the floor we talked at length for an hour about her incredible progress. She told me that all of our talks and the medication had finally “sunk in” and that she was tired of being held captive in her own home.

She went on to describe a feeling of freedom that she hadn’t felt since she was a little girl. Kay is a testament to the remarkable improvement that the partnership between medication and structured psychotherapy can bring to an OCD sufferers life.

Through the use of modern psychopharmacology and individualized targeted psychotherapy it is possible to conquer chaos (mental and physical) and maintain healthy living.

Gregory H. Salerian, MCSW is the coordinator of Conquer Chaos – an individualized program designed to assist people to increase their organizational, emotional and logistical efficiency in day to day life.

Should news agencies smudge journalistic ethics for higher ratings? MSNBC does not seem to mind – that is precisely what it does on its now infamous series of investigative reports on pedophiles, “To Catch a Predator”.

As host Chris Hansen smugly grills men on Dateline MSNBC “To Catch a Predator” he may or may not know that these men are (in most cases) neurologically compromised and are cursed with obsessive intrusive thoughts, which lead to behavioral responses most in the public do not want to believe: uncontrollable compulsions.

In a recently televised report Hansen and his team, as they routinely do, catch a middle-aged male who had been chatting with a decoy from PervertedJustice.com. Hansen repeatedly asks questions like, “Why are you here? Why are you doing this? Don’t you know this is wrong?” The guilt-ridden man writhes in shame and struggles to provide the impossible – a rational reason or excuse. The answer – the man’s brain is diseased.

Certainly, pedophilia particularly in the Internet age is a problem. It needs to be dealt with by legislating and enforcing laws that call for humane, evidence-based solutions to protect society.

The men shown on Dateline NBC exhibit symptoms of Obsessive Compulsive Disorder – dysfunction in a human organ – the brain. Similarly, diabetes is caused by dysfunction in a human organ – the pancreas. In both cases the organ does not create or regulate the correct amount of a vital biochemical. In the case of OCD, the neurotransmitter serotonin has been implicated by research. In both cases, medication has the capacity to regulate the irregular biochemical activity. If someone with diabetes does not take medications such as insulin they become ill and may die. If someone with OCD does not take their medications they can not control their impulsive thinking which leads to compulsive behavior.

OCD is no different in its basic etiology – it is hereditary and biological in nature, and society’s best chance at reducing pedophilia is to understand and accept its biological nature and design and implement interventions based upon evidence based medical psychiatric research.

The individuals’ lack of control is shown by MSNBC as they highlight several repeat offenders who admit to having seen “To Catch A Predator”, were wary of entering a trap, but came in anyway. Sane people don’t take those kinds of risks – people with diseased brains do.

This past June, NBC’s former Dateline Producer Marsha Bartel sued NBC for one million dollars for allegedly firing her for voicing ethical concerns about how the men seen on the show are solicited for entertainment. She alleges that NBC pays Perverted Justice to run what she calls “trolling operations” to lure men to homes to have sex with minors by using actors in internet chat rooms. She alleges that, “NBC unethically provides law enforcement with video equipment and video tapes.”

These men need help. In some instances it may need to be forced on them. Legislation is required to make mandatory neuropsychiatric treatments and police monitoring of computers and movement of these individuals. If Dateline MSNBC can “catch a predator”, certainly, as a society we can develop a system to “catch, treat and monitor a predator” rather than catch, humiliate, and profit off of a predator.

Although not as sexy, a constructive report would be to investigate whether or not legislation exists to enforce mandatory psychiatric treatment and police monitoring of perpetrators’ movements and their Internet activity. If such legislation exists, is it being enforced? Is it working? How can it be improved? Additionally, mandatory (chemical) castration should be debated and considered.

MSNBC could do it – maybe call it, “To Treat a Predator”.
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Author Info:
Gregory H. Salerian, MCSW, LGSW received his Master’s degree in Clinical Social Work from Catholic University of America. Mr. Salerian lives and works in Washington, DC and has co-authored two scholarly articles published in a peer reviewed journal, The Forensic Examiner. Salerian appeared on Washington, DC’s CBS affiliate WUSA9 to discuss the article he co-authored about the failing health of President Roosevelt during his fourth term presidency and its’ consequences for the nation. Gregory Salerian is in private practice at the Washington Center for Psychiatry under the supervision and tutelage of Alen J. Salerian, M.D. and Janice Berry Edwards, PhD.