Sthe compulsions that crippled Howard Hughes, as well as those affecting his fellow OCD sufferers, can be divided into two groups’, behavioral (observable acts) and mental (thought rituals).Behavioral compulsions include all the classic and well-recognized OCD rituals. Hughes was troubled primarily by washing and checking, the two most common types of severe compulsions. Another widespread behavioral compulsion is asking for reassurance. Other common examples include hoarding, repeating, tapping, and ordering.
Washingmany experts think that washing is the single most prevalent type of behavioral compulsion. Judith Rapoport, M.D., of the National Institutes of Health, a top OCD researcher and author of the acclaimed book, The Boy Who Couldn’t Stop Washing, reports that more than 80 percent of the people who come to her clinic for treatment of OCD have been bothered at some time by washing rituals.At the root of washing compulsions, not surprisingly, is an obsession that a part of the body is unclean. Washing eases the feeling temporarily, but once the scrubbing is done, the thought returns. More scrubbing follows. Dermatologists are often the first to diagnose this disorder, as people frequently seek treatment for the skin damage caused by this excess.Handwashing compulsions are OCD’s most recognized symptom. They are, indeed, the hallmark of the disorder. A typical example is provided by a math teacher:
I get to thinking that my hands are unclean in some way. It’s not that they look dirty. And it’s not that I imagine germs on them, either. It’s just that I have this feeling they’re unclean. So I’ll lather them up good, wash them for a couple minutes, and dry them carefully. But pretty soon I’ll touch something and then I’ll get the feeling again. Some evenings after work I wash my hands every five minutes. They’re in bad shape. I have to put medication on them and wear gloves when I sleep.
The most famous description of excessive handwashing is found in Shakespeare’s Macbeth:
doctor: Look how she rubs her hands.gentlewoman: It is an accustomed action. … I have knownher to continue in this a quarter of an hour. lady Macbeth: Yet here’s a spot. . . . Out, damned spot! Out,I say! . . . will these hands never be clean? . . . Here’s thesmell of blood still: All the perfumes of Arabia will notsweeten this little hand.
Although this would seem to be a good description of compulsive washing, in the context of Shakespeare’s play it probably does not represent true OCD. Lady Macbeth’s handwashing occurs during sleepwalking, and her ritual is driven not by clinical obsessions but rather by depressive delusions or preoccuptations fueled by her guilt over Duncan’s murder.
Checkingchecking compulsions is also very common. A recent study of 250 consecutive patients from Harvard’s outpatient OCD clinic found that 63 percent complained of checking rituals.With this type of compulsion, a person must examine a situation over and over to make sure that no harm will come of it. Obsessions such as, “Is the gas shut off?” and “Are the doors locked?” drive the checking. A young wife described the torment and disruption that these rituals can cause:I stand there and turn the light switch off and on, off and on, off and on, off and on. I can’t make myself stop. It’s crazy. What happens is that I have the thought that maybe I didn’t completely turn it all the way off. Maybe the switch is somewhere inbetween the off and on position and a fire will stat because of a short circuit. I know that this does not make sense. Still, I have to keep on switching back and forth until I get it just right. I might stay there for ten or fifteen minutes. One time the light switch started smoking. Now my husband swears at me and yells, “Leave the light switch alone of you really will start a fire!”
Requesting Reassurancethis type of compulsion tests the patience of family members more than any other. Here, a sufferer becomes obsessed that something terrible has happened and is compelled to coax a pledge from another person that everything is okay. “I didn’t hit anybody with the car, did I?” “That lump doesn’t mean I have AIDS, does it?” The OCDer asks over and over, unable to stop, knowing the answer she’ll get, but needing to ask again anyway. Reassurance must be endlessly provided. A newlywed explained how her marriage was almost on the rocks due to her reassurance compulsions:1 love my husband more than anything. But I get the crazy thought that I might be interested in other men. I’ll be walking in the mall and I’ll notice a handsome guy, and afterward I’ll get to wondering ifI looked at him too long, if maybe that means I’m interested in him. I’ll worry all day; I can’t stop myself from thinking that I might have had thoughts of unfaithfulness. Then, because I feel so guilty, I’m driven to tell my husband. I know it makes him feel bad, but I have to. He says that it’s okay, that he knows I’m not interested in anyone else. Then I feel better. But I’ve been doing this every day, and it’s driving him nuts.Hoardinghere, the natural tendency to save things is stretched to a pathological degree. A young man whose apartment was more than half filled, floor to ceiling, with magazines and newspapers explained that he was afraid to throw an article away because he might later remember that there was something critically important in it. Then, if he couldn’t find it, he might get so upset that he would have a nervous breakdown.Repeatingwhen a routine action is repeated compulsively, and when— unlike in washing, checking, reassurance, and hoarding rituals—it bears no logical relationship to the obsession preceding it, this is called a repeating compulsion. One student, when struck by a harm obsession, compulsively repeated the action he was engaged in; this could be combing his hair, crossing his legs, or writing his name. Several quick repetitions usually sufficed to chase away the obsession. Repeating compulsions often must be performed a certain specific number of times. A young woman, in response to “a feeling of dread,” scratched her head, brushed her teeth, or chewed on Life-savers four times, no more no less.Rubbing, Touching, and Tappingthese common compulsions also defy logical analysis. A student with harm obsessions needed to tap her fingers ten times to prevent her tormenting thought from coming true.Orderinghere, items must be arranged so that they are “just so.” These rituals differ a bit from all others: They occur frequently in young boys, and their corresponding obsessions are often hard to identify.It has been hypothesized that ordering compulsions bear some resemblance to another kind of abnormal, repetitive action, the jerky movements referred to as “tics.” Ordering compulsions may represent a hybrid symptom between OCD and the related neurological disorder of tics, Tourette’s syndrome.*13/338/2*
Archive for May, 2011
Cost-EffectivenessCost-effectiveness studies have suggested benefit from antibiotic prophylaxis, but the assumptions inherent to these studies were inappropriate, limiting the usefulness of their conclusions. Two recent analyses were performed – one in the general population and one in patients with mitral valve prolapse. The study in the general population assumed that antibiotic prophylaxis is 100% effective, which is unlikely, and that 15% of IE (Infective Endocarditis) cases are related to dental procedures, although this number has been estimated to be closer to 4% to 10% in other studies. The mitral valve prolapse analysis also assumed 80% efficacy. Further study in this area is needed, with application of more accurate estimates of patient and physician adherence to recommendations, effectiveness of prophylaxis, and updated costs of complications of endocarditis and costs of antibiotic use.
Considering ReferralThe current recommendations for antibiotic prophylaxis of IE are designed to facilitate widespread application by primary care physicians. Some possible reasons for referral would include the work-up of an undiagnosed murmur, clarification of a congenital heart defect, or suspected penicillin allergy.*51/348/5*