CHAPTER 13 - IMAGES OF OBSESSIVE COMPULSIVE SPECTRUM DISORDERS
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There are a number of SPECT studies that report hyperfrontality (increased right and left
anterior prefrontal cortex activity and increased anterior cingulate gyrus activity) and
increased basal ganglia activity in obsessive compulsive disorder. Of interest,
hyperactivity in the anterior cingulate gyrus has also been noticed in oppositional
defiant disorder and violence. The anterior cingulate gyrus, which is heavily innervated
by serotonergic fibers, has been postulated as being involved with shifting attention and
cognitive flexibility, deficient in all of these disorders. Treatment with serotonergic
antidepressants such as fluoxetine and clomipramine decrease the hyperactivity in these
areas.
active front-on view
heavy increased cingulate activity and right and left anterior lateral
prefrontal cortex activity (together termed hyperfrontality).
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OCD
On the outside, Gail was normal. She went to work every day, she was married to her high
school sweetheart, and she had two small children. On the inside, Gail felt like a mess.
Her husband was ready to leave her and her children were often withdrawn and upset. Gail
was distant from her family and locked into the private hell of obsessive compulsive
disorder. She cleaned her house for hours every night after work. She screamed at her
husband and children when anything was out of place. She would become especially
hysterical if she saw a piece of hair on the floor, and she was often at the sink washing
her hands. She also made her husband and children wash their hands more than ten times a
day. She stopped making love to her husband because she couldn't stand the feeling of
being messy.
On the verge of divorce, Gail and her husband came to see me. At first, her husband was
very skeptical about the biological nature of her illness. Gail's brain SPECT study
showed marked increased activity in the cingulate system, demonstrating that she really
did have trouble shifting her attention.
active front-on view
heavy increased cingulate activity
With this information, I placed Gail on Zoloft. Within six weeks, she had significantly
relaxed, her ritualistic behavior had diminished and she stopped making her kids wash
their hands every time they turned around. Her husband couldn't believe the change.
Gail was more like the woman he married.
ODD - Oppositional Defiant Disorder
13 year old boy with severe oppositional defiant disorder
Road Rage
side active view
increased cingulate and left temporal lobe activity
28 year old female who has become aggressive while driving on many occassions.
side active view
marked increased cingulate and left lateral temporal lobe activity
37 year old male attorney who, on several occasions, chased other drivers who had cut him
off and on two occasions got out of the car and bashed their windows in with a baseball
bat he kept in the car. After the second incident, he came to see me. He said, "If I
don't get help for this I'm sure I'll end up in jail." His cingulate
gyrus was markedly overactive, causing him to get locked into the negative thoughts and
subsequently be less able to control his frustration. His SPECT scan shows: marked
increased activity in the cingulate gyrus and left temporal lobe (arrows), which
correlates with irritability and overfocus issues.
Pathological Gambling
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marked increased cingulate activity
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Adam came to our office when his wife left him. His gambling had gotten out of control. In
the past few years he began neglecting his business spending more of his time at the
racetrack and driving back and forth to the casinos in Reno and Lake Tahoe. "I feel
compelled to gamble. I know it is ruining my life, but it seems I have to place a bet or
the tension just builds and builds. It is all I think about!" Adam's SPECT study
showed heavy increased cingulate activity. Explaining the cingulate system to Adam was
helpful. He could identify many people in his family who had problems shifting attention.
You should see our family gatherings," he told me, "someone is always mad at
someone else. People in my family can hold grudges for years and years." In addition
to going to Gamblers Anonymous and being seen in psychotherapy I prescribed a small dose
of Prozac for him to help him shift away from the obsessive thoughts about gambling.
Eventually, he was able to reconnect with his wife and rebuild his business.
Chronic Pain
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marked increased cingulate activity
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Stewart, a 40-year-old roofer, hurt his back ten years ago when he fell off a roof. He
underwent six back operations but remained in constant pain. He was essentially bedridden
and about to lose his family because all he could think about was the pain. The threat of
losing his family catalyzed him to get a psychiatric evaluation. His SPECT revealed marked
overactivity in the cingulate system. He was placed on Anafranil 200 mg. a day. After 5
weeks, he reported that his back still hurt, but he was much less focused on the pain. He
was able to get out of bed and start back to school. Other researchers have also reported
several cases of intractable pain that were also responsive to treatment with
anti-obsessive medications.
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