AS GOOD AS IT GETS August 13, 1998

Pre-Movie Introduction:
Dr. Bruce Fuchs:
Good evening. My name is Bruce Fuchs. I am the director of the Office of Science Education, and I'd like to welcome you to our fourth film in our series, Science in the Cinema this summer, the summer of 1998.

Before we get started, I'd like to introduce you to somebody that some of you know. As the director of the office, I am often the beneficiary of your thanks when you're leaving and you thank me for this event. I also know that I don't do everything for this event, so I want to introduce you to my partner. I'd like to you meet Ellen Dobbins. Ellen works in the Office of Science Education. And for the past four of the five summers that we put on this event, she's been my partner. We've selected the movies together and so, please on the way out, give her your thanks, as well as me, or your criticism, as well as me. So thank you, Ellen.

So let's go ahead and start tonight's film. It's a long one, and we're very fortunate to have as our guest expert after the film, Dr. Judy Rapoport, who's been working with obsessive-compulsive disorder for a number of years. Your task is to figure out which of the characters in this film might actually have this disorder.

Post-Movie Discussion:
Dr. Bruce Fuchs:
Good evening again. Did you enjoy it? So was the Academy correct? Jack Nicholson won the Oscar for Best Actor. Helen Hunt won the Best Actress award and Greg Kinnear was nominated for the Best Supporting Actor. It's now my pleasure to introduce tonight's speaker. Her name is Dr. Judy Rapoport. I'm going to tell you just a little bit about her before we turn it over to her. She got her bachelor's degree from Swarthmore College, her M.D. degree from Harvard. She did an internship at Mt. Sinai. She did psychiatric residencies at Massachusetts Medical Center and at St. Elizabeth's Hospital here in Washington. She did post-doctoral training at the Psychological Institute in Uppsala, Sweden, and also at the Karolinska Hospital in Stockholm. She then came to the NIH. During her time at the NIH she has worked both at the National Institute of Mental Health and the National Institute for Child Health and Development. She has continuing an academic appointment at the Georgetown University Medical School. And currently, her position at the National Institute of Mental Health is as chief of the Child Psychiatry Branch. One of her major fields of research interest is obsessive-compulsive disorder. Did you detect which of the characters had it in tonight's film? And she wrote a popular book on this subject entitled "The Boy Who Couldn't Stop Washing." So please help me welcome tonight's guest, Dr. Judy Rapoport [applause].

Dr. Judith Rapoport:
Thank you. I'm going to give just a very few minutes talk about this movie and obsessive-compulsive disorder, but no one who sees a good movie can't start off by saying this movie is obviously about a great deal more than obsessive-compulsive disorder–about people and intimacy, and humor, and the importance of people for each other that go far beyond disease and have much more to do with just life.

But speaking as an expert on OCD, there are a few points to make. And I'm only gonna, as I say, speak for a few minutes ‘cause an evening like this, the most interesting and important part is usually questions that may come afterwards. But certainly, Jack Nicholson gave a very good example of some of the typical obsessions and compulsions that someone may have.

First of all, and most strikingly that in many ways, he's quite a rational, reasonable, and a normal person, and then he has these dramatic islands of irrationality, magical behaviors with these strange rituals, repeating, counting, and most pervasively and strikingly, contamination. And contamination fears are very interesting. Obsessive-compulsive patients, whether they've met anybody before with this or not, whether they are children or adults, do a lot of things very very similarly. This magical sense of contamination–disease by wearing a jacket in a restaurant when you don't have a jacket and a tie and so on.

It's an interesting point how gratuitously nasty he was and this is a point where I think art departs from reality. That certainly, people with obsessive-compulsive disorder can be lonely, alienated, and depressed, but let me say that the one thing that I think is not typical is the extraordinary degree of hatefulness that I think was a certain amount of artistic license here to play up totally other aspects of the story. Certainly, his reference to making pills is a good PR for one of the two, but only one, of the mainstay treatments for OCD. He presumably was put on one of the now five different effective medications for obsessive-compulsive disorder. It would have likely been an anti-depressant and out of many anti-depressants, it's the ones with serotonin action that are main line first drug treatments for OCD.

While he didn't specifically talk about behavior therapy, what was clear, what you saw was that life was doing behavior therapy–that it was forcing him with his motivation inspired by other people to have to confront doing things that would be against his usual avoidance for contamination, not doing the rituals because other things interfered. And certainly, every day life like that can be effective behavior therapy. And he was lucky enough to clearly be benefitting from some combination of the two on his own. About 30 percent of patients, however, don't respond to these treatments and for those there is a fair amount of other active research for other kinds of medical and non-medical, non-pharmacological treatments that are effective.

But to come back to the fact of OCD, what was always one of the most fascinating aspects of this disease to me is the fact that increasingly, there's evidence that there is a very biological circuitry, brain biological circuitry, that is associated with these behaviors and that there are much more specific kinds of behaviors as I say, around contamination, around doubt, around repeating, about magical numbers. And one does have a lot of interesting speculations about why the brain would evolve such circuits; is contamination avoiding some sort of evolutionary adaptive circuitry, for example, that fascinates those of us who have studied the biology of the disorder.

There is a lot more to say but, as I say, the very juxtaposition of a very normal, charming, and increasingly attractive man, certainly a talented writer, a good piano player–together with these very weird nonfunctional islands–is almost a hallmark of the disorder. I think because it's late and because I'm usually more interested in the questions, what I will do is stop here, and have been told to ask that if people do have questions, would they use the microphone.

Question: I have two questions. One, is OCD hereditary? And two, what was with the stepping on the cracks? Is it just the whole idea of "step on a crack, break your mother's back" and all that kind of stuff?

Question: Hi. In reference to the stepping on the cracks, the cleanliness, and the other manifestations of OCD, how common is it for someone to have several kinds of these manifestations all at once in the same person?

Answer: One of the interesting things is how hard it is to predict what people are going to have. There's a list of kinds of symptoms you can have, but you'll find one person who only has one symptom, for example, particularly washing, and someone else who has three or four major things such as washing, counting, concerns about symmetry. And there are some forms that are related to OCD that typically tend to happen by themselves. Many people who are hoarders, for example, don't have other OCD symptoms. Some people who have trichotillomania, a form of pulling out their hair one strand at a time which is thought to be genetically related, they very often don't have other OCD symptoms. But it's very common to have several as the protagonist did tonight.

Question: Are they like that particular and stuff? Are they like mean and everything? Like what he did in the movie?

Answer: No, the being mean part...I think the question was, if I hear him right, do people with OCD, are they that particular and mean? The meanness I think was somewhat overdone for other artistic reasons. The particularness–I actually do know of patients who do indeed bring their own utensils and use plastic utensils at home so that they can throw them out and have fresh ones for every meal.

But you can actually have very particular islands of particularity, for example, when in some of our studies, some teenage boys who would insist on changing the sheets on their bed several times a day and never using towels twice when they were taking part in a study in here at the NIH clinical center, in other ways were like typical teenagers. Their clothes were always on the floor and no one could get them to hang them up. So it's particular often in very special ways and not necessarily everything.

Question: Are children more amenable to treatment than adults?

Answer: The treatment rate seems fairly similar, both with respect to medication and if children are old enough to comply with behavior therapy. There's not a striking difference.

Question: Dr. Rapoport, I have a couple questions. One is, are there different forms of OCD? In other words, you said there were 30 percent that don't respond to the serotonin treatments or behavior treatments. So does that suggest there's different fundamental biological events going on in these two different populations? Second question is: what's the pattern of recovery when they are in treatment? Are there relapses and do you have any way of knowing what triggers the association for particular islands of irrationality? In other words, do you have any clue as to why those particular things, like not stepping on cracks or hand washing might be part of the sort of repertoire that characterizes....?

Answer: Well, the first question was about predictors of treatment. And there isn't very strong predictors of treatment except that certain forms that we think are related to OCD, such as the hoarding and the hair pulling, seem to be somewhat less sensitive to the treatments than the other kind. There's a lot of very interesting theory about why things are–why the symptoms of OCD are the way they are. One notion as I sort of alluded to take contamination fears that you can think of certain ethological models, which is the biology of animal behavior and that many animals have instinctive behavior about not soiling the nest for example, about avoiding certain of their own bodily fluids, and the contamination seems to often revolve around that kind of thing. Other of the contaminations, washing and so on, we have speculated may relate to grooming behaviors. Other doorway rituals are perhaps to do with particular "checking" behaviors to do with guarding entrances and exits.

You can see patterns of this in animal behavior and if you believe in biological psychiatry, you end up realizing that at some level, you are a sociobiologist, and that is something that I take a lot of pleasure in thinking about, but it's very hard to prove.

Question: My question is – I got two questions for you. One: could shopping be an OCD ailment? I have -- I know that to be true but I want to see what your opinion is on that. And two, could there ever be a way, a pill with some kind of way where OCD could be put in remission if not cured, could it be cured?

Answer: The second question first. About a third of people treated just with medication do have a very striking and dramatic remission and are without symptoms. But, plenty of others have only partial effect. And what you tend to see is a lessening and in the good responders about 80 percent. Compulsive shopping does feel like a compulsion and we actually did a study like that. You should know that certain credit card agencies run support groups for people who are compulsive shoppers, since it is in everybody's interest for that to be better. There haven't been many very careful or systematic studies on this, but the ones that have been done including our own, suggest that if it's going to be related to something, it's more likely related to depression. And in one study that we did, a very small and pilot one, the serotonin OCD kind of antidepressant seemed to have some benefit but no more than the typical non-serotonin antidepressant, which for us we interpreted meant it's more related to depression and compulsive shoppers have a high rate of depression associated with it.

Question: You alluded to hoarding earlier in the evening. I had not heard that as an OCD symptom. Can you elaborate on that and at what point hoarding is recognized as OCD?

Answer: Well, one of the forms that you do see as a form of OCD again, often with otherwise very successful and rational people is their inability to throw things away. And to a certain extent, these are traits that are very common in all of us. Who of us who have either had a roommate or been married to anybody hasn't been exquisitely aware of where each of us are on a dimension of who throws things away and who's neat and who isn't? But when hoarding is a problem, a diagnostic form of OCD, this is very severe. I'm talking about people whose apartments would get condemned if the firemen were to go into it, people with grown children who can't come back to visit because there is no room in any of their old bedrooms. And at this point, these people become very, very anxious when they try to throw things away. And it seems to be a kind of extra ritual that makes them feel more secure, the "what-if-I-should-ever-have-need-of-this" –a kind of avoiding possible doubts of not finding something when they need it.

Question: Is compulsive behavior and obsessive behavior, is it possible to have those as separate items of behavior patterns?

Answer: Yes, as a matter of fact, plenty of people just have thoughts and plenty of people can just have compulsions and have no idea why they do that. We had some impression that the younger children perhaps are more likely to just have compulsions and as they get older, things can evolve over time. Things may be much more to do with thoughts. It can get a little bit complicated ‘cause some people start thinking about mental rituals and so on and so forth; is counting a mental ritual or just an obsession, for example. But, in general, mixtures may be somewhat more common but it's certainly not rare to have people with just one or just the other.

Question: I wanted to know if OCD was linked with low self esteem or, in other words, maybe it was learned early in life by an abusive parent who wanted them to clean their room and therefore, they picked up this compulsive cleaning habit and so forth?

Answer: Well, certainly, initially there were some interesting case reports that led that to be popular theory, but the systematic research, in fact, in general hasn't supported that. People with OCD do not seem to have remarkable backgrounds. And although I've certainly heard isolated cases of people who have had some horrendous, overwhelming, traumatic experience who following that did have obsessive-compulsive behaviors, the vast majority of studies do not show any type of personality, toilet training, strict and rigid family upbringing and so on. It's very interesting to see these rituals emerge. We had a pair of brothers who came from a family which was neither particularly religious or neat and one of them washed all day and the other prayed and was excessively religious all day. And where that came from, clearly they had the same disorder but they didn't share either of each other's problems nor did the parents share any of these preoccupations.

Question: Mental illness unfortunately comes with a stigma. And those of us who live with it every day and live with it in our families unfortunately have to deal with even more than just the symptoms of the disease. I was curious if you felt that this movie, As Good As It Gets, sheds more of a positive light on OCD, a negative light, or didn't really do much for it, the whole thing?

Answer: I actually was at a meeting of the OC foundation where a large number of sufferers were debating this point. I think they felt that overwhelmingly, more positive than negative. First of all, although as I have said several times, he is I think, gratuitously nasty as far as the syndrome goes, he had enough positive things and the nature of the disorder and his attempt to get well was convincing enough. They got thousands and thousands of calls and new members on the basis of this movie. The OC foundation was extremely grateful for that and I think that's part of why they are positive about it–because it got more people to call. And they've heard some complaints based on what you're talking about but they thought it in effect was more de-stigmatizing.

Question: I wanted to ask you, I have heard there's a study at NIH about the connection of strep throat with children and OCD. Could you elaborate on that?

Answer: Yes. The question was the relationship between OCD and strep throat. And I should say more generally, one of the reasons for the excitement about OCD–obviously one was that a whole new group of drugs turned out to be effective for a what's a very common disorder, but the other reason for excitement, is that there are some structures in the brain called basal ganglia, which were thought to be related strictly to motor disorders like Parkinson's. And now, it turns out that a number of disorders of the basal ganglia are associated with OCD such as Tourette's disorder for one and other disorders of the basal ganglia. Well, there's a disorder in association with strep called Sydenham's chorea that happens to some people with rheumatic heart disease, which is a reaction to strep. And Dr. Susan Swedo showed that patients with Sydenham's chorea who have this heart disease and then, basal ganglia disorder–Sydenham's chorea–that's associated with strep, about 70 percent of them have obsessive-compulsive disorder or symptoms. And so, she went on to show that yet another disorder is associated with that and then made a leap that perhaps some children just have the strep and don't have the heart disease or the Sydenham's chorea. It's still new research but I think she has a lot of evidence that does support that there's probably such a group. The big question is how big is that group.

Question: I had a question for you. I work as an organizer. I'm over here, hello! I work as an organizer. I go into people's homes and I help them to disperse things and some of the people that I work with seem to be hoarders of paper, of books, of things that are otherwise meaningless in their life. But they're coming to me for help, so they're in a motivated state. I don't, I'm helpful to them but I would like to be more helpful. Are there any hints you can give as to techniques, phrases, behavioral steps to take that could help them from my point of view on site?

Answer: Sure. Well, I think it's an awkward position because giving help first requires a real assessment of what kind of contract you have with the patient. And I've seen several hoarders who have in a very good way turned people with jobs like you into co-therapists in a very constructive way. But I also have seen other people with hoarding problems who are very much doing this because they want to avoid having a label or insight to it. So I have simple advice that's very hard to follow which is to try to pick up from talking to them about it the degree to which it really interferes with their life. Is this just someone who's very messy and is something of a clutterer as opposed to someone who really has a problem. And if they really have a problem, getting them to tell you about that and end up asking you for suggestions I think might be the next step.

Dr. Bruce Fuchs:
Before we end our evening and I ask you to you help me thank Dr. Rapoport, I would like to invite you all back next week to see The Three Faces of Eve. And, I've been passed one final question I'd like to ask. And that is essentially, does Jack Nicholson's character correctly depict OCD where he is so debilitated in some aspects of his life and yet functions very, very highly as a writer and a piano player?

Answer: I wouldn't give him an A+ but he gets pretty high grades for the way he's doing it and more severely ill patients could be that debilitated. However, more fascinating to me are the number of people I see who are that debilitated but keep it a secret. One man I treated for years who was an officer of and the president of one of the largest stores, and chain of stores in the Washington area in terms of business–and very successful, but was not married and spent most of his free hours checking whether the fence in his backyard in a very large Potomac estate was perfect, that used up all his time that otherwise would have been for any sort of interpersonal life. And so keeping it secret is perhaps, which wouldn't make as good a movie, can be a skill of amazingly debilitated people. But in general, I'd give him an A if not an A+.

Dr. Bruce Fuchs:
Thank you so much Dr. Rapoport.

Dr. Judith Rapoport:
Thank you [applause].