October 7, 2009

Force of Habit

A gutsy psychiatrist takes on the toughest cases of obsessive-compulsive disorder

By Julie Flaherty

Entering a patient’s house for the first time, Michael Jenike, A67, humors the desperate pleas to turn the door handle back and forth repeatedly, ending on an even number, and open and close the door an even number of times. But the coddling only goes so far. Having spent nearly three decades treating people with obsessive-compulsive disorder, he’s not afraid to tell a patient who hasn’t bathed or changed his clothes in two years to “get his gruesome ass in the shower and wash off the stank.”

“There is a disconnect between what the patients know and what they feel, and generally people go with what they feel,” says Michael Jenike, A67. Photo: Kathleen Dooher

The OCD Whisperer he isn’t. He has the brashness of a former Vietnam fighter pilot—the full force of which he reserves for insurance company reps who hesitate to cover treatments. He also meets with patients at their homes, ignoring the boundaries that more cautious psychiatrists observe.

“I don’t even see the logic of not making house calls for these people,” says Jenike, who recently spent the better part of a week with a man in Georgia who has been standing in a shed, naked, shifting and smoothing dirt, for nine years.

An estimated 1 to 2 percent of people have OCD, an illness marked by intrusive thoughts and burdensome rituals. Researchers are unsure of its causes, although studies on twins have pointed to a genetic component, and some children develop it after having a strep infection.

Jenike, a Harvard Medical School professor of psychiatry who has authored or edited several books on OCD, thinks of it as a breakdown in the mind’s sense of certainty. The average person may lock the front door and head to bed satisfied, while an OCD sufferer with an unfounded fear of burglary may bolt the door over and over and still not feel sure it is locked. “There is a disconnect between what the patients know and what they feel,” he says, “and generally people go with what they feel.” In extreme cases, the repetitive behavior becomes a ritual that takes hours a day.

Jenike gets to treat some of the worst of them—at their homes, at the clinic and research program he founded at Massachusetts General Hospital and at McLean Hospital, where he started the first residential program for OCD in the country. Most of his patients are helped with combined behavioral therapy and medication; Jenike was an early proponent of that dual strategy, which has since become the standard treatment. The medications include some of the same drugs used to treat depression, while the behavior therapy is a lot like the “exposure” methods used to treat phobias, except instead of learning to sit next to a spider, the OCD patient tries to walk through the kitchen without stepping on every tile, for example.

The idea of specializing in OCD came to Jenike during his psychiatric residency, when he observed the sometimes cruel way the illness leaves patients’ rationality intact. “Schizophrenics, a lot of them, aren’t really aware of what a mess they are,” he says. But OCD patients realize that “what they are doing is nuts. They are driving their family away. They can’t work. They can’t have friends or relationships. They are fully aware of it, and they are unable to stop it. It puts them in a state of incredible suffering.”

Few have suffered more than his patient Ed Zine, a young man who developed a terrifying sense that tragedy would befall his family if he took a wrong step or said a wrong word. (Imagine taking the children’s rhyme “step on a crack, break your mother’s back” as dogma.)

That led to his compulsion to repeat any action, word or thought that triggered this ominous feeling—in reverse. He thought if he could rewind segments of his life, like a videotape, he could keep bad things from happening. It started with subtle habits like going out the same door he came in, retracing his steps on the stairs once or twice, and avoiding rotaries and one-way streets. Later, as a slave to countless micro-reversals, he could spend seven hours just trying to cross his basement bedroom, which he never left. Showering and brushing his teeth became rituals too complicated to endure. His sheets were green and slick with filth and his body was pocked with sores.

As recounted in a new book about Zine’s struggle, Life in Rewind, by Terry Weible Murphy, Jenike was the first doctor to venture into that squalid basement. Slowly, the psychiatrist gained Zine’s trust, even handing him the soap as he took his first shower in two years.

But after several months of treatment, Zine was no closer to leaving his basement. A frustrated Jenike broke down and cried. Seeing how much his recovery meant to the doctor, Zine recalls in the book, was what gave him the strength to fight back against the OCD. “Crying is not one of my regular tactics,” Jenike says, “but people have to know you’re concerned about them.” Zine is now working, married and the father of two young daughters.

It’s a far cry from 30 years ago, when OCD patients were considered untreatable, or consigned to years of psychotherapy. Still, Jenike says, there are therapists who fail to diagnose or treat the condition properly, which is why he evangelizes for the Obsessive Compulsive Foundation and further erodes the physician mystique by giving out his email address (jenike@comcast.net) in magazines and on national radio shows.

“For OCD patients,” he says, psychotherapy “does nothing but make it worse. Thinking about and analyzing your crazy thoughts—that’s like having a skin cancer and sitting around trying to analyze why it has a certain shape and color. That’s not really the point, is it? You’ve got to find a way to cut it out or deal with it.”

The best treatment, by Jenike’s lights, is calling OCD’s bluff, with some drugs to take the edge off the anxiety. While it’s not a guaranteed cure (Zine, for example, still tries to exit a mall through the same door he went in), 97 percent of patients at McLean Hospital’s OCD institute report that their symptoms improve. Even the dirt-smoother in that Georgia shed may one day have his life back, Jenike says. “There’s a pretty good shot we could get him out this year.”

This story first appeared in the fall 2009 issue of Tufts Magazine.

Julie Flaherty can be reached at julie.flaherty@tufts.edu

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