Dr. Jeffrey Schwartz got a phone call at 3 p.m., a script before 5 p.m. and the next afternoon he was there, sitting with Leonardo DiCaprio, exploring the intricacies of one of the most debilitating mental illnesses in medicine.
DiCaprio was tackling the role of Howard Hughes in The Aviator, a part requiring him to arc — as Hughes did — from genius billionaire to shaggy recluse, caught in the grip of obsessive-compulsive disorder. Schwartz’s books, Brain Lock and The Mind and the Brain, had established him as one of the world’s foremost authorities on the underlying mechanisms and treatment of obsessive-compulsive disorder, a condition that plagues sufferers with unreasonable thoughts and fears, which in turn compel repetitive behavior.
He would not teach DiCaprio the mannerisms of people with OCD, Schwartz announced on day one. Instead, he would show him “how to become a person with OCD,” so his brain was “like the brain of a person who has the disease.”
The message was ominous, but DiCaprio proved game to try. He quickly pointed Schwartz to a particular segment of the script. “Right here, for three pages, I only have one line,” he said. Show me the blueprints, repeated 46 times, with minor variations.
Schwartz explained that people afflicted with OCD engage in a wide variety of problematic behaviors — compulsive hand washing, door opening, repetitive checking of ovens and doors, even repeating the same word, phrase or sentence. The cause, at a neurological level, is hyperconnectivity between two brain regions, the orbitofrontal cortex and the caudate nucleus, creating a tidal wave of unfounded mortal fear and triggering habitual response as the only way to attain calm. But the worst part is that, despite recognition that all these thoughts and behaviors are irrational, the OCD sufferer feels driven to obey them, nonetheless.
Schwartz walked DiCaprio through the underlying neurology to help him understand that, for Hughes, those four words — show me the blueprints — held a magical power, offering him an escape from his fear. “Those words, he’s repeating them like his life depends on them,” Schwartz advised. “But he also understands that this doesn’t make any sense.”
In the 2004 film that eventually emerged, this scene is perhaps the most painful to watch. DiCaprio, as Hughes, twists the sentence in new directions with each rephrasing, emphasizing different words and employing different cadences. Sometimes he races through the sentence almost under his breath. Other times, he slows down, seeking the right combination of sounds, the right rhythm, to free himself from the fear roiling in his gut. All the while, his face betrays a tortured self-revulsion.
DiCaprio left The Aviator with an Oscar-nominated performance and perhaps a mild case of the disease. It reportedly took him about a year to get back to normal. And today, his willful descent into the illness and subsequent recovery represents one of the most dramatic public examples in our popular culture of neuroplasticity — the ability of the brain to change in shape, function, configuration or size.
But Schwartz says mainstream science has yet to come to grips with an experience like DiCaprio’s, based on what Schwartz calls “self-directed neuroplasticity,” the ability to rewire your brain with your thoughts. This kind of power doesn’t only rescue his patients, he says. It rescues free will.
The notion that we have free will flies in the face of much modern neuroscientific research, which suggests an ever-increasing number of our “choices” are somehow hardwired into us — from which candidate we vote for to which flavor of ice cream tops our cone. In fact, neuroscientists like David Eagleman and Sam Harris have released best-selling books offering that we are, at bottom, high-functioning, delusional robots.
And so, at a time when free will is on the run, few of our culture’s most prominent thinkers agree with Jeffrey Schwartz — a scientist, as it happens, who is entirely comfortable with being disagreeable.
On a warm, fall evening, Schwartz leads me to the campus at the University of California in Los Angeles to witness an OCD group therapy session. Short and squarely built with tight, curly hair and the stooped shoulders of an aged wrestler, Schwartz ambles through the parking lot until he spots one of his patients and calls out to him, warmly, by name.
“How you doing?” he says.
The man, smoking a cigarette and leaning against a brick wall just outside the entrance to Schwartz’s building, waves and indicates with a hand gesture, pointing inside, that he’ll talk in the group session. Schwartz nods, turning to me as we pass him. “Uh-oh,” he says. “Maybe things aren’t going so well for him.”
Schwartz takes the last couple of strides ahead of me and opens the door to the Semel Institute for Neuroscience and Human Behavior, a three-story glass and brick collection of classrooms and labs. “Well,” he says, cocking an eyebrow at me. “Here we go. These are my people.”
Walking into a room filled with Schwartz’s patients is like walking in on a band of revolutionaries. They have that easy air of familiarity and quiet sense of accomplishment. They greet Schwartz, their leader, warmly. People speak of regaining time previously lost to their compulsions. One man, an actor, says he feels confident enough to audition for parts again.
Paula Scott, the senior client among them, captures just how dramatic their trip has been. “When I first met Jeffrey,” Paula says, “I was thinking about killing myself. Now, I am not even struggling with my OCD.” Paula’s illness is still present, but the condition no longer torments her, no longer controls her. OCD is just something she handles as she goes about her day.
All is Suffering
The insights underlying Schwartz’s groundbreaking techniques can be traced back to his youth. The Holocaust had ravaged his bloodline, a heavy legacy about which an elder relative educated him. “I remember he told me that it was my job to live for these people who had died,” says Schwartz, “and he didn’t mean that as some sort of metaphor, or to inspire me. He meant it literally.”
While other kids his age played, he spent long hours in the library, reading through Holocaust trial transcripts. On page after page, he read testimony about people who performed horrifying acts for the sake of power, money or simply to get along in a country suddenly steeped in the wicked. He emerged, he says, with an image “of humanity as being fallen and in need of some kind of help.”
His college years, spent at the University of Rochester, yielded another influence: the focusing power of mindfulness, a Buddhist practice in which adherents learn to view their own thoughts and impulses with complete impartiality. Aided by mindfulness, Schwartz did so well in school he was accepted as an honors scholar in philosophy in Edinburgh, Scotland.
When he embarked on his career in medicine, he knew he wanted, somehow, to combine all these elements: He wanted to demonstrate that the Buddhist practice of mindfulness could help us choose something other than holocausts and heal our fallen humankind.
Schwartz got the chance in 1983, when he agreed to work with UCLA neuropsychiatrist Lewis Baxter to tease out the mechanism of OCD. The Baxter team would be using the then-new positron emission tomography (PET) scanner, a hulking imaging machine Schwartz remembers “looking like something out of 2001: A Space Odyssey.”
To conduct a PET scan, technicians injected patients with a biologically active tracer particle made partly of positrons (positively charged electrons) and attached to some other molecule with a role in metabolism, like water or glucose. By tracking the positrons emitted as the tracer breaks down, the machine can capture images of biological processes. In this case, Schwartz and Baxter aimed to follow blood flow in the brain.
While the team worked, Schwartz scoured the literature for insight and found a largely overlooked study by neuroscientist Edmund Rolls. Rolls used monkeys to investigate the orbitofrontal cortex (OFC), an area of the brain associated with decision-making. The brains of the monkeys were imaged as they grew comfortable licking a bar in order to obtain a sweet liquid. Then they were imaged licking the same bar after the liquid was replaced with a salty brine.
Rolls found activity in the OFC spiked when the monkeys were surprised by the new liquid. It was an ingenious study, Schwartz thought. Rolls had revealed the OFC to act as an error detection circuit. It made sense then to look at the OFC in relation to OCD, which fills patients with mortal fear that something is wrong.
Around the same time, Schwartz suggested the team investigate the caudate nucleus, a tail-shaped structure near the OFC that serves as the habit center of the brain. The caudate nucleus, he thought, might act as a kind of nexus for OCD — a traffic hub where rational thinking in the cerebral cortex meets the more primitive, emotion-ruled centers of the brain’s limbic system. It would be a natural ground zero for the noxious brew of repetition and terror to collide.
The research took many months. But one day Baxter took Schwartz aside to say, “We’ve got it.”
The data were clear. OCD subjects, as opposed to healthy controls, demonstrated significant hyperactivity in the OFC and caudate — even at rest. The images turned up in PET scans as bursts of color, rendering these brain regions as small fires, perpetually burning and, clearly, altering the functioning of the brain even when no episode was underway.
Free Will Therapy
Now that the neural circuitry of OCD was identified, researchers could test therapies. Using imaging technologies like PET, they could see if a given treatment tempered the fire in the brain.
For Schwartz, this was the chance to invoke his interest in mindfulness. He imagined a woman caught in the grips of ceaselessly washing her hands, yet aware her hands weren’t dirty. Able to reflect on the bizarreness of her thoughts and her behavior, she continues to wash only because it seems like the only way to ease her fear that she is contaminated.
In this sense, OCD reflects a key aspect of mindfulness meditation — granting the patient a detached perspective from his or her own thoughts. Schwartz speculated that this awareness could enable a mindfulness-based treatment strategy. After all, if the point of mindfulness is to stand back dispassionately from all our ideas and impulses, couldn’t an OCD patient use mindfulness to step back even from mortal fears and compulsions? Perhaps mindfulness could help rewire the OCD circuit in the brain.
Schwartz met one of his earliest patients, Paula Scott, in 1987, when she was deep in the throes of a case of OCD so surreal and severe she regularly contemplated suicide. Paula’s illness manifested as the irrational fear that her boyfriend was an alcoholic and drug addict.
Schwartz thought Paula’s case was particularly compelling because the repetitive behavior she chose to alleviate her fear demonstrated just how aware she really was. She knew, for instance, that if she constantly peppered her boyfriend with questions about drug and alcohol use, he’d realize something was off. “I had to find a way to conceal my feelings from him,” she says, “while still giving in to the compulsion.”
Her solution: question him rigorously without tipping him off to her particular fear. She asked him multiple questions about his day, essentially asking him to walk her through what he ate for breakfast, when he got to work, what he did that morning, and with whom he ate lunch, seeing if he might slip and say something that hinted at drug addiction.
Others joined Paula in Schwartz’s therapy group. They spoke of rubbing their hands raw to avoid contaminating themselves and, by extension, their loved ones. They talked of being late for work because they spent so much time checking the oven and the door locks. And each week, Schwartz urged his patients to experience their OCD symptoms the way a mindfulness practitioner, in meditation, strives to experience every thought — dispassionately, without succumbing to emotion.
To be continued