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Monday, October 13, 2014

Obsessive Compulsive Disorder (OCD): Are you Really Suffering from Obsessions?

 There are three major theories for what causes OCD. The most well-known is the biological model. The biological model is popular because pharmaceutical corporations have nearly 100,000 sales reps telling every doctor in the country to prescribe their drugs, with an emphasis on the newest. However, all drugs for OCD work about the same and only one in five people who take it will have any benefit at all; but, one in 50 will have increased suicidal thinking or behavior. Also, there is an average of only a 15% reduction in symptom intensity with medications. The problem is that therapists do not have the time or money to market CBT, ERP or other very effective interventions. These interventions are just not profitable for psychiatrists: why spend 45 minutes with one individual when you can see five in the same amount of time?

   Psychiatry's search for the "biological cause" for all "mental defects" started over 100 years ago. Some people credit Dr. George Still with this over-simplistic endeavor. In 1904, Dr. Still speculated that "moral defects" or behavior problems had biological causes. Doctors applied the disease model to human behavior. Behaviors like defiance, fidgetyness, inability to hold a job and so on, were categorized and medical interventions were tried. There was no further evaluation needed - if the individual presented with the "symptom," then it is just assumed to be a biological cause. All sorts of horrific procedures have been attempted, such as lobotomies, ice-cold baths, weeks of isolation, days of restraint, insulin shots, and electric shocks. Various drugs were tried; for example, early on, Opium and Cocaine were used; Freud considered Cocaine to be a panacea for mental health problems for quite some time.

In the 1960s, ideas emerged in psychiatry that pills "corrected a chemical imbalance in the brain," for example with Serotonin or Dopamine. There is no proof that these ideas are true, but even today, some doctors and most pharmaceutical corporations still make the claim or explain the action of "medications" to patients in this manner.

"Obsession" is a desire, not a fear. Don't confuse a fear with a desire
just because the OCD has been inappropriately named.

With regards to OCD, many people still believe that OCD is caused by a chemical imbalance of Serotonin, or Noradrenalin, or a combination of both. Some people are told that their OCD is caused by other brain dysfunction, such as an "overactive anterior cingulate gyrus," or an "under-active frontal lobe," or a "dysfunctional nucleus accumbens," or "problems in the basal ganglia," or a combination of these. However, there is no convincing evidence that brain anatomy problems cause typical cases of OCD. Medications generally reduce the intensity of OCD symptoms by 15%. That's not very good for moderate to severe OCD. Also, there are many side effects to pills that have serious consequences, such as significant weight gain and loss of sex drive. Ultimately, like distraction techniques, medications do not cure OCD, they only mask the symptoms for some period of time.

Psycho-dynamic theory suggests that OCD is caused from repressed anger or other emotions, and that the unacceptable or disturbing issues are then repressed and substituted with or transferred to obsessions and compulsions which are more tolerable. Psycho-dynamic therapies have not been very helpful for alleviating the symptoms of OCD.

Cognitive theory asserts that the core issue is the negative thinking people have from the initial negative thoughts; for example, "I must be a terrible person to have a thought of killing my brother." The intrusive thought of killing brother causes anxiety, and the idea that "I must want to kill my brother" is even worse. Behavioral theory adds that compulsions can become habitual because they relieve the anxiety. CBT has had good success with OCD, but some people are not willing to commit to doing the techniques which would cure the problem, such as exposure and response prevention.

One issue is how providers view OCD. Nearly all research is geared towards biological hypothesis, while very little is put towards other factors. Biological theorists keep returning to the chemistry lab. Most new drugs are "me-too" drugs and will only work as well as previous brands. 
There's something called Single Loop Learning. Single Loop Learning (SLL) is a learning process where we 
(1) develop a belief about something (theory or hypothesis), 
(2) then we create a plan based on the belief, then
(3) if the plan fails, we do not question the beliefs, we only implement a new strategy.
For me, the entire field on psychiatry is based on Single Loop Learning. The researchers in the field of mental health are not going back and questioning the underlying beliefs about disorders. They continue to act as though these disorders, these syndromes like OCD and GAD, are real, when in fact, they are not real - they are artificial constructs which are heavily influenced by culture, profession, gender, institutions and corporations - least of all, science. 

Double Loop Learning (DLL) is the process of questioning the underlying beliefs on which our actions are based. For example, the Catholic Church used to believe that the Earth was the center of the universe. One day, Copernicus discovered that the Earth actually revolves around the Sun. The Catholic Church opposed this idea for centuries. Copernicus must be wrong; perhaps he is insane, perhaps his telescopes are faulty, perhaps the planets sometimes move in unexpected manners which we humans are not privy to; perhaps God himself was playing tricks on his eyes in order to quash his hubris. The Church would consider every possible problem and not officially apologize for their mistake until 1992 - about 400 years later. This is just an example to illustrate the point, but I don't expect a church to be open-minded, but I do think that for a field of science like psychiatry to be credible, it must rigorously scrutinize its underlying beliefs and assumptions.

Currently, Psychiatry is in the same boat as was the Catholic church. The evidence is clear that psychotropic medications are a gigantic failure, that mental health problems are not diseases, that there is no such thing as a chemical imbalance, that genes play a much smaller role in mental illnesses like OCD, depression and anxiety, that your brain is okay, that pharmaceutical corporations and money have influenced the behavior of psychiatrists more than any other single factor. But, most psychiatrists continue to blame their patients for not getting better: "you need a higher dose," "you need a different medication," "you need another medication," "are you not taking them as prescribed?" "Medications don't work for everyone, you must have 'refractory' OCD," "why are you questioning me?" "you are beyond help!" - Single Loop Learning: the theories are correct, "something is different about you!"

How would you feel if I told you that nothing was wrong with you? That OCD is normal. Would you think I was crazy? Well, as it turns out, that OCD is not pathological; that OCD is not abnormal. OCD is not only normal, but it is functional; the symptoms of OCD have been wrongly-named. To begin with, an "obsession" is something that you desire. However, people with "OCD" do not desire anything bad; that is why they're so distressed. OCD is not a problem with obsessions, it's a problem of worries and fears. We obsess about things we like: baseball or football for example. To obsess means to desire. By calling the fears of OCD, "obsessions," we've been telling people that they desire something bad. But they don't. So, if you have OCD, you should know that you don't desire anything bad, you are not obsessing - you are fearing! So, don't confuse a fear for a desire.**

Then what should we call OCD? We should call it a disorder of "worrying," like: "I-worry-really-bad-all-the-time-I-need-help-disorder" ("disorder" means that the problem is bad enough that it causes lots of distress or problems functioning at work or in relationships).

Yes, OCD is really about worries, much like GAD (generalized anxiety disorder). The difference is that with OCD, you worry about things that are "bizarre," disturbing, or weird, and the worries are intrusive or don't seem like your own thoughts. In essence, these are both disorders of worrying about things, whether it's worrying about paying the bills or passing a test (GAD), or worrying about being possessed by the devil or killing everyone in your sleep (OCD) - it's worrying. 

Who's gets to be the one to decide 
that what you worry about is bizarre?

In reality, both GAD and OCD worries are normal or common. An outsider may think your worry is bizarre, but it's usually not a fair judgement to make when you don't know someone's life history. In both disorders, worrying causes the anxiety. But anxiety has a function, too. Anxiety is not pathological. Anxiety is not a genetic mutation that we should take chemotherapy for to make it go away. If you want to understand more about drug-free ways to manage and cure anxiety, please call to schedule an appointment.

**There are people who have severe OCD, where they can't work or enjoy anything; in these situations, their OCD is still not pathological by cause, but it is a disease in that it is negatively impacting their ability to enjoy life and function. However, even people with severe OCD can be cured.

Mental Health Disclaimer: The information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for professional mental health treatment or medical advice. The reader should always consult his or her mental health provider to determine the appropriateness of the  information for their own situation or if they have any questions regarding a mental health or medical condition or treatment plan. Reading the information on this website does not create a therapist-patient relationship.


  1. I am taking Prozac and it has not helped with my OCD it has however helped subdue my depression. What is worse Hours of compulsions or deep depression. I choose the OCD.

    1. Sorry to hear that it hasn't helped. I hope you will try finding someone who is licensed and trained to provide CBT and ERP for OCD. All the best.