Lack Of Inhibition

Today I would like to address a central phenomenon in OCD. Most forms of the disorder have at their core: a lack of inhibition.

What is that? you may ask. I feel contrained by the affliction, it damages my life. I am nervous and unable to do things I want or need to do! And you, Sir, dare call this: lack of inhibition???

Let's see... why is 'lack of inhibition' a valid concept then?

OCD patients have intrusive, obsessive, fearful thoughts. They seem to circle around in the head and don't flee when you want them to. You cannot suppress them. Now, the latter observation is crucial. OCD patients usually know that they have something that most others experience too, once in a while. But patients have it in excess. Trains of repetitive and unsettling thoughts, about something, or more things, that 'aren't just right' and need be put right. The nature of these thoughts is: harm, damage, lack of order and symmetry, lack of cleanliness and hygiene, lack of completeness, fear of intruders in one's territory, and so on.

What sets patients apart is precisely: the capacity to suppress the thought patterns, even if these are recognized as nonsensical. This I call: lack of inhibition. The thoughts cannot be inhibited qua their presence. They lead a life of their own.

We take one step further. Patients respond to the thoughts by performing rituals. This is the behavioural response, it serves to reduce fear and anxiety. Which it eventually does... at a price, a steep price. The rituals are time-consuming, and incapacitating. There is no escaping them. They must be appeased, it seems, tamed, like a wild animal that has to be put at rest, with a lot of effort. Again, we lack inhibition. We must perform the ritual to its end. Stopping halfway is impossible; if we do that, the worrying thoughts keep on rearing their ugly heads.

I will conclude for the day with three remarks:

1. lack of inhibition is represented, matched, by certain abnormalities in brain circuitry and connectivity. It is highly intriguing that the descriptions I gave above, about thoughts and behaviours, have a mirror image in our brain, and refer to regions that normally perform the tasks that are so 'deformed' in OCD. Personally, I haven't often seen such a match between symptoms and brain regions in psychiatry. It is almost as precise as: hey man! I can't walk! Look, my leg is broken!

2. the level of incapacitation in OCD is very high. The World Health Organization (WHO) ranked OCD in its Top Ten of most incapacitating disorders worldwide. Unfortunately, few clinicians and therapists know this. Even worse: I have met various clinicians who stated: we can treat OCD successfully today! This is evidently untrue, as I will prove. Mind, I write this not to make people hopeless and sad, I do so because false promises are the worst kind of promises. And I think that people in clinics who predict unrealistic outcomes may have an unrevealed interest on the side: they may have a financial involvement because they practise a certain form of treatment with their patients, and want to attract probands.

3. if we calmly look at the various forms of OCD, we see a pattern emerging. Take: checking, washing, counting, hoarding, religious obsessions, sexual obsessions. What do these forms have in common?

(Jeremy Paxman commands me to give the answer right now...)

The keyword is: evolution! OCD has a strong link with the capacities humans need to preserve themselves, to rear their children, to procreate, and to provide safety. It is about: territory protection; about: hygiene; about: stocking food and stuff for bad times; about: praying to God; and about many more related issues.

True, dat. But why OCD then? Well... the above beautiful qualities (hey, sex is great!) have spun out of control in the disorder. In fact, they have become grotesque and have exceeded all boundaries. That is the sadness of the affliction.

We OCD patients thus are normal. Abnormally so...

(tbc)

Is OCD A 'Mental' Problem? Or The Result Of An Abnormal Brain?

I sought to make a provocative title expressly here. I want to say: in how far do we have a concept of 'mind' and 'consciousness', and also 'memory'? Does trauma play a role in OCD?

Many OCD patients have a lot of shame about their condition. They seek to hide it, and to function as 'normal' as possible. Within certain boundaries this is possible, although the personal cost is enormous. If one needs to check doors for half an hour before leaving the house (for school, work), and then again in the late noon (when visiting friends), and again before bedtime, then already the disorder is extremely taxing. Nervousness, fear, sweat, tiredness: all are the direct result of OCD. Often there is no time for hobbies. Rearing one's children may be too heavy a burden, with serious conflict as a result, the partner may think of a divorce. Not because he or she fell out of love with their significant other, but because he or she cannot muster the courage and energy anymore to cope with the partner's disorder.

You may not believe this: the average time that elapses between onset of symptoms and the decision to visit an expert is about 17 years!

Another serious thing: contrary to what is the case in other types of psychiatric afflictions, the average OCD patient knows very well that his or her obsessive thoughts and behavioural rituals are 'not normal'. The patient has a good 'meta-cognition': this means that the subject can 'look from a distance to him/herself', and say: hey, what I am doing is strange and not rational. Because checking a lock one time, and one time only, is enough!

A posh term for this is: 'ego-dystonic': the disorder does not blur boundaries about what is normal and what is not. The thing is: the patient can at the same time not limit the ritual to what he or she would perceive as 'normal'. The ritual 'takes over' every time, has a life of its own, and only when the obsessive fears are 'quenched', then it can be ended.

Am I mad? This is the question that patients are vexed by. I state here: NO. You are not mad. You have a good sense of the normal and the abnormal. You do not belong in the 'nuthouse'.

These remarks must be seen in context, and not as insulting to psychiatric patients. They should be seen as comforting and inspiring. To make a move in the right direction.

'Madness' is a rather old-fashioned word, a term that can imply so much that it is rather meaningless. The greatest artists over the ages had their 'divine inspiration', or: madness if you will. But the serial killer is mad also.

I want to say: psychiatry, and neuroscience (neurobiology), have made great leaps in the field of this type of disorders. Fantastic techniques are available to visualize on a screen how the brain of OCD, depressive, and schizophrenic patients work. And they can show how nerve cells work in different ways in patients, compared to average people. We know how the blood flow in the brain is altered in obsessions and rituals.

Try to see OCD like a skin wound. Tissues and blood flow work differently. We can see how they work differently. And this is the first step towards finding a real solution for a 'problem in the brain'.

You may not believe this: almost all types of medication that are prescribed in OCD were not designed to combat OCD. They were synthesized to counteract all kinds of diseases; but in patients with obsessions and compulsions, there was a very surprising, unexpected effect: the symptoms of OCD were alleviated!

Only now are we able to:

1. find out what exactly is functioning in a different way in the brain, in OCD;

2. design proper types of medication targeted exclusively at these dysfunctions.

And this means that in the next years therapies will become available that have much less side effects than current medication still does.

Hopeful, isn't it?

About myself

I am a man aged 50. Single. In my puberty I had recurring obsessions with certain themes: people should not touch some of my clothes, and these should stay 'pure', in their new state. Because I attached a lot of meaning to them in terms of my appearance. Also: I had a terrible early morning mood. Furthermore, I was enormously afraid of losing my hair. Now, I know that everyone has these things to a certain degree. In my case, however, I can say that they threatened my happiness to a large extent. If something 'was not right', then I got very, very sad.

After I began at University, things got worse. I rented a room with a landlady in my new hometown. I was lonely. When I left that room on Fridays, to go to my parents for the weekend, I had to check electrical household appliances, current sockets in the walls, door locks. To such an extent that I could not predict how long the measures would take, nor which train I could catch to go to the parental home. I arrived late almost every week. Terrible. Apart from having to run to the bus station, and to phone my folks that I would be late again, there was the down mood at home: he's not in time for dinner as he promised to be.

Just before I was to complete my M.Sc. degree, I got mentally 'frozen' by the disease. I couldn't make any appointment anymore, save for the ones where I calculated in that I would have to start 'checking' about a full hour or even more before leaving my apartment. I checked: faucets, stoves, windows (all had to be fully closed), flasks of shampoo, bottles with shaving cream, after shave, cupboards (closed?). I was terribly afraid that either (1) I would forget to check an object (leave it out of the ritual, so to speak) and also forget to close the front door, or (2) that someone (the landlord) might sneak in during my absence and damage or steal a beloved object. Whilst away, I thought about these dangers almost continuously, and frequently checked if I had my keys with me. Even then: when I was at home strange fears plagued me: had someone (even a dear friend) taken my keys in the pub, for instance, gone to my room, done damage or stolen something, and then returned to that pub, and hung the keys back again at my belt, all this with me not noticing it? Even with all the power of logical reasoning that this was impossible, I could not drive away those fears. Late in the evening, I drunk alcohol to alleviate my pain. Sometimes I had this sadness: it had happened. The worst had come true. So I had to make a fresh start after that disaster. Which was, as I very well knew, a harrowing fantasy.

All this is only the surface, the tip of the iceberg.

(to be continued)

Obsessive-compulsive Disorder (Beta)

Hello to everyone -

welcome to my weblog about obsessive-compulsive disorder. My aim is to provide information and to learn from the contributions of visitors who supply their own knowledge, experience, and opinion on this unsettling and disabling affliction. Although psychology, psychiatry, and neurobiology in the strict sense have made great progress in the past decades in unraveling the many factors that contribute to the condition, it can be stated that the general public knows little about it. Too little, in my view. This situation leads to unnecessary suffering for patients and their families and friends alike. Patients may hide OCD (as it is known) for many years. This way, relatives and friends can become 'co-patients', much as is the case in alcoholism. Furthermore, the longer a patient hides OCD, the more damage is done to his or her social and professional life. Major depression can be the result of protracted suffering from OCD - but OCD and depression can also exist in such a close relationship that experts term it: co-morbidity.

If anyone feels like writing in at this early stage, feel free to do so: it can of course be done anonymously, so there's no wariness needed in this respect.

I hope this thing works!