Understanding OCD.

According to the WHO, Obsessive-Compulsive Disorder is one of the top 10 most debilitating illnesses in the world. This means that OCD is one of those diseases that seriously impedes an individual’s ability to normally function in life.

The problem with us today, and the reason for writing this article, is that we like to casually label our common emotions with names of serious diseases. We say we are depressed when we feel sad. We define our nervousness as anxiety. Similarly, people who have a habit of being orderly or neat declare themselves of having OCD. This is dangerous in two ways: it undermines the severity of the disease and the suffering of the people actually having the disorder. Also, constantly labeling yourself as a patient suffering from a serious, debilitating illness can end up in you internalizing that state of mind and actually end up developing the disorder.

So, in this article I will try to comprehensively explain what OCD actually is and hopefully make you enough aware to stop using it as a misnomer to explain your minor personality flaws that can easily be corrected.

OCD: The Psychological Explanation.

OCD is a type of anxiety disorder which has three fundamental elements: Obsessions, Compulsions and the anxiety binding the two together.

Obsessions, in the simplest terms, are aggressively intrusive thoughts. These thoughts can be distressing, frightening, violent etc. These thoughts are persistent, recurring, emerge spontaneously out of nowhere, and violently disrupt the normal train of thought of the individual.

Compulsions are actions, behaviors, or rituals an individual does in response to obsessions. On the surface these rituals may or may not seem to have any logical connection to the obsessions. For example, a patient may have recurring thoughts of his family dying in a terrible car crash, and in response to this he performs a ritual of knocking on his door 10 times before he leaves the house. This may not make any logical sense to the healthy person, and neither does it to the patient. Then why do they do it?

This is where anxiety and operant conditioning play their part. You see, obsessions are not merely intrusive thoughts. They are recurring, intrusive thoughts accompanied by a significant amount of anxiety. The nature of these obsessions is such that if the patient ignores them and does nothing to respond to them, it results in an extreme anxiety reaction or even a panic attack. Now imagine this, you’re in your room enjoying a book. Suddenly, you are infected with the gruesome mental image of someone close to you dying in a car crash. You get perturbed by it but you understand that it’s just a thought and you choose to ignore it. However, the more you ignore it the more your heart races. Your throat starts to close and you find it difficult to breathe. You start sweating and your hands start shivering. Now, you are in full panic mode. Any sense of rationality and logic has left your mind. The only thing you can think and focus on is how to calm yourself down. In that extremely anxious state, your mind tells you that unless you count to 70 for seven times your body cannot relax. You do the ritual and you immediately feel a sense of relief. That is OCD.

Now, the fundamental problem of OCD (and potentially the key to its treatment) comes here. By performing the compulsion to alleviate the anxiety caused by the obsession, you only make the obsession stronger. To explain this let me briefly tell you about operant conditioning. Operant conditioning is the strengthening or weakening of a behavior through reward or punishment. For example, we reward our children for getting good grades. This makes them work harder to get better grades next time so that they can get a bigger rewards. The more we reward this behavior the harder they work and the bigger the prize they expect. Similarly, when a patient performs the compulsion to satisfy the obsession, he reinforces the obsession and makes it stronger. This will make the obsession more frequent and progressively stronger. The compulsions it will demand will be increasingly extreme. This traps the patient in a never-ending, exhausting, and frequently anxiety-inducing loop of obsessions and compulsions.

OCD: The Neurobiological Explanation.

The explanation for OCD would be incomplete if I were to exclude the dysfunctions or abnormalities occurring in the functioning of the brains of OCD patients. To have a neurobiological understanding of OCD, we need to understand how the brain works and what are the specific parts of the brain that are involved in OCD. Let’s try to unravel this.

The brain has two main functions. The first is to control the autonomic functions of the body. These are those functions that we do not control consciously like breathing, heartbeat, the digestive system etc. The second function is cognition and perception i.e., how we think about and perceive things. Both of these functions are not mutually exclusive. In fact, most of the time they occur in connection with each other. For example, when you think about a distressing thought your heartbeat increases, or when your stomach contracts you automatically perceive that you are hungry. So, both the autonomic system and cognitive part of the brain work in connection with each other.

Now to the parts of the brain involved in OCD. Studies have found that OCD is caused by dysfunction in the cortico-striatal-thalamic loop, which is a neural circuit in the brain. This circuit involves three parts: the cortex, striatum and thalamus. The cortex is the part of the brain responsible for cognition and perception. The striatum is involved in go and no-go type of behaviors i.e., doing an action or refraining from it. The cortex and striatum are constantly in crosstalk with each other. The cortex perceives a stimulus and the striatum decides whether or not to respond to it. The third part, the thalamus, is responsible for collecting stimuli and relaying it to the cortex. The thalamus has a gate, called the thalamic reticular nucleus, which allows certain information to move on to the thalamus and suppresses the other. For example, right now you are focused on reading the words of this article and completely unaware about how the air in the room feels against your cheeks. Only when you read the previous sentence does the feeling of the air enters your conscious awareness. This is due to the thalamic reticular nucleus allowing certain pieces of information to enter your conscious awareness while suppressing others. The thalamic reticular nucleus not only does this with sensations but also with thoughts.

Now the exact nature of the dysfunction in the CST loop is still unknown. So, this next bit is partly researched and partly my own hypothesis. In OCD patients, the thalamic reticular nucleus malfunctions and is not able to suppress unwanted thoughts from entering the conscious awareness, hence the obsessions. Furthermore, the cortex misperceives the threat posed by the obsession as a genuine threat, which results in rapid autonomic arousal (i.e., anxiety symptoms) and in a panicked state thinks up of a compulsion. It further associates subjugation of the autonomic arousal with the performance of this compulsion. Finally, the striatum sends the green signal to perform the compulsion instead of refraining from it. And this sets the precedent that the relieving of that particular obsession is associated with the performance of said compulsion.

Treatment of OCD

There are multiple approaches for the treatment of OCD. Doctors prescribe SSRIs, which suppress the functioning of the CST loop. Cognitive-behavioral therapy is also an effective technique to pursue. In CBT, the patient is exposed to the obsession and is prevented from performing the compulsion. The objective is tolerating anxiety and refrain from alleviating it by performing the compulsion, as this reinforces the obsession. By doing this, the therapist is actually aiming to disrupt the circuit from the from the cortex (thinking part of the brain) to the striatum (part dealing with doing or not doing a behavior). However, this process is extremely anxiety-inducing and should be done progressively. A hierarchy of fears is established where the least disturbing obsessions are ranked at the bottom, and at every step of the hierarchy the degree of anxiety induced by obsessions increases. The patient has to start from the bottom and “master” every steps to progressively move towards a cure.

OCD is a very serious medical condition and must be treated as so. I hope from this article I was able to comprehensively explain what OCD actually is and how it works. If so, you can use this to help people close to suffering from OCD, or at least understand their condition, support them in their struggle and seek help.