Many may be aware that obsessive-compulsive disorder (OCD) features a pattern of unwanted thoughts and fears, even obsessions, that lead you to do repetitive and rigid behaviors. It's a compulsive behavior that interferes with daily activities, causing significant distress. Despite efforts to ignore or get rid of bothersome thoughts or urges, they remain, so these behaviors then become like rituals. Many people with OCD know or suspect their obsessional thoughts are not realistic, but they still can't seem to disengage from the obsessive thoughts or stop their compulsive behaviors.
Generally, OCD centers around certain themes. Maybe one has an excessive fear of getting contaminated by germs so to ease that concern, they compulsively wash their hands until they're sore and chapped. This causes great shame and embarrassment for many with this condition, but there are some helpful treatments. There are also a variety of ways this presents that may surprise you.
Obsessive-compulsive disorder usually includes both obsessions and compulsions, but you may just have one and not the other. It is common to not even recognize that your #obsessions and compulsions are excessive or unreasonable, but they take up a great deal of time and interfere with your daily routine and social, school or work functioning.
Obsessive compulsive disorder is often thought of as more so surrounding the ritual or compulsive side of the disorder, but there are many who get stuck in the thoughts - fears of something going wrong, fears of an accident or someone getting hurt. These thoughts alone, intrusive as they may be, are not always thought of as OCD when they are the prominent feature. Consider though when clients articulate fears and worries, that maybe their anxiety or depression or even suicidal ideations are in fact obsessive.
Obsession Symptoms
Repeated, persistent and unwanted thoughts, urges or images that are intrusive and cause distress or #anxiety are obsessive. You might try to ignore them or get rid of them by performing a compulsive behavior or ritual. These obsessions typically intrude when you're trying to think or do other things. Again, these often do have themes, such as fear of contamination or dirt; doubting and having difficulty tolerating uncertainty; needing things orderly and symmetrical; aggressive or horrific thoughts about losing control and harming yourself or others; and unwanted thoughts, including aggression, or sexual or religious subjects. Sometimes these thoughts are quite meaningless too, persistent images, sounds, words, or music.
Fear of being contaminated by touching objects others have touched is an example of obsession. Doubts that you've locked the door or turned off the stove are obsessive thoughts when they reoccur. Intense stress when objects aren't orderly or facing a certain way, may be particular, but when it disrupts your life or the life of others, this may be signs and symptoms of obsession. Images of driving your car into a crowd of people, thoughts about shouting obscenities or acting inappropriately in public may be obsessive, even unpleasant sexual images, and avoidance of situations that can trigger obsessions, such as shaking hands.
Compulsion Symptoms
OCD compulsions are repetitive behaviors that you feel driven to perform. These repetitive behaviors or mental acts are meant to reduce anxiety related to your obsessions or prevent something bad from happening. However, engaging in the compulsions brings no pleasure and may offer only a temporary relief from anxiety.
You may make up rules or rituals to follow that help control your anxiety when you're having obsessive thoughts. These compulsions are excessive and often are not realistically related to the problem they're intended to fix. Compulsions typically have themes as well. They may revolve around washing and cleaning, checking, counting, orderliness, following a strict routine, and demanding reassurance. For some, these rituals last all day.
Examples of compulsive behavior may be hand-washing until your skin becomes raw. Checking doors repeatedly to make sure they're locked or checking the stove repeatedly to make sure it's off are also examples of compulsive behaviors. Others count in certain patterns or repeat prayers or word phrases silently. Remember the Julia Roberts movie, Sleeping with the Enemy? Her predator required the canned goods to all be turned the same way and the hand towels to hang exactly even. Constantly seeking approval or reassurance can be compulsive for some, or they may avoid certain people, places, or situations that cause them distress and trigger obsessions and compulsions. Avoiding these things may further impair their ability to function in life and may be detrimental to other areas of mental or physical health, but again, avoiding people and places due to trauma is not the same as OCD as their is a valid reason with trauma.
Severity Varies
For some, OCD begins in their teenage or young adult years, but it can start as young as early childhood too. Average onset is 19 years of age, but about 25 percent experience symptoms before the age of 14 years. This impacts about one in 200 children and in an average size elementary school about two to four children will suffer with OCD, and in a large high school, about twenty kids. The real concern here is that since OCD can truly disrupt your life and your ability to be productive at work, many of these kids become financially dependent on their parents and don't leave home.
Symptoms usually begin gradually and tend to vary in severity throughout life. The types of obsessions and compulsions experienced can also change over time. Symptoms generally worsen under stress, but typically OCD is a lifelong struggle with mild to moderate symptoms. Some do experience them severe enough that they are exceedingly time-consuming and can become quite disabling.
Diagnosis requires the presence of obsessional thoughts and/or compulsions that are time-consuming (upwards of an hour), causing significant distress, and impair work or social functioning. The challenge in this #diagnosis is discerning when someone is demonstrating perfectionist qualities and whether they are truly facing obsessive compulsive behaviors. One can desire a clean home or flawless results and not have OCD. One can also have more obsessive like thoughts from #trauma or within an abusive relationship that are in fact valid. Obsessive thoughts about real problems is not obsessive compulsive disorder. If these thoughts though are impacting your quality of life, it's time to get evaluated.
OCD can be associated with hoarding and is commonly diagnosed in young boys who also have ADHD. Among adults, it affects men and women quite equally. It may even seem to have a bit of a superstitious quality. Insomnia can result when you fall asleep at night constantly thinking about the things you need to check, or even if you have to leave your bed to reassure yourself.
What Do We Do About It?
Therapy can increase one's quality of life and improve functioning. Treatment may improve their work or school life and help them develop and enjoy relationships, even pursue leisure activities. The mainstay of conventional medicine's approach to treatment is cognitive behavioral therapy, medications, and surgery. Cognitive therapy often utilizes the exposure and response prevention method, in which the individual is exposed to feared situations or images that focus on their obsessions and then the compulsive behavior is not performed, with the intent to demonstrate that staying in the feared situation without anything terrible happening identifies these as just intrusive thoughts and not actual threats. It is then thought that these individuals will learn to cope with their thoughts and avoid the ritualistic behaviors which decreases their anxiety over time. Certainly this does invoke anxiety though, so it is helpful in some and not in others. Some won't even attempt this and others it can be helpful for more mild fears but not the more significant issues.
With regards to medication, the selective serotonin reuptake inhibitors (#SSRIs), typically used to treat depression, are the favored approach for treating OCD. Fluoxetine, Fluvoxamine, Paroxetine, and Sertraline are commonly used. Usually the dose is higher than one would use for depression though, but this really isn't effective for everyone. Sometimes one medication fails to work and another in the same class does. It is hard to really judge effectiveness for about six to twelve weeks on the medication, so treatment takes time to discern. Combining medication with the cognitive therapy mentioned above can be especially helpful.
The literature has really leaned into offering gamma ventral capsulotomy, a surgical procedure, for those who aren't responsive to typical treatments and otherwise are really impacted by their condition. This isn't utilized as much as could maybe be helpful though because it is quite invasive. Deep brain stimulation, which involves implanting a device in the brain, is another option; however, it too is invasive and complex to manage. Not many are even trained to offer these treatments or to provide the long-term support needed.
What Does a Functional & Integrative Provider Do About OCD?
While conventional medicine approaches OCD as a chemical issue, functional medicine clinicians are going to look at #epigenetics, inflammation, gut health, neurotransmitter balance, and other lifestyle influences in the treatment of OCD, including trauma and evaluating coping tools. Our gut health impacts our brain health so an inflamed gut can wreck havoc on our brain function.
We do know there are some genetic factors. This last year a publication evaluating about 1300 individuals identified the SLITKR5 gene as prominent in those with OCD and so now scientists are studying how this gene may be triggered in individuals. Inflammation as well is also being studied, along with the role of the microbiome. Those with OCD have been found to have an overall low colony count and low diversity of microbes within their microbiome, and now various strains are being studied to better identify their impact on OCD. Lactobacillus rhamnosus and Lactobacillus casei have been particularly minimal in these individuals. Further, genetic markers, such as cRP, IL6, and TNF-alpha have all been found to be elevated in those with OCD, so the data is growing connecting #inflammation and the gut biome in those with obsessive-compulsive disorder.
There is not a single issue with OCD, but rather a combination of issues although that is how it is treated in conventional medicine. Serotonin is not the only issue here. Medication is not the only fix, and they are only effective about half of the time and pose significant side effects. We also know, even in conventional medicine, that there are issues related to blood flow but again, we try to throw serotonin at it fairly exclusively. Functional medicine offers a system mindset, so we look at the entire person and how each system and each lifestyle behavior and even environment can impact their condition.
Dr. Hyman, grandfather of functional medicine, talks about OCD with Dr. George Papanicolaou in his podcast, The Doctor's Farmacy, about a gal with significant OCD who ultimately proved to have gut dysbiosis or an overgrowth of bacteria and fungus in her gut, even in her urine, and she was found to have DHPPA. This is thought to be benign, but of course, anything benign in excess is no longer benign and this one in particular is known to have psychoactive effects, even a trigger in autism. He treated her with antibiotics and antifungals and after 15 years of significant OCD, she completely resolved her obsessive and compulsive behaviors.
We often think OCD is purely psychological but in this previous case, it was infectious. Strep and #PANDAS (or PANS) have also been associated with OCD. Cases having utilized intravenous ozone in treatment regimens have been shared among functional medicine clinicians for children who were nearly non-functioning but who later demonstrated essentially, complete recovery after treatment. Addressing the infection and the inflammation that may be underlying in OCD can offer real relief.
Nutritional panels and even toxic burden, such as heavy metals are also helpful evaluations, and they can impact the microbiome. Vitamin B6 and zinc have been found low in individuals with OCD as well, when nutritional panels are evaluated, and each are important in the manufacturing of neurotransmitters and brain function which goes unaddressed if antidepressants are your only approach. Additionally, evaluating for Lyme and a variety of other viral infections are important too as they can be the underlying trigger.
Genes with variations that create proteins or enzymes can impact your brain in a variety of ways, so an epigenetic profile is one of my top priorities. If we find, for example, that dopamine or norepinephrine are slow to break down because you have receptor issues than we can identify higher levels of dopamine impacting your neuro-processing. This looks different in everyone, but often these individuals will have less stress resilience. Any stress will push them into fight-or-flight right away. They get anxious and can #panic. They may be easily agitated or get irritated very quickly. Combine this with OCD and these people are struggling, which looks like a psychological problem when in fact, it's a bit more biological.
Self-Care and OCD
Maintaining a healthy lifestyle can help in coping with OCD. Getting enough good quality sleep, eating healthy food, exercising, and spending time with others can help with overall mental health. Also, using basic relaxation techniques such as meditation, yoga, visualization, and massage can help ease the stress and anxiety.
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