The Neurobiology of Obsessive Compulsive Disorder (OCD)
"OCD is among the most terrible of psychiatric disturbances. Anyone who has seen a man or woman whose skin is macerated from repeated scrubbings, or who cannot leave a room for fear of germs, or who spends long hours repeating meaningless calculations, or who cannot stop demanding reassurance over an unlikely but paralyzing source of dread, will have the sense of how distinctive and relentless OCD is."
This page considers OCD in its complex form and not that of obsessional behaviour such as stalking or the man next door who loves his Harley more than he loves his wife. Last year I was consulted by a man who told me that he was desperately ill with OCD in reality he was screwing the 18yr old baby sitter but "OCD" sounded better than "I just can't keep it in my pants."
Incredibly, this man had convinced his wife that it was he that was the victim in all of this because he was so "unwell" and that she simply wasn't showing him any real understanding. But things can get like this sometimes. He felt that he needed to maintain the relationship with his wife and didn't want to lose the security. He wanted to keep screwing the baby sitter, but he knew that taking up with her full time would be the very thing that would end that particular relationship as well as incurring the wrath of his wife. Oh, what was the poor man to do......
OCD is an unusual disorder from a therapeutic point of view. Increasingly, I am gaining the belief that it reflects a true neurological disorder rather than a psychological one. Certainly in medical practice OCD is increasingly being treated by neurologists rather than psychotherapists - a transition not unknown in medicine - a great many people were once diagnosed as "hysterics" prior to these days our understanding of neurology has improved beyond this dismissive diagnostic some of the time.
In order to examine how OCD operates within any particular neurological system I will list out the data gathered about the epidemiology and manifestation of OCD, collected from a variety of sources. I do this not to state "how it is" but rather that the NLPerson may gain an insight into the neurology with which he interacts when working with an OCD client.
Incidence: 2.3% of the population affected. Compare this to the usual 1% incidence of the population diagnosed with schizophrenia.
Gender: Equal distribution but males appear to demonstrate symptoms earlier than females. Of childhood OCD, 75% are male.
Variants of manifestation:
Washers and avoiders
- fear of contamination
- fear of hurting another person
Checkers and horders:
- Have to count in multiples and sets of multiples
- Fear of losing objects
Intrusive thoughts and urges
- obsessional negative thoughts
- voice hearing (internal representation)
- replaying scenarios in minds eye, over and over.
Bowel and bladder obsessors.
Neurobiology: The area of the brain known as the basal ganglia have been attributed a role in the modulation of movement and in particular in enacting "motor scripts" (ie riding a bicycle, repetitive tasks). The frontal lobes have been implicated in the selection of motor scripts and especially in the inhibition of behaviour. The caudate nucleus is also implicated in a persons ability to start/stop certain activities and thoughts. OCD is also thought to involve an abnormality in serotonergic function.
Co-Morbidity: A strong correlation with behaviours experienced with Tourettes Syndrome. 60%-90% of OCD sufferers report having had at least one major depressive episode.
- Medication typically SSRI's (ie Prozac etc) or Clomipramine (a tricyclic SRI).
- Cognitive Behavioural Therapy. Desensitization and exposure therapy.
- Psychosurgery. (Modern day lobotomy about 25-30 cases in the UK per year).
Spontaneous remission occurs in 10-20% of OCD people without intervention. Depressive groups will show up to a 40% placebo response, whereas OCD groups show less than a 2% placebo response. This is important research and is supportive of the neurobiological perspective (origin?) of this condition.
Prognosis: It is reported that up to 80% of OCD people will improve with CBT and medication. From experience, I would suggest the improvement rate to be much, much lower and the despair repeatedly described by users of news:alt.support.ocd suggest that medication, no matter how high the dosage will sometimes provide no noticeable benefit. However, current prescription advise is that even though the patient doesn't show a response to one particular SSRI, this doesn't mean that another won't demonstrate an improvement.
Reduction in OCD symptoms typically occur between 6-12 weeks after commencing an SSRI whereas depressives typically show a drug response within 6 weeks.
Typical manifestation of behaviours:
- Continuous feelings of uncleanliness.
- Repetitive washing of hands etc.
- Hording of junk mail, newspapers, cereal boxes etc, lest something of value be accidentally lost.
- Repetitive checking of plugs, sockets, gas dials etc, repeated returning to house having left for rechecking etc.
- Fear of harming others. A drive home may consist of repeated retracing of journey checking for the imagined RTA victim that the driver may have hit.
- Fear of contamination. Typically, of contaminating others rather than vice versa (aka "The M.J. Approach")
- Concerns of body appearance, repeated visits to plastic surgeons, never appearing in public with facial mask, etc.
- Excessive concern with morality and sin. (See the film "Carrie" or watch God TV on a Sunday for more information on this).
- Counting ever thought and action depends on a significant number of repetitions or counting.
With regards to this latter manifestation, consider this interesting exchange observed on usenet (news:alt.support.ocd):
"now for almost everything I touch, if I'm leaving the area it's in I have to touch it in
multiples of four, so first I do like 4 lots of four but then if I'm not satisfied with that I'll
touch it another 4 lots of four times but this means I have to add another two lots of 4 lots of
four so in a few months I can see myself taking an hour to leave a room only to have to do it again
somewhere else" A.D
An amusing reply came from a fellow 'counter' who rather unhelpfully wrote:
"All words can be broken down into 4s too! Take any word and spell it out; for example lets
use the word "invite" contains 6 letters. Six (because the word has 6 letters) consists of 3
letters; and three (3) consists of five letters and five (5) consists of 4 letters. Works for any
Given the high suggestibility demonstrated by the majority of OCD people I have seen, I guess life may never be the same again for the unfortunate A.D. When dealing with a "counter" I recommend whacking them with a trance the minute they arrive at your door - otherwise you risk them becoming so pre-occupied with their counting in relation to what you say. The Bandler/Erickson handshake interrupt works particularly well with OCD clients, give it a go and see what happens...
"I grab the stick, "C'mon Scamper, let go!" tug-tug-tug, her teeth dig deeper into the stick leaving gashes permanently etched into the winter aged wood. I reason out loud "Scamper, if you'd just let go, you'd have more fun." My words catch the sharp March wind, hit me in the face
"If you'd just let go, you'd have more fun."
A curious feature of OCD is that the manifestation of the biology of the disorder is fairly consistent accross cultures and the content of the disorder is easily formed into the distinct categories described above. It is important to distinguish whether the client performs the compulsive acts and rituals in order to relieve an obsession (as in the 'counting' example above) or to prevent a potentially fearful outcome.
This will play an important part when examining the thresholds and meta-programs ie the exit point of the behavioural TOT[E] unit.
How does the person know when the ritual has been performed enough times in order for the obsession to have been suspended?
An interesting explanation comes from Rita Carter in her brilliant book, "Mapping The Mind" (Add this book to your Christmas list!) :-
The animals were shown green and blue lights and trained to associate the blue light with the reward of fruit juice, and the green light with a salt drink. Once they had grasped the link...the salt drinks were switched...when this happened an area of the brain that had been quiet until then leapt into life. The neurons in the orbital cortex that lit up were not simply responding to the saltiness of the drink - taste discrimination and the simple "ugh" reaction happen elsewhere in the brain.
This particular areas was clearly activated by the discovery that something was not quite right... - a built in error detection devise. Once the monkeys got used to getting a salty drink occaisionally...the reaction disappeared.Since then brain scans on humans have shown that this area is particularly lively in people with with OCD. When a person with a hand washing compulsion is told to imagine themselves in some filthy place their caudate nucleus and orbital frontal cortex fire away like mad. An area in the middle of the brain - the cingulate cortex - also responds strongly. This is the part of the brain that registers conscious emotion, and it's involvement demonstrates the emotional discomfort generated by OCD.
A similar brain pattern can only be produced in a normal person by persuading them to think very hard about some major catastrophe like watching their home burn down... After these imaginings have been engineered in the subjects' minds and when the researchers tell them they can relax and forget about their terrible thoughts, the person with OCD continues to show to show a lit-up caudate nucleus and orbital frontal cortex. It doesn't matter to them that the laboratory and their hands are obviously shiney clean, the thought that they are contaminated just won't go away...their error detection mechanism has somehow become stuck on alert, and no matter how often the appropriate turn off action is carried out it continues to shriek it's warning.
Generally speaking from a NLP representational level, OCD will take on either a predominantly auditory phenomena or a predominantly visual phenomena.
One client might begin the sequence with asking himself the question, "Are my hands clean?" (Auditory) before proceeding to compare the external visual input of his hands with an internal picture with which to compare them (Visual) and feeling bad/unclean (kino) when the pictures do not match.
Next he moves on to making a picture of himself contaminating a clean and valuable object (Visual), before hearing a chorus of voices shouting at him to punish him for being so wicked (auditory), thus making him feel worse...
Uninterrupted, this loop starts to gain momentum for this client where the sequence begin to run faster and faster, the pictures get bigger and brighter, and the sounds get louder and louder. Uninterrupted, the client will go into a head spin and begin to feel like he will literally burst.
In order to try to counter this experience, he begins to scrub his hands again and again so that the pictures become more manageable and the voices stop shouting at him. For the OCD sufferer this complex and devastating TOTE without exit will be viewed with great pain.
For the NLP practitioner who recognizes the strategy, the inevitable question of "Ever thought about not doing that?" must surely arise. I have asked this question to many OCD clients and the answer always takes the same format, "Yes, but what if?" -
But what if.the map does equal the territory? How would they know if it didn't?
Let's rewind the strategy for one second.when he looked at his hands after asking himself the question, what did he compare them to in order to know that they were contaminated with dirt? And the next time when he looks at his hands, what would happen if he feels good?