OCD

What is OCD?

Obsessive-Compulsive Disorder (OCD) involves thoughts and behaviors that are intrusive, repetitive, rigid, and dysfunctional to daily life. It can be a debilitating cycle of distress.

The Historical View: Psychoanalysis and Unconscious Conflict

Historically, the psychoanalytic explanation viewed OCD symptoms as solutions to unconscious psychological conflicts, often established very early in life (even at a pre-verbal age).

In this formulation, the individual has unacceptable drives or desires (due to guilt or fear of punishment) and seeks to disown or repress them. It’s a process of "undoing" prohibited thoughts through competing activities such as checking or over-intellectualizing.

Why Insight Therapy Isn't Enough

This theoretical view stems from Sigmund Freud’s treatment of the "Rat Man" in 1909. The goal was to provide insight into these unconscious drivers. However, historical records and current research show that insight therapy alone yields minimal lasting change for OCD. While Freud's theories are elegant, they lack empirical support for significant clinical relief.

The Current View: It’s Biology, Not Just Psychology

Current thinking posits that even if OCD has psychological roots, it ultimately relies on brain structures, brain circuits, and brain chemistry.

There are specific brain centers involved with detecting threats and monitoring habits. In OCD, these centers:

· Over-detect threats.

· Become over-stimulated.

· Lead to over-activation of behavioral rituals.

This process is correlated with brain chemistry, such as an oversupply of the neurotransmitter glutamate and an insufficiency of serotonin. It creates a persistent loop of activity—a "stop signal" failure—where the brain doesn't trust that a task is complete, urging the person to correct something ... urgently.

The "Trait" of Obsessiveness

Current research indicates that for people with OCD, the brain circuitry is wired for error sensitivity no matter the content.

This phenomenon is known as Error Related Negativity (ERN). Brain centers responsible for threat detection can become activated even when performance is correct. This creates a chronic internal signal that "something is wrong," even when nothing is actually wrong. It is not the content of the thought that matters, but the hyperactive neural pathway itself.

The Gold Standard Treatment: Exposure and Response Prevention (ERP)

Because the issue is largely circuitry rather than deep-seated meaning, behavioral interventions are more effective than talk therapy alone. Exposure and Response Prevention (ERP) is the gold standard.

How ERP Works

ERP "breaks" the cycle by exposing the person to obsessional triggers without allowing them to engage in the compulsive response.

· The Goal: Research shows that while ERP does not necessarily change the neural firings (the alarm), it decreases the urge to respond.

· The Result: The alarms remain, but the response urgency is muted. The person gains agency, learning that they do not have to obey the signal. Urgency is transformed into tolerance.

Treating Obsessive Thoughts

It is easy to see how ERP applies to behaviors (like hand washing or fear of being on an airplane), but it can also work for thoughts (e.g., "I’m a loser" or “Bad things will happen”). In these instances, imaginal exposure is used. This is where the patient writes down the obsessions or listens to recordings of them, introduces doubt and builds tolerance to the distress.

The Role of Medication

Improvement with ERP is typically between 50% and 60%. For those who do not achieve acceptable remission, medication is sometimes recommended.

Medications (such as SSRIs, clomipramine, and in extreme cases, anti-psychotics) help make the error signals less emotionally urgent. They dampen the distress, making rumination less automatic. In all cases, medication should be managed by a psychiatrist, and outcomes are generally best when medication is combined with some form of ERP.