Saturday, May 18, 2024

COLUMN: Obsessive-compulsive disorder isn't what it looks like on TV, and that matters

April 8, 2024

Here's a thought experiment: don't think about a panda. Did it work? Or are you thinking about a panda? I'm assuming, now that you've read the word panda for the third time, that you're thinking about the black and white creature in some capacity. So you messed that one up. It's okay; I have another one. Try this one: don't think about a panda. 

Did it work?

Didn't think so. So, what? Are you some kind of panda enthusiast? If you are, good for you. If not, how can we explain the fact that you've been unable to get the thought of pandas out of your head since you started reading this? 

Well, it turns out thinking about something makes you think about it more (I know, crazy). But we can take that a step further, because even after I asked you to forget about the panda, you couldn't. In fact, if you try it with pretty much any other thought, you’ll find the more you try to push it out of your head, the more it stays in your head. Because that's just how thoughts work. The more you think about something in any capacity, the more it floats around in your mind.

But who cares about pandas, right? More specifically, who cares if you can't get them out of your head? It might get a little annoying, eventually, but nothing more than that. Plus, it's not like being perceived as a panda enthusiast makes you a bad person or anything. 

So let's make a leap. Let's replace pandas with something a bit more taboo, like maybe the thought that you're a murderer. Or the thought that maybe you didn't turn the stove off when you last left your home, and you've put people's lives in danger. Or maybe even the thought that you're going to lash out and hurt someone close to you.

Just like our panda, the fact that you're now thinking about any of the aforementioned thoughts continues to not indicate anything about your character. But what if you weren't reading an article? What if you were just minding your own business and any one of those thoughts popped into your head? Would it then be reasonable to say that it does indicate something about your character?

Most would say no, as we have a word for those kinds of thoughts. We call them intrusive thoughts, and if you've been on social media at any point in the last two years or so, you should be familiar with the term. However, in my experience, the internet-defined intrusive thought seems to refer more to a sense of impulsiveness rather than what I've just described above.

Similarly, we also see the term obsessive-compulsive disorder, or OCD, being tossed around in casual conversation, usually describing a desire for perfection or a need for cleanliness. However, obsessive-compulsive disorder is much more than this.

OCD consists of two main elements: the obsession and the compulsion. 

The obsessive thoughts in OCD are recurrent and persistent thoughts, urges or images that cause marked anxiety or distress, according to the manual many professionals use to diagnose the disorder, the DSM-V. 

Sounds sort of familiar, right?

The compulsive side of OCD is defined as repetitive behaviors or mental checks that someone feels driven to perform in response to an obsession. This can include hand washing, checking, praying and counting.

Compulsions (sometimes referred to as safety behaviors) provide fleeting relief from obsessions, which in turn reinforce them. The result is obsessions returning at a higher frequency, thus continuing the cycle.

OCD becomes diagnosable when the obsessions and/or compulsions impair someone's ability to function. 

If that's the case, then surely "letting your intrusive thoughts win" (as some users tend to put it) and getting a tattoo is much different from acting on intrusive thoughts about murder. Similarly, a simple preference for neatness has to be different from spending hours organizing objects so they're "just right."

For answers to this, I spoke with Laura Lokers, co-founder of the Anxiety and OCD Treatment Center of Ann Arbor. Lokers explained to me how OCD actually works in the brain, and how intrusive thoughts play into it.

Essentially, when an intrusive thought enters any brain, the brain employs an "alarm system" for that thought, as it's often distressing. And for people with OCD, according to Lokers, that alarm system works just the same as it would with neurotypical people. The big difference, she said, is with the alarm clearing system.

So when a thought like "What if I'm a murderer?” pops into the brain, the person with OCD is going to have more trouble dismissing it as just a thought than the neurotypical individual, Lokers said. But it's not like people with OCD don't know their thoughts are irrational and excessive, they do. They just can't trust that they're ever going to be 100% certain about them. 

"OCD is not a problem of not knowing the answer," Lokers said. "It's a problem of not trusting the answer."

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Lokers put it like this: imagine asking someone for directions, with the catch being you know they're a pathological liar. Sure, they can give you an answer, but no matter how many times you ask for directions, you'll never really trust them.

So certainty is the issue here. Those of us with OCD set impossible standards for what we deem to be an acceptable level of certainty.

To get more scientific, Lokers talked about the caudate nucleus, a section of the brain she said essentially tells us to "move on."

For example, if you've ever asked yourself "Did I shut the car door?" you were checking in with the caudate nucleus, Lokers said. 

For neurotypical people, Lokers said if the level of certainty is above 70%, then they move on with their day. But for folks with OCD, that level of certainty sits close to 100%, making it difficult to confidently move on from a thought. 

This applies to most thought contents, whether that be the question "Did I leave the door unlocked?" or "Am I a murderer?"

So while I can't speak for everyone’s experiences with OCD, especially because symptoms vary so widely, I speak for myself when I say people don't understand this side of OCD. 

And where there's lack of understanding, there's an inherent unconscious bias.

For so many years (and still quite often now) people with OCD have been treated as bad people for their intrusive thoughts. And, according to Lokers, this is because people often get stuck on the content of the thoughts.

"These folks are often treated like they are dangerous people," she said. “They are statistically the safest people to be around, because they're the most concerned."

Yet Lokers said this hasn't stopped her from seeing children being taken away from their parents because judges and even other mental health professionals don't understand that people with OCD tend not to act on their thoughts, and instead are simply anxious/scared of them. 

When I was seeking treatment for my OCD, I was lucky enough to get in contact with mental health professionals who helped me understand how I can view intrusive thoughts as exactly that: intrusive (a lot harder than it sounds).

But too often, both on the internet and in real life, I see people met with ostracization when they open up about their intrusive thoughts. Because when the "internet definition" of intrusive thoughts becomes the norm, it's no surprise people are shocked or scared upon hearing the contents of people's real intrusive thoughts. That's the primary reason why I’ve never opened up about my intrusive thoughts outside of therapy.

It's this lack of understanding that has allowed us to turn the disorder into an adjective.

It goes beyond just OCD and intrusive thoughts, too. The same concept can be applied to a myriad of mental disorders. Using "schizo" as a synonym for paranoid, calling someone bipolar because they're experiencing mood swings or calling someone a psychopath because they're being mean creates misconceptions about the character of people who actually have those disorders.

When these phrases are normalized, it makes it so much harder for those with certain mental disorders to feel comfortable sharing symptoms that they quite literally have no control over. 

After all, if you're using the phrase "schizo" as a negative adjective, then what's your first thought going to be when you meet someone with schizophrenia? 

Being told "I'm a little OCD, too" when opening up about my mental health was not affirming, and I’m not blaming individuals for not knowing the intricacies of mental disorders. Rather, I believe there's a societal misconception that we're more accepting of mental disorders because we encourage awareness and check in with loved ones. In reality, it takes more than that. 

Reaching out to a friend about their mental state means nothing if the reaction to their symptoms is disgust, anger or fear. 

I think it's great we're moving from a society in which too much display of mental disorders was a one-way ticket to an asylum to a society that is more accepting of people seeking help. But we still have a ways to go. To fix society's negative perceptions of mental disorders is to backpedal on years of subtle ableism that has embedded itself in western culture.

However, in a world where an estimated one in five adults lives with a mental illness, your understanding statistically makes the life of someone close to you a better one. 

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