Obsessive Compulsive Disorder (OCD) sucks. It feels good to say it, in the past I would have never been able to go that far. I used to ruminate on numbers excessively, perform actions 3 times but not 4 times, sit on the couch a certain way, etc… At one point my OCD had escalated to the point where I got in and out of my car 100 times before being able to leave my apartment. It left me with significant hip pain for a couple weeks and even more shame. This was my life with OCD. OCD isn’t always about being clean or tidy in the way the media usually portrays it. OCD can take this form, but at its heart OCD is about performing compulsions out of fear that something terrible is going to happen if you don’t perform it. Hence the performing of actions a certain amount of times, or having incessant and ruminating thoughts about doom that only exist in your mind.
I believe that my battle with OCD started with the chronic stress that I experienced with managing my medical conditions. My story of OCD didn’t truly begin until the spring of 2017 when I was 25. In the spring of 2016, however, my world was flipped upside down with a diagnosis of high grade dysplasia in my stomach, a precursor to stomach cancer and a treatment plan of removing my stomach. A submarine-sized pill to swallow. Surgery went well though, they caught it early and I was on my way to recovery. Except for my brain; it went into hyperdrive to start protecting my body. It started with a voice in my head saying you can’t quit, you can’t give up, you have to keep fighting. This somehow manifested into running up and down the stairs and applying deodorant multiple times before I could leave the house. I would have to apply the deodorant perfectly as I viewed my arm pit as my stomach and if I didn’t hit the circumference with exact precision then the cancer would come back. The following spring after my surgery, just as I was feeling good about my stomach surgery recovery, I started having trouble running and walking up stairs. I initially chalked this up to burnout but went to the doctor just to double check things. After a lengthy work up I was diagnosed with pure red cell aplasia (PRCA). My immune system was destroying my red blood cells as they were made, which left me extremely anemic. Now running, one of my best responses to stress, was gone. From there numerous compulsions evolved that aren’t worth the space on this page. Instead, I would prefer to talk about some of my thoughts on the physiology and mechanisms of OCD. I’m well aware that being told your compulsions aren’t real isn’t helpful, because trust me, it wasn’t helpful for me either. But I’m a big believer that fear is just the absence of knowledge and the more you know about your enemy the better you can disarm it.
Therapy was initially suggested for my OCD. In my experience though therapy very much focuses on talk therapy or the top-down approach which deals with conscious and active parts of our brain. Doctors and therapists will also most likely say that OCD is a lifelong diagnosis as well. However, there are a growing number of therapists that are starting to work more in a bottom-up approach, which takes into account more active visual and movement therapies. For an excellent explanation of the science of these techniques see Bessel Van Der Kolk’s ‘The Body Keeps the Score’. While what worked for me is not necessarily a purely bottom-up approach I still believe it has merit, especially for individuals where the traditional top-down approach has not been beneficial. What I found to work for my OCD is more of a mixed bag approach. I believe that this approach worked because like any medical condition, OCD is nuanced and there most likely isn’t a silver bullet fix that is applicable to OCD. For me, identifying and then managing four drivers of my OCD was what helped me on the path to recovery; cortisol, dopamine, serotonin, and oxytocin.
Cortisol is ubiquitously known as the stress hormone. In acute loads it is what keeps us alive, but chronic release is debilitating. Chronic release is caused by stimuli that exist in our modern world; such as meeting endless deadlines at work, or waking up and realizing that Charles Barkley is the most sane person in the room. Robert Sapolsky, a neuroscience professor at Stanford University and one of my favorite authors has done a significant amount of work on stress, community, and human behavior. One piece of his life’s work is that humans are ill-fitted for the chronic stress that we encounter today, which is different from the acute stressors of our ancestors. In brief, the chronic stressors that we face today cause continuous activation of the hypothalamic-pituitary-adrenal-axis (HPA axis).
Source: Wikimedia Commons
Chronic activation of the HPA axis results in an abnormal release of cortisol (CORT in the diagram). This constant release of cortisol results in decreased efficiency of neurons related to learning, memory, and judgement, obviously an important tool to have when dealing with OCD. Additionally, chronic stress increases the size and function of the amygdala which is an area of the brain that contributes to the body’s response to fear and anxiety signals (1). The foundational work done by Sapolsky helps to understand the mechanism, but cortisol has also been found to be chronically elevated in patients with OCD by a recent meta-analysis as well (2).
Dopamine is another hormone that can contribute to the nauseating cascade of OCD behaviors. Dopamine is a feel good hormone, it, along with serotonin drive much of human behavior and are also what give us pleasure. An interesting aspect of dopamine though is that since it modulates excitability, there are pre-clinical imaging studies that show that an over productive dopamine system can exacerbate OCD (3). Dopamine is released during the pursuit of a goal, and especially when the probability of an outcome is uncertain. This is part of the reason why humans can become obsessed with sports, gambling, and any product with an uncertain outcome. I also believe it can drive OCD behavior because the compulsions that come with OCD also have an uncertain outcome. Sometimes the compulsion hits just right and is enough to break the habit, other times it is crippling and can leave you performing an action repetitively waiting for that perfect dopamine hit. The most common and lowest barrier entry to dopamine release that exists in the developed world is social media. These platforms have developed such an enormous following because they are more or less dopamine crack houses. The anticipation of photo posts, likes, and virtue signaling that drive people to them also result in a dopamine overload and unsurprisingly are why it’s almost impossible for users to quit using them. In a way social media can then become like gasoline for OCD as it further conditions your brain to run off of unsustainable dopamine sources just like it does with compulsions. This hyper-excitability can then harm sufferers of OCD, especially those who may have a nervous system already in hyperdrive from past trauma.
Along with cortisol and dopamine there is also serotonin, which is produced in the brain but also heavily produced by enteric nerves and epithelial cells in our gastrointestinal tract. Serotonin is a heavy modulator of our mood and nervous system. In short, it’s part of what makes us feel good on a daily basis. A pharmacological treatment for OCD are SSRIs (selective serotonin reuptake inhibitors). Basically these drugs function by keeping serotonin in the synapse (which is the space between two neurons) longer. This increased exposure to serotonin in the synapse is then thought to have an ameliorating effect on OCD symptoms. Interestingly, an enormous portion of endogenous serotonin is produced and released in the gut, modulated by the gut microbiome, a current firecracker in the biomedical research realm. Whether we like it or not the gut microbiome is heavily modulated by diet and lifestyle, especially fiber intake. The current dietary recommendations for fiber intake is ~30g, which very few people actually meet. Even worse is that based on current research 30g is most likely not anywhere close to what is needed for a thriving microbiome. Unfortunately, the hyper-processed diet that many of us follow further exacerbates this problem by not only being low in fiber but also causing dopamine spikes and swings that we know can contribute to an exhausted nervous system, therefore further intensifying OCD.
Finally, there is oxytocin, ubiquitously known as “the love hormone”. Yes, it’s released when bonding with a loved one but it is also most likely released when your best friend surprises you with your favorite beer. Currently there isn’t data that closely ties oxytocin to helping with OCD, however some of the physiology of how oxytocin works leaves a plausible argument for it being helpful. Once released, oxytocin has an ameliorating effect on the amygdala, (remember that fear and anxiety control station mentioned earlier). This down-regulation of the amygdala can then help us to relax more and decrease our fear and anxiety which could then help with the fear and ruminating thoughts caused by OCD.
When taken together it starts to make sense how these four hormones; cortisol, dopamine, serotonin, and oxytocin all are able to shape an individual’s OCD. So what’s my solution? Well to be frank my solution is novel only in the aspect that it uses multiple angles to approach OCD. Most of these ideas have been written or talked about more thoroughly by others, but it was only by integrating them into my life that I began to get better.
The piece that helped me the most was merely understanding my OCD, which is why I outlined these key physiology hormones. While being told that compulsions are not rational was not helpful, learning about the roots of my OCD was incredibly therapeutic. No one else took the time or was able to piece together my medical history and apply the physiological consequences of this in a coherent manner. I frequently would tell doctors and therapists that my mental health didn’t begin to decrease until my physical health did. Unfortunately, this was never acknowledged or investigated by any practitioner I saw, which is why I took to learning more about how my life experiences and underlying physiology may have affected me and how they could relate to OCD.
One piece that I find very interesting about the physiological undertones of OCD is that our modern world is incredibly well designed to exacerbate them. As mentioned previously we live in a cheap dopamine flooded world. Our food, our media, and most of our lifestyles deprive us of the long term sustainable dopamine that we get from a goal that takes work. We also don’t spend time in nature or eat right which saps us of serotonin. We’re constantly under some sort of modern stress that leaves us burned out, hyper-aroused, and flooded with cortisol. And then when you mix all of these factors together it doesn’t leave a ton of time for a natural and warming oxytocin release.
When my OCD was at its worst I was experiencing many of these exact exacerbating factors, I was in a career that wasn’t right for me, I had no sense of control over my physical health, and still hadn’t reeled in my diet to where it is now. It took time, but once I addressed these factors my OCD improved rapidly. The first step I took was changing jobs. Everyone’s life circumstances are different and their ability to do this is different, but for me it was immensely beneficial. My previous two careers had been built completely on productivity and corporate profit. Mix this in with a shot of office politics and it was the perfect cocktail to blow my cortisol and HPA axis up. Once moving to a career that was more aligned to my interests, one that gave me meaning, and autonomy, then my OCD started to fade. This wasn’t all it took though. I also had to get a sense of control of my health. This only occurred after searching out and finding providers that truly thought through my health history. These providers still had the same certifications; immunology, hematology, gastrointestinal disease, etc… as my previous providers, but where they stood apart from other doctors is that they completely listened, and had no defense mechanism. Their goal, just like my own, was to help me get better. Every doctor probably thinks that they’re doing this and that they’re on the same page with their patient, but far too often they aren’t. After these two major changes everything else began to fall into place and the rest of the pieces of my life that I changed were gravy. I cleaned up my diet, I was back in my home state of Michigan seeing plenty of friends and family, and I continued to read medical journals, textbooks, and anecdotal evidence to help with my OCD. In the end, getting a hold of my OCD was a lot like putting out a fire in my brain, cheap dopamine sources and chronic stress was like kerosene that continually burned me out and kept my brain on fire. Conversely, changing jobs, getting a hold of my physical health, and the other lifestyle changes mentioned previously were like cool cool menthol on my noggin, slowly, but surely returning me to where I wanted to be.
Since they were so helpful to me I’ve left the names and some of the links to books that have been the most helpful to me. With the most helpful book being first.
- ‘Why Zebras Don’t Get Ulcers’ by Robert M. Sapolsky
- ‘The Body Keeps the Score’ by Bessel Van Der Kolk
- ‘Behave: The Biology of Humans at Our Best and Worst’ by Robert M. Sapolsky
- Vyas, A.; Mitra, R.; Shankaranarayana Rao, B.S.; Chattarji, S. Chronic stress induces contrasting patterns of dendritic remodeling in hippocampal and amygdaloid neurons. J. Neurosci. 2002, 22, 6810–6818. [CrossRef] [PubMed]
- João Sousa-Lima, Pedro Silva Moreira, Catarina Raposo-Lima, Nuno Sousa, Pedro Morgado. Relationship between obsessive compulsive disorder and cortisol: Systematic review and meta-analysis. European Neuropsychopharmacology. Volume 29, Issue 11, 2019. Pages 1185–1198
- Koo MS, Kim EJ, Roh D, Kim CH. Role of dopamine in the pathophysiology and treatment of obsessive-compulsive disorder. Expert Rev Neurother. 2010 Feb;10(2):275–90. doi: 10.1586/ern.09.148. PMID: 20136383.