The Science & Treatment of Obsessive Compulsive Disorder (OCD)

KEYPOINTS

• 01

  OCD is an itch that gets worse when you scratch it

  Obsessions are unwanted, intrusive, recurring thoughts; compulsions are behaviors performed to relieve the anxiety they cause. The relief is brief and reinforces the loop, so the next obsession comes back stronger. Anxiety binds the two together. People with OCD usually know their fears are irrational, such as believing a left turn will cause a death, yet the urge feels overwhelming.

• 02

  Common, debilitating and often hidden

  Huberman cites estimates that 2.5% to perhaps 4% of people have true OCD, and says it ranks seventh among the most debilitating illnesses of any kind. The range is wide because many people disguise symptoms out of shame, using small hidden rituals such as tapping a thigh or counting silently. Most people with OCD never seek evidence-based treatment.

• 03

  Three broad categories: checking, repetition and order

  Checking includes returning to the stove or locks 20 or 30 times. Repetition includes counting sequences or, as bandmates described of Joey Ramone, walking a stairway a set number of times. Order covers symmetry, cleanliness and 'incompleteness,' a sense that something is not right and cannot be left. Many intrusive thoughts involve taboo, violent or sexual content, which deepens the shame.

• 04

  A cortico-striato-thalamic loop is the core circuit

  Imaging studies consistently show heightened activity in a loop linking the cortex, the striatum (which selects actions and holds them back, 'go' and 'no-go') and the thalamus, which gates what reaches awareness. Stimulating these circuits in animals produces compulsive grooming to the point of hair loss, and effective treatments reduce activity in the loop. Twin studies suggest roughly 40 to 50% of cases have a genetic component.

• 05

  Exposure therapy works by raising anxiety, not lowering it

  Unlike most anxiety treatment, cognitive behavioral therapy with exposure and ritual prevention guides patients, step by step, to articulate their deepest fear and face the trigger, whether real or imagined, then refrain from the compulsion while anxiety peaks. Patients learn anxiety can exist without the ritual. Huberman describes protocols summarized by Columbia's Helen Blair Simpson: two planning sessions, then about 15 exposure sessions at twice a week or more, with homework.

• 06

  In head-to-head data, exposure therapy beat SSRIs

  In a 12-week study (Foa and colleagues, 2005), placebo did nothing, while exposure therapy cut Y-BOCS severity from about 25 to about 11 by four weeks. SSRIs helped significantly but less, with gains from weeks four to eight. Starting both together added nothing over therapy alone, but adding exposure therapy for someone already on an SSRI improved symptoms further. Medication changes should go through a physician.

• 07

  SSRIs help even though serotonin may not be the root problem

  Options include fluoxetine, fluvoxamine, sertraline, citalopram and the less selective clomipramine. Yale's Christopher Pittenger notes in a 2021 review that serotonin is not clearly disrupted in OCD, but serotonin supports cognitive flexibility, and OCD involves rigidity. Real benefit often takes 10 to 12 weeks. For non-responders, psychiatrists may add a low-dose neuroleptic, which acts body-wide and can cause motor and other side effects.

• 08

  Newer treatments remain unproven

  Psilocybin has not yet matched its depression results in OCD. In a 2020 placebo-controlled study of 14 adults, smoked cannabis high in THC or CBD had little acute effect on OCD symptoms. Small ketamine studies show some relief in some patients. Transcranial magnetic stimulation over motor areas may help break the rapid obsession-compulsion pairing, with most excitement around combining it with therapy or medication.

• 09

  Hormone patterns differ in OCD

  A study of 30 patients and 30 controls found elevated cortisol and DHEA in women with OCD, and higher cortisol with lower testosterone in men. Huberman suggests both patterns could reduce GABA-mediated inhibition, though cause and effect are unknown and hormone-based treatments are untested.