I went back to read 4 of your pieces on OCD to get a proper idea on what you already said about the topic.
What pervasive myth/misunderstanding do you think is most inhibiting progress to OCD alleviation advocacy? What perception would you turn 180?
To give an example as a point of comparison, I was diagnosed 3 years ago with a very severe variation of ADHD. By far the worst myth for ADHD is that it was an improperly over diagnosed and overprescribed condition, when the situation was exactly the opposite. And even after I got diagnosed and shared about it, I’ve had conflicts with others who had deep rooted skepticism of everything to do with psychiatry as a scientific field and clinic practice, telling me that ADHD diagnosis is largely fake. I could only imagine what such people faced 10-15 years ago.
If there was greater advocacy to catch children early to get them properly medicated, it would have eliminated an enormous amount of suffering.
1. Lack of knowledge in the community the existence of some of the more disturbing themes (Harm OCD, POCD, Sexuality OCD).
2. Lack of understanding of the sheer severity of the condition.
3. A reluctance to explore more aggressive treatment options because of a sense that 'management' of the condition is adequate.
4. Rigid insistence on the classical obsessions + compulsions model. Although both are usually present *to some degree*, often one is much more prominent than the other, and this should not prevent diagnosis in cases where it is appropriate.
5. Lack of understanding that insight is a spectrum in OCD- some people with OCD genuinely believe their own fears, others do not believe them at all, and yet others think they are plausible. The classic case of "patient who has insight but can't stop ruminating and compulsing" is not always right!
6. Related to 5- There is an extremely fine balance between A) Not over reassuring the patient B) Doing some thought challenging and even- to a limited degree, some reassurance. The best clinicians were able to navigate this -to challenge my beliefs with evidence, arguments and case studies of other people with OCD *when that was what the situation called for*, all the while keeping the focus on me growing in my capacity to dismiss my fears indpendently. The balance is extremely fine, and most clinicians can't manage it- either they engage too much with the content of the thoughts- encouraging excessive reassurance seeking- or they engage too little, and the patient, trapped in a web of their own delusions, starts to actually believe their fears might have reality.
What relationship do you think there is between colloquial OCD and clinical OCD?
For example, I *hate* getting sticky or greasy stuff on my hands. Hate it so much. If I'm hiking and I get tree sap on me, it will actually ruin my day. I pack alcohol wipes in case this happens, but it'd still make me pretty miserable and I'd spend the rest of the hike worried I'd missed some on my shirt or backpack.
People call this "OCD", but I'm not so sure. Seems perfectly reasonable to me. Is that on the same sliding scale, or in a different category?
In general, no connection between colloquial and real OCD is my guess. May be related in some cases, e.g. through autism and OCPD. Popular depictions of colloquial OCD include germphobia which can definitely be a symptom of real OCD.
I haven't looked into the hereditability of OCD. The standard result seems to be ~45% hereditable. My deep suspicion is that the normal ways we study hereditability are very misleading, especially for non experts. I plan to do a deep dive on this at some point- although I'm not sure I have anything to add yet that hasn't been said already.
For myself, I think my OCD is profoundly reflective of the way I view the world- it reflects autism and my ADHD. This is not to say these are "non-genetic" factors. Not only our conditions, but our very world view is shaped by your genes in conjunction of the environment they interact with.
I also have OCD. Tried to dive into philosophy just because i like it. But OCD makes it so important that makes me being disfunctional in the daily day (work, friends, family and love ones, other interest, etc). Any advice or insight on this?
I found her descriptions of OCD thought patterns be shockingly accurate. Unfortunately, I assumed the internet was forever and didn't save the blog, and now it's gone. (I even tried to convince squarespace to let me pay the author's bill, but for any number of reasons they didn't let me do that)
Could you describe in kinda narrative form the greatest progress you’ve made in coping with it and any ideas, ways of thinking, or behaviours that eased any aspects of it?
The biggest progress I made was seeing a therapist with a very long background in OCD, who put my symptoms in the context of many hundreds of other similar cases.
After this, the next biggest burst of progress came a few years later. I worked with a therapist with less experience with OCD, but much cheaper (free in fact) and with boundless compassion and enthusiasm. I saw her for a long time and it helped me change the ways I thought.
Explicitly resolving to see OCD as the cost of a mental constitution that allows me to do great things, and as a barrier that gives me a chance to heroically overcome it is useful.
Living with a friend also led to a burst of progress. Not being alone is very important to me.
I would be really interested in hearing you expound more on this:
> Explicitly resolving to see OCD as the cost of a mental constitution that allows me to do great things, and as a barrier that gives me a chance to heroically overcome it is useful.
I was recently diagnosed with OCD and have been feeling shitty about my behavior patterns [I perceive as] derived from my OCD/anxiety.
OCD gives you many opportunities. This is not to say that, of itself, OCD is worth having- certainly not, but if you seize the opportunity you can gain from it, maybe even more than you lose.
You can use it as an opportunity to develop courage, by fighting against much greater barriers than most people. You can use it as an opportunity to develop compassion for those in pain by thinking about your pains and seeing them in others. You can use it as a way of gaining wisdom by seeing that people can be radically different from each other, and thus that simple models of what all people are like do not apply. You can use it as a starting point for thinking philosophically about thought, doubt, desire and the self.
Just as you have spoken of "Pure O," do you think there's such a thing as Pure C? That is, where the compulsive aspect dominates at all times: not necessarily in response to an obsession or to quell that anxiety, but instead designed to increase anxiety/discomfort purely for the sake of having to endure it (and proving once again that you could). I.e. intense perfectionism/just right sensations applied to all sorts of rituals just to maintain the infrastructure of forcing yourself to do them. So it's more about leveraging subjective feelings of agency and "will" than moral stuff. Think fear of weakness rather than badness.
I am just wondering whether this classic model of "obsession triggers compulsion designed to reduce anxiety; reinforce rinse and repeat" is always useful, especially where the compulsive or body-based side dominates. Not to mention neurodivergent profiles. Curious what your experience has been with perfectionism and "just right" experiences.
I cannot diagnose OCD especially over the internet. However, that does sound a lot like it could potentially be OCD with the obsessive element that the compulsions help manage being thoughts that if you don't do the compulsions you have failed or are weak in some way- obsessions can relate to compulsions in all sorts of ways. They key question is does it cause distress or impedance of function? If it causes substantial distress or impedance of function, it is certainly worth seeing someone.
Thanks, and certainly didn't mean to put you in the awkward position of diagnosing (already diagnosed). I was mostly interested in your thoughts on the compulsion/perfectionism side and the possibility of Pure C as a coherent concept. What you say makes a lot of sense though.
I think it's a conceptual possibility- but to the extent that you worry about the compulsions at all, and doing the compulsions relives that worry- even if the obsessions can only exist in conjunction with the compulsion as in the case you describe- there are obsessions. It's hard to imagine OCD without at least very minimal obsessions in the sense of recurring thoughts- because these are almost constitutively necessary for the presence of anxiety.
However, I certainly think OCD can be more "obsession focused" or more "compulsion focused".
If this question is too hard or confusing, a much easier question would be: have you ever tried ketamine, or know anyone who has benefited from ketamine for their OCD?
Not sure I understand your first paragraph, but the second makes me think of Tourette Syndrome. TS and OCD are commonly co-occurring conditions, and I've seen some speculation about a possible relationship between the "just right" feeling and the premonitory urge to tic in TS or tic disorders, so in that sense a tic disorder could be said to be a pure D form of OCD, and maybe there are other forms. Sorry if I misunderstood your comment.
Yes, Tourette's is definitely in the mix! Good call. In general, people underestimate how nuanced Tourette's can be (it's rarely 100% involuntary), so you could definitely see it as being on a continuum from classic OCD. My understanding is that "just right" also encompasses symmetry concerns and completion obsessions, which could be anything from how objects are lined up to the shape of your haircut. So, not necessarily body-based or movement-based. There's a very philosophical book on TD released recently, which I've been meaning to check out: https://link.springer.com/book/10.1007/978-3-031-19104-6
In terms of the first paragraph, I think part of what I was getting at is the possibly important distinction between OCPD (obsessive personality) and OCD. But OCPD has all this psychoanalytic baggage, so it tends to get ignored. David Shapiro describes that compulsive element really beautifully in his book Neurotic Styles from the 1960s and especially, his second book Autonomy and Rigid Character.
I went back to read 4 of your pieces on OCD to get a proper idea on what you already said about the topic.
What pervasive myth/misunderstanding do you think is most inhibiting progress to OCD alleviation advocacy? What perception would you turn 180?
To give an example as a point of comparison, I was diagnosed 3 years ago with a very severe variation of ADHD. By far the worst myth for ADHD is that it was an improperly over diagnosed and overprescribed condition, when the situation was exactly the opposite. And even after I got diagnosed and shared about it, I’ve had conflicts with others who had deep rooted skepticism of everything to do with psychiatry as a scientific field and clinic practice, telling me that ADHD diagnosis is largely fake. I could only imagine what such people faced 10-15 years ago.
If there was greater advocacy to catch children early to get them properly medicated, it would have eliminated an enormous amount of suffering.
1. Lack of knowledge in the community the existence of some of the more disturbing themes (Harm OCD, POCD, Sexuality OCD).
2. Lack of understanding of the sheer severity of the condition.
3. A reluctance to explore more aggressive treatment options because of a sense that 'management' of the condition is adequate.
4. Rigid insistence on the classical obsessions + compulsions model. Although both are usually present *to some degree*, often one is much more prominent than the other, and this should not prevent diagnosis in cases where it is appropriate.
5. Lack of understanding that insight is a spectrum in OCD- some people with OCD genuinely believe their own fears, others do not believe them at all, and yet others think they are plausible. The classic case of "patient who has insight but can't stop ruminating and compulsing" is not always right!
6. Related to 5- There is an extremely fine balance between A) Not over reassuring the patient B) Doing some thought challenging and even- to a limited degree, some reassurance. The best clinicians were able to navigate this -to challenge my beliefs with evidence, arguments and case studies of other people with OCD *when that was what the situation called for*, all the while keeping the focus on me growing in my capacity to dismiss my fears indpendently. The balance is extremely fine, and most clinicians can't manage it- either they engage too much with the content of the thoughts- encouraging excessive reassurance seeking- or they engage too little, and the patient, trapped in a web of their own delusions, starts to actually believe their fears might have reality.
What relationship do you think there is between colloquial OCD and clinical OCD?
For example, I *hate* getting sticky or greasy stuff on my hands. Hate it so much. If I'm hiking and I get tree sap on me, it will actually ruin my day. I pack alcohol wipes in case this happens, but it'd still make me pretty miserable and I'd spend the rest of the hike worried I'd missed some on my shirt or backpack.
People call this "OCD", but I'm not so sure. Seems perfectly reasonable to me. Is that on the same sliding scale, or in a different category?
In general, no connection between colloquial and real OCD is my guess. May be related in some cases, e.g. through autism and OCPD. Popular depictions of colloquial OCD include germphobia which can definitely be a symptom of real OCD.
Have you found any methods or concepts to help you manage or cope with it?
1. Therapy from someone with a long background in OCD who could put it in perspective and compare with the experience of other people with OCD.
2. Cold showers.
3. Ashwagandha
4. Living with someone else.
5. Exercise.
6. Socialising a lot.
7. Projects with a sense of larger meaning.
8. Trying to have a heroic conception of myself.
How heritable do you think OCD is? What are the non-genetic causes?
I haven't looked into the hereditability of OCD. The standard result seems to be ~45% hereditable. My deep suspicion is that the normal ways we study hereditability are very misleading, especially for non experts. I plan to do a deep dive on this at some point- although I'm not sure I have anything to add yet that hasn't been said already.
For myself, I think my OCD is profoundly reflective of the way I view the world- it reflects autism and my ADHD. This is not to say these are "non-genetic" factors. Not only our conditions, but our very world view is shaped by your genes in conjunction of the environment they interact with.
I also have OCD. Tried to dive into philosophy just because i like it. But OCD makes it so important that makes me being disfunctional in the daily day (work, friends, family and love ones, other interest, etc). Any advice or insight on this?
In a past article on OCD you linked to this blog:
https://notmakinglemonade.com/myblog/2020/2/5/im-so-ocd-about-scrupulosity
I found her descriptions of OCD thought patterns be shockingly accurate. Unfortunately, I assumed the internet was forever and didn't save the blog, and now it's gone. (I even tried to convince squarespace to let me pay the author's bill, but for any number of reasons they didn't let me do that)
Do you have anything from that blog saved?
Thanks bear
Could you describe in kinda narrative form the greatest progress you’ve made in coping with it and any ideas, ways of thinking, or behaviours that eased any aspects of it?
The biggest progress I made was seeing a therapist with a very long background in OCD, who put my symptoms in the context of many hundreds of other similar cases.
After this, the next biggest burst of progress came a few years later. I worked with a therapist with less experience with OCD, but much cheaper (free in fact) and with boundless compassion and enthusiasm. I saw her for a long time and it helped me change the ways I thought.
Explicitly resolving to see OCD as the cost of a mental constitution that allows me to do great things, and as a barrier that gives me a chance to heroically overcome it is useful.
Living with a friend also led to a burst of progress. Not being alone is very important to me.
I would be really interested in hearing you expound more on this:
> Explicitly resolving to see OCD as the cost of a mental constitution that allows me to do great things, and as a barrier that gives me a chance to heroically overcome it is useful.
I was recently diagnosed with OCD and have been feeling shitty about my behavior patterns [I perceive as] derived from my OCD/anxiety.
OCD gives you many opportunities. This is not to say that, of itself, OCD is worth having- certainly not, but if you seize the opportunity you can gain from it, maybe even more than you lose.
You can use it as an opportunity to develop courage, by fighting against much greater barriers than most people. You can use it as an opportunity to develop compassion for those in pain by thinking about your pains and seeing them in others. You can use it as a way of gaining wisdom by seeing that people can be radically different from each other, and thus that simple models of what all people are like do not apply. You can use it as a starting point for thinking philosophically about thought, doubt, desire and the self.
Just as you have spoken of "Pure O," do you think there's such a thing as Pure C? That is, where the compulsive aspect dominates at all times: not necessarily in response to an obsession or to quell that anxiety, but instead designed to increase anxiety/discomfort purely for the sake of having to endure it (and proving once again that you could). I.e. intense perfectionism/just right sensations applied to all sorts of rituals just to maintain the infrastructure of forcing yourself to do them. So it's more about leveraging subjective feelings of agency and "will" than moral stuff. Think fear of weakness rather than badness.
I am just wondering whether this classic model of "obsession triggers compulsion designed to reduce anxiety; reinforce rinse and repeat" is always useful, especially where the compulsive or body-based side dominates. Not to mention neurodivergent profiles. Curious what your experience has been with perfectionism and "just right" experiences.
Thanks for doing this AMA!
I cannot diagnose OCD especially over the internet. However, that does sound a lot like it could potentially be OCD with the obsessive element that the compulsions help manage being thoughts that if you don't do the compulsions you have failed or are weak in some way- obsessions can relate to compulsions in all sorts of ways. They key question is does it cause distress or impedance of function? If it causes substantial distress or impedance of function, it is certainly worth seeing someone.
Thanks, and certainly didn't mean to put you in the awkward position of diagnosing (already diagnosed). I was mostly interested in your thoughts on the compulsion/perfectionism side and the possibility of Pure C as a coherent concept. What you say makes a lot of sense though.
I think it's a conceptual possibility- but to the extent that you worry about the compulsions at all, and doing the compulsions relives that worry- even if the obsessions can only exist in conjunction with the compulsion as in the case you describe- there are obsessions. It's hard to imagine OCD without at least very minimal obsessions in the sense of recurring thoughts- because these are almost constitutively necessary for the presence of anxiety.
However, I certainly think OCD can be more "obsession focused" or more "compulsion focused".
If this question is too hard or confusing, a much easier question would be: have you ever tried ketamine, or know anyone who has benefited from ketamine for their OCD?
No and no. I would be very curious to read on the literature at some point.
Not sure I understand your first paragraph, but the second makes me think of Tourette Syndrome. TS and OCD are commonly co-occurring conditions, and I've seen some speculation about a possible relationship between the "just right" feeling and the premonitory urge to tic in TS or tic disorders, so in that sense a tic disorder could be said to be a pure D form of OCD, and maybe there are other forms. Sorry if I misunderstood your comment.
I did also think of tic disorders when reading Chris's comment, although I'd stress I'm not a doctor.
Yes, Tourette's is definitely in the mix! Good call. In general, people underestimate how nuanced Tourette's can be (it's rarely 100% involuntary), so you could definitely see it as being on a continuum from classic OCD. My understanding is that "just right" also encompasses symmetry concerns and completion obsessions, which could be anything from how objects are lined up to the shape of your haircut. So, not necessarily body-based or movement-based. There's a very philosophical book on TD released recently, which I've been meaning to check out: https://link.springer.com/book/10.1007/978-3-031-19104-6
In terms of the first paragraph, I think part of what I was getting at is the possibly important distinction between OCPD (obsessive personality) and OCD. But OCPD has all this psychoanalytic baggage, so it tends to get ignored. David Shapiro describes that compulsive element really beautifully in his book Neurotic Styles from the 1960s and especially, his second book Autonomy and Rigid Character.