Hi Everyone,
I came across this paper from Dr. Jonathan Grayson and thought I would share it. This paper really makes sense. Please let me know what you think.
Stay Strong!
Jason
Is OCD a biological or a learned disorder? - Treatment implications
Dr. Grayson
Just to add and clarify a bit about biology and learning. I think it is important in discussing biology to have some idea of the role of biology beyond "I have OCD because of activity in my caudate nucleus." I would immediately want to know, how does that make me have OCD?
To date, Hewlitt a psychologist from Vanderbilt is the only one I know who has made an attempt to take what we know about the brain to explain this. Here is my version of Hewlitt. There is a part of the brain that responds to uncertainty with discomfort. From an evolutionary view this makes sense, after all, it is useful for primitive man in a jungle to be nervous about noises he can't identify. There is another part of the brain that responds with satisfaction to completing activities. Again, from an evolutionary point of view, you need this to have the desire to build all we have today. In OCD the threshhold for these responses is lower, that is, it takes less uncertainty for the individual to feel more anxious and when an activity is completed, the individual does not get the feeling of completion. That's the basic idea. Remember, this part can come and go over time. But when your body is in this state, what happens? Everyone does a little check every now and then, has a nasty thought, or feels something is incredibly yucky. And so we respond. Unfortunately, when your body is in the OCD, you are now beginning to learn your OCD, because, another thought by Hewlitt is that in this state your body is better at learning avoidance responses. And so by accident, the cycle begins and you begin to add to your behavior learned fears. And there are a number of things we know about learned fears: they can be overwhelming, they can be very resistant to change and most important, they are unaffected by medication.
What does this mean for treatment? Medication is important if your body is in the OCD state, as it will trigger more frequently. However, not everyone is always in the OCD state, but to date we have no tests that can identify this. Even on the PET scans where we can see OCD like activity, they currently don't reliably differentiate OCD sufferers from non-sufferers. We know that if someone is very depressed, medication is probably necessary. In fact, at our center, when we use medication, we do not look for improvement in OCD symptoms to see if it is working, because the learned part can be so powerful that it can mask the effects of medication. Keep in mind, and I know this is confusing, this does not mean medication isn't working. We have seen people on medication who are still symptomatically OCD, dysfunctional and overwhelmed with anxiety. But, because the meds are working, they are able to make gains rapidly. Our measure of medication working is its effect on depression. For some reason, depression symptoms are more responsive to medication. In our experience, if it works on depression, then it is working on the biological part of OCD. But again, meds don't change learning. You don't take an SSRI and forget how to type, suddenly develop a love for things you have hated, or lose learned fears or have changed patterns of thinking. It is for this reason that meds alone usually only lead to 30 to 50% improvement, better than nothing, but for many far from enough. For learning, this is where ERP comes in, along with the decision to decide to learn to confront and accept your own personal uncertainties.
Can you get better on meds alone? We have seen very few cases of this and I suspect that such individuals have built upon the relief meds gave them and essentially have done their own CBT. The other times we have seen this are for children whose parents identified OCD before they really had a chance to learn it. Does this mean you have to be on meds forever? The question can only be answered individually. Some people have predictable cycles and can raise and lower meds or go off at certain times. Others can go off for years and maybe forever. Others will always need meds. And this is not a matter of willpower or strength, it is a matter of biology and genetics and it isn't fair. How do we know if someone can go off? The answer is simple. We gradually withdraw them from medication and if depression and OC symptoms don't return they can go off and if they do return, they need to stay on the meds. Finally, what about people with OCD who aren't depressed, do they need meds? It is a guess. I have seen some people choose meds and benefit and others choose not to use meds and be able to. The nice thing about SSRIs, they work if your body can use them as opposed to being happy pills that work for anyone. Or another way to put this, SSRIs have no street value.
Can you get better from CBT alone? We have some individuals who have done this. We warn them that this doesn't mean they will never need meds. They may not have been biologically OCD at the time they came into treatment, but that part may return and if it does, they will probably need meds. When I say it is a learned and biological problem, I mean just that. There is an interplay between the two and it is simplistic to view them as either/or.
Jonathan Grayson, Ph.D.
Director
The Anxiety and Agoraphobia Treatment Ctr.
112 Bala Ave.
Bala Cynwyd, PA 19004
Phone: (610) 667 6490
Fax: (610) 667 1744
