Relief and Then...

I feel like I have experienced some relief from my OCD in the past few days, ever since getting lost in the woods the other afternoon/early evening.

The funny thing about getting out of my head and back into the world is that I've realized there are all these things I've neglected--cleaning my house, cleaning my kitchen, my relationship, my job (not so much), and my friendships. It suddenly feels like these things matter again and I feel angry at myself for not giving them sufficient attention--particularly my relationship.

And it's all feeling a little stressful now. It's like I've been suffering so much, what I really need is some peace. But life isn't giving that to me. Now I have to deal with the mess I left when I wasn't feeling so good. The thing is stress triggers OCD for me, so I need to manage this feeling that I'm having as best I can so that I'm able to actually pay attention to the important things.

The Monoamine Hypothesis Revisited

So, I've gotten a couple comments regarding my previous post--The Monoamine Hypothesis.


The first comment was essentially that I actually have good scientific reasons for much of what I said in the post, but that I didn't include any references. And that much of what I said came off as hippy bullshit without strong scientific backing. Indeed, much of what I wrote is unconventional. Some of what I wrote was some of own my conjecture and alluded to questions that I have regarding the topic. (For example, we know hormones affect mood. So why all this emphasis on neurotransmitters?)

Marcia Angell, MD, and former editor of the New England Journal of Medicine wrote a review in the New York Review of Books on a few books that tackle the topic of antidepressants usage in this country. She writes,

When it was found that psychoactive drugs affect neurotransmitter levels in the brain, as evidenced mainly by the levels of their breakdown products in the spinal fluid, the theory arose that the cause of mental illness is an abnormality in the brain’s concentration of these chemicals that is specifically countered by the appropriate drug. For example... because certain antidepressants increase levels of the neurotransmitter serotonin in the brain, it was postulated that depression is caused by too little serotonin. Thus, instead of developing a drug to treat an abnormality, an abnormality was postulated to fit a drug.
That was a great leap in logic, as all three authors point out....

But the main problem with the theory is that after decades of trying to prove it, researchers have still come up empty-handed. All three authors document the failure of scientists to find good evidence in its favor. Neurotransmitter function seems to be normal in people with mental illness before treatment. In Whitaker’s words:

Prior to treatment, patients diagnosed with schizophrenia, depression, and other psychiatric disorders do not suffer from any known “chemical imbalance.” However, once a person is put on a psychiatric medication, which, in one manner or another, throws a wrench into the usual mechanics of a neuronal pathway, his or her brain begins to function…abnormally.

Carlat refers to the chemical imbalance theory as a “myth” (which he calls “convenient” because it destigmatizes mental illness), and Kirsch, whose book focuses on depression, sums up this way: “It now seems beyond question that the traditional account of depression as a chemical imbalance in the brain is simply wrong.” Why the theory persists despite the lack of evidence is a subject I’ll come to...

So, that more or less sums up what in my previous blog post was factual. I would recommend to anyone interested in this topic that they read the remainder of the review--it is quite fascinating. Or the books that she reviews--I've read both Unhinged and Anatomy of an Epidemic.

The second comment (posted to the comments section of my previous post) asked what my biases towards antidepressants are. 

Yes. I am biased against antidepressants. I'm hesitant to take medications in general, but more specifically, I don't know anyone who's taken them who speaks highly of them. Some of the people I know who have taken them say that they work and some say they don't. But even those who say that they do work complain of various side effects--sexual dysfunction, feeling emotionally numb, and unwanted personality changes.  I don't know anyone who has killed themselves on them, either though.

That said, I have tried to approach this question several times with an open mind. There have been a few instances over the past few months where I have felt shitty enough that I hoped that there existed some sort of medication that would ameliorate problems with relatively few side effects. When I look into the data on them, though, I am never particularly impressed. I consistently find that they are not particularly effective, we know very little about their long-term use (but what we do know doesn't look good), and they cause problematic side-effects. There is one medication that does seem to be comparatively effective for OCD--clomipramine (anafranil). Clomipramine is a first generation antidepressant--a tricyclic not an SSRI. I would consider taking it shortish-term, but it's side effects are particularly nasty. There's no way I would be prescribed it even if I asked for it for this reason.

There are a number of long-term concerns I would have with taking SSRIs. First of all, let's say that they are effective short-term (which is questionable--they beat a placebo in only about 50% of the studies done on them; unfortunately it is this 50% that is published). I still am not sure I would want to take them. SSRIs do induce mania in a significant number of cases (I'll have to look up the percentage). A few of my relatives have bipolar, so this is something that concerns me. If on the other hand they helped me, what would happen when I decided to go off of them? SSRIs cause "discontinuation syndrome"--a euphemism for withdrawal--which could cause me to experience a relapse worse than what I am experiencing now. So, then, I would be confronted with the choice of whether or not to remain on them long-term. Well, there are a few concerns with remaining on them long-term. They stop working as well the longer you take them, so that might lead to an increased dosage or a relapse (back to square one). Also, they've been linked to cognitive decline (memory loss) with long-term use.

I should note that most of what I read about efficacy of SSRIs--both short- and long-term--relates to depression. Since it is somewhere around 10 to 20 times more common than OCD, it is much more studied.

The Monoamine Hypothesis

The monoamine hypothesis is hypothesis that the monoamine neurotransmitters--serotonin, norepinephrine, and dopamine--are responsible for mental illness. Supposedly, deficiencies of serotonin and norephinephrine are linked to increased depression and anxiety, whereas an excess of dopamine is linked to schizophrenia. The reality is that if you look at neurotransmitter levels in untreated people with and without mental illness you don't find a statistically difference in neurotransmitter levels between those with and without mental illness. There also aren't any correlations to be found between the severity of an illness and neurotransmitter levels--severely depressed people don't have any less serotonin than mildly depressed people.

This isn't to say that neurotransmitters play no role--they clearly do something because when people go off of drugs that target these neurotransmitters (SSRIs, SNRIs, atypical antipsychotics, etc.) they experience a subsequent change in these neurotransmitter levels and often experience a relapse. However, it is too simplistic to say that depression, for example, is caused by low serotonin because it's not. We don't know what it's caused by. Perhaps the distribution of neurotransmitters is what's important.

It seems to me that there's enough evidence to say that there is some sort of complicated link between neurotransmitters and mood. But the monoamine hypothesis is too simplistic in a number of ways:

• It ignores what I think ought to be considered at least an equally important contributing factor to mental illness: structural differences in the brain. There's evidence that people with generalized anxiety and depression have more gray matter in certain parts of their brain and less in others, whereas people with OCD have the reverse proportions of gray and white matter. It's also been shown that you can induce OCD-like behaviors in animals by damaging their basal ganglia.
• The monoamine hypothesis also seems to ignore hormones. We know that mood changes can occur in conjunction with menstruation, pregnancy, and being a teenager, so it has to be a vast oversimplification to say mental illnesses are caused by total neurotransmitter levels alone. I haven't really seen anything on hormones directly affecting neurotransmitter levels, so I tend to think that they affect mood by a separate mechanism from neurotransmitters.
• Like I mentioned before, perhaps the distribution of neurotransmitters or what neurotransmitters do to the structure of the brain may be important. The monamine hypothesis only speaks of total levels. SSRIs might do something (it's unclear to me what they do) because they increase serotonin everywhere in the brain. Or flooding the brain with serotonin might induce structural changes. Who knows? This is conjecture.

The thing is science likes simplistic theories. Our limited brains are really only capable of grasping the the simpler phenomena in the human body and in nature. The thing is, it would be great if mental illness could be reduced to a few key chemicals in the brain. Well, this means we could develop drugs to target these chemicals and people could take these drugs and pharmaceutical companies could make money. Oh, and of course, people would happier and more functional.

We seem to have capitalized on the possibility that the monoamine hypothesis is true, because it would be convenient if it were. Not to mention profitable for the pharmaceutical industry. And most people, psychiatrists, and doctors, seem to think that the monoamine hypothesis is true. Just watch an ad on TV for an antidepressant, "Depression is caused by a chemical imbalance in the brain. Such-and-such drug can fix that imbalance." Not true! 

Just to note, the monoamine hypothesis in and of itself doesn't mean that antidepressants don't work. They could work (or do something weird), but they don't fix a chemical imbalance in the brain because there is no measurable chemical imbalance in the brain. If they do work (or do something), they do it by causing an imbalance in the brain.

Needing to Make a Change

A while ago I read Crazy Like Us by Ethan Watters. He proposed that mental illness--anorexia in particular--was an expression of our inner turmoil. He looked at how anorexia rates have skyrocketed in Hong Kong over the last couple decades, coinciding with an influx of Western narratives about mental illness in general and anorexia in particular. This is not to say that anorexia didn't exist at all in Hong Kong previously, but rather that both the incidence and narratives changed around it. For example, anorexics in the early 80s would complain of physical discomfort upon eating, whereas anorexics of the 2000s readily repeated the Western rhetoric about fears of becoming fat and feeling out of control around food. Watters theory was that with the influx of Western ideas about anorexia, girls and young woman latched onto it as a way to express their inner turmoil, a way to do so that would be recognized as a need for help.

Now, I don't know if it's fair to say that people always choose their mental illness as a cry for help--I certainly don't feel like I chose OCD. However, I do think it might be fair to say that is an expression of some sort of inner turmoil I am experiencing. Something about my life isn't working right now--it could be any number of things--and I don't think my OCD will go away until I begin to address this.

A few of my friends and I are planning a trip in December that will hopefully be a way to address this feeling healthily. My fear in reflecting on what in my life isn't working is that it's good obsession fodder. There are lots of questions and the questions can feel urgent. An then attempts to answer the questions can lead to doubts and difficulty making decisions. Obsession, obsession, obsession! I want to avoid this, but I don't want to avoid healthful reflection on what isn't working for me.

I feel a little stuck. Where to begin in making changes? I'm convinced it isn't any one thing that's causing my inner turmoil, but rather a combination of things. Stress at work, boredom in general, stagnation in my relationship (ROCD, I'm telling you to shut up now), stagnation in my social life, lack of any sort of spirituality in my life, lack of meaning in my work, too much work, not eating well, allergies, too many things to deal with... who knows? Hopefully some clarity will come to me.

The Experience of SSRIs

I read a friend's blog post today about how scientifically minded people often take a long time to recover from illness, whether that be physical or mental. She gave several reasons for this, but a big one was that scientifically minded people are unwilling to try anything that's unproven. The evidence has to be clear cut.

I'm one of these people who reads studies in medical journals every time that I consider taking almost any medication, supplement, or herb. (Well, I do tend to just trust my doctor on short-course antibiotics for strep or UTIs. And pain meds, because I'm in a lot of pain and desperate when I have asked for them.)

But I think this is problematic. Medical research is rarely definitive. Medications can be around for decades before we fully understand their side-effects, contraindications, and the situations in which they are effective. There are plenty of substances whose long-term efficacy we don't understand because either the research isn't there or the research is only being selectively presented.

Furthermore, relying on medical data, I miss out on any sort of experiential knowledge that may exist. I keep wondering why my therapist suggests SSRIs for me. The data says that SSRIs take a long time to improve OCD symptoms (2-3 months versus 2-3 weeks for depression) and as far as I can tell are completely ineffective for treating hair pulling and skin picking. And I should point out that there is new data coming to light that's showing that SSRIs are barely more effective than a placebo and equally effective to an active placebo for treating depression. So, given that they seem to take longer to help with OCD, it wouldn't surprise me if they didn't work at all for it. But that's supposition.

Given this, I have a couple of theories as to why my therapist recommends them. First, he may have been brainwashed. Second, his experiential knowledge may contradict the data. His patients seem to improve on them or claim to improve on them. But, as any good scientist knows, anecdotal evidence can be flawed.

On the other hand, particularly for mental illness, I think the experience matters a great deal and perhaps more than efficacy. To get through a difficult experience you have to be able to form some sort of useful narrative around it that might include the reasons it happened, what you learned from it, how you will carry it with you. If SSRIs can positively contribute to such narratives, there is where their efficacy might lie. And this cannot be measured in any study.

But I know that the experience of SSRIs isn't black and white. Lots of people on OCD forums talk about trying to get off of them--and it's a struggle. The friend I talked to last week said that they interfered with his artwork. Other people say that they find that drugs make them fell emotionally dull or have debilitating side-effects. 

I recognize the value of experiential knowledge, but I'm a scientist at heart and I don't think I can throw away my scientific understanding of psychopharmacology just because my therapist and mom say I should. I tend to trust scientific knowledge much more than anecdotal evidence when the two don't match up. The thing is it's not always possible to cohesively integrate experiential and authoritative (scientific) knowledge. So where does that leave us? We have to pick one approach and neither approach is truly holistic. Either that, or make a random decision and hope for the best.

On Doctors and Trust

Ideally we would live in a world where you could trust your doctors and actually tell them all the relevant information about what has going on with you and your health. The idea being the better informed your doctor is the better he or she can advise you on your health. But this isn't the world we live in for a lot of reasons, many of which I won't get into. E.g. pharmaceutical industry, health insurance industry, etc.

I was reflecting on this issue last week when I went in to the doctor to obtain a benzodiazapene prescription. I wasn't entirely forthright with my doctor. Ideally, I would've said my OCD was keeping me up at night. But instead, I said I was stressed about work and was having trouble sleeping and that in a week I'd be fine--I just needed something to get through it. It wasn't a lie, but the truth is more complicated. I'm not out of the woods yet (and at the time I knew I wouldn't be). My doctor doesn't know I have OCD because I don't feel like there's a reason for him to know unless I decide to take medication for it.

So, why the lack of honesty? Well, for one, young women aren't taken particularly seriously by doctors (or anyone for that matter, I sometimes feel like). I told my gynecologist in college that I thought my birth control pills were making me depressed. She replied to me that I probably felt down because I ate too much Halloween candy, not even asking if I had eaten any Halloween candy, which I don't. I don't eat candy at all and haven't since I was 10 or so. I told her this, and only then did she reluctantly switch me to a different pill. There have been a few times which I was told I might have an STD, when I knew that I didn't. "Well," the doctor would say, "I'd really like to do such-and-such test anyway." I would reluctantly agree because if I didn't get the test the doctor probably wouldn't let the matter go. (Also, I have contamination fears, so it's hard for me to say no to a test. After all, maybe I did get herpes from a toilet seat.)

One could say it's just me who feels this way about doctors, but a lot of other young women I know feel the same way (and some young men too...). The author of The Woman Who Thought Too Much mentions that when she was in her 20s, she would tell doctors she was depressed and they would tell her to go out and have some fun, date more, have a good time. When she told doctors in her 30s that she was depressed, they would say, okay, let's have you do a round of CBT, oh, and here's some Prozac.

In addition to being young, a woman, and unmarried, I don't really want to add crazy to that list. I don't have any confidence that an MD would a) understand OCD or b) treat it sensitively. So, I don't tell my doctor I have OCD. If I did, I might in addition to being taken less seriously also get repeatedly asked to take drugs.  

The thing is I find this kind of problematic. When you go to a doctor you are essentially communicating that you need or want help--you are in some sort of situation where you don't know how to proceed or are concerned that without their treatment injury and/or death might result. (Well, doctors are also gatekeepers for prescription drugs, so you may be going to get a drug that you would otherwise be unable to obtain. In this situation, deception makes total sense.) It seems imprudent on a fundamental level to purposefully not communicate what may be pertinent information. The thing is if you don't know how to proceed, you might not even know what is or isn't pertinent information.

Furthermore, particularly if you're having some sort of mental crisis, you may not be fully equipped to make good decisions. I know when I feel particularly bad, I am willing to do many things that I would otherwise think were stupid in order to get relief. 

But the reality is that I don't trust my doctor. I don't trust that pharmaceuticals will always help me. They may, in fact, harm me. Maybe in some sort of severe health crisis I would have to trust my doctors because I would have no other options. But for now, I'm in charge. I navigate my own care, which means I make my own stupid decisions. I decide what's relevant, even though I may not be the best equipped person to do so.

It's a sucky situation to feel like you cannot put your care in someone else's hands.

Some Thoughts

I'm having a bit of a flaky day, emotionally that is. I woke up feeling intensely bleh and was having trouble getting going. I finally got up the motivation to shower, and while in there, I decided that I needed to prioritize my own needs better. I called in sick to work. I feel guilty and flaky, but at some point, my needs are more important.

I also have been having trouble today managing my OCD. So, I decided 2 weeks was too long to go without seeing my therapist. I scheduled an appointment for next week. Compulsion? Relief seeking? Maybe, but I won't ruminate about it.

I struggle a lot with therapy. I feel like I don't really understand it, it's cultural context, or whether it will help me. But this is an obsession. I have to accept that I don't understand it and fundamentally can't know whether or not it's good for me.

I do wonder why I keep wanting to go to therapy. (I don't think this is an obsession, because it doesn't feel unwanted.) I sometimes wonder if there are tangential reasons why I go. For example, there aren't really any older men in my life who are or have been respectful of me. I wouldn't count my father. There's an older man at work I get along with fine, but he's not respectful of me or the other young women I work with. He's usually not blatantly disrespectful of me (because I pander to him--I've learned well how to deal with obnoxious older men, I suppose), but he did repeatedly and obnoxiously tell one of my coworkers she was "making a big mistake" about what was really quite a trivial matter. There was an older man I respected a great deal at an internship I did a few years ago, but he would read my writing and say that I sounded too presumptuous. I was, after all, only 22. Maybe I should put some sort of disclaimer in my writing saying this is how I see things as a 22-year-old. (23 I would say!) It wasn't very respectful for him to interact not with my ideas but with my age. I suppose there have been a few older male teachers who have taken a liking to me--an English teacher in middle school, a math teacher in high school, and a professor in college. There was never really enough emotional or intellectual closeness to really discuss what I wanted or needed or where I wanted to go. These teachers more pushed me in directions for which they thought I seemed well-suited. In any case, I wonder if I've found a bit of a lost father figure in my therapist.

This all sounds very Freudian and bullshitty upon writing it.

But there is some reason I keep going. It's not like I feel better immediately following my sessions, as I know some people do after many of their sessions. Sometimes, I even feel worse. I do feel like I occasionally have some insight into my own psyche after going, but, for the most part, I feel like I have a very good understanding of what my issues are and what I'm supposed to do about them.

I think I'm looking for a reason that I keep going because I'm concerned that I go almost entirely for hand-holding. I find this frustrating and infuriating. I feel like I should be able to manage on my own once I have good insight and know what to do. But I'm not managing on my own. I'm having a hard time. Then, my brain jumps to the future. Am I going to be dependent on this forever? Will this make me better or worse? Do not need immediate answers... ignore... ignore.

Medication and Hair Pulling

From Wikipedia:

Medications can be used. Treatment with clomipramine (Anafranil), a tricyclic antidepressant, was shown in a small double-blind study to significantly improve symptoms,^[21] but results of other studies on clomipramine for treating trichotillomania have been inconsistent.^[3] Fluoxetine (Prozac) and other selective serotonin reuptake inhibitors (SSRIs) have limited usefulness in treating trichotillomania, and can often have significant side effects.^[22] Behavioral therapy has proven more effective when compared to fluoxetine or control groups.^[3] Dual treatment (behavioral therapy and medication) may provide an advantage in some cases, but robust evidence from high-quality studies is lacking.^[1] Acetylcysteine treatment stemmed from an understanding of glutamate's role in regulation of impulse control.^[23]
Many medications, depending on individuality, may increase hair pulling.

Some Obsessions I've Recently Discovered

I mentioned feeling nibbled around the edges in my last post. The advantage of having one consistent obsession is that you can figure out how to handle it. Nibbling is a little more difficult, because it takes me a little while to realize what I'm doing, especially when my compulsion is ruminating.

So, I've realized that I obsess about the following things:

• Whether or not being in therapy is a good idea. This one can take on a number of different manifestations. For example, should I be seeing my therapist more often? I'm not seeing him for 2 weeks. Is that really a good idea? Or, I wonder, should I be in therapy at all. Maybe therapy is just hand-holding. Maybe I need to be a big girl and not do my compulsions and do ERP on my own. Or, I ruminate about how much therapy costs. 
• Whether or not I've disclosed everything I should disclose to my therapist. I had intended to tell him last session that I've been messing around with SAMe, but didn't quite get up the nerve. Or it didn't quite come up. So, then the questions: Should I have told him? You have to disclose relevant information to you therapist for therapy to be useful. Or maybe it's good I didn't tell him? Maybe since he and I don't see eye-to-eye on meds, telling him what supplements I take is unproductive and perhaps will cause unwarranted concerns. But then again, SAMe seemed to have positively affected my mood and attempting to go off it seems to have negatively affected my mood, so maybe by taking it, I'm not really better and am in need of more treatment and he should know. 
• How I come off in therapy. Sometimes my therapist points out compulsions that I don't realize are compulsions and I feel dumb. Or maybe I was sounding too presumptuous by interrupting when I know where he's going with something. Aaah! But it doesn't matter. At all. I'm there to be dumb and presumptuous.
• Whether or not my OCD symptoms are improving or worsening. Have to know now! I ruminate all the time about this one. Of course, ruminating about whether you are getting better or worse really only makes you worse. Ah, OCD backfires, as usual.

I just realized I am feeling better. Is writing down my obsessions a compulsion? Is this whole blog just a microcosm of my OCD?  Aaah! Things are getting to meta, too circular.

Nibbled Around the Edges

My therapist yesterday said that OCD nibbles you around the edges when it can't sink its teeth into you. This is how I feel a lot of the time. Nibbled around the edges. It sounds better than having OCD sink its teeth into you, but I feel worn out, anxious, and sad. These too are triggers for more nibbles.

I find myself wanting to talk about my problems to people, but these days my problems aren't real. They're all fake, trivial, or unsolvable problems and I know this. I feel like to talk about what I'm having trouble with I have to say I have OCD. Then I have to explain what OCD is--no it's not just about washing your hands. It can be anything, everything, and it can happen all in your head. Obviously, it's easier just not to tell people, especially people at work. It probably isn't a good idea to tell people at work that I'm crazy anyway.

Last weekend I met up with let's just say an old friend. I told him I had OCD and he talked to me about his bipolar. I felt like we were so different, yet somehow kindred spirits. He told me about how he couldn't paint when he was on meds, so he went off of them. But his partner liked him better when he was on them. It sounded like a hard situation. He asked what my obsessions were about and I gave him a few examples. The funny bit was that I mentioned I had sexual obsessions sometimes, but didn't really explain. A few hours later, I realized that he probably imagined something much more embarrassing for me than what I actually experienced. Sexual obsession makes you think sex addict, not feeling continuously terrified that you've somehow magically stopped ever being attracted to men.

Speaking of meds, I talked to my therapist about skin picking. He told me meds could help with that. I have yet to investigate that claim. What if meds do help with it? Should I reconsider my stance on meds? I really want to stop skin picking--it's leading to scarring and it's a waste of time. Well, I suppose I'll investigate.

I have the urge to skin pick right now. It's such a shameful habit. It's gross and painful, yet I find I can't stop myself. I feel out of control. I mean, I suppose it's better to not be able to control skin picking than it is to be unable to control murderous rages.

I'm in a pseudo-open relationship. Kind of. Not really. It's been years since I've slept with anyone other than my boyfriend. I sometimes wonder if my skin picking stops me. I certainly don't think it's the only reason I don't want to sleep around. But it seems like a major mood killer to have to explain to someone you're trying to have a one-night stand with that you pick yourself in private areas until you bleed. No, no, no. It's not like cutting. You don't do it "feel" something or to inflict harm on yourself. You don't want to do it, you just can't stop yourself. These days I even have trouble getting naked in locker rooms. I'm not sure what's worse--someone thinking I have a weird skin condition or thinking that I'm a skin picker. Better to keep covered.

The conversation about skin picking with my therapist was surprisingly insightful, despite it's brevity. It's considered an OCD-spectrum disorder meaning that it often goes along with OCD and maybe has the same underlying structural causes in the brain. Basically, we really have no fucking clue but we'll pretend that skin picking and OCD are manifestations of the same thing, whatever that thing is.

The difference between OCD and skin picking is that OCD is a much shorter loop. OCD kind of goes trigger -> obsession -> compulsion -> obsession -> compulsion and so on. So, stopping the compulsion prevents that loop from continuing. Eventually the obsession fades if you just sit with it. Skin picking is more complicated and I guess everyone with it has to kind of figure out what the loop is for them and address it at each stage. It's obviously not as simple as preventing a compulsion.

So, I guess here's what a loop might look like for me: (Warning: this is gross)
Hair somewhere I don't want it -> pluck it ->wanting to pluck other hairs -> ingrown hairs -> irritating texture -> desire to remove ingrown hairs -> squeezing and/or skin picking to remove ingrown hairs -> scabs -> irritating texture -> removing scabs/bleeding -> more scabs -> curiosity about whether there are hairs under the scabs -> more skin picking and hair pulling.

I feel a little better with the insight that skin picking is more complicated than OCD. I mean, to stop it I have a number of links in the chain to address, and not just one. God knows that it's hard enough to not be OCD and all you have to do to stop OCD is not do your compulsions.

Magnum Opus

I have this urge to write some sort of a magnum opus about navigating the mental health system through the lens of my experience. I'm not really sure that the lens of my experience is really magnum opus worthy or what the point of the opus would be.

I suppose what's going on is I'm trying to digest my near break-down over the weekend, or whatever not sleeping and calling my therapist, doctor, and coworker frantically outside of business hours was. Maybe freakout would be more accurate. I suppose what follows could be a first draft of my opus, and a very rough incoherent one at that.

I did go to my doctor Monday as I was unable to see anyone Sunday. My doctor gets horrible reviews on yelp, yet for some reason I really like him. I find him to be one of the only approachable doctors I've ever interacted with. In any case, when I went to see him on Monday I was able to navigate my way into getting a benzodiazapene prescription to help me sleep. I felt kind of proud of myself for manipulating the situation. Manipulating may be too strong a word, but I figured out what to say to get what I wanted. This isn't a skill that comes easily to me. Again, my doctor is comparatively easy for me to deal with, so I can't give myself too much credit.

Immediately after going to the doctor, I went to see my therapist. It was the weirdest appointment I've ever been to. Somehow I felt like we were much more at ease and upfront with each other, which was weird. Perhaps this is a good thing in the therapeutic relationship--to actually be upfront and banter a bit more, be less calculating in word choice.

What was weird was better being able to read my therapist better. I sensed some firmness with me at one point, some surprise at one of my stranger obsessions, and some concern. I told him I'd be out of town next week and he said that skipping last week (due to a holiday) didn't seem to work out so well for me. We picked a another day I would be in town next week. I agreed, but nonetheless I felt weird he said it. 

I also was asked to explain my insomnia issues, what drug I got from my doctor, how much and when I was supposed to take it, and whether I saw my usual doctor or not. It all felt very clinical to be discussing these things with someone who I share my weirdest thoughts with. He took careful notes, in response to which I asked, "So, this is going in my file." He responded, "I'm the least of your concerns." There's something unsettling about your nuttiness being on paper, especially when it it's actually nutty and not just mild neuroticism.

After the appointment there was additional weirdness. (I feel like this blog post is just turning into a list of things I feel weird about. Okay. Whatever). I felt weird about my and my therapist's conversation on Sunday and how so much went unsaid when we talked about it on Monday. On Sunday when I frantically called him he said that I could get something for my anxiety or insomnia, but that I really ought to go for an SSRI antidepressant--it would help me with the anxiety and the OCD as well. I was in a bit of state of desperation, so all the resistance I could really muster was, "well, I'll have to think about that one." I didn't really ask what I wanted to know, which was what are the merits of long versus short acting benzodiazapenes or how to avoid getting addicted. The phone call was also meant to me a sort of heads up (so obviously I was going to be asked about it later, see above). I guess what I wanted wasn't really thought out. On Monday, he asked what the outcome of my appointment was and I told him firmly that going on antidepressants was not something I was going to consider at this time. In hindsight, that statement was a bit milder that how I really feel about the topic, which is I do not want to take antidepressants ever. I do not think they work and I do not want to fuck up my brain with them. Honestly, I feel more or less the same way about benzodiazapenes, so don't expect 100% consistency from me on that topic.

What was weird was I never really got to explain why I thought what I thought or even that I thought he was giving me bad advice. Of course, his response was totally to be expected, particularly given the Luvox notepad I saw on the first day and the YBOCS form with the Lexapro logo from my second session. (I didn't know psychologists were bribed by pharmaceutical companies. When did that happen?)

I feel strangely about the therapeutic relationship. My therapist is supposed to give me advice and I am supposed to follow it. But what happens when I don't trust the advice? Admittedly, my therapist is a psychologist not a pychiatrist, so psychopharmacology isn't something we need to see eye-to-eye on. Nonetheless, when you don't fully trust someone, you spend a certain about of energy filtering what the say. On some level, though, this is an inevitable part of any human relationship.

I'm just feeling confused about therapy. It's so strange, so entangled with all of our modern lies.

Diagnosis 300.3

My therapist gave me a bill yesterday. It wasn't a bill in the sense that I've paid; I suppose it was a kind of receipt so that I could get reimbursement from my insurance company if my insurance company did that, which is doesn't.

Anyway, none of that is really important. What was interesting was that my bill said that I had a diagnosis of 300.3. I didn't know what 300.3 was, so I looked it up: "ICD-9-CM 300.3 is a billable medical code that can be used to specify a diagnosis on a reimbursement claim."

300.3 is specifically obsessive-compulsive disorder:

• "Anxiety disorder characterized by recurrent, persistent obsessions or compulsions: obsessions are the intrusive ideas, thoughts, or images that are experienced as senseless or repugnant; compulsions are repetitive and seemingly purposeful behavior which the individual generally recognizes as senseless and from which the individual does not derive pleasure although it may provide a release from tension.
• "Disorder characterized by recurrent obsessions or compulsions that may interfere with the individual's daily functioning or serve as a source of distress."

I suppose that's all fine and good. I do have OCD, in as much as it means anything to have a psychiatric condition.

But there was something a little unsettling about the whole thing. For one, being labeled as 300.3, a number, is a little strange. Does it really take that much more room to write out Obsessive-Compulsive Disorder? OCD abbreviated is shorter by two whole characters than 300.3 anyway.

Also, I wasn't ever really told I had been formally diagnosed. It's no surprise--we've been talking about OCD since session one. I had been thinking of asking at some point, "Am I formally diagnosed with OCD?" But hadn't upon realizing that it was a form of reassurance seeking--a way to confirm that my problems were indeed not "real" and were symptoms of my disorder.

The bill also concerned me for a bigger reason. Now that I've been formally diagnosed, if I ever try to apply for health insurance on the private market am I required to write in that I have 300.3? I've always had the plan of someday leaving my job and starting my own business and I might need my own health insurance in that case. I already had to pay a 30% markup last time I applied for health insurance on the private market for mild asthma, for which I take no medication and have had only very mild symptoms for the last 5 or so years. Will I have to pay another 30% markup for 300.3? Who knows? The situation may never come up. Maybe I'll ask my therapist about it next time anyhow. 

Oh boy...

I haven't posted in a few days because I've been a total mess. I started having insomnia a couple weeks ago and it was getting progressively worse. I think the insomnia was related to attempting to go off inositol. Or maybe some impending work stress. Or both. Anyway, chronic insomnia tends to lead to me being nuts.

Yesterday, I really hadn't slept much and was feeling particularly nuts. I attempted to see a doctor to get sleep and/or anxiety meds to get me through the week. I also called my therapist, which turned out to be useless (probably a complicated form of relief seeking). I discovered that 1) it is impossible to see a doctor on a Sunday for a non-emergency and 2) while I like my therapist, we clearly have very different opinions on medication.

I actually slept some yesterday and I'm feeling saneness begin to flow up through me. It's a relieving feeling.

Down the Past Couple Days

I've felt really down the past couple days, but I feel like I'm starting to snap out of it. Or at least I hope I am.

I've been taking inositol for 2-3 months and I think I tried to go off of it too quickly. Inositol is a supplement that potentially helps with OCD and anxiety, as well as depression.

I recently read The Anatomy of an Epidemic by Robert Whitaker. He presents a convincing case that antidepressants, as well as other psychiatric drugs, don't work particularly well short-term and long-term actually make outcomes worse. This is because the brain adapts to the increased serotonin and undergoes potentially permanent structural changes to produce less of it. This means that attempting to go off an antidepressant is very difficult because without the medication levels of serotonin drop producing depression. It takes your brain a while to adapt to not having the drug and increase it's production of serotonin. 

Not very much is understood about inositol, but it now seems unwise to consistently mess with my brain chemistry because it may not benefit me in the long term. Anyway, I got impatient. I was thinking every day that I stay on this chemical the harder it will be for me to adapt to being off of it. I kind of rushed my tapering off of it. And now I'm back on it. It's unclear how long it'll take for it to start helping again.

The Wrong Type of Therapy Can Be a Game for People with OCD

I've been reflecting on my experience with my previous therapist, probably because she tried to contact me on Friday.

I've been reading The Woman Who Thought Too Much by Joanne Limburg. She discusses how a prominent psychoanalyst noted that therapy can become a game for people with OCD. The idea behind psychoanalysis is that the patient is entirely open during the session and the psychoanalyst uses the themes and dynamics that come up to diagnose and treat the patient. Well, people with OCD often have this problem of obsessing over how to say things just right as to avoid any inaccuracies, especially inaccuracies that have to do with their own mental state and treatment. Therapy can become a game for people with OCD: they strategize endlessly on what to say when and how to say what, whether they are revealing too much or not being honest enough. This is not to say that people with OCD don't take therapy seriously; rather they take therapy too seriously and it can become a breeding ground for new obsessions.

My previous therapist wasn't a psychoanalyst; I suppose what we were doing was cognitive therapy without behavioral therapy. Maybe there was some new-agey stuff mixed in too. Regardless since her approach didn't emphasize behavioral therapy which is the only type of therapy documented to be a viable treatment for OCD, I do think think therapy became a bit of a game for me. I ruminated endlessly on what to say when, what to reveal, and how to reveal it. I never found these details significant, though, because for whatever reason I didn't see them as part of the bigger picture of a tendency towards obsessive thinking. Until I realized I had OCD, that is.

I also went to the therapy group my old therapist ran for a while. At one point she posed a question to the group: What makes it difficult for you to open up to the group? I answered that I was afraid that talking about my problems might somehow be really harmful to someone else. Therapy was evoking harm OCD in me and I even directly admitted it!

I would mull over therapy group a lot. There were just so many things I could try to keep tabs on. How did I come off? Maybe I came off as whiny. Did I really explain my problem well? Maybe someone was upset because of what I said.

This is not to say that group therapy is never an option for people with OCD. Group therapy might actually be a good exposure for someone with OCD. It's just important to know what is going on.

Rabies ... Again

If you met me, you wouldn't expect me to be the type of person with contamination fears. I'm not particularly neat, I'm not squeamish at all about things like eating raw eggs, and public restrooms really don't bother me.

I do have one contamination fear, though, and it's a weird one: Rabies. It's frustrating because I really love animals, but this obsession makes me 1) avoid touching animals I don't know or 2) feel very uncomfortable when I force myself to.

I distinctly remember not being afraid of rabies two years ago, but something happened. I can't really remember a specific event, but all of a sudden it became something I got concerned about whenever coming into contact with animals. At the height of my rabies phobia, I was looking daily for a cat that had scratched me to make sure it hadn't come down with rabies. I know, that's a weird compulsion.

Today, it resurfaced a bit. I was running with my neighbor's dog and a little dog charged out and started attacking my neighbor's dog. A fat woman came out and called her little dog back over. I don't know if any biting took place--it all happened so fast.

But now I am practicing avoidance and  having a hard time convincing myself not to. My neighbor's dog may be rubbing rabies all over my couch right now, she might give it my cat, and she's even touching my elbow. I know I really should just rub my hands all over the dog and not worry about it, but I skin-picked by pinky and it's a little bit raw and I don't want to get rabies on that finger. 

Okay! I'm going to be good. Exposure time!

Surprise Morning Obsession!

I have been obsessing all morning. Mostly about getting older. There's a line on my face and I don't know how long it's been there (maybe even a couple years), but now every time I see it, it reminds me that I'm getting older. I've started seeing lines on other people's faces that I had never noticed. Maybe this has to do with my new glasses, or maybe it's really just about the obsession. I want to go back to not noticing these things.

Now, I'm really not old but any stretch of the imagination and I'm at least five years off from wanting to have kids, so really, there's nothing to worry about. Not that getting older is ever something to worry or obsess about. It happens and there's nothing to be done about it.

I then decided I was obsessing about getting older really because I'm not satisfied with my current line of work. If my work were more interesting and felt like it was going somewhere then getting older wouldn't be a bad thing; it would just be part of getting to where I wanted to be.

I started thinking if I want to do something more interesting, I really need to go back to school. I started researching PhD programs. Ugh. It would be at least two years before I could get into such a program and that would mean taking a lot of classes and do a lot of volunteer-type work in order to be able to get in. I would have to decide about quitting my job and I'd be old when I finally finished.

I started to cry. I seemed to have encountered an impossible problem. I was too old to do anything and my life would just suck for the next 40 or so years until I retire.

OCD trap: I gave into reassurance seeking. I called my partner and told him my morning ordeal. He told me I didn't really want to go to graduate school (which I don't) and that if I wanted to do something else I should take a direct route to working on that. He suggested continuing to put effort into this blog, which I am now working on.

I get frustrated at myself for these few-hour obsessions. In hindsight they are obviously obsessions--the flood of questions, the sense of extreme urgency, my inability to focus on anything else. At the time, though, they somehow seem real and important and it takes me a while to realize that they're not. I wish I could just skip over the hours of obsessing by realizing early on in the process that I was having an obsession and reminding myself that these absurd questions didn't require my immediate attention.  Somehow, though, it never seems to work that way.

I suppose this is part of the reason I'm in therapy: I have trouble managing my obsessions. Yet something I've noticed is that therapy isn't really about recognizing obsessions earlier, it's about getting rid of the ones that are plaguing you. I asked my therapist about this last week, and he didn't have much to say on the topic that I didn't already know. I can't really expect any magic words that will allow me to get any better nipping obsessions in the bud. At the end of the day, it comes down to self-control. I know what an obsession looks and feels like, it's just a matter of doing what I'm supposed to do as soon as I possibly can.

Skin Picking and Other Bad Habits

I used to think of my skin picking, lip chewing, and hair plucking habits as weird disgusting things that I did. I knew that they were nearly impossible for me to stop doing for any length of time, but I didn't really see them as connected to other parts of my personality.

Well, I'm reading The Woman Who Thought Too Much, an OCD memoir by Joanne Limburg. I find it eerie how similar the author and I are in some ways. (Of course, we're totally different in other ways.) One thing that we both do is skin pick. This is apparently common among a lot of OCDers. Skin picking, hair pulling, etc. are considered to be on the OCD "spectrum."

As an aside, I actually have a lot of trouble with the word "spectrum." The idea behind using the word "spectrum" is to group together conditions that have the same underlying cause, but have different manifestations. The problem is we don't actually understand the underlying cause of any mental illness (read Unhinged or The Anatomy of an Epidemic). We have ideas and suppositions, but nothing definitive. Using the word "spectrum" allows us to talk precisely about things we aren't really equipped to talk precisely about at all.

That said, it does seem like OCD and skin picking do have some real relationship to each other, at least in that people who have one often have the other.

It's a little bit strange for me to realize how predictable I am. It's really no surprise given that I have OCD that I also have skin picking issues. I hindsight, my skin picking, which started at a young age (it has taken on various forms over the years), might have been an early indication that I would develop OCD in the future.

For some reason, my predictability makes me feel somewhat powerless. Like if OCD and skin picking are caused by some set of structural defects in my brain, these aren't easily changeable things. They're probably things I'll struggle with for the rest of my life.

However, I'm trying to be optimistic. Just because something has a structural root doesn't means that the symptoms are unchangeable. People with OCD go into remission all the time, and there's no reason that I shouldn't expect the same, particularly given my current level of effort.

Not Asking for Reassurance is Hard

It is so hard to not ask for reassurance. Nearly impossible, in fact. I feel like I only succeed like 25% of the time. Sometimes I find myself asking for it, when I know that I shouldn't and I get angry at myself after receiving the reassurance. Why did I have to do that? Reassurance doesn't really accomplish anything. It's not self-serving most of the time and it's more often self destructive. I know this, but it's still hard. I'm so accustomed to asking for it, that it's such a hard habit to break.

On the upside, I'm trying to give myself a lot of credit when I don't ask for reassurance. I'm even trying to view it positively when I delay reassurance seeking. I tell myself, I'll ask in ten minutes or I'll ask tomorrow morning.

If in Doubt ... It's an Obsession

I think it was in mid-June that I first read the advice that if you are in doubt about whether or not something is an obsession, you're better off treating it as an obsession. This immediately struck me as sound advice. Of course, if someone is prone to obsessive doubt if they are doubting whether or not something is an obsession, it probably is.

On a practical level, though, I didn't find this advice terribly useful. Yes, I am prone to obsessing, I thought, but there are "real" problems and "fake" problems. Sure, chances are if I'm concerned something is an obsession or not, it probably is, but it doesn't mean that it definitely is.

Lately, though, I've started to understand this advice on a deeper level. First, you can obsess about a real problem, but it being a real problem doesn't make your obsessing any more useful. Obsessing is almost never productive, and almost always unpleasant.

Second, if you're prone to OCD, you're probably an obsessive person in general. So, assuming that something is an obsession means accepting this about yourself as a person. You probably have obsessive thoughts about little things all the time. You may not even find all of these obsessive thoughts unpleasant. Obsession is just part of how you think, but it often gets out of hand.

Having a Hard Time with a New Exposure

I started seeing a new therapist about a month ago. It's been great. We talked a lot about what I've been obsessing about. A big one for me is obsessing about obsessing, which I hadn't quite realized I was obsessing about. This can take on various forms. One way that this goes is, "Omg. I could have an obsession about x. Wouldn't that be terrible." Then I keep checking periodically to see if I'm obsessing about x. But I'm not exactly obsessing about x, just hoping that I won't.

Another way that this goes is something happens that makes me stressed and then I start obsessing about something. The obsession wanes and then I start thinking, "Here we go again. You got stressed and you know that makes you obsessed, so now you'll just keep obsessing for months, like happened before." (I got injured and really stressed and that's when I went to see my first therapist for what I now know is OCD.)

Two weeks ago, my therapist and I came up with a first exposure, which was a tape recording of "I may have an obsession today that may never go away." I listened to it as continuously as possible for a week, and I think it helped. However, it didn't really get at my what my fear of having an obsession really is.

My fear really is something more like my life will pass me by, that I won't be able to be present in the things that I do. So, we came up with a new recording for that one.

The thing is, a good exposure is hard to listen to and work on. It takes a lot of energy. And lately, I don't feel like I've had much resilience, so I haven't wanted to work on it. And honestly, I haven't worked on it as much as a should.

Before starting with my new therapist, I went back and forth for a long time about whether to go. The big question for me is did I need hand-holding? I would also wonder if I would become dependent on therapy, if it was worth all the money, if it would be a waste of time, or if it would make me worse. I suppose I was obsessing about whether or not to go to therapy.

But the thing is there is no way I would be doing such a hard exposure right now if it weren't for being in therapy. Being accountable to someone else forces you to do things that you otherwise wouldn't have the balls to do.

Oh yeah, and I may be wasting my time and money, therapy may make my OCD worse, and I may be in the process of becoming dependent on it. Those are some uncertainties that I do have to live with.

Old Therapist

My old therapist attempted to contact me today. I suppose I appreciate it. From her perspective, I did kind of fall off the face of the earth six weeks ago. Although, that raises the question of why it took her six weeks to realize I had fallen off the face of the earth.

I found myself stuck on how to respond. I do really wonder what was going through her head. Did she not think I had OCD? Did she think I had OCD but had no clue how to treat it? She wrote that she would appreciate a phone call from me.

Well, I think I started to OCD on how to respond to her. What should I say? What did I want to figure out from her? When should I call her? What did I not want her to know? How would I confront her? (Saying, "Hey, you missed to boat with me! What happened?" wasn't likely to produce the desired results.)

I eventually called a friend and she talked some sense into me. She basically said that I wasn't really going to get any closure from talking to my old therapist and that I should write her a short email saying I was alive and not waste any more effort on the issue. She said that my old therapist and I had different world views and that we weren't really going to figure out our differences in a five minute phone call. Anyway, that's more or less what I did. I even noticed a grammatical error in what I sent but decided to send it anyway.

I guess at this point I just have to live with the uncertainty of not knowing what she thought my issues really were. Another friend of mine once said that closure comes from within. And in this case, she is definitely right.