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.

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.

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. 

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!

People Don't Understand OCD

I've had a number of OCD situations come up that are easily mistakable for real issues.

A few months ago, I was talking to a friend about my ROCD (relationship-themed OCD). Then, I didn't know what OCD was, muchless what ROCD was. I told her I was having a lot of anxiety about my relationship. She told me that anxiety means something and that I needed to take my feelings seriously and explore them. My therapist at the time would say the same things. This only fueled my OCD issues.

A month or so later, I was talking to my mom about my fears of being a lesbian. A few days after that, I discovered what HOCD (homosexuality-themed OCD) was and then told her that I thought I had OCD. She flipped out and told me that questions of sexuality were a real issues, ones worth taking seriously. Always. Needless to say, I haven't been talking to my mom much about my issues.

Again today, I was talking with a friend about an issue I was having. She at one point said, "That's a totally reasonable thing to worry about! That's not like worrying about leaving the stove on or the door unlocked."  Well, yes and no. Yes, it's a different worry. One that in some situations is reasonable to worry about it. The thing is, I wasn't really worrying, I was obsessing. Or maybe it was some combination or worrying and obsessing. Regardless, it was taking up my energy in an unproductive way and was beneficial for me to treat as an obsession. My friend just didn't get it, so I stopped talking to her about it.

I think largely because of my experiences with my new therapist I am much more confident about what is and isn't an OCD issue. At the same time, I'm feeling a bit isolated. One of my good friends is having a lot of problems and has shared the concern that she is occupying too much of my time voicing her issues. The truth is, I'd love to tell her about some of my issues, but I think she might just think I was really weird and not be helpful to me.

Maybe this is all a good thing. I think sometimes I tell people my problems as a means of reassurance seeking, which I need to stop doing. Nonetheless, there are only a few people who really know the meat of what I've been struggling with the last few months.

Unhinged by David Carlat

I recently finished reading Unhinged by David Carlat. All in all, it was a thought provoking book that is worth reading for anyone who is trying to navigate their own mental health.

One of Carlat's main points is that we have thrown therapy out the window and replaced it almost entirely with psychopharmacology. This isn't a good thing, Carlat argues, because psychiatrists miss what's really going on, why a patient is coming in for treatment then, and how the patients thoughts and behaviors are causing or exacerbating their current difficulties. Psychiatrists medicate and move on.

This is an argument I encounter a lot both in my reading and in my personal interactions. When I told a friend of my I was going to see a therapist she said, "That's good. Medications don't treat the underlying cause. They're just a bandaid. Therapy gets at the underlying causes of what's going on."

I do agree that medications don't treat the underlying cause. Whatever they do is complicated and contentious. However, in all this therapy hoopla, no one really seems to get at what therapy does. There's a good deal of evidence that therapy does help at least some people and research shows that it is often times more effective than psychiatric drugs. But therapy can also harm some people. And so much depends on what type of therapy we are talking about, what the patients issues are, how good the therapist is, whether patient and therapist are a good match, etc. It just strikes me as irresponsible for Carlat to advocate so strongly for more therapy without really exploring what its limitations might be. Admittedly, the book would be deeply discouraging if it just said psychopharmacology is a limited approach and didn't present an alternative. 

I say all this for deeply personal reasons. I went to a therapist (a psychologist who practiced CBT, came highly recommended) a few months ago who just didn't seem to get OCD. It was really frustrating and a suffered more than I would've otherwise under her misguided advice. I'm happy to have not gone the medication route, but the therapy route hasn't been an easy one either.