Everything you know about OCD is wrong

July 20, 2023 9:27 AM

Obsessive-compulsive disorder (OCD) can cause significant distress and suffering, and while the usual treatments (such as SSRIs and cognitive-behavioural therapy) can help, many patients are often left with residual troubling symptoms. Enter Dr. Michael Greenberg, an American psychologist and former OCD sufferer who seems to have had a breakthrough in understanding the psychological underpinnings of OCD: it all boils down to the tension between expressing needs and fear of the consequences of doing so. This then leads to rumination, which is easier to stop than you might think.

• Dr. Greenberg interviewed on the OCD Stories podcast
• Dr. Greenberg talking about how it's necessary to approach OCD from both a cognitive and psychodynamic perspective

posted by greatgefilte (19 comments total)

I posted this because I had a very similar experience to him and came to exactly the same conclusions on my own, which made a huge difference in my life. I expect there may be a number of fellow OCDers around here who might appreciate this perspective. There's still work to be done in terms of organizing his theory into a coherent paper/book and testing it rigorously but I think there's a lot of merit to it.
posted by greatgefilte at 9:34 AM on July 20, 2023 [12 favorites]

I don't have OCD myself, but I do have issues with rumination on specific topics, and those rumination links themselves have some very interesting things to explore - thanks a lot for that!
posted by FatherDagon at 9:50 AM on July 20, 2023 [2 favorites]

I like this. It feels like reworded psychodynamic theory as applied to OCD. An example of how therapy models and approaches all seem to converge in the end and what matters in any particular course of therapy are the components emphasized by the therapist and client over others. This, in my experience, is what many good therapists already do. It feels like it's often the more academic/research-oriented/"evidenced-based" therapists who seem lately to be discovering integrative ("transdiagnostic") approaches and claiming discovery of some new land. But I guess that's the way these things go and of course there is value in the validation and articulation of practices that workaday therapists have already been doing.
posted by flamk at 10:09 AM on July 20, 2023 [2 favorites]

I've been struggling over the past few years, with various periods of greater or lesser frequency, with crippling attacks of panic or near-panic. I've seen therapists about this before, but always struggled to articulate that the "anxiety" I was describing was different from worrying, or how it felt nearly impossible to control or prevent.

A few months ago, some Reddit post pointed me to Greenberg, and his writing/interviews with him led me to find a therapist who practices Exposure and Response Prevention therapy; I've also been able to understand that this panic I've been feeling is a manifestation of the more traditional OCD compulsions I experienced when I was younger (checking, symmetry, intrusive thoughts), and derives from harm avoidance. It finally feels like the work I'm doing now is addressing the issue directly, instead of just mitigating the symptoms.
posted by Theiform at 11:48 AM on July 20, 2023 [10 favorites]

Rumination causes X. If someone isn't Ruminating, they don't experience X. So if someone says they aren't Ruminating, but they have X, they clearly have failed to stop Ruminating.

Ruminating includes thinking about something, but also not thinking about that thing. It includes choosing what to think about, even if it isn't about that thing. It involves choosing not to think about something. It also includes thinking about what I'm telling you to do.

But, we know that my instructions are successfully followed when your problems go away.

Isn't my theory of how to solves this great! Literally any experience by anyone can be explained as being consistent with my theory. Any experience you have can be slotted as failing to do what I'm asking you to do, so if it doesn't work, my theory remains valid!
posted by NotAYakk at 1:13 PM on July 20, 2023 [6 favorites]

Thanks for posting this, OP. I do not have OCD or, at least, I don’t have a diagnosis for it. I have had problems with rumination and I think the links are fascinating. Thank you so much
posted by Bella Donna at 1:36 PM on July 20, 2023

Ruminating includes thinking about something, but also not thinking about that thing. It includes choosing what to think about, even if it isn't about that thing. It involves choosing not to think about something. It also includes thinking about what I'm telling you to do.

As much as I understand it, the idea is that the brain will create thoughts and feelings, and you can't control that, but your responding to those thoughts/feelings (which includes actively trying to not respond) is a choice.

Your directing attention to the obsession is itself the thing that makes it distressing; otherwise, it's just one of the many thousands of thoughts/feelings you have every day and don't pay attention to.

If you have OCD, the obsessive thoughts/feelings will continue to occur from time to time, but because you just carry on with doing anything else, rather than directing your attention to the worry or feeling, or to actively trying not to have the worry/feeling, the obsessive thought/feelings will eventually pop up less frequently and go away faster.
posted by Theiform at 3:00 PM on July 20, 2023 [7 favorites]

The instructions for how not to ruminate literally begin with "Don't ruminate."
posted by Flunkie at 3:12 PM on July 20, 2023 [5 favorites]

This is a much better hypothesis than a book I saw when I was a teenager, which claimed that OCD was caused by too-rigid toilet training. These ideas seem interesting.

I've never been officially diagnosed with OCD, but that's mostly because I have never been to a therapist - it's pretty obvious to me that I have a (thankfully mild) form of it. Over the years, I've learned various coping strategies to deal with obsessive thoughts, such as keeping lists, sending reminder emails to myself, sticking to a routine as much as possible, and coming up with plans for what to do if one or another of the Possible Horrible Things actually happens.

There's also the realization that what is going on in my head doesn't necessarily match what is happening in the real world - my brain sometimes gives me inaccurate information.
posted by tallmiddleagedgeek at 3:49 PM on July 20, 2023 [5 favorites]

This is a much better hypothesis than a book I saw when I was a teenager, which claimed that OCD was caused by too-rigid toilet training.

Obviously a scam to sell less-rigid toilets
posted by jason_steakums at 3:57 PM on July 20, 2023 [7 favorites]

I used to get a short bout of OCD about 5 minutes before a migraine maybe half the time I’d get a migraine; the other times I mainly got extremely hungry to the point I’d have to drop what I was doing and eat several thousand calories:

The OCD is characterized by intrusive and recurrent obsessive thoughts and repetitive behaviors that are engaged to relieve the anxiety caused by the obsessive thoughts. The OCD is classified under the group of anxiety disorders and its association with migraine and/or CDH has been also described [9, 15, 17, 18]. It is worth mentioning that patients with migraine are five times more susceptible to suffer from OCD [9, 16].

One of my partners had much worse and more frequent OCD, and was also very sensitive to flashing lights:

Epilepsy and OCD

People with epilepsy are more likely to be affected by OCD, particularly those who have temporal lobe epilepsy.

It is not entirely clear why this is. There is some evidence that damage caused by seizure activity to connections in the brain can cause changes in behavioural patterns potentially causing OCD.

I feel like OCD is generally one of those things your brain does for reasons of its own — as part of its internal economy — and then people try to make up good reasons for why they do such a weird thing.

Kind of like those people who are conscious during brain surgery to guide the surgeon, and then the surgeon moves the probe and their arm jumps, asks the patient why their arm jumped and the patient replies that they just really thought it was a good idea to move their arm right at that moment.
posted by jamjam at 4:03 PM on July 20, 2023 [4 favorites]

I have OCD. At this moment it's quite bad. I will read this material but I have read so much like it that I do not intend to get my hopes up.
posted by Ray Walston, Luck Dragon at 4:30 PM on July 20, 2023 [1 favorite]

People who have lived with and loved diagnosed OCD sufferers, and have known firsthand how horrific and out-of-control and literally self-harming the symptoms can be, and what a years-long process finding effective and livable meds and doses can be, have scant patience with "self-diagnosed OCD." Fidgety small habits and liking things tidy are not symptoms of the disorder. If it's hurting, please see a doctor. But I'd ask people thinking about sharing their self-diagnoses, or who sometimes use phrases like "I'm a little OCD about that ha-ha-ha," to consider what it might feel like to have one's debilitating mental health challenges trivialized. I hope we might be empathetic.
posted by vitia at 8:14 PM on July 20, 2023 [10 favorites]

I came across that article about rumination when I was desperate to understand what was going on and it is so incredibly wrong I don't really know where to start.

Reading it delayed my process of figuring out how to look after myself.

I'll try to find some resources to post here, but in the meantime here's what I learned:

People are different from one another. People's brains work differently and that manifests as behaviors that some people (like many therapists, and the person who wrote that article) are incapable of understanding except by pathologising.

Telling someone who ruminates to just stop ruminating is like telling that person to just stop breathing.

Ruminating is correlated with anxiety, it's not the cause.

For someone like me, who can get stuck in ruminating loop, it can be painful, and it's helpful to know how to interrupt such a loop. Which is by noting what is going on, grounding myself in the moment, and distracting myself with things that stimulate my sympathetic nervous system.

But the rumination itself serves a purpose and it's harmful to just try to suppress it and escape it all the time.

So I also do things like ruminate with mindful intention, which means either talking out loud, or journalling.

But the most important step for me is to accept that ruminating is just a part of how my "normal to me" mind works.

It's like most people have a casing on that part of their mind so they don't hear the noise of their mind working, but that casing is missing for me.

That means I need to be careful not to get my fingers caught in the unshielded machinary, and sometimes I need to wear ear protection because the noise is disturbing.

But this unshielded mind situation isn't solved by trying to stop the machinary, and sometimes (many times!) it's necessary to hear the machine so that I know how to look after it.

It's like the difference between driving stick shift vs automatic.
posted by Zumbador at 9:39 PM on July 20, 2023 [22 favorites]

I had also felt like stopping paying attention to the obsessive thought/feelings I had was as impossible as stopping my brain from telling me that my whole body was on fire! And I had also done work on minimizing that with mindfulness, grounding, etc, which did help in the moment.

The problem is that although that helps, it also tells the brain that it was correct to flag that thought/feeling as a real issue that needed to be responded to. And so the brain will make the next time that thought/feeling occurs seem even more important! and even more impossible to stop paying attention to!

Compulsions feel compulsive because they seem uncontrollable, while this work teaches that even if a brain presents some thought or feeling, you can in fact choose whether you engage with it. Even though it seems at first as impossible as choosing to stop breathing.
posted by Theiform at 10:32 PM on July 20, 2023 [1 favorite]

As long as there's space for "what worked for me might not work for you because brains can be different", right?

I tried the techniques mentioned in that article. With absolute dedication, for more than a year. Supported by a therapist who believed in that approach as well.

Did me quite a lot of harm.

People are different.
posted by Zumbador at 11:44 PM on July 20, 2023 [5 favorites]

It's like most people have a casing on that part of their mind so they don't hear the noise of their mind working, but that casing is missing for me.

That is an excellent metaphor, thank you Zumbador.
posted by Bella Donna at 12:30 AM on July 21, 2023 [1 favorite]

But I'd ask people thinking about sharing their self-diagnoses, or who sometimes use phrases like "I'm a little OCD about that ha-ha-ha," to consider what it might feel like to have one's debilitating mental health challenges trivialized

Saying this not to fight but to bring up another dimension -- some of us with actual diagnosed OCD will also say things like "I'm a little OCD about that ha-ha-ha" because it's a frequently recognized shorthand for "please accept that something here is really distressing me in ways that I can't easily get past like most people would and yes I know that's not common and am aware it's potentially annoying to others and sincerely am troubled by that but I really do need to make this request" that also lets you not get into the details about extent or severity or whatever.

Also, like most neurological conditions OCD can range in severity from mild to debilitating, and even at the relatively mild end it can be plenty distressing and disruptive.


I feel like OCD is generally one of those things your brain does for reasons of its own — as part of its internal economy — and then people try to make up good reasons for why they do such a weird thing.

That's my feeling, personally. This guy's theory doesn't ring any kind of internal bell for me with my own experience. If it helps some people that's wonderful, but I'm wary of any approach that "all boils down to my one true (and Simple™) explanation". Especially since so many doctors and psychologists are of the single-explanation school for even the most complex and diverse conditions. (Fortunately, it's clear that said tendency is solely and entirely due to their deep-seated fear of the painful emotional consequences of being wrong.)
posted by trig at 3:40 AM on July 21, 2023 [10 favorites]

Especially since so many doctors and psychologists are of the single-explanation school

So many people are of the single-explanation school. Lots of people seem unable to engage with or even actively distressed by the idea that people are different and what works for one person might not work for another person.
posted by straight at 11:15 PM on July 21, 2023 [6 favorites]