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Doubt as a driving force in OCD


Interview with Diana Pascal


Doubt as a phenomenon is found in various parts of psychiatry. The depressed patient suffers from painful ambivalence and accompanying doubts in various areas, mainly due to overthinking and rumination. Doubt is also common in psychotic syndromes, on other grounds such as delusions, thought disorders and cognitive dysfunction. The anxiety-driven patient with generalized anxiety has difficulties reconciling with an unpredictable future where anything can happen, and the struggle against uncertainty can fill all waking time.

No condition is as fundamentally driven by doubt as obsessive-compulsive disorder (OCD), which in Swedish is also called "disease of doubt" - a term that well describes the essence of the current issue. In OCD the uncertainty is related to one's own senses. - Have I really checked the stove and unplugged the iron? Are my hands really clean, or should I wash them again, just to be safe? The suffering resulting from this uncertainty, and later the level of impairment, can become significant. What causes this and what can be done? To find answers to these questions, I contacted one of the country's more senior doctors in the field, Diana Pascal.


Diana Pascal has worked with OCD for several years. She is active at the OCD Program at Psykiatri Sydväst in Huddinge. Her research includes studies on Deep Brain Stimulation in OCD, and her clinical work is entirely focused on patients with OCD and related disorders.


- Uncertainty and subsequent doubt are pathognomonic for OCD, it is the very engine behind most symptoms within the syndrome. The affected person often has an elevated level of anxiety as a base, and somewhere along the way, doubt arises, and thus compulsive actions as a way to momentarily reduce discomfort.


Interestingly, Diana says, uncertainty and doubt can also be induced in healthy subjects. By repeating routine behaviors such as checking the door or water tap several times, around ten, doubt about the performance arises.



Uncertainty can sneak into more and more areas, not only control and hygiene compulsions but also purely existential ones. - Am I living as I should? Am I behaving morally and ethically correctly? Am I making wise choices? Diana discusses the fact that complete certainty can never be achieved. Our brain makes decisions based on unconscious statistics. We handle life based on what usually works. More perfectionist individual face difficulties doing this, due to intolerance of uncertainty, and will therefore suffer from the slightest hint of uncertainty.


As with several other psychiatric conditions, genetics and environment play a clear role in the OCD. Studies where twins are separated from each other show an increased prevalence of OCD in both individuals. Likely, model learning also plays a significant role, where one imitates how role models act and relate to reality.


Ritualized behavior is seen in both patients with autism spectrum disorder and among patients with OCD. In autism, the behavior is rather routine-bound and ritualized and follows the individual's desire to do things in a self-decided way, and is therefore to be described as egosyntonic. The person with OCD experiences the obsessive thought as intrusive and meaningless, usually ego-dystonic, which makes the compulsive action more repetitive than routine-based, also painful, even if some relief may occur in the moment. In both cases, significant functional impairment can occur. The doubt itself can increase with an increasing number of repetitions and can sometimes become stronger in the presence of co-existing depressions.


Comorbidity between doubt, OCD, and other conditions, not least depression, is high. The social consequences often become significant, not least due to social isolation. Remarkably many have low nutrient levels as contamination fear or fear to use electric appliances may severely affect eating habits. Some isolate themselves at home and rarely expose themselves to sunlight. Symptoms can provide clues about the need for extended somatic investigation, such as checking vitamin levels.


We reason a little about treatment. Diana highlights the limited effect of SSRIs. – Studies show that antidepressants have a significant effect on OCD-symptoms and the ability to ignore obsessive thoughts, an effect similar to what patients experience in depression, where one may find it easier to turn away from negative thoughts and experience a decrease in anxiety together with an increase of energy. When medicated, one may find it easier to also resist compulsive actions and carry out ERP treatment (exposure with response prevention, a specific CBT treatment with high evidence grade in OCD).


The effect size of medication treatment is however lower compared to the effects of cognitive behavioral therapy (ERP), where changes in behavior can help patients become free from their symptoms.


Neurobiologically, it is about breaking overactivity in different networks in the brain, such as in the cortico-striato-thalamo-cortical (CSTC) circuit. When doubt becomes high, with the help of increased influence from subcortical structures such as basal ganglia, insula, amygdala, the ability of the higher cortical functions such as inhibitory control and rational thinking do not work.


In most cases, psychotherapy with or without medication treatment has a good effect. In extremely rare cases, invasive methods can be used. Historically, capsulotomy was used, an irreversible method where fibers within the CTSC that pass the internal capsule are severed. In some individuals, this led to symptom improvement, although sometimes associated with severe and irreversible side effects. The method is therefore no longer used in Sweden. Deep brain stimulation (DBS) has gained ground since the 2000’s, where efforts are made to reduce traffic in the CSTC with the help of electrical stimulation, a minimally invasive and largely reversible procedure. The advantage is also that one can manage both side effects and adjust the effect by changing the stimulation point and parameters, i.e., without changing the physical location of the electrode.


Excellent depictions of OCD can be found in the world of film. In "As Good as It Gets" from 1997, Jack Nicholson plays a misanthropic writer who cannot stand changes and has severe hygiene compulsions. Involuntary exposure therapy leads to consequences in this entertaining and actually instructive film. Toc Toc is a Spanish film comedy from 2017, portraying a group of patients with different dimensions of the obsessive-compulisve disorder. □


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