Part 2: Should I use medications to treat my OCD?
In Part 1 of the “Should I use medications to treat my OCD series”, we reviewed the evidence from randomized controlled trials and meta-analyses of these trials which demonstrated that ERP on its own is as effective as combined ERP plus SSRI treatment.
This evidence leads us to the question: If the meta-analyses show that, on average, there’s no benefit to adding a SSRI to ERP treatment, how come it’s such a common recommendation provided to OCD sufferers?
Before we go further, a quick reminder:
As an OCD therapist, I can provide information about the research evaluating medication effectiveness and the possible role of medications in OCD treatment. However, I’m not a prescribing professional. Any decisions regarding beginning, stopping, or changing medications should be made in consultation with a qualified prescribing professional, such as a psychiatrist or primary care provider. So: Please be sure you consult with your prescribing professional before making any change to your medication use!
Now, back to the question: If the meta-analyses show that, on average, there’s no benefit to adding a SSRI to ERP treatment, how come it’s such a common recommendation provided to OCD sufferers?
I suspect that one of the reasons that combined treatment is so commonly thought to be the best choice is related to prominent OCD treatment providers recommending it.
To show what I mean, consider the following YouTube clip from Dr. Jonathan Grayson, one of the world’s leading OCD therapists: https://www.youtube.com/live/3AEqhmbz_0g?si=HLvZ3uNpI-AkYbdH&t=1418
From the clip, here’s the transcript of the kind of OCD provider recommendation I want to challenge:
Patrick: Have we ever seen any clients that got better from ERP and successfully came off of medication?
Jonathan: Um….Can I answer? I don’t know if you agree with me on this. But we’ll find out. Um, and I don’t know if we’re going to have to do the other one, you know what I’m talking about.
Patrick: Yah.
Jonathan: OCD is a learned and a biological problem. So, when you ask that question, you’re acting like it’s, it’s, it’s like there’s these two things that are separate and they’re not separate. Now, medication alone, generally leads, if it’s working, to 25 to 50% improvement. For a lot of people that’s not like not really worth it. That’s because the learned part of OCD is so powerful it can override the meds. I’ve had many people come in on medication, be really dysfunctional, do ERP, do great and feel like, “Oh OK, I don’t need the medication” I always say “that’s probably not true” they go off the meds and then discover the meds were doing something. So, you are stuck with Patrick and I, doing ERP, but quite likely the meds are necessary. And actually, the way I tell if meds are useful, I do not look for improvement in OCD, I want to see improvement in depression, because that seems to me more susceptible. So, if they’re getting better from their depression, the meds are working, and you need to do it. But, the idea that you can get off medication…no, that, that really, you know, I’m sorry, you actually have a biological problem and can’t depend on that. If you do get off meds successfully, I would say to you, “That’s cool. But it doesn't mean your body won’t switch back and you’re going to need them in the future. Because some people are very stable in their need for meds and other people it goes up and down. So. Anyway.”
The research:
Jonathan’s claims in this clip are congruent with views he presents in his (generally excellent) book Freedom From Obsessive-Compulsive Disorder.¹ In chapter 2, Jonathan wrote, “OCD is both a learned and a biological disorder…when it comes to OCD we do know that biology precedes learning…OCD is a neurobiological disorder – that is, the differences between you and non-sufferers are reflected in the biology of your brain…The most studied theory of this sort regarding OCD is called the serotonergic theory…The research indicates that [OCD sufferers] have enough serotonin but that it is not as available as it needs to be for certain brain communications to take place…(pp. 13-16).
Before I describe the reasons I think that Jonathan is wrong, I first want to note that I very much admire Jonathan. He’s been a wonderful advocate for OCD sufferers and I’ve learned so much from him about treating OCD with ERP (for example, see this blog post).
Nevertheless, I think he’s making some very important mistakes in the YouTube clip, in his book, and that’s what we’ll review below.
Let’s first observe this: In the YouTube clip, Jonathan isn’t pointing to scientific studies that demonstrate that OCD is caused by a “biological problem”. He’s simply asserting it. In his book, he also doesn’t provide specific references but, instead, states “Research suggests…”
If I were to ask him something like, “Jonathan, you say that OCD is a biological problem. What evidence do you have that OCD is a biological problem?” Jonathan would begin by admitting that you can’t go to a doctor’s office and obtain a blood test that shows you have OCD. You can’t even go into a clinical research facility and complete a brain scan to show you have OCD.
Put more academically, and I’ve no idea if Jonathan is aware of this or not, a comprehensive review on this subject has demonstrated there are currently no clinically actionable biomarkers for OCD.²
What this means is that, although researchers are able to find associations between biological components and OCD, none of these associations are reliable enough to provide an OCD diagnosis. This includes all the research exploring brain structure and function, chemical and molecular analysis, cytokine measurement and analysis, cortisol levels, brain-derived neurotrophic factor levels, etc.
Why are these associations not enough to provide an OCD diagnosis? Because they aren’t reliable enough. For example, although the brains of many diagnosed with OCD exhibit, for example, hyperactivity (increased brain activity) in the prefrontal cortex, other studies show that the brains of many diagnosed with OCD exhibit hypoactivity (decreased brain activity) in the prefrontal cortex.³
Researchers are well aware of this shortcoming. As a result, they provide qualifying language and call for more research related to their findings. For example, researchers emphasize the heterogeneous nature of OCD, the overlap with other mental health conditions (such as depression, other anxiety disorders, and personality disorders), and the need for increased precision in studying more specific areas within the prefrontal cortex (such as the dorsolateral prefrontal cortex, ventrolateral prefrontal cortex, orbitofrontal cortex, anterior cingulate cortex) and how these areas of the cortex interact with other regions of the brain (e.g., cortico-striato-thalamo-cortical circuit; the limbic system, etc.).⁴
So, to recap, what we’ve covered so far is that we don’t have evidence that’s able to identify the biological cause(s) of OCD. Of course, that doesn’t mean that there isn’t a biological cause. It just means that if there’s a biological cause, we haven’t found it yet.
And now we need to take an even deeper step into this research. How come I say we need to take an even deeper step?
Often, when having discussions around the causes of OCD, people will ask me something like, “OK, William, but human beings aren’t ghosts. We’re biological organisms. So of course the brain is causing OCD unless you believe in some sort of outdated idea of “evil spirits” or a dualistic conception of human beings (dualistic is the idea that the mind and the body are radically distinct types of things that, somehow, interact and it’s not a widely accepted view in medical science).
True, I believe we’re biological organisms, I don’t believe “evil spirits” are causing OCD, and I’m not a dualist. But the claim: “We are biological beings so of course OCD is caused by the brain” is, while intuitively appealing, an oversimplified idea that, in fact, is not congruent with what leading researchers think about the brain, the mind, and OCD.
In part 3 of the “Should I take medications to treat my OCD” series, we’ll move further into the more complicated idea of causality and how this relates to the similarities and differences between the brain (the organ within the skull) and the mind (the processes and felt quality of subjective experience, such as awareness, remembering, conceptualizing, inferring, hallucinating, and having the thought, and related feelings, ‘my hands are contaminated’).
References:
Grayson, J. (2014). Freedom from obsessive compulsive disorder: A personalized recovery program for living with uncertainty. Penguin.
Fullana, M. A., Abramovitch, A., Via, E., López-Sola, C., Goldberg, X., Reina, N., ... & Radua, J. (2020). Diagnostic biomarkers for obsessive-compulsive disorder: A reasonable quest or ignis fatuus?. Neuroscience & Biobehavioral Reviews, 118, 504-513.
Ahmari, S. E., & Rauch, S. L. (2022). The prefrontal cortex and OCD. Neuropsychopharmacology, 47(1), 211-224.
Jalal, B., Chamberlain, S. R., & Sahakian, B. J. (2023). Obsessive‐compulsive disorder: Etiology, neuropathology, and cognitive dysfunction. Brain and Behavior, 13(6), e3000.
