There are few aspects of Obsessive Compulsive Disorder more contentious than the misuse of the term “spectrum” to describe a broad range of severity of the condition. The phrase “I’m a little OCD” will generally enrage the average person with actual diagnosed OCD, because there is no such thing as “a little OCD”.
Mental health professionals use the term “OCD spectrum disorder” specifically to mean a medical condition, such as body dysmorphic disorder (BDD) and trichotillomania, which can be related to OCD and which can be comorbidly present with OCD. They don’t use “spectrum” to mean a continuous range of severity of OCD from very mild to debilitating. To avoid any confusion, I will use the term “range of severity” in this post.
But some experts in OCD are starting to seriously consider the possible existence of an OCD range of severity. To be clear, it is already generally accepted that there is a narrow variation, ranging from moderate to severe.
In my personal experience I’ve only met or talked online with people with actual OCD which falls into this range. The severity of an individual sufferer’s OCD can vary. Sometimes it can be moderate. Other times it can be more severe. For some sufferers, the severity of their OCD can vary by time of day or time of year. When first learning about other people’s OCD, this was a revelation to me. My own OCD, prior to undergoing therapy, was unwaveringly severe every waking second, unless I retreated into nature, for a brief respite. I had thought that everybody’s OCD would be exactly like mine was. 100% on, full blast, all the time.
So I admit that I have a history of having preconceptions about what is or isn’t OCD. I am therefore treading a little more carefully towards the subject of a broader range of diagnosed severity. My gut reaction is to shout, “NO YOU ARE NOT A LITTLE BIT OCD! THERE’S NO SUCH THING!” But… what if there is a broader range of OCD suffering?
The thing which makes OCD what it is isn’t the intrusive thoughts, everybody has intrusive thoughts. It’s how a person reacts to those intrusive thoughts. A “normal” person will just think “well of course I’m not going to push somebody in front of a train”, then they move on to thinking about what to cook for dinner. A person with OCD may hold onto the thought and start to obsess that they are a potential murderer. This horrifies them, so they avoid train stations for fear that the thought will come true. It won’t come true, but that’s not what the OCD constantly whispers.
So there already exists a dividing line between what is considered “normal” and what is considered “disordered”. Some people are suggesting that we move that dividing line to the left a bit. The diagnosis is partially achieved and quantified by completion of a questionnaire. Depending upon how highly you score, you are rated “normal” to subclinical, not requiring treatment or moderate to severe, requiring treatment.
So what’s wrong with potentially having a broader scale of diagnosable OCD severity? Essentially it’s the problems of popular cultural misconception and subjectivity, compared to medical reality.
There are three bits to OCD, not two. What bits? What bits am I talking about?
I’m talking about the Obsessive bit, the Compulsive bit and the Disordered bit. This is the basic distinction that the media stubbornly refuse to understand.
Put in very basic terms, you can experience the “O” bit and the “C” bit, but without the “D” bit, it’s simply not OCD. But how can that be? Surely if you are obsessed and compelled, it must be OCD?
Not necessarily. The crucial factor isn’t what is thought or what action is done, but how that thought is reacted to, why the action is done and how much the thoughts, reactions and actions interfere with living a normal life. How much suffering is there?
Take, for example, the media’s favourite portrayal of OCD, the cleaning compulsion. The common misconception is, “I spent a whole hour tidying the house. I’m so OCD, but a tidy house satisfies me so much”. The person has thought, “My house is untidy and is annoying me. I need to tidy it” and they then tidy it. Their house becomes tidy, they are no longer annoyed and they feel positive for having completed a dull chore. They might be obsessive about tidiness. They might be compelled to keep their house tidy. But what about the “D” bit?
A person with OCD would typically think, “My house is untidy. I am a bad person because my house is now a hazard to people’s health, harbouring germs and risking injury through accidents. Someone could die because of my untidy house. If someone dies because my house is untidy, it will be my fault. I will have caused that person’s unnecessary death. I must tidy my house completely right now, before someone dies”. And then they tidy the house. And again. And again. And again, because they fear that even the tiniest bit of overlooked untidiness could cause death”.
This sounds incredibly extreme to a “normal” person. People normally react to such an example with, “Wow, that must be at the really severe end of the scale”, but sadly it’s not. That is an absolutely typical example of the intrusive thought – reaction – compulsion process for an average OCD sufferer. The main variations between moderate and severe OCD are the extent to which the condition consumes a sufferer’s time, energy and focus, resulting in suffering.
This is the “D” bit. How disordered is your life as a result of having the condition? Is the condition all consuming, exhausting, terrifying, guilt inducing, shameful, soul destroying, debilitating? It’s not called a disorder for nothing.
There is no grey area. There is no broad range of tones of severity. If OCD is a light, it’s either on or off; there’s no infinitely adjustable dimmer switch. It is a harsh and glaring spotlight. Either your mind is in turmoil because you have the disorder or it’s not, because you don’t. There is no “little bit OCD”. No subtle mood lighting for a satisfyingly tidied house.
What happens if the normal/disordered cutoff gets moved to the left a bit? The fear of many OCD sufferers is that it will legitimise the “little bit OCD” myth, further underplaying the true severity of the condition for most sufferers. It is already viewed popularly as a joke condition. Not a proper mental illness, but just being a bit of a fruitcake like Monica out of Friends.
If some people are diagnosed as sufferers of an apparently less severe form of OCD, will that trivialise the condition further? Will these people be given access to treatment – medication or therapy – that they are currently denied? Will more mental health resources be made available for OCD treatment or will an already threadbare single duvet have to stretch across a now double bed? I could have a pretty good guess at the answer to that last question.
I would hope that any professional expansion of the concept of an OCD range of severity would be as a result of earlier diagnosis of the condition after onset, to take into account the smaller amount of time that a person has been thinking and acting in an abnormally conditioned manner. Earlier diagnosis is a fantastic thing. It reduces the amount of time that a person is alone in suffering & it reduces the extent of the mental scarring inflicted by OCD.
If the earlier stages of the transition over the threshold into the “D” bit can be diagnosed and treated sooner for more people, then I am happy to see an expansion of the severity range concept.
Wow! What a title! Sounds like an Agatha Christie novel or a cheap horror movie. It’s actually the title of a BBC Panorama documentary which hypothesises a link between SSRI antidepressant medication and an increased propensity to commit violent acts.
Is there a link? Statistically yes maybe. A very tiny percentage of people taking SSRIs experience psychosis as a side effect, but statistically more people are killed as a result of trying to put on a pair of trousers. So why is there not a documentary about trouser deaths called Leg Ends Of The Fall? I believe it is because of the manner of the respective causes of death.
Accidental deaths caused by embarrassing wardrobe malfunctions would be uncomfortable, voyeuristic subject matter. You don’t kick a man when he’s down through no fault of his own. So what’s the difference between that and someone who’s mentally ill through no fault of their own?
It’s because violent mentally ill people are juicy subject matter. A ratings winner. The subject retains a ghoulish car crash fascination. The notion that mental illness equates to violent, dangerous derangement is deeply embedded in the public’s psyche. Why else were lunatics locked in mental asylums, strapped in straitjackets, if not to prevent them from being a danger to others?
There are many variations of the escaped mental patient urban myth, with invariably innocents being slaughtered by the rampaging, almost supernatural human monster. The thing cannot be reasoned with; it is beyond reason. It is animalistic, bloodthirsty, evil. Something to be hunted and killed on sight.
The factual reality is that mentally ill people are more likely to be a victim of violence than the general population. Only 3% of mentally ill people ever commit a criminal act of aggression. That means that 97% never commit an act of aggression. The person a mentally ill person is most likely to harm or kill is themselves. Suicide is the biggest cause of death in men aged 20-49 in the U.K. and the biggest cause of death of teenage girls worldwide.
What then is the basis for a 21st century documentary about mentally ill killers, that lingers over gory details? According to Shelley Jofre, the BBC reporter who made the documentary, it is a public interest story. I see that it’s a story the public will be interested in, but is it in the public interest?
The Panorama programme claims that the incredibly rare side effect of SSRI medication causing psychosis, potentially leading to aggression and violence, needs to be more widely known to both the general public and to people taking SSRIs. The problem with this argument is that family doctors and prescribing psychiatrists already weigh up potential side effect risks and discuss them with patients before prescribing. And there are many possible side effects from taking SSRI medications, the most common of which include weight gain, sedation, fatigue and loss of sex drive. The average person taking an SSRI has been informed by their doctor of likely side effects, thoroughly read the leaflet that comes with the medication, probably read up some more about the risks on Wikipedia and discussed the risks with other people taking the same medication. The vast majority of mentally ill people are already very well aware of the potential and actual side effects of taking SSRI medications.
What about the wider population? Don’t they deserve to know the danger too? If the 40,000,000 prescriptions for SSRI medications in the U.K. every year are going to trigger a nationwide bloodbath, don’t the public have a right to be warned? Therein lies the central weakness in the programme’s premise. 40,000,000 SSRI prescriptions per year already in the U.K., no mental patient slasher movie apocalypse as a result.
I don’t deny that there are records of isolated cases where an SSRI may have contributed to a tragic incident. But is the potential danger both proven and statistically significant enough to warrant making an hour long documentary about it? What about the much more prevalent side effect of an increased risk of death by suicide among teenagers when they first start taking some, but not all, SSRI medications? That kills more people. Surely that’s more newsworthy?
The unpalatable reality is that few care about mentally ill teenagers killing themselves. It’s dull TV, compared to bloodsoaked rampaging mental patients. Real Hannibal Lecters lurking in our midst.
This perpetuates the myth that mentally ill people are inherently violent and a well behaved one is just one waiting to explode in a killing frenzy at any moment. Drugs are supposed to suppress this huge danger, not enhance it. A dribbling, sedated, locked up mental patient is the only safe one.
This is of course total nonsense. One in four of us will suffer a mental illness in our lifetime. The vast majority of people will be treated with a combination of medication and therapy. Out in society. Not locked up. Normal, but unwell people, not dangerous in any way.
What are the likely outcomes of the documentary being aired?
There is a small possibility that a handful of people who are taking SSRIs and experiencing psychosis as a side effect will realise what has been wrong and seek help and advice from their doctor. This is a good thing.
Something which is much more likely is that some mentally ill people currently benefitting from taking SSRI medications will stop taking them, to avoid the remote possibility of becoming violent. The benefits of that medication will then stop. Clinically depressed people will slide back into the abyss. People with anxiety disorders will retreat back into tormented Hell. Some of these people may well take their own lives as a result. The documentary could possibly cause more deaths, not fewer.
Then there is the stigma issue. Some think that the term “mental health stigma” is overused. In the face of the ongoing tide of derision, fear, mistrust and demonisation of mentally ill people, I can assure you that the term could be used much more indeed. Just like black people and gay people have had to stand up and say enough is enough, mentally ill people are now standing up to be counted.
My name is Patrick. I suffer from clinical depression, severe OCD and PTSD. I am a mentally ill person, a loving husband, a good father. I take a high dose of Prozac, an SSRI medication. It helps me to function normally. I’m not an unquestioning fanboy of Prozac. I have side effects from taking it, but I’m zero danger to anyone. Enough is enough. The unwarranted stigma against all the ordinary people just like me has to stop. This documentary will perpetuate stigma and prejudice. That is harmful and dangerous. Much more dangerous than a rare medication side effect.
My wife is a dietitian. Starting yesterday, she and the team of dietitians she leads are trying out some of the clinical and controlled diets that their patients experience. So, for a week, my wife has chosen to be a temporary vegetarian.
Two of my daughters are already vegetarian; the other is a devout carnivore. But, for this week, the whole family is having a go at the vegetarian thing, in solidarity with my wife.
We’re into our second day and it’s going OK so far. We bought a lot of vegetables and vegetarian food at the supermarket yesterday. We didn’t buy any fish or shellfish – we’re not doing the ‘pescetarian’ cop out, but we’re also not trying the full vegan thing either. I will struggle enough with just a vegetarian diet.
One thing I insisted upon was trying some of the facsimile products, like Quorn ‘chicken’ nuggets. We will make some meals from scratch, but I wanted to try some of the foods which are considered as ‘cheating’ by some proper, permanent vegetarians. If one likes meat, but for whatever reason chooses to be vegetarian, then why not have some things which are meatlike in taste and texture?
We have been trying to have one or two meatfree evening meals a week, so we’ve already tried some products. I find the Quorn Mince an unconvincing texture, so we just use it to bulk out a smaller amount than normal of proper beef mince. This week, we’ll have only Quorn mince, so I’ve decided that chilli sin carne would be the best way to disguise it, with kidney beans, peppers & onions adding some bite and texture.
As well as trying the food, I will also be attempting to cook some of the meals. Normally, I struggle with contamination OCD intrusive thoughts so much that it renders me incapable of handling raw meat products. The decontamination rituals make preparing a meal distressing, prolonged and impractical. So I’m seeing how I deal with veggie cookery. I will still have to face handling things like eggs, so there are some pretty big triggers remaining. It’s still going to be a challenge. I will do my best.
I’m keen to try a couple of Indian and North African recipes. I’d like the experiment to be a balance between cooking from scratch and lazy convenience foods.
My wife will be taking professional nutritional, qualitative, cost and environmental impact notes throughout the week, in order to present her findings & experiences to her team. I think that the added data of the whole family participating will make the experiment much more useful. Since it’s only day two, I haven’t yet started to crave bacon sandwiches, but I expect to. From past experience, vegetarian ‘bacon’ is both weird and disappointing. I do intend to try doing a veggie fry-up though, with veggie sausages, which are OK.
Do I expect to go permanently vegetarian by the end of the experiment? Not a chance. I will always be carnivorous, but it would be good to broaden the repertoire of vegetarian food which could be interspersed among the usual non-stop meat frenzy.
The experiment ends
It was an interesting week. We set out with a few objectives and achieved some, but not all of them. We had some of our preconceptions challenged and confirmed other things we expected to be true.
So, will we repeat the experiment? No, I don’t reckon we will. Will we eat fewer meat based dishes, more vegetarian dishes and more vegetables? Definitely. We will also be trying a more varied diet, with more seafood and less red meat, which is a positive outcome. I’m glad that we joined in with my wife’s experiment. It was educational.
I have a faith. I believe in God. I don’t believe in Big Angry Beardy Man In The Sky. I believe that God is good. More specifically, God is the capacity for good within people, enacted in their lives. I believe that evil is the absence of the capacity for good. I believe that Hell is the absence of God.
I have been to Hell. I have called out to God in the greatest extremes of my mental despair and he hasn’t replied. He wasn’t there when depression was doing its damnedest to kill me and three times nearly succeeded. I was on my own. Hell is the absence of God.
I’ve thought about this a lot since. How can I still have a faith when God has never been there with me during the darkest moments? Never. Not once. And they were very dark moments indeed. I’ve heard the old “God moves in mysterious ways” bollocks:
“Maybe He was there all along, guiding you and you just didn’t realise.”
“Maybe God’s answer was that you were strong enough to get through it yourself.”
“Maybe there was someone more deserving of His attention all those times. Think of all the starving babies in Africa. Aren’t you being a bit selfish?”
All bollocks. God wasn’t there with me. I was on my own. I prayed, but it was a monologue into the void, with no reply. I had to go on alone. I had to believe in myself and trust myself. I had to help me. Yes, those were my footprints in the sand; Jesus wasn’t carrying me.
This sounds like shouty, bitter, former-Christian-now-Atheist ranting, but it’s not. I still believe. I still have a faith. I still thank God when I experience good things. I still pray informally and often. But why? If I had asked a close friend or family member for help under those circumstances and there had been zero reply, I would have cut them out of my life from that point onwards. Why haven’t I booted God into the middle distance?
I have always had a questioning faith. I believe that blind, unquestioning faith is no faith. Yet this question is a biggie about the continued existence of my faith at all. It’s a fair question. Do I have an answer to it?
God is good. Literally, not descriptively. Substantially. I see good in my kids. I see so much good in my wife. I see good in my dachshund. I see good in nature. I see good in people’s actions towards each other every day. Doesn’t this mean I’m a “glass is half full” kind of person? A kindly, optimistic, naive soul who always sees the good in things? Not at all. My World view can often be bleak and cynical. I have experienced the very worst of man’s inhumanity to man at first hand. I know how cruel and indeed evil human beings can be and I literally have the physical and mental scars to prove it.
Am I just stupid and stubborn then? Refusing to relinquish yet another dysfunctional lifelong core belief? Am I so feeble minded that I need a “made up sky fairy” to guide my moral compass, for fear I would run amok without its steadying guidance?
On this point I can firmly say no. I have OCD. A common type of OCD obsession is Religious OCD, where the sufferer experiences obsessions and extreme incessant anxiety for having unholy thoughts or not being religious, faithful and pious enough. I have never ever experienced this. My moral compass is true. I don’t need to be a Holy Joe, going to church twice a day, to know that I am a decent person, living my faith through my actions.
Seeing the capacity for good being enacted in the world is my evidence of God. There is a lot of the lack of the capacity for good – Evil – in this world too. That doesn’t surprise me at all. It saddens me.
I have my own capacity for good. To have a living faith is to use that capacity for good to the common benefit. I’m no saint by any means. I don’t know the words to all the hymns (and I mime the words anyway). I don’t go to church services enough. I rarely feel worthy to receive communion. (Facts, not OCD religious thinking). But I live it. Quietly. I am there, even when God isn’t. The capacity for good within me is there. Godliness, not God. I make God present by using that capacity for good. I don’t believe in an omnipotent, omnipresent being. By definition, there’d be no evil if there was one. Sometimes we are on our own, like it or lump it.
Depression dulls the senses. It stops you from experiencing. It stops you from being. It stops you from doing. If you do nothing, your capacity for good sits idle. God is not there. He cannot be. Depression isn’t evil, but it is Hell in its true sense. Hell is the absence of God.
I have been lucky a few times in my life to be able to make God present for others in their darkest hour. Not in a preachy, self aggrandising, bible waving way. Quietly. Just by being there, listening, holding a hand, offering a few words of support, letting them know they aren’t alone in Hell. God is the capacity for good, put into use. God is good.