La Folie du Doute

“OCD was once called ‘la folie du doute’ (‘the madness of doubt’), highlighting the central role of self-doubt in its symptomatology (Janet, 1908).” – Yes, I know it’s French.

So, what is it? There’s science behind all this and it’s not just – “Oh, hey, I can’t make a decision.” – or – “I need to touch things an even number of times” (or if you’re someone else – obsessive hand washing, hoarding, over-the-top house cleanliness and order, excessive lock checking, self harm thoughts, etc).” There is plenty of discussion on what causes something that affects 2-3% of the U.S. population (~3.3 million). What it is, when you get right down to it – It’s part of anxiety disorder and brought on by part of a broken system in the brain.

Some thoughts are that it’s causes are possibly hereditary, it might be a spontaneous mutation, perhaps some stress that caused a gene to switch on as a child, maybe an illness like streptococcal infections causing an autoimmune response that causes injury, or perhaps environmental factors. Maybe various combinations of all the above. The brain is an organ after all. That being said decades ago, there was little to know but as of late, study into OCD has increased significantly. I’m lucky, to an extent, as my OCD is less worse than a lot of other sufferers.

Anyway, I feel it best to pull quotes to help describe medical thoughts on OCD, as I’m not a medical professional, and then link to the original articles if you want to explore more. It’s a lot to read, and perhaps boring, but I’ve highlighted some text that I feel best describes things, some in layman’s terms, more scientific in others, or that just resonate the most with me:

“…OCD produces profound morbidity. Difficulties with decision-making and intolerance of uncertainty are prominent clinical features in many patients. The nature and etiology of these deficits are poorly understood. We used a well-validated choice task… to investigate differences in valuation and value-based choice during decision making under uncertainty…Participants’ choices were used to assess individual decision-making characteristics. OCD participants did not differ from healthy controls in how they valued uncertain options when outcome probabilities were known (risk) but were more likely than healthy controls to avoid uncertain options when these probabilities were imprecisely specified (ambiguity). Compared to healthy controls, individuals with OCD were less consistent in their choices and less able to identify options that should be clearly preferable. These abnormalities correlated with symptom severity. These results suggest that value-based choices during decision-making are abnormal in OCD. Individuals with OCD show elevated intolerance of uncertainty…”

“… Of note, the circuitry that is linked to valuation (Bartra et al, 2013) is abnormal in OCD (Maia et al., 2008; Menzies et al., 2008). This raises the possibility that abnormalities in valuation may contribute to decision-making difficulties observed clinically in patients…”

“Individuals with (OCD) often exhibit indecisiveness, pathological doubt, and avoidance of uncertainty (Rasmussen and Eisen, 1992; Reed, 1985; Tolin et al., 2003), even when the task at hand is unrelated to their primary symptomatology (Hamilton, 1957).”

“In OCD and compulsive individuals, some decision making acquires an abnormal emotional valence, because of abnormal activity in the OFC.” This leads to abnormal activation of the ACC and prevents an individual from making a quick or automated decision. Individual ends up in a vicious cycle where anxiety about decision making increases activation in the OFC which makes it increasingly hard to make a decision. The DLPFC is implicated in the executive function that terminates a compulsion. It is no coincidence that dysfunction of orbitofronto-striato-thalamic circuits are a cause of pathology in OCD, since these areas play a key role in decision making (Heekeren et al., 2008).”


“…brain scans of people with OCD are different than those of people without it – the prefrontal cortex of the brain is overactive in people with OCD….

…It also appears to be related to an imbalance in the levels of the neurotransmitters serotonin and dopamine, with serotonin levels being abnormally low and dopamine levels, abnormally high. Certainly, though, the OCD brain, specifically the prefrontal cortex, uses far more energy than the non-OCD brain.”

“The loop is of particular relevance to hyper- and hypo-kinetic movement disorders, such as Parkinson’s disease and Huntington’s disease,[2] as well as to psychiatric disorders of control, such as ADHD,[3] OCD,[4] and Tourette syndrome.[5]

 In OCD, the loop may be dysfunctional, with an imbalance between the indirect and direct pathways resulting in unwanted thoughts, getting “stuck”.

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