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Why understanding OCD is a path to having a less anxious and more satisfying life
🕑 Added 2020-05-12 12:41:31 +0000 UTC
It's been a while so I thought I'd do something different for the newsletter. This is a long form post, about twice as long as my typical video script.
So recently I’ve been working on the follow up video to my “Why do we find Satisfying things so Satisfying?” video. In that video I said that we find completing things correctly, feedback that something was completed correctly provide us with an enjoyable sense of satisfaction and difficulty of the task enhances the satisfaction.
I wanted to address the practical application of each of these things - completion, feedback and difficulty, but found that once again that would mean a very long video. To keep you guys from having to wait weeks again for a video, I’m going to break it up into three videos, one for each topic. I’m starting with “Completion.”
Let me start out by saying I’m not a very organized person. Ever since I can remember, my philosophy was something like “why waste time planning when you can spend it doing.” I thought I was very cool being able to manage all the things I needed to get taken care of in my head. I was wrong about being “cool” and wrong about “being able to manage all the things I needed to get taken care of.” As I got older, I understood more the benefits of being organized. Sometimes in a burst of inspiration I would say “Now I’m finally gonna get started on being organized” and I would clean out my inbox, try and better order my room, organize papers books and whatnot, but I never felt quite confident that my system was effective and I didn’t have a clear picture of the implications of being disorganized, so the organization effort stopped halfway. I’ve slowly been building the skill, but progress is slow.
I took the Big Five Personality Test and scored very low on conscientiousness. “Conscientious people tend to be efficient and organized as opposed to easy-going and disorderly." Definitely not me. Whether your organized or not this could be a fun read, but if you’re very organized you might be left thinking “well I didn’t need a breakdown of OCD to understand that…”
Low level, background anxiety
As part of the research I was rereading Jordan Peterson's book "12 Rules for life," and in that, he says "The parts of your brain that generates anxiety are more interested in the fact that there is a plan than in the details of the plan.” I thought this was really interesting and might help me tackle the topic of “How to use completeness to make your life more satisfying” from the angle of “How to make your life feel less incomplete and therefore at least not unsatisfying.” I was listening to the audio book, so I opened up the kindle version of his book to check the reference and find which paper(s) he referenced. There was no reference. That was too bad because I really thought that if that were true it would have some big implications. My ever-chomped fingernails can attest that I am often anxious. I don’t have an anxiety “disorder” or panic attacks, nothing like that - just the general everyday “I forgot to do X, that seems pretty important, I need to do that right now but I need to get this script written” that I’m sure everyone experiences (…at least I assume they do…)
Here’s a helpful flow chart: 
*Actually, this should read "Continue what I was doing, but be slightly anxious" - it's just a small pulse of background low level uneasiness.
Eventually, I found a paper of Peterson’s published in 2012 in “Psychological Review” titled Psychological Entropy: A Framework for Understanding Uncertainty-Related Anxiety. This was a fantastic paper to say the least, but it’s too much to unpack here. It helped me put some pieces together from 3 papers on Obsessive Compulsive Disorder and I’ll address the implications of these. In the Satisfying video I was talking about Obsessive Compulsive disorder, and I thought it was interesting to look at as OCD patients seem to suffer from “lack of satisfaction” i.e. they can wash and wash but not be “satisfied” that they have washed their hands enough.
What’s so interesting about OCD?
You can often understand a lot about how something works by seeing what happens when it breaks. I learned a little bit about computer hardware when I built my computer in high school, but I learned far more when it suddenly stopped booting up. Similarly, disease states offer a chance to better understand how the body works. In fact, neuroscientists learned a lot about how different brain regions worked by watching what happens when they’re damaged (lesioned).
With that in mind, I became quite interested in what was happening in people with OCD. The three papers I mentioned were written by Woody and Szechtman from McMaster and Waterlooin Canada.
“In brief, we hypothesize that such [OCD] symptoms, despite their apparent nonrationality…” (they explained earlier in the paper that OCD patients are very aware that their obsessions and compulsions are completely irrational and unbeneficial) “…have what might be termed an epistemic origin—that is, they stem from an inability to generate the normal “feeling of knowing” that would otherwise signal task completion and terminate the expression of a security motivational system.”
We make decisions with feeling, not just rationale
Don’t worry about “security motivational system” - we’ll get to that in a bit. For now let’s explore this part I bolded. This feeling of knowing is very important, because as research by Antonio Damasio (author of Descarte’s Error) suggests, we don’t make decisions based on rational computations, but based on a feeling that our decision is correct.
A portuguese neurologist in 1936 developed an untested surgical treatment, frontal lobotomy, to treat individuals with severe emotional problems.[S] The frontal lobe is necessary for processing emotion as well as performing and interpreting emotional behaviors. Damasio had a frontal lobotomy patient who, “when asked to schedule a next visit, spent half an hour carefully searching out and weighing all logical possibilities” before Damasio finally stopped him. Damasio argued that this represented the failure of feeling to inform decision making. I assume that for many people, many decisions in their life weren’t made based on logical reasoning, but because it “felt” right.
What’s the logical reasoning for determining a stopping point for hand washing? You can’t see germs. How often do you see people closely inspect their hands before rinsing to make sure the soap covered the entire surface area of their hands? (Not that this is necessarily what goes on in the minds of OCD patients) Obviously we just “wing it” when it comes to stopping our hand washing.
Woody and Szechtman say that with OCD, “the underlying problem is a lack of closure…” Milner, Beech and Walker’s research from 1971 found that in trial that checked participant’s ability to detect a tone, obsessional performed as well as people without the disorder. However, when they given the ability to double check - to ask to hear the trial again before giving their final answer, they found that the people with obsessive symptoms asked for significantly more repeats of the trial. Obsessive people “demand more information to arrive at a decision,” they’re indecisive. Taking Damasio’s point about decision making, we could say obsessive people are unable to achieve the feeling necessary to inform them they they are making the correct decision.
Work by G. F. Reed in 1977 found that the “decision difficulty experienced by the obsessional individual is inversely related to the amount of structuring available in the task itself.” Suggesting that an obsessive person should have zero trouble with a task like “insert the wooden shape into the corresponding hole,” but would start to have some trouble with anything that has more than one correct answer like “Pick the best day to have your doctor appointment next week.”
You’ve surely heard people refer to themselves as “OCD” as in for example “I’m just so OCD about the arrangement of my books.” When someone says that you do not interpret that to mean “I have a disorder that causes me to obsess about how my books are arranged. My thoughts on the arrangement of books are something along the lines of ‘These books absolutely must be in order of book size, and then color, otherwise a snake could find a hiding spot in here, wait for me to fall asleep and then kill me.’ This anxiety generates a compulsion to arrange the books several times a day and sometimes I will return home in the middle of errands to make sure the books are still in order.” Instead, you interpret that to mean “I really like having my books in order.”
Woody and Szechtman say that “One of the most striking features of OCD is the inability to feel reassured by seemingly obvious and compelling information from the senses. According to the 1901 Dictionary of philosophy and psychology by J. M. Baldwin, some older terms for OCD in French, German and Italian are “folie de doute,” “Zweifelsucht,” and “follia del dubbio.” All of these translate as “the doubting (or questioning) mania.”
Uncertainty Associated Anxiety Spectrum
Let’s imagine that we lie on a spectrum of “uncertainty associated anxiety.” 
So OCD is a different thing from this spectrum, but looking at how OCD works may provide some hints as to how to move yourself to the left - out of the orange and into in the green on this “Uncertainty Associated Anxiety Spectrum.”
Uncertainty, Certainty, Fear and Anxiety
Let’s imagine three scenarios.
(1) It’s Monday morning, you have tons of things to do and barely enough time for them, the only thing that you know you must do is attend the 3PM meeting. You have tasks A, B, C and D that are clearly more important than the other 7 things you need to do, so you pick one of them at random. You start working on task B. Halfway through the activity, you remember something your boss told you about task C and D. You realize the task you’re working, B, isn’t as important as C or D so you stop and begin working on D. Your confidence in yourself as a person competent of choosing the best actions for yourself drops a little bit. You finish task D and begin frantically working on C. You finish that too. It’s relieving to have those two top priority tasks done, but now you’re not sure if you should do A or B. You take a break and surf your phone for a bit. By the end of the day you’ve completed task D too. Before you go to bed, you take note of how satisfying the day was. Not very.
(2) You’re stuck in the dark, bewildered, fearful and anxious. As you shift your weight to peek around the cluster of trees you’re taking cover behind, your foot slinks in the mud. You barely register the smell of burning grass anymore as you train your attention to your sight and hearing. You’re not sure whether to shoot at your enemy’s last known position or to run. You only have two magazines. Shooting would give away your position and running through the wet muddy terrain is difficult and your next source of cover is about 300 meters out. If the enemy spotted you, that’d be it. You see a flash of something in the distance, about 150 meters out. You frantically begin to unload your magazine in that direction and bullets start flying your way. You keep shooting. The bullets stop coming. Did you take out your enemy or are they just taking cover? Are you safe or not? Is now the time to run? You remain fearful, anxious and satisfaction isn’t even a word on your radar. You unload the rest of your magazine in the enemy’s direction. Still anxious and unsatisfied that your actions had the desired effect. You reload. The sun won’t be up for another 3 hours at least.
(3) It’s 11AM on a Sunday. You check your email and see that the results for that free contest you had forgotten about came in. “Did I win? …Of course I won, why else would they email me!” You excitedly open the email. Indeed, you have won. You get to choose between a Playstation 4 or a Nintendo Switch. The cheaper game console comes with a game to make up for the price difference between the two. You own neither of these video game systems and you really wanted them, which is of course the reason you entered the contest. You can only choose one. You equally desire the two systems. You begin researching what games are available for each system, the hardware specs of each system and what games will be released in the near future for each. 30 minutes into researching later and there is no clear winner. You feel a little anxious. You check by when you need to claim the prize and defer the decision to later. By night time you still have not made a decision. As you go to sleep you find yourself excited about getting the new video game system, but the excitement is punctuated by small pulses of anxiety that you might pick the suboptimal system.
(4) You go to the range to practice your archery. You hook your release onto the bow string, point your arrow at the target and draw the string back until it hits the mechanical stop. Your shoulders and back are a bit sore from last week’s practice but you’re used to the feeling. You look through the sight at the target, you have a pulse of intuition and release the string. Your arrow hits the bullseye. You hear that dweeb Jeff say from behind “lucky shot.” Jeff was just chastising you the other day for using the term for a serious disorder, “OCD,” to describe your non-pathological desire for order on your bookshelf. You notice he and 5 other people are watching you. You line up another shot. This time you split your first arrow with the second. You are absolutely confident that the action you just did was completed in the most correct way possible and everyone on the course knows this too. You experience immense satisfaction. Jeff mumbles something.
(1) You are able to achieve some satisfaction by completing important tasks. However, anxiety is generated by the lack of certainty that you’ve prioritized your tasks well.
(2) The uncertainty and danger of the situation generate immense fear and anxiety. While you have taken action in an attempt to alleviate the situation, you cannot gain satisfaction from your actions as you do not feel that they are effective
(3) This situation seems entirely positive. You did not and do not have to do any work or pay any money to receive one of the two yet your uncertainty generates some anxiety.
(4) This situation completely lacked uncertainty. The correctness of your action was immediately apparent and satisfying.
The interesting thing about the fear and anxiety in situation 3 is, let’s say for example that instead you’re advancing down a hallway with no doors, and at the end of it you see an alligator running towards you. Since there’s no where to turn and there’s only one way out, what you should do becomes immediately apparent - you need to run back towards where you came from. You’re surely very fearful, but if you examine the experience, I don’t think you will find you would have been anxious.
This reminds me of a cat with an unexpected cucumber behind it. The moment it registers the snake-like cucumber, it reflexively flings itself into the air. Does it feel any anxiety in that moment? 
The Security Motivation System
Woody and Szechtman explain that there is a “fear module” that handles fear-based, escape and avoidance learning. “It works by conditioning its central motive state of fear to cues of imminent danger, such as the presence of a predator.”
On the other hand, the focus of their paper is a “security motivation system” which they say is distinguished from the fear module “in three ways: (1) it is based on subtler, conditioned stimuli suggesting hidden risk, typically in the absence of any signs of manifest danger; and (2) its central motive state is anxiety or wariness rather than fear, involving activation of distinct brain regions; and (3) its characteristic behavioral output typically involves probing the environment and gathering information, rather than avoidance.”
They explain that because predators rely on the element of surprise to most effectively catch their prey, prey animals need to be well aware of “unpredictable environmental changes that may signal the possibility of an upcoming emergency.” When the anxious animal becomes aware of certain “environmental changes,” it may cautiously perform some checking behaviors. For example, this study found that if you expose a rat to cat fur, it will then spend most of its time hiding in a box while poking its head out to scan the environment.
Woody and Szechtman say that this “security motivation system” implies “that we are built to recognize fragments of real threats… and that those fragments evoke searching and checking rather than the more commonly discussed defensive responses, such as escape.” Animals not familiar with their environment will act more anxious and cautious and spend a lot more time checking the environment.[R]
They say that the compulsion for symmetry in OCD people may not seem to have much to do with danger, but “if the environment is made symmetric and orderly, deviations are more readily detected, facilitating the checking for changes that may signal potential danger. That is, as long as symmetry is maintained, there is no disturbance, and things remain ‘the way they ought to be.’” Imagine if you have an incredibly messy house to the point that you have to start digging around through piles of clothes to find a for the soup you just made. The configuration of your house is different every day because nothing has a place, things end up wherever they’re tossed. Let’s say that on a Friday afternoon around 5PM, a burglar sneaks into your house and carefully selects things hidden from plainview to steal. When you get back home from work, would you even notice that danger was afoot just an hour ago?
Achieving the ‘Feeling’ of Satisfaction
One of the big points from Woody and Szechtman is that this feeling of anxiety generated in the brain of OCD patients is something that creates a yearning for satisfaction. In the paper they explain that desires are generated, but the signal that satisfies those desires is not simply reversing the signal that generated the desire in the first place. So for example when someone is severely dehydrated and they drink for a few minutes, “thirst motivation disappears long before the fluid can be absorbed by the gut and correct the chemical changes that generated the thirst.” You “feel” satiated and are thus compelled to stop drinking via signals unrelated to whatever signalled the thirst in the first place. A key point of this paper is figuring out what acts as the “satisfaction” signal for OCD patients when they are experiencing the compulsion to re-clean their room 5 minutes before they need to go to work or wash their hands 23 times in the middle of a lunch meeting.
They say that a “feeling of knowing” serves as an essential terminator of species-specific motivation. How do you pick a date for your doctor’s appointment? You don’t list out stats for which days of the week have the highest rates of car crashes, you take a look at your calendar, you see Wednesday Thursday and Friday are all free, but Thursday feels the best, so you pick that. When do OCD patients stop washing their hands? See the title of this paper in the Journal of Anxiety disorders: ‘I wash until it feels right’ . Unfortunately, it takes a long time to get that feeling.
Here’s where it gets interesting: What part of the brain generates emotions? Work by by Jaak Panksepp in 1988, then by J. Parvizi and A. Damasio in 2001 has strongly implicated the brainstem in the generation of emotions and feelings. Recent advances in neuroimaging have accelerated research into the brainstem’s role in emotion.[R]
All information relayed from the body to and from the cerebrum and cerebellum must traverse the brainstem so of course the brainstem needs to be used to activate behavior. However an interesting proposal of Woody and Szechtman is that the brainstem also generates “crucial feedback, giving rise to [satiation], which inhibits [behavior related to the ‘security motivation system’].” (They use this term “yedasentience” to describe the feeling of knowing you did enough action to achieve security, but I think “satiation” works just as well for our discussion.) They say “…engagement in behavior, in and of itself, is the condition that stimulates [satiation].”
This is interesting because with eating or drinking, you can have all kinds of desires that are satiated by putting the right things in your stomach. You can achieve satiation by protein[R], or you can even achieve decent satiation on a very low calorie diet if you add enough medium chain triglycerides.[R] You can crave salt[S] and apparently vitamin deficiencies can get children to crave cod liver oil.[R] Yet with OCD patients, they crave a behavior, and though it is very difficult to achieve the feeling of satisfaction, the only way to get it is to do the behavior. Despite being fully aware of the irrationality of their behaviors, feeling trumps logic and the craving will remain until they actually perform the behavior.
This reminds me of this TED talk by Daniel Wolpert I watched a while back where he says "We have a brain for one reason and one reason only. And that's to produce adaptable and complex movements. Think about it - movement is the only way you have of affecting the world around you." Surely the point of this anxiety you feel is to get you to do something. If you haven’t done anything - you haven’t done any movement pertaining to the source of that anxiety, your brain wouldn’t be a very good brain.
Neurotransmitters and Satisfaction
In my satisfaction video, I brought up the concept of the enjoyable feeling of “satisfaction” acting as a “stop” signal for behaviors. I only brought up endogenous opioids at that time to make my point. One example that I ended up leaving out was that when you flood the brain with opioids, the animal or human achieves a state of “maximum” satisfaction and motivation to do anything ceases. Per Panksepp’s Affective Neuroscience: “Higher doses of opioids reduce all social behaviors including play, and very high doses of opiates reduce all behaviors and induce a catatonic immobility.”
Opioids aren’t the only pleasurable neurotransmitters. There’s also for example endocannabinoids, oxytocin and serotonin. You’ve probably heard about serotonin being associated with overall happiness. Hence, drugs that raise serotonin levels are given to depressed people to try and alleviate their chronically and drastically depressed mood. This study found that reported levels of happiness were positively correlated and reported levels of sadness were negatively correlated with serotonin synthesis in the region of the brain associated with anxiety generation.
Woody and Szechtman say “…there is evidence that serotonin may act as a satiety like terminator signal.” They explain that ceasing of sexual behavior, satisfying appetite and exhaustion from voluntary exercise all have to do with brain serotonin.”
Next, as explained earlier, achieving satiation of “security motivation” has an anxiety reducing effect. You’re anxious about something being not how it should be, you perform the behavior, you’re satisfied with the effectiveness of the behavior, the anxiety is gone. 
Serotonin itself also seems to reduce anxiety. “…a serotonergic feedback signal is also consistent with an expected relief-of-anxiety effect.”
Finally, they point out that: “…an inhibitory signal that is serotonergic is consistent with the beneficial effects of serotonin reuptake inhibitors in OCD and the proposed [satisfaction] dysfunction in OCD.”
So what?
So what’s the point with all this? Say we apply this to people without OCD, does it mean we doomed to feel anxious until we have our taxes done and handle all 500 unaddressed emails lest always have low grade anxiety gnawing at our brains?
Well, I certainly hope not.
In the satisfaction video, I brought up the “Zeigarnik effect” which essentially says that unfinished tasks or goals are far more likely to remain floating around in your mind. One example is where it was found that waiters could easily remember unfulfilled food orders, but could hardly remember any of the ones that they already successfully fulfilled.
E. J. Masicampo and Roy F. Baumeister published a paper in 2011 explaining that as expected, “unfinished goals caused intrusive thoughts during an unrelated reading task…” Here’s the good news: contrary to the standard assumption that cognitive activation will persist until a goal is fulfilled, they found that “allowing participants to formulate specific plans for their unfulfilled goals eliminated the various activation and interference effects.” The title of the study is Consider It Done! Plan Making Can Eliminate the Cognitive Effects of Unfulfilled Goals They also say: “Committing to a specific plan for a goal may therefore not only facilitate attainment of the goal but may also free cognitive resources for other pursuits. Once a plan is made, the drive to attain a goal is suspended—allowing goal-related cognitive activity to cease—and is resumed at the specified later time.”
Actually, I came across this paper via David Allen’s book “Getting Things Done.” In regards to the Masicampo and Baumeister he says: “His conclusions simply verify what I’ve experienced for decades: uncompleted tasks take up room in the mind, which then limits clarity and focus.”
There is usually an inverse relationship between how much something is on your mind and how much it’s getting done. - David Allen
Allen’s method for organizing your thoughts and to-dos could be organized into a single flow chart and put on a single page. In fact, here it is: 
Yet, his book is 300 pages. However I think what’s most important (and is clearly why he explains his process in so much detail) is understanding exactly why the method works. The method is essentially teaching you to think of yourself as a 6 foot tall mass of ants. Ants take on and complete enormous goals like building an intricate nest. 
Be the ants
A single ant is quite stupid, lacking an ability to plan or even a working memory. Yet, through the phenomenon of stigmery, the ants can fulfill their collective goal. The principle of stigmergy is that a trace or mark left in the environment by an individual action will stimulate the next action. Ant two does something in response to the actions of ant one. Ant three does something in response to that. Eventually, just by performing the correct action in response to the marks they interpret, an ant colony is built.
Similarly, David Allen recommends you dump out the contents of your brain into multiple external reservoirs. You’ll have a reservoir for projects like “Trip to Fiji.” Ant Joseph one will write a list of context specific actions that the appropriate Ant Joseph #1 will then enact. Something like “Confirm with boss when I can take 5 days off when I notice boss seems free and in a good mood.” At that moment, Ant Joseph #1’s obligations are fulfilled. The action is sufficiently completed and there’s no need to be anxious about all the necessary actions to actually arrive in Fiji. Then, Ant Joseph #67 (i.e. “when boss is free and in a good mood” Joseph) will act on that.
So how perfect does the plan have to be to get anxious thoughts about an incomplete goal to leave you alone? According to Baumeister’s model, merely determining the next action is sufficient. Ant Joseph #1 has no idea what the boss will say - it’s Ant Joseph #67’s job to find that out. Once Ant Joseph #67 finds that out, he can either do some actions right then or leave the next task to another Ant Joseph.
If we think back to the four scenarios I described - the day at work, the night time firefight, the video game contest and the arrow shot to the bullseye, we can see how this termite approach reduces uncertainty in our behaviors and clearly defines the conditions for success. I just finished lunch, what should I do right now? I have so many things to do. Well, let’s look at what I’ve written. “Skim OCD as a Disturbance of Security Motivation after lunch. If it seems worth while, read in depth for 20 minutes and summarize up to three video-worthy points.” OK that’s clearly the thing to do.
Since most work nowadays is “knowledge work” and not manual labor, the paths to success and the conditions for success are rarely perfectly clear, so reaching the level of satisfaction you get from hitting the bullseye with an arrow is unrealistic. However, with an approach that focuses on clear actions in a specific context, we can reduce the anxiety generating uncertainty in our brains and we should be able to stay more focused on our tasks as unfinished tasks have already been addressed by the context specific actions you ascribed to them during your planning session.
The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small, manageable tasks, and then starting on the first one. -Mark Twain
The secret of getting ahead is thinking of yourself as a 6 foot tall mound of ants. -Joseph Everett
Comments
seventhfonist425
That was a really interesting post! Kind of a bummer it won't be a video though, since I feel like the last video on things that were satisfying, didn't really have a meaningful topic? Reading this post really helped me tie all the information together in a really tightly wrapped package that definitely felt much much more satisfying.
It's almost a creepy synchronicity that you suddenly publish this. I think I told you I have OCD and for the past year I've been having very disturbing intrusive thoughts connected to memory hoarding and pathological doubts. The problem with these is that the more the more the questions are answered, the newest and more twisted are the new questions. Like a hydra that doesn't stop growing heads. It's quite debilitating. Trying to get to the source of it all. There is an Italian therapist, Giorgio Nardone that has a very interesting approach to it in which the irrational thoughts and actions have to be solved through their inner logic (even if it's not a logical one in the proper sense) and not through what people without OCD might consider logical. Maybe taking a look to it might be interesting for you. I'm sure his work is available in English somewhere.
