Sometimes I’ve been guilty of joking that I’ve got a little bit of OCD. But after seeing OCD and Me (1) on Amazon Prime I realized that the people who really do have this suffer more than we know and they often interpret jokes like I’ve made as a real slap in the face. Mea Culpa.
Call me a wuss if you want but now I am almost moved to tears at the agony they feel.
If you have OCD you know the obsessions don’t make sense. But you can’t rid of them.
These are unwanted distressing intrusive thoughts, senseless ideas, images, urges, or doubts. You may feel them as awful, invasive, and persistent. Completely not who you are and what you believe. OCD is classified as an anxiety disorder not doubt because these obsessions can and often do provoke guilt shame anxiety and stress (2)
The compulsions are repetitive behaviors you feel compelled to do. In a perfect world they’d calm down the anxiety related to the obsessions but if they do it it’s only a little and really short lived. They really don’t make you feel better. Sometimes they seem to be meant to prevent something bad from happening.
If this is you, please know you’re not alone. In the US about 1 in 40 adults and 1 in 100 children have OCD (3). Further more, here are other conditions called OCD related disorders that are in the same family. These include things like (4):
- Body Dysmorphic Disorder
- Hoarding Disorder
- Trichotillomania (Hair-Pulling) Disorder
- Excoriation (Skin-Picking) Disorder
- Other Specified Obsessive-Compulsive and Related Disorders, e.g., body-focused repetitive behavior disorder (such as nail biting, lip biting, cheek chewing and obsessional jealousy
If you go to a traditional doctor and get diagnosed with this, chances are you will put on medicine. As a functional medicine doctor, I don’t have the love affair with pharmaceuticals that may docs have but if they help, I totally understand why they’re offered and why people are glad for them.
Does conventional therapy help?
The medicines usually used are SSRIs or Anafranil (clomipramine) and they help most people, but often only partially. Full recovery is only noted to be 20% (5)
Cognitive behavior therapy can help also (6), but it’s helpfulness does not argue against OCD’s biological underpinnings.
Some people, especially the kind that might consult an integrative doctor, might think “Surely the cause of OCD isn’t a lack of Prozac. Are there any natural treatments that could help?”
As a matter of fact there are.
Everyone is a unique individual of course and an integrative practitioner can get tests to help you hone in on what might be the most helpful for you but some of the players include:
Whether or not a person decides to use SSRI medicine we can infer from their usefulness that serotonin plays a role in this puzzle.
It starts here as that is the amino acid building block from which we make the immediate precursor of Serotonin through the enzyme Tryptophan Hydroxylase (TPH). When we increase tryptophan in the gut we increase serotonin in the brain. In fact when scientists went to study the effect of low serotonin in the brain they often do Tryptophan depletion studies using a defined tool called the Acute Tryptophan Depletion (ATD) procedure which results in major psychiatric / psychological symptoms and an 80-90% decrease in tryptophan (7)
influx across the blood-brain barrier.
Well, why not just “eat more protein? It’s a little trickier than that. First of all protein is not tryptophan though it’s made of amino acids that include tryptophan. The problem is that for one reason or another like being on an acid blocker or just getting older our stomach acid may go down and we may not be breaking this protein down well enough. Further, if we eat a lot of protein with other large neutral amino acids i.e. tyrosine, phenylalanine, and the branched-chain amino acids (BCAA; leucine, isoleucine and valine), then our tryptophan which is also a large neutral amino acid will get absorbed less because it’s competitive amongst all of those (8). Tryptophan is not easily absorbed on a high protein diet.
So how would I know how my tryptophan levels are?
You can actually get a test for that. Some but not everyone could benefit from a little extra stomach acid like betaine hydrochloric or apple cider vinegar, perhaps even a digestive enzyme. Depending what the levels show free form amino acid might help. Does this mean you should take tryptophan separately? That would be a discussion with your holistic practitioner. That could depend on your levels and your degree of inflammation. As we will see later if you are inflamed too much tryptophan can sometimes backfire on you.
Serotonin Synthesis Cofactors
Tryptophan is the building block but what about the process of turning that building block into serotonin once we have it? Can we do that?
Folate is one of the cofactors early in the process of turning tryptophan to 5HTP. So we can just get folate levels? Well not so fast. Folate is an umbrella term for all of forms. The most useable form is called by many methylfolate. We also think of folic acid in this context but that is actually a lab made synthetic form that is actually blocks L methylate from absorbing so folate in this case folic acid may be high in the serum but low in the CSF (the fluid surrounding your brain and spinal cord).
There are a whole host of things that can lower your useful folate L methylofolate. Like certain drugs, medical conditions, lifestyle choices, obesity, aging itself, and genes.
Regarding genetic certainly the gene that has had the most observation of MTHFR especially the 677 allele. Certainly if someone has a particularly unhelpful variant of that(especially C77 TT) or a high homocysteine level that’s be evidence that L methylfolate might be even more important
is an especially helpful cofactor for serotonin metabolism also. It’s been show to help Tryptophan Hydroxylase 2, the form that’s active in the brain which is so critical in OCD (9)
Other Cofactors In serotonin synthesis
B6, B 12, C, D Znc magnesium
5 Hydroxy tryptophan (5HTP)
This can be especially helpful if there is inflammation. The reason is that when there is inflammation, Tryptophan can be diverted to a very unstratetgic pathway through a neurotransmitter called glutamate which is an excitotoxin. 5HTP on the other hand can’t be diverted that way but some caution should be used in conjunction with SSRI’s due to the concern about serotonin syndrome.
Inositol is a really fascinating compound. It has nothing to do with serotonin synthesis but when serotonin goes from one neuron and crosses into the synapse, the space between neurons activates the receptor on the other neuron. Once activated, that neuron uses inositol to accomplish the effect of serotonin. So, inositol is the so called “Second messenger.” Inositol by itself has been shown to help depression in people (10). Further it’s been shown to help people with OCD not on meds (11). That said short 6 weeks trial of people somewhat refractory to SSRIs who were nonetheless on SSRIs found that adding inositol was not that impressive (12). Another similar trial found the same result but a subset did see clinical improvement (13). You can see how a conventional psychiatrist would dismiss this thinking “I’ll just keep them On SSRI’s” But consider that some people don’t want to be on SSRIs philosophically. Some people don’t like the side effects like weight gain and sexual dysfunction. Further, natural supplements sometimes take longer to be appreciated clinical and these were very short trials.
Everyone is a unique and without talking and testing it can be hard to pin point the exact causes and significance of them in any individual. If you are holistically minded and feel that you or someone you care about had OCD or a condition in the OCD family, I urge you to each out to a health practitioner of the same mind.’
To see more possibilities of things that can help see part 2
- Abramowitz, J. S., & Jacoby, R. J. (2014). Obsessive‐compulsive disorder in the DSM‐5. Clinical Psychology: Science and Practice, 21(3), 221–235 https://psycnet.apa.org/doiLanding?doi=10.1111%2Fcpsp.12076
- Beyond OCD.org https://beyondocd.org/ocd-facts
- Beyond OCD.org https://beyondocd.org/ocd-facts
- Gunnar Skoog, MD, PhD; Ingmar Skoog, MD, PhD A 40-Year Follow-up of Patients With
Obsessive-compulsive Disorder Arch Gen Psychiatry. 1999;56(2):121-127. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/204712
- Dean McKay , Debbie Sookman , Fugen Neziroglu . Efficacy of cognitive-behavioral therapy for obsessive-compulsive disorder Psychiatry Res. 2015 Feb 28;225(3):236-46 https://pubmed.ncbi.nlm.nih.gov/25613661/
- Zepf F et al. Acta Psychiatr Scand. 2013;128(2):105-106. Kötting W et al. Acta Psychiatr
Scand. 2013; 128(2):114-123.
- Riedel, WJ. Brain Behav Immun. 2002;16(5): 581–589.
- Soyak, Hüda Murat; Karakükcü, Çiğdem Investıgation of vitamin D levels in obsessive-compulsive disorder Indian Journal of Psychiatry: Jul–Aug 2022 – Volume 64 – Issue 4 – p 349-353 https://journals.lww.com/indianjpsychiatry/Fulltext/2022/64080/Invest_gation_of_vitamin_D_levels_in.5.aspx
- Double blind placebo controlled trial of the treatment of inositol for depression Levine, Joseph et al. Am J Psychiatry, Vol 152(5) May 1995. 792-794 https://pubmed.ncbi.nlm.nih.gov/7726322/
- Inositol treatment of obsessive compulsive disorder Fux, Mendel, et al.; Am J Psychiatry, Vol 153(9) Sept. 1996. 1219-122 https://pubmed.ncbi.nlm.nih.gov/8780431/
- Medel Fux, Jonathan Benjamin and R. H. Belmaker International Journal of Neuropsychopharmacology (1999), 2, 193-195. https://pubmed.ncbi.nlm.nih.gov/11281989/ abst