Instant Genius - Why OCD is a serious, debilitating mental condition, not just a need for cleanliness or order

Episode Date: March 14, 2025

We all experience distressing or intrusive thoughts at some point in our lives but for around two to three per cent of us these can be incredibly difficult to ignore and can begin to have a significant debilitating effect on our lives. Clinically this is known as obsessive compulsive disorder or OCD – a condition that many of us will have heard of but few understand. In this episode, we speak to Dr Marjan Biria, a psychologist and neuroscientist based at University College London. She tells us about some common obsessions and compulsions experienced by those with OCD, why thoughts are not actions and why people who say they are ‘a little bit OCD’ because they like cleanliness or order are significantly misunderstanding the condition. Learn more about your ad choices. Visit podcastchoices.com/adchoices

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We all experience distressing or intrusive thoughts at some point in our lives, but for around 2 to 3% of us, these can be incredibly difficult to ignore and can begin to have a significant debilitating effect on our lives. Clinically, this is known as obsessive-compulsive disorder, or OCD, a condition that many of us will have heard of, but few understand. In this episode, we speak to Dr Margin Brea, a psychologist and neuroscientist based at University College London. She tells us about some common obsessions and compulsions,

experienced by those with OCD, why thoughts are not actions, and why people who say they're a little bit OCD, because they're like cleanliness or order, are significantly misunderstanding the condition. So welcome to the podcast. Thanks very much for joining us. Thank you so much for having me.

So today we're talking about obsessive-compulsive disorder or OCD. So let's start with some definitions, you know. What exactly are obsessions and compulsions? And how do they differ? That's a really good question. So OCD has two main parts, obsessions which are intrusive thoughts, they are unwanted, they could also be intrusive images or urges, ideas. They are very stressful, but also very hard to get rid of them.

They may feel stuck in your mind no matter what you do. And compulsions, they are usually in response to these intrusive thoughts or images to reduce the anxiety that they could cause. We can have physical compulsions, such as cleaning, which means. many people are familiar with, but they can also be mental, for example, repeating a word in your mind to cancel out bad things from happening. So what are some sort of common obsessions then? Are there any sort of themes that we can talk about? Yeah, so OCD is actually quite diverse, but some of the common obsessions are fear of contamination. Again, I think many people might be familiar with this one. Being afraid that you would get sick because of a germ,

or toxin, you can have fear of harming others, even accidentally, worrying they might have hit someone with their car and did not realize it. Intrusive, violent or sexual thoughts, for example, having unwanted images of hurting a loved one or having inappropriate sexual thoughts about a child, people can also have religious scrupulosity that is obsessing over whether they have committed a sin or offended God. People can also have fear of making a mistake and being responsible for a catastrophe. For example, by leaving the stove on, they could cause a fire. Some people might also have a need for symmetry or things just feeling right. these are just some of the most common examples of obsessions.

Yeah, great. So do people with OCD actually sort of truly believe these obsessions? So most people with OCD, they have insight and recognize that their fears are irrational. But the anxiety attached to them is so intense that it is difficult to ignore them. And some people especially, if their OCD is very severe, may struggle with poor insomnia. and believe that their fears are justified. But in general, people do believe that their fears do not make sense, but nonetheless, they are still extremely anxiety-provoking.

So what are some examples of compulsions then? As I mentioned earlier, we can have physical or mental compulsions. Some example of physical compulsions are excessive cleaning or washing, for example, showering multiple times a day, or repeatedly disinfecting objects. Another example is checking behavior, making sure the doors are locked, appliances are off, or rereading messages or emails to make sure that you didn't do any mistakes, you didn't do anything wrong.

But you can also have mental checking. So you can go over past events in your mind to make sure that you didn't do anything wrong. Another example of common compulsions is repeating actions until they feel right. For example, touching objects or certain number of times or rereading a passage over and over until it feels right.

So some more examples of mental compulsions are silently praying or counting or repeating certain words in your mind to cancel out bad things from happening. And the last one is seeking reassurance, asking others if they are sure everything is okay, Googling symptoms if you are worried about your health. It's really important to mention that we need to keep cultural differences in mind because, for example, some cultures may have some ritualistic

mental actions that might resemble compulsions, but they might be normal in that culture. So we need to take the norm within that culture into account. And some compulsions may be more common in different ethnic groups due to cultural norms, religious beliefs, it's important to be aware of this. And I haven't mentioned another category of compulsions because they happen in prenatal OCD. So some people with prenatal OCD, they might show similar compulsions, but in a different context. So they have a fear that they are going to harm their baby or their baby might get harmed. So, for example, they might show excessive cleaning of clothes or toys. So it is still excessive cleaning, but in the context of protecting their baby,

or constantly checking things or going mentally over things they have done. But again, this is just to protect their baby from harm. So how common is OCD? So in the general population, OCD affects around 2 to 3% of people. It means that millions of people worldwide struggle with it. Many cases go undetected in childhood and adolescence and even during adulthood, mostly due to the embarrassment associated with the nature of the symptoms. For example, if people are experiencing inappropriate sexual thoughts or other taboo subjects,

it's much harder for them to seek help and they might get diagnosed much later in life. But it is also important to realize that these two or three percent, are people whose symptoms were severe enough to get a diagnosis. But OCD, like any other mental health problem, happens on a spectrum, meaning that all of us experience intrusive thoughts and possible compulsions, but with a much milder severity that not meet the thresholds of OCD diagnosis. So what sort of effect can it have on people's lives? OCD can be extremely disabling.

It can consume hours of a person day. It can interfere with every aspect of someone's life. It can interfere with their work, their relationships, if they are still studying, it can impact their studies, their school. It can lead to isolation. There are people that do not leave their house or cannot even hug a loved one. The distress and exhaustion from constant anxiety and ritual can make daily life extremely painful and extremely difficult for many people with OCD. You often hear people say, you know, oh, I'm a little bit OCD, and they mean that they like things to be clean or tidy or ordered. So how do you feel about that?

I'm glad that you asked this question because this one really makes me frustrated because it shows that there are many people who have no idea about OCD actually is, and they have no idea about the negative consequences of using this phrase in this way. Some people have misconceptions about OCD being a useful thing, meaning that you are very organized. And this kind of casual use of OCD minimizes the disorder. OCD isn't about simply liking order or cleanliness. It's about intense, often irrational fears and compulsions that cause

distress interfere with someone's life, and someone who prefers a neat desk or enjoys organizing their closet doesn't experience the crippling anxiety that someone with OCD experiences. Misinformation about OCD may stop genuine OCD sufferers from realizing that they even have OCD, and also it may create an impression that OCD is something quite trivial, comical, and not a serious illness. Peak pollination season, and my business is scaling fast. To keep the nectar flowing,

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Visit focal powered by name.com for more information. So OCD is often portrayed in the popular media. I mean, are there any depictions that you think, you know, oh, they've really got it right? There are many media portrayals that focus on cleanliness OCD and miss the wide range of obsessions and compulsions people with OCD tend to experience. But there are some series and movies that get it a bit closer

to what OCD actually is. And one of them is the... the TV series Pure, which depicts the intrusive sexual thoughts, and it gives a bit of a more accurate representation of OCD, although they might not show the true suffering that people with OCD experience and the nature of their symptoms, which can be present most of their waking hours. There is also shows like Monk, which although portrays OCD in a more comic way, but it still highlights the suffering and the impact of monk, the main persona, the impact of OCD that he experienced in his personal relationships and his work. But it is important to remember that

OCD is extremely diverse and no one show can depict the full range of OCD symptoms and, more importantly, the negative impact it can have on all aspects of someone's life. But they are still helpful to raise awareness of OCD and that OCD is not the same as liking cleanliness. So many people with OCD obsess about sort of taboo subjects, as you've said there. I mean, what's a good piece of general advice for people struggling with the shame that can come with these continued thoughts? The most important thing to remember is that thoughts are not actions. Everyone has random, sometimes disturbing thoughts, which they, do not take seriously, but people with OCD fixate on them and believe that they have meaning,

and that's actually the main part of the problem. But these thoughts are not your fault. Having an intrusive thought doesn't mean that you want to act on them or that you will act on them. I think it's also important for people to know that this kind of OCD is extremely common. So please do not suffer on your own. Try to educate yourself and connect with other people who experience similar kind of symptoms and thoughts. There are peer support groups. There is a lot of psychoeducation material on websites such as Mind, OCD UK, OCD action, Bortchard OCD. And the last piece of advice,

if you still do not have an OCD diagnosis and you suspect that you have OCD with any of these taboo subjects as your intrusive thoughts, it is really, really important to find a mental health professional with OCD background. Because you don't want to talk to someone who does not understand that your symptoms are part of OCD. And if they show a negative reaction, it may leave a negative impact on you. So please try to find someone who is familiar with OCD, who can help you, and please also use the resources I mentioned earlier. So can people with OCD ever actually enact their violent thoughts? My short answer is no.

People with OCD do not tend to act on violent thoughts. People with OCD have a very high sense of responsibility. And unfortunately, the fear of harming others is so much that is what driving their compulsions because they want to make sure

that they will not act on these intrusive thoughts or images. So you mentioned there the show pure. So that's about sort of pure O is the conditions quite often called. So what are some common signs and symptoms of that? Before I answer this question, I just want to add that pure O stands for purely obsessional, which can actually be quite misleading because the name suggests that there are no compulsions at all, and people tend to have mental compulsions in reality as opposed to

physical one. So sometimes people don't have obvious physical rituals, like checking the door, checking the stuff, or cleaning, but they experience intrusive thoughts, images or impulses, and engage in mental compulsions such as excessive rumination, reassurance seeking, mental reviewing. So some warning signs include constantly analyzing whether they are a bad person because of their thoughts or replaying past events to check if they have done something bad, experiencing excessive guilt or shame over their thoughts, or performing mental rituals in their mind to cancel out unwanted thoughts or canceling out unwanted things from happening.

And I also want to add that some clinicians believe that there are people who actually experience only obsessions and no-com. Although this does not happen often, it is really, really important for a mental health practitioner to first very carefully to look for mental compulsions before deciding this. So what do we know about how or why OCD develops? We don't know exactly how OCD develops, but there is evidence that there are genetic factors for OCD. For examples, there are studies showing first-degree relatives of people with OCD have a higher risk to develop OCD themselves. Or there are genetic abnormalities found in OCD that relate to glutamate and serotonin receptors. There are also neurological factors.

So scientists have found differences between brain regions, activity and connections, in regions of the brain that are part of the cortical, striato, talamo cortical circuit. There are also environmental factors. For example, stressful life events can trigger or worsen symptoms. If you have had a painful childhood experience or suffer trauma, abuse, discrimination or bullying, you might learn to use obsessions and compulsions to cope with the anxiety or to give you some sense of control, which is ironic because longer term, what happens is that OCD takes over control. There is also pregnancy or giving birth, which can sometimes trigger

perinatal OCD. And there are some cases of OCD that appear in children after an infection with strep bacteria. It's called pandas. It stands for pediatric, autoimmune, neuropsychiatric disorders associated with streptocococcal infections. It's a very long name. So the infection triggers an autoimmune response that affects the brain, leading to a sudden onset of OCD and ticks in children. And lastly, I wanted to mention something else that people know much less about, and that is medication induced OCD or obsessive-compulsive symptoms, which we see quite often in people treated with atypical or second-generation antipsychotic medication, especially Clozapine. So clinicians need to monitor people with OCD symptoms if their patients are being treated with this group of medications,

especially Clozapine, which is generally prescribed to people who do not respond to other types of medication. And this is their last resort for these people, which treats their symptoms, but induces new OCD symptoms. So how do we diagnose OCD? A mental health professional tends to diagnose OCD using clinical interviews. These are criteria from either DSM-5 or ICD-11 criteria. The key factors are the presence of obsessions and or compotions and the significant distress they cause, the time they consume, usually over an hour a day is spent on obsessions and compulsions. So the key is the impact on life, work, relationships, because like other mental health problems,

OCD symptoms are on a spectrum. It's not a category. We cannot say someone is 100% OCD versus 0% OCD. All of us check if the door is locked before we leave the house or go over past events to make sure we did not do anything wrong. It's about the extent of it and the impact it has on our lives. So are there any sort of additional mental conditions that are commonly found in people with OCD? So there can be mental health problems as a consequence of experiencing OCD symptoms and how debilitating OCD symptoms are. Many people experience anxiety and depression as a consequence of their OCD symptoms. But OCD can often coexist with anxiety disorders, depression, tick disorder, body dysmorphic disorder, and many people with OCD also struggle

with perfectionism and generalized anxiety disorder. So what are some of the kind of best therapies and treatments for OCD at the moment? According to nice guidelines, CBT is the first line psychological treatment for OCD, especially exposure response prevention. And in terms of medication, SSRI's antidepressants are commonly prescribed. There might be new medication developed based on how we think OCD brain may look like in terms of neurometabolites and their imbalances, which was actually what I studied during my PhD at the University of Cambridge. And that is by restoring the balance between the main inhibitory and exhibitary neurochemicals in the brain. So they are the on and off switch for neuronal activity.

But clinical trials are needed to test this, and this is going to take some time. At the moment, for more severe forms of OCD, deep brain stimulation or surgery might be an option, by making a lesion or reducing the activity of brain regions as part of the circuit I mentioned above, as part of the cortical striato-talamo cortical circuit, which are hyperactive in OCD. The most common brain regions that are targeted for lesioning or deep brain stimulation are anterior singulate cortex, internal capsule, subthalamic nucleus, or globus palidus and nucleos accumbens. But for less severely impaired patients who do not respond to other treatments, there may be therapeutic possibilities using TMS, which stands for transcranial magnetic stimulation. This is administered

via magnetic coils that are positioned against the scope to readjust the activity of these brand regions that I just mentioned. So just one sort of final question then. What's the best way to support a friend or partner who does have OCD? That's a really good question. I think first of all, try to educate yourself about OCD. Learn about OCD, read about it, read about other people's stories on websites, like mind, OCD, UK, OCD action.

The second piece of advice is be patient and non-judgmental. These fears feel very real to people with OCD. And the third advice is encourage them to seek professional help because OCD is really hard to beat on your own. And if their OCD symptoms has some of those taboo subjects, they might feel ashamed to seek help. and your encouragement can really help them. Last but not least, this is a really important piece of advice.

Try not to engage with their compulsions. Reassuring and helping with compulsions can feel helpful, especially if they are very scared or upset, and you might have all the best intentions in the world, but it can actually make things worse in the long term because it does not give them an opportunity to learn that if they do not engage in their compost, emotions, nothing bad happens. But try to validate their feelings and try to explain to them

that you understand this is really difficult, but you just don't want to make their OCD worse. Thank you for listening to this episode of Instant Genius, brought to you from the team behind BBC Science Focus. That was Dr Marjan Biria. If you liked what you just heard, then please do consider subscribing to Instant Genius on your preferred podcast platform. If you're interested in watching our presenters and guests in person, then please also check out our YouTube channel at ScienceFocus. The current issue of BBC Science Focus magazine is out now. Pick up a copy wherever you buy your favourite magazines or download us on your preferred app store. You can also find us on Apple News or online at sciencefocus.com. This podcast is sponsored by name, audio and

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