Changing Themes: Neurobiology x Environment = ?

If you’ve suffered from OCD for a while, you probably know that themes change. Or maybe you’re new to your diagnosis and haven’t yet realized that the besieging thoughts you have about your relationship, your health, your sexuality, whatever they may be are just the many heads of the same monster. Well, they are, which means that the interventions that work for one theme will work for the rest as well, with some minor adjustments.

What I’ll be addressing in this post is the question of why OCD themes change. If you live with OCD, you can probably intuit part of the answer to this question. Themes change when we are confronted with something new that threatens something we care about. A new OCD theme can attach to something previously untouched by OCD, or can arise because the brain has discovered a new way that trouble can lay siege to something already heavily guarded by OCD.

For example, most of us value our relationships. Individuals who have troubled relationship histories may be particularly vigilant about the health of their relationships. Typical Relationship OCD (ROCD) obsessions may be the only manifestation of an individual’s illness for while. These obsessions are usually partner-focused or relationship-focused  (is my partner “good enough”? Are they the best fit for me? How can I be sure this is really love?). If treatment is successful, the person suffering from these obsessions will learn and accept that there is no way to find definitive answers to these questions, and that living a values-based life despite the presence of OCD means embracing the element of uncertainty that is inherent to every aspect of being human. The mind in a state of acceptance will no longer respond to OCD’s cues to be vigilant and to solve the problem posed by an obsession. A sufferer may experience a temporary or lasting remission of symptoms.

It is also possible that as soon as the ROCD theme loses its power over a sufferer, they begin experiencing obsessive doubt about their sexual orientation (or the state of their health, their partner’s safety, really the possibilities are endless). The threat, in this case the fear the impossibility of having a loving, harmonious relationship, has found new expression in another theme. But it’s important to note that although the Wizard may have changed his mask, he’s still played by the little man behind the curtain (Codde, 2022). The strategies used for accepting uncertainty in the first instance will work again.

On a broad scale, it’s interesting to note why we fear what we fear. Most of us can relate to the desire for a healthy long-term partnership. We learn gradually, throughout our upbringing that our life partners are critical players in the stories of our lives, our fulfillment, our success. But what if we lived in culture in which our partners were not intended to be everything to us? What if we lived in a culture in which the dynamics of partnership and marriage were first and foremost economic or political? In which it was understood that a spouse cannot and should not play more than one specific role? Would ROCD be as prevalent as it is for us?

Research demonstrates that OCDs rate of occurrence and theme content vary across cultural contexts and have changed over time. There are certain OCD themes and related disorders that are specific to a region or a specific population or subculture. It may seem intuitive that in highly religious communities, OCD may be more frequently occurring and often is expressed through religious and moral obsessions (Scrupulosity). There is evidence dating back to the 15th century that Scrupulosity was the most common expression of OCD in highly religious Western cultures at the time. This, given the role of Christianity in the west in the late middle ages, is unsurprising. There is also record of more neutral themes appearing in Babylonian texts:

One such text states that the sufferer, “does not know why he has a morbid fear of beds, chairs, tables, lighted stoves, lamps, etc., of leaving or entering a city, city gate, or house, or of a street, temple, or road” ( Reynolds & Wilson via Williams)

Of course, we can’t know if the polytheistic religion in Babylonia was more forgiving of moral uncertainty than the Christianity of medieval Europe in the minds of OCD sufferers. But the influence of cultural elements such as these in the presentation of OCD throughout history cannot be denied.

In Brazil, particularly from a sample of patients living in Rio De Janeiro, aggression, harm, and violence were the most commonly occurring themes. In India, especially among women, contamination is primary. In Japan, where collectivism and family integrity are highly valued, themes around offending others or bringing shame to one’s family line are more common in OCD and related disorders than they are elsewhere in the world. In Middle Eastern countries, religious themes are most prevalent. In white Americans, checking and hoarding compulsions are the most prominent, while in black and African American communities, contamination and cleanliness are primary.

Different religious sub-themes are found within different religious communities. In Western Christian samples, protestant values breed obsessions around cleanliness, washing, and monitoring and controlling thoughts. Similar results were found among Catholic friars and nuns, with a high incidence of thought-action-fusion (the feeling or belief that thoughts and actions are equal in terms of meaning and gravity) contributing to obsessions around thought control and suppressions. In Orthodox Jewish communities, obsessions around cleanliness, prayer, and consulting religious leaders are highly occurring, despite the fact that compulsions around the laws fundamental to religious Jewish life may be difficult to assess due to the stringent practices that are typical of living by these laws.

In my own experience interacting with the OCD community over the past ten years, I’ve witnessed the widespread emergence of themes related to gender identity as discourse around this subject grows in the general public’s awareness. Even more recently obsessive concerns about gun violence, pandemic, and climate collapse are showing up more and more frequently in individuals presenting for OCD treatment.

OCD sufferers know that a debilitating fixture of the disorder is the particular interplay of isolation and shame leads to the belief that an individual is uniquely monstrous, unfit, or ill. I hope that these collective patterns in content and theme demonstrate that at its core, OCD is an acute sensitivity to the environment interacting with a normal urge to be safe, well, altruistic, and in control. Viewed this way, OCD is a laudable effort on behalf of the psyche to protect us and those around us. It may be difficult to accept that we are not uniquely deranged or different, but it is usually the truth.

 

References

The OCD & Anxiety Show with Matt Codde LCSW. (2022, June 17). OCD & Anxiety Changing Themes [Video]. YouTube. Retrieved October 16, 2022, from https://www.youtube.com/watch?v=sovNcvTRvBE

Nicolini H, Salin-Pascual R, Cabrera B, Lanzagorta N. Influence of Culture in Obsessive-compulsive Disorder and Its Treatment. Current Psychiatry Rev. 2017 Dec;13(4):285-292. doi: 10.2174/2211556007666180115105935. PMID: 29657563; PMCID: PMC5872369.

Williams, M. T., Chapman, L. K., Simms, J. V., & Tellawi, G. (2017). Cross-cultural phenomenology of obsessive-compulsive disorder. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 56–74). Wiley Blackwell. https://doi.org/10.1002/9781118890233.ch4

 

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