Medication
In this section I will share my understanding of medication for OCD
However, before I start, I wish to put the disclaimer that I am not a medical professional. If you have any questions regarding medication, including whether you should take it or not, please see your doctor
There are two popular explanations for how medication works for OCD:
(a) Chemical Imbalance Theory
(b) Numbness Effect
(a) Chemical Imbalance Theory
The most common form of medication for OCD are Selective serotonin reuptake inhibitors (SSRIs). They were originally created for depression, hence why they are also called anti-depressants, but it was discovered that they could also benefit anxious patients
The general understanding is that anxious patients have a chemical imbalance, in particular, they don’t have enough serotonin
Let me explain this chemical imbalance theory and how medication is meant to help
Serotonin is one of the happy chemicals
For a person to be happy (and therefore not anxious), serotonin has to be spread to enough nerve cells in the brain.
The spreading of serotonin is meant to work like this. All nerve cells in the brain have a small gap between them. Certain nerve cells produce serotonin and want to pass it onto the nerve cells that need it. Those nerve cells that produce serotonin cannot directly give it to the other nerve cells.
Instead, they deposit the serotonin into the small gap between the nerve cells, and hope the nerve cells that need the serotonin just take it from this small gap. If the serotonin is not taken from that small gap, then the nerve cells that created it just take it back. So, the serotonin is not spread to the nerve cells that need it.
What SSRIs are meant to do is stop the nerve cells (that produce the serotonin) from taking it back. So, the serotonin sits in the small gap until the nerve cells that need it are ready to take it
This is the most common explanation for how SSRIs work. It dates back to the 1960s. However, when you dig deeper, you can find many flaws with this chemical imbalance theory. These include:
- When the medication is taken, the serotonin levels increase almost immediately, but the reduction in symptoms (anxiety, depression etc) can take up to two months to come through
- Many drugs that increase serotonin are wholly ineffective in treating anxiety and depression
The below articles in the 'Guardian' and ‘Psychology Today’ talk about this in more detail. Admittedly they concentrate more on depression than anxiety, but according to popular theory, both conditions stem from chemical imbalances, so what applies to depression can also apply to anxiety
Psychology Today article on serotonin
Modern Understanding
If anxiety (and depression) isn’t a chemical imbalance, what is it?
Modern thinking suggests that anxiety (and depression) is a problem of circuitry, not chemistry. In this view, symptoms of anxiety (and depression) result from failure of synapse formation and changes in the activity level of various emotional signalling centres, set in motion by overactivity of the stress response system, often in response to early adverse experience
What the above means in simple terms, is that it is stress and trauma that causes mental illness. This is different to the chemical imbalance theory, which says that is missing chemicals that cause mental illness
As a side note, if stress and trauma are indeed the root causes of mental illness, this provides further evidence that psychoanalysis offers the best understanding of psychology. The modern view highlights “overactivity of the stress response system, often in response to early adverse experience,” which aligns closely with psychoanalytic thinking: negative childhood experiences can shape later mental health.
While the chemical imbalance theory is increasingly seen as outdated, SSRIs may still reduce anxiety through another mechanism: the numbness effect
(b) Numbness Effect
SSRIs, and some other drugs, can make the brain feel numb or emotionally blunted. In practice, this means the OCD thoughts still occur, but they feel less threatening, and the anxiety they normally trigger is reduced.
But this reduced anxiety comes at a cost — the same numbness that dulls fear and worry can also lessen positive emotions, making everyday experiences such as eating food less enjoyable.
I’ll explain the numbness effect in more detail by looking at how it appears across two Dose Durations — Partial Day Effect and Full Day Effect.
Partial Day Effect
For some patients, the numbing sensation lasts only part of the day. The medication produces a numbing sensation that typically lasts around 8 to 12 hours after each dose. For example, if a patient takes the medication at 9am, the numbing effect may continue until roughly 9pm the same day. After that point, as the sedative impact wears off, the protective effect disappears, and the OCD symptoms return to their usual intensity.
Even though this partial day sedation is often described as a side effect, for some patients it is actually the mechanism that makes the medication helpful, because during those hours the anxiety response is reduced.
However, the same numbing can also dampen positive emotions, making everyday pleasures like food less enjoyable.
Full Day Effect
For other patients, the numbing sensation extends across the entire day. This provides continuous reduction of anxiety, rather than limiting relief to an 8–12 hour window.
Another advantage of the full day effect is that, for some patients, the same dose provides stronger anxiety relief than the partial day Effect during the 8–12 hour window.
The trade off is that while this stronger and more persistent numbing provides greater anxiety relief, it also dulls positive experiences more than the partial day effect.
And just like the partial day effect, this continuous numbness is often described as a side effect, yet for certain patients it is the very reason the medication is effective, because it consistently reduces the anxiety.
To ease the dulling of positive experiences caused by numbness, short term therapy such as CBT can help reduce OCD anxiety within 3 to 12 months. Thus, patients may be able to lower their medication dose, lessening the numbness and regaining enjoyment of everyday activities. In some cases, therapy may reduce the anxiety enough for you to stop your medication altogether, and manage any remaining anxiety using techniques learned in therapy. Always speak to your doctor before reducing or stopping any medication.
My Personal Experience
I took SSRIs, and they did help me. In particular, they made my brain feel numb, which meant each OCD thought registered as less threatening. As a result, the anxiety these thoughts normally triggered was reduced.
This experience reflects what I described earlier as the numbness effect. The medication did not stop the intrusive thoughts themselves — they still appeared in my mind — but the emotional impact was blunted/reduced
Importantly, this numbness did not mean I lost the ability to think clearly or function in daily life. I could still use my intellect at work and remain fully aware in situations that required attention, such as crossing busy roads.
If your anxiety is severe enough, you should seriously consider taking them. When they work, they can reduce the anxiety significantly
SSRIs do have drawbacks, in the form of side-effects. When you first start taking them, it is common to get things like diarrhoea, headaches, feeling disorientated etc. These side effects tend to go by around two weeks for most people
Numbness can also appear when starting SSRIs. If this numbness disappears after the first couple of weeks, then it is simply a temporary side effect. However, if the numbness continues beyond that period, it is not a side effect — it is the very mechanism by which the medication reduces anxiety. For more detail, refer back to the Numbness Effect section.
Other Medications
If you are not prepared to take SSRIs due to their side-effects, there are two more medications that you can try
These are Pregabalin and Propranolol. They both have less side-effects compared to SSRIs, but the reduction in anxiety is also a lot less. I took Propranolol first, and the reduction in anxiety was around 2%. I stopped taking that and then tried Pregabalin, and the anxiety was reduced by around 3% to 4%. These medications did not help me significantly enough when I was taking them, so I ended up taking SSRIs. But it could be different for you
Conclusion
To conclude, it’s important to remember that medication of any kind will not eliminate OCD thoughts. Instead, they lessen the anxiety the brain generates in response to them.
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