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Some Thoughts

Yesterday I did a small presentation to a group of doctors, who are specializing in treating people with substance addictions.

It was a nice and satisfying event, for the range of topics covered already was wide, and since there was good interaction between the doctor who was the chief speaker, me (invited), and our audience.

And so it happened that we talked about addiction, depression, OCD, autism, ADHD, and the treatment options available. The host had included lots of facts from the history of medicine in his talk, nicely illustrated with photos, figures, drawings, front pages of very old books. Actually, some of these caused a jolly good laugh in all of us – which suggests that that we regard as ‘contemporary’, ‘modern’, ‘state of the art’, and even ‘unsurpassable’ today, may strike a comparable audience 2128 A.D. as extremely outmoded and fairly ridiculous too (if we manage to save our precious climate, that is).

This small introduction my way of announcing the continuation of this blog. I went through major life changes during all the times when I did not write much, and there were long stretches when I did not write at all too.

I hope the new and stable life conditions I am in now will allow for much more information on OCD. I must admit that, being trained as a scientist, I revised my views on many aspects of mental illness in years gone by. There were no revolutions, nor did I suddenly see the light when changing my point of view on the topics. I hope to make these things clear – and moreover I hope that my readers may find benefits in my writings.

One last point of interest: I lowered my use of the antidepressant paroxetine (an SSRI) three months ago, to a level that usually is the minimum prescription in treating depression: 20 mg/day. I did not experience symptoms of withdrawal, nor did I get a higher urge to perform OCD-related acts: the rituals of checking locks, doors, faucets, windows, the stove, and so on and so forth.

This is as puzzling as it is positive, I think.  I will ponder it, and tell you about my thoughts on this.


Genetic Aspects of OCD Will Follow Shortly

I had planned to write a new post on the genetic origins of OCD today.

But whilst scanning new research, I learned that this effort will take a bit of time. The situation anno 2017 is markedly different from that in, say, 2007.

For instance, there’s the vast field of epigenetics, it has been expanding at a rapid pace. I quote this brief explanation from Wikipedia:


Epigenetics are stable heritable traits (or “phenotypes“) that cannot be explained by changes in DNA sequence.[1] The Greek prefix epi- (Greek: επί– over, outside of, around) in epigenetics implies features that are “on top of” or “in addition to” the traditional genetic basis for inheritance.[2] Epigenetics often refers to changes in a chromosome that affect gene activity and expression, but can also be used to describe any heritable phenotypic change that does not derive from a modification of the genome, such as prions. Such effects on cellular and physiological phenotypic traits may result from external or environmental factors, or be part of normal developmental program. The standard definition of epigenetics requires these alterations to be heritable,[3][4] either in the progeny of cells or of organisms.


Epigenetics is the key link between our DNA proper and our environment. The old expression to describe the interaction between genes and surroundings is: G x E.

I am almost inclined to say: the mysterious x-factor in this small formula is epigenetics.

PANDAS: What was that again?

The acronym PANDAS stands for:

pediatric autoimmune neuropsychiatric disorders associated with Streptococcus infections.

That is a whole mouthful, you’ll agree.

We’re talking about a unique sub-set of psychiatric patients: there are children in whom an acute manifestation of OCD and/or tic disorders occurs. This is special, because with OCD the symptoms usually develop over time.

The disorders were initially thought to be caused by infection with Group-A beta-hemolytic Streptococcus (GABHS).

Susan Swedo and her group published an important research report on  this in 1998.

Two decades later, there have been changes in the concept of PANDAS; actually, it is now named: PANS (pediatric acute-onset neuropsychiatric syndrome). It hasn’t been accepted as a distinct disorder (or group of disorders) yet – but that doesn’t mean there haven’t been additional findings.

  • several agents other than Streptococcus may be involved in its inception
  • there is a male predominance in the patient population: 65% of it is male
  • 54% of those affected show a specific association with Streptococcus
  • gender and pubertal status have a strong effect on symptom course and chronicity of the illness
  • the rate of co-occurring medical illness is high – a general immune dysfunction is suggested by experts
  • PANS has a considerable impact on the daily life of the children
  • antibiotic treatment is advised to resolve the symptoms of infection early on
  • it may be that the resident immune cells of the brain, the microglia, aren’t functioning well in PANS

Now, we are lucky: some fine articles on these matters are available at the open source of the National Institute for Mental Health, in Bethesda, Maryland, via the Pubmed site:

…and here’s a figure (sans comment) to whet your appetite, from the first article:

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Next Time…

…I will present some new findings on PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections – impress your friends!) and on the genetic origins of OCD.

Please stay tuned.

OCD and Free Will

This is an interesting concept –

the freedom of our will has been a central topic in philosophy all through human history. When the neurosciences had their big lift-off in the 1990s, they too began to make inquiries into brain areas thought to be key in making choices.

Decision-making is something that is more difficult than it may sound at first. We must try to somehow sketch what choices we can reasonably make at all. We also need to see into the future: which action of ours will have which practical consequences?

One may think: what action is profitable for me? What promotes my health and well-being? Or: what brings money into my bank account? On the other hand: one can consider: how can I make my wife or husband happy? My children? I am the happiest whenever I see those around me happy.

Actually, there are a multitude of motives, reasons, and feelings at play.

It is typical for these, our, times that I often see the motive of personal interest and profit rear its head, as if unselfishness and the love for others weren’t ‘cool’ enough to mention in the context of decision-making.


Over to OCD.

All those who suffer from the illness, and those who are in their vicinity, know that there is something dreadfully wrong with a patient’s freedom to choose. People with OCD are living at the wrong side of a thick wall of clear glass: they perceive all too well how ‘the others’ live, enjoy life, act spontaneously, make mistakes, forgive and forget about those mistakes, eat well and carefree, and make music and love.

That is painful to see. For someone with OCD wants nothing more than to live like the others. But she/he can’t. There are the inner commands, the duties, the demon that wants to perform the patient all the unnecessary and irrelevant, ever-repetitive checks, controls, acts of cleaning or hoarding, and so on and so forth, ad infinitum et ad nauseam.

OCD is more about surviving than about living.

The only hope that is there for the patient is the brief time window of very relative freedom that will open after the exhausting rituals.

Even within this window (e.g. if one has succeeded in attending a dinner with others, or a movie together) there is this piece of knowledge lurking in the background: the demon hasn’t been conquered; he will return.


It is clear that the freedom of choice, the scope of one’s free will, the ‘freedom to be spontaneous and impulsive’ – in order to experience life’s true joys, is by far not as broad and rich as it should be.

Neuroscience has described a number of brain areas that are closely associated with our capacity for decision-making. At this point it is important to emphasize that ‘being associated’ is not the same as ‘causal relationship’. ‘Associated’ can best be thought of as ‘occurring together in time’; a person may be in a test situation in the lab, perform a task that is about making choices, and a brain scan can be made. Certain phenomena in the scan are observed, that are different for people with OCD, as compared to healthy subjects. We cannot say at this point in time that these differences cause, or are the result of OCD. They co-occur (which is always a good starting point for refining the methods used, in order to get on the trail of what actually might be causal, in a later stage of research).

Three areas thus identified are: the dorsal anterior cingulate cortex (dACC), the nucleus accumbens (NAcc), and the anterior limb of the internal capsule (ALIC).

I came across this scientific article, recently:


Neuromodulation. 2016 Apr;19(3):239-48. doi: 10.1111/ner.12405. Epub 2016 Feb 21.

Psychosurgery Reduces Uncertainty and Increases Free Will? A Review.

The authors looked at numerous results achieved with the method of psychosurgery – that is an invasive type of surgery, tiny modifications, changes are performed in the brain itself.
(I find this unsettling: actually meddling with someone’s brain tissue? But on the other hand: there are forms of OCD that can’t be treated well enough with cognitive behaviour therapy and/or pharmalogical treatment. And these can be so degrading for one’s quality of life, that in the end they may be the lesser of two evils.
And, let’s not forget: the other form of brain treatment in depression and anxiety, deep brain stimulation (DBS) is also an option: a tiny pacemaker that can alter neuronal activity in affected areas of the brain is implanted. Pilot projects have shown good results so far – and with our ever-evolving micro-technology there really a reason for good hopes.)
Here are the (literal) conclusions of the above authors:
MethodologyIn modern psychosurgery three target structures exist for obsessive compulsive disorder and addiction: the dorsal ACC, the nucleus accumbens, and/or the anterior limb of the internal capsula. Research in all three areas reports favorable results with acceptable side effects. Psychosurgical interventions seem to exert their effect by a common final common pathway mediated via the pregenual ACC.


Successful neuromodulation increases the capacity to choose from different options for the affected individual, as well as inhibiting unwanted options, therefore increasing free will and free won’t.




I think they put it very simple, and very well.

What we see here is not the outcome of a small set of smart and smooth investigations. Not at all. It is the preliminary result of long years of trial and error, great effort, serendipity, courage, and foremost: the willingness and cooperation, as well as the sheer guts of patients with OCD, who dared to go hand in hand with researchers into unknown areas of our brains.


I will look if I can find a nice picture of the areas involved, labeled as such in a photo or drawing of our brain.

A Slight Return

Hello dear, and faithful readers of this blog –

it’s a lovely day.

Seeing that my stories and essays still attract numerous people every day is quite an experience – it makes me happy.

My weblog has been dormant for a long time, in fact for so long that it seems not very useful to go back in time and feel sad about it – better to go ahead.

I will, however, post about all the things that I did and felt in this interim. In many occasions they are directly linked to OCD, so if told in their context, they may be helpful in getting a clearer view on OCD, one’s inner life, and the relationships of this private life with all of outside reality, most of all: other people.

For now, I must log off, and that has to do with the fact that I started a second site; that deals with mental problems (stress, anxeity, depression, ADHD, autism, eating disorders, and others afflictions) within ‘our’ political and economic realities.

My ‘our’ refers to people all over the world, for human communities have become homogenized globally, mainly in economic terms.

I will be back, I hope you folks will be back too!

Best from Frank in Holland.


So, here I am.

Two times I tried to start a new blog on OCD, with the intent to make that more structured, hierarchical, more accessible.

It did not work out.

First thing is: you have to re-write so many things you already talked about, and that is boring. I re-read numerous entries with the benefit of a perspective from  huge distance in time. And hey! I could well live with what I wrote. People with OCD tend to be afraid of the unknown (in many walks of life). I thought beforehand: hm, what bloopers will I encounter?

I was pleasantly surprised. So I think it’s more fruitful to diligently work my way forward. And I want to construct a handy search/index function to help readers get immediate access to a topic of special interest.

There have been fine new discoveries in the scientific field of OCD. ‘Fine’, in terms of providing hope for better treatment. I will write about that.

Another field of interest, relatively new to me, is: autism, or rather: autism spectrum disorders (ASD), as it’s called now in DSM-V, the diagnostical manual in psychiatry. Autistic conditions share quite some ground with OCD. I will delve into that shortly. Even more broadly speaking: there are canny similarities between ASD, OCD, and substance use disorders (SUD). I think that the two disorders apart from OCD will get an important place in the blog.

Finally: what struck me in the study of the above three conditions was that one inevitably gets confronted with the question: what is free will? I don’t think I will solve this question that is as old as mankind itself. But there are intriguing indications from neuroscience, that give us a bit of insight into brain areas that have to do with aspects of our will, with our ability to make choices, informed choices.

People with OCD know that that what they do is odd, unnecessary, not normal. That is has the potential to damage their relationship, their occupational life, perhaps their own life, in the end. But they can’t stop their compulsive behaviours. Same goes for people who drink way too much alcohol. The proper balance has gone out of the window. One can say: I can see that my excessive washing behaviour makes me unable to keep appointments. My boss is complaining. He’s losing his patience. I may get unemployed. So from a rational point of view, I know that I’d be better off to limit my showering to ten minutes in the morning. But I can’t stop! I begin, and suddenly it’s 90 minutes later! I just can’t stop! It’d even be better to go to work with only my face cleansed and some deo on, than have to live this dangerous way! Help!

Free will is impaired. That person does something he very consciously does not want to do.

A conundrum, in many respects – and an unseen, but terrible human drama.

Existence may be at stake.


I just discovered a new science article of great interest. I will read it; for now I will leave you with its abstract:

Neuromodulation. 2016 Feb 21. doi: 10.1111/ner.12405. [Epub ahead of print]

Psychosurgery Reduces Uncertainty and Increases Free Will? A Review.



A definition of free will is the ability to select for or against a course of action to fulfill a desire, without extrinsic or intrinsic constraints that compel the choice. Free will has been linked to the evolutionary development of flexible decision making. In order to develop flexibility in thoughts and behavioral responses, learning mechanisms have evolved as a modification of reflexive behavioral strategies. The ultimate goal of the brain is to reduce uncertainty inherently present in a changing environment. A way to reduce the uncertainty, which is encoded by the rostral anterior cingulate, is to make multiple predictions about the environment which are updated in parallel by sensory inputs. The prediction/behavioral strategy that fits the sensory input best is then selected, becomes the next percept/behavioral strategy, and is stored as a basis for future predictions. Acceptance of predictions (positive feedback) is mediated via the accumbens, and switching to other predictions by the dorsal anterior cingulate cortex (ACC) (negative feedback). Maintenance of a prediction is encoded by the pregenual ACC. Different cingulate territories are involved in rejection, acceptance and maintenance of predictions. Free will is known to be decreased in multiple psychopathologies, including obsessivecompulsive disorder and addictions.


In modern psychosurgery three target structures exist for obsessive compulsive disorder and addiction: the dorsal ACC, the nucleus accumbens, and/or the anterior limb of the internal capsula. Research in all three areas reports favorable results with acceptable side effects. Psychosurgical interventions seem to exert their effect by a common final common pathway mediated via the pregenual ACC.


Successful neuromodulation increases the capacity to choose from different options for the affected individual, as well as inhibiting unwanted options, therefore increasing free will and free won’t.

© 2016 International Neuromodulation Society.