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Dear Dr. Saltzman,

I was initially diagnosed with OCD during my early teens, and I have realized that everyone I know that has/had a history of OCD (diagnosed and otherwise) are, like myself, absolutely capable of living their daily lives in all aspects, for example: They go to work, they have personal investments, they make very intelligent decisions on a daily basis, they are very much capable of everything, their only "flaw" being that, in comparison to the little worries of those without a history of OCD, their personal little worries are a bit more magnified to them due to OCD's knack of reminding them.

Taking above into consideration, seeing as people with a current/previous history of OCD seem very much normal in their daily judgment skills/decisions/etc. as either employees/housewives/investors/decision-makers/etc., wouldn't you say that OCD is a very "normal" trait among many people and is not a "handicap" in regards to OCD patients' soundness of judgment/decision/comprehension?


[name withheld]

Dear [name withheld]--

Thank you for your question. It is a good one.

According to the Diagnostic Statistical Manual (DSM) which is used by many psychologists and psychiatrists to evaluate patients diagnostically, Obsessive Compulsive Disorder (OCD) may be found in a patient if that person suffers either from obsessions alone, or from both obsessions and compulsions. Obsessions are defined as recurrent and persistent thoughts, impulses, or images which are experienced as intrusive and inappropriate, and which are not simply excessive worries about real-life problems. Compulsions are repetitive behaviors (hand washing, arranging, checking, etc.) or mental acts (praying, counting, repeating words silently, etc.) which the person feels driven to perform in response to an obsession.

An example may help to make this clear. The person with classic OCD might continually worry that her house will catch fire when she is away from home, and, although she knows that this is unlikely, cannot stop worrying about it. Then, in response to her worries, she might begin, before leaving home, to check the stove to make sure that she has not left it lit. But checking it once will not be enough. When attempting to leave the house, she might get as far as the front door, but then have to go back to check the stove again because she is not totally certain that she really has turned it off. And this cycle of getting as far as the front door, and then having to return to the kitchen might be repeated again and again until, in a really bad case, she cannot leave the house at all. And the really frustrating thing about this problem is that she may be certain that her thoughts are unreasonable, but still she cannot banish them, and cannot help repeating the compulsive ritual of checking the stove.

In the stove example, the compulsion relates to the obsession in a way that is realistic, but excessive. In other words, checking the stove once might make sense, but having to check it twice, or fifty times, is over the top, excessive and unreasonable. But often the compulsion has little or no relation to the obsession. For example, some religious people are obsessed with the idea that their ordinary thoughts are blasphemous, and may be compelled, for example, to shower or bathe ten times a day in order to deal with the thoughts. Obviously, this is not just excessive, but entirely unreasonable since "dirty" thoughts cannot be cleansed by showering either once or ten times a day.

To put this more simply, OCD is a mental disorder in which someone is troubled by disturbing thoughts which will not subside, and which cause significant fear, worry, or anxiety. Then, often, in order to try to rid him or herself of these fears, the person begins to perform a repeated pattern of certain rituals which either are excessive or frankly unreasonable. And the person knows that the thoughts and resultant behaviors are excessive and unreasonable. (In the blasphemy example, if the person does not know that the obsessional and compulsive behaviors are unreasonable, that person is delusional, not compulsive).

Now you say that you, along with others you know who have been diagnosed with OCD, "are very much capable of everything, their only 'flaw' being that, in comparison to the little worries of those without a history of OCD, their personal little worries are a bit more magnified." If this is true, then I would say that you, and the others you mention, have been misdiagnosed, because real OCD is not at all like what you describe. In true OCD, as I have seen this in my practice, the sufferers are not capable of "living their daily lives in all aspects," as you wrote. That is the point: OCD is a disorder, meaning that ordinary life is being interfered with to a significant extent in one way or another. In fact, the DSM makes this completely clear in the diagnostic criteria statement for OCD:

"The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships."

Therefore, I would say that either you are minimizing the extent of your distress, or that you do not suffer from OCD, but just a slightly heightened propensity to worry obsessively, which is not OCD at all.

Now, your letter raises three interesting points which I would like to address. In the first place, you say that people suffering from OCD "go to work, they have personal investments, they make very intelligent decisions on a daily basis, etc." Yes, that is certainly true of most OCD sufferers, except those who lose jobs because they cannot get out the front door of their homes in order to get to work, or spend all their money on unnecessary precautions, or lose important relationships because their partners cannot continue to abide their level of obsession and compulsion, etc. If your point is that OCD does not imply a lack of intelligence or of ethical reliability, I agree totally. But I cannot agree at all that OCD does not handicap, as you say, its sufferers in one way or another. The handicapping is inherent to the very definition of OCD. Again quoting from DSM:

"significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships."

Now, as to the second point: you ask if OCD is not "a very 'normal' trait among many people." This raises the question of what is normal, and I would like to discuss that a bit. To grasp this question fully, it is necessary to understand that the latest advances in genetics, in studies of identical twins separated at birth, and in real-time brain imaging provide convincing evidence that many, if not all, personality traits are inherent to the individual at birth, and that being a "worrier" certainly is one of them. In other words, people are born already programmed to be essentially who they are in many ways. Yes, it is true that environment can make a difference, particularly the early experiences with family and especially within ones peer group, but environment goes only so far, and not at all as far as many people suppose or would like to think.

In the last half of the 20th century, it was fashionable to believe that heredity was relatively unimportant, psychologically speaking, and that how a child was treated by parents and friends made much more difference. Possibly this was an attempt by some to project the American political ideal, "all people are created equal," onto psychological understanding. Further, in the last twenty years or so of the last century, the argument was advanced that personality was "socially constructed," meaning that human nature was not largely the same regardless of where or when one was born (as now we understand to be true), but that personality was created culturally. All this was a mistake. I argued against it at the time, and am pleased to see that recent information makes untenable the social constructionist explanation of human personality.

As a psychologist, I can tell you from experience that all people are certainly not created equal psychologically. We are born with most of our traits already in place, and although these can be modified to some extent, either positively or negatively, by early experiences, the plain fact is that some of us are naturally calm and care-free, for example, while others simply cannot stop worrying. And these differences cannot be attributed to environment since studies of identical twins separated at birth show that twins (who are identical genetically, but shared no home environment) are much more alike psychologically and behaviorally than they are like the children in the families with whom they were raised (the children, in other words, with whom they shared an environment).

But a third point raised in my mind by your question is, I think, the most interesting. Human nature, since it is the result of evolutionary processes which take place only over vast stretches of time, changes very slowly if at all. Therefore, the personality traits we see in present time are the same as they were thousands of years ago. There were calm, sanguine people then, and there are now. There were chronic worriers then, and there are now. However--and this is the point--since culture, living conditions, and requirements for survival certainly do change, a personality type that was useful and successful in the ancient past, might be problematical in the world of today.

Let me give an example. Some people demonstrate a strong lack of interest in forming close relationships, and prefer to be alone most of the time. This same kind of person often has no particular interest in following social mores and conventions. Perhaps, also, he or she is pretty much unmoved by either praise or blame. This is a personality type called "schizoid," and in modern society, where most people live huddled together in cities and towns, and the structure of making a living resembles a vast, interconnected beehive, the schizoid person often is considered strange, unattractive, and perhaps mentally ill. But in another time, when surviving and thriving demanded other ways of being, the so-called "schizoid" person might have been perfectly adapted. Imagine today's "normal" person, who needs to being in constant contact with others by cell phone, email, or recently by means of "twitter," and, if all else fails will maintain the fiction of human contact by staring at a TV screen. How could such a personality possibly cope with the task of leaving the tribe to go hunting solo for a week or two? For such a task as that, the schizoid personality seems perfectly created. And indeed it was. It was created, by means of Darwinian evolutionary processes, over countless eons during which "schizoid" people were perfectly adapted for certain tasks. Being so adapted, they thrived, survived, and thus surviving were able to produce children who also carried the genes for schizoid personality. And so, the genetic information which produces the schizoid type of outlook continues to be part of the human inheritance. That is how we people of today got to be they way we are. Our forebears had certain traits that worked well, and they got passed down to us. So, in a real sense, most, or even all, of what we are is "normal," but that does not mean that all of it works well in today's specialized world.

There is a lot more to be said about this, but in the interest of publishing my reply to your question, and due to the large backlog of questions I still hope to answer, I will leave it here for present. Perhaps I will add to this answer later, for it seems to me that this topic, what is normal?, is particularly important.

By the way, my apologies to those who have sent questions to which I have yet to reply. This site has become, thanks to your interest, the number one ask the psychologist page in the world. I am gratified by the interest, but this also means that I receive many more questions than I can answer. Sorry, but I will do my best to reply to as many as possible.

Be well.

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