Can’t just stop:
Chapter 1: What is a compulsion?
Compulsion: Something you have to do because it relieves anxiety, not because it’s pleasurable.
Addiction: the behavior is at first intensely pleasurable.
Impulse?
But they’re often used interchangeable in everyday speech as well as in medical/academic dealings, and this is confusing.
Chapter 2: OCD
Intrusive thoughts, overwhelming desire to act. E.g woman to had to keep checking to make sure her cat wasn’t in the fridge, even if she saw the cat walking around. If it develops, most likely to appear between 10-12 or in late teens/early adulthood. Both are periods of neuronal proliferation and then pruning. The thoughts are ego dystonic, meaning they feel like they’re coming from an outside source rather than from within. They clash with your ideas of who you are or what you know to be true. And once you give in to the thoughts, it brings no joy, just temporarily relieves the anxiety. People with OCD usually recognize that their thoughts are mad. Therapy often includes showing someone nothing bad will happen if they don’t follow compulsions. Like touch door knob and don’t wash your hands.
Chapter 3: With treatment, from blood in a snowbank to Hollywood.
About the compulsion to seek medical treatment absent signs of illness. They’re convinced they have a serious disease, only by getting medical tests or treatment can they relieve the anxiety. Psychiatrists used to think this stems from early bad experience with illness, but this doesn’t appear to be the case. Mindfullness based cognitive therapy seems pretty effective at treating this.
Chapter 4: In the shadow of OCD, carrying conscientiousness too far.
The personality trait most relevant to compulsions is conscientiousness. People with obsessive compulsive personality disorder (OCPD) tend to be disciplined, dutiful and deliberate. This is separate from OCD, few with OCD are overly conscientious. OCPD compulsions are much milder than OCD, but the compulsions feel egosyntonic, they’re coming from within you and they’re rational. It’s the rest of the world that’s mad.
Chapter 5: Video games
Different from other compulsions because video games exploit aspects of human psychology that are nearly universal. People who play compulsively do it to quell anxiety and escape, and this justifies the continuation of the behavior even if it’s disrupting your life. Game designers try to keep players in the flow zone as long as possible. They use variable reinforcement (value of reward for a given accomplishment changes) and intermittent reinforcement (varying probability of getting reward).
Often, people who play compulsively don’t describe the experience as fun.
Chapter 6: Smart phones and the web
Internet addiction disorder was originally proposed as a joke, (because everyone has it was the idea), but a lot of people reached out because they found it relatable and distressing. But concerns include who determines what excessive is, how do you determine if it’s pathological when it’s tied up with many aspects of success in the modern world?
Chapter 7: Compulsions past
This is about historical reports of compulsions. Scrupulosity was very common; this is irresistible urge to engage in religious rituals or thoughts and constantly feeling like you didn’t do it enough. Hoarding books etc. Pre renaissance, weird behaviors were thought to be caused by demonic possession, but later, more naturalistic explanations were sought.
Chapter 8: Compulsive hoarding
Often the home becomes unlivable, with goat paths between towers of stuff the only way to navigate through the home. Spouse dying seems to be a risk factor, prevalence increases with age. The hoarding thoughts are typically egosyntonic, feels like part of you. The hoarder’s attachment to possessions and distress at tossing it seem like a core part of them. They derive comfort from stuff, and it actually doesn’t actually cause them distress. It allows them to feel prepared for every eventuality, and often begins in childhood. Might be tied to dysfunction in decision making, they can’t efficiently make decisions about what is valuable and what is not, and this manifests is just keeping everything and feeling very anxious about throwing anything away.
Chapter 9: Compulsive acquiring, or I’ll take two
Like Jenny, who already has goat paths and no room at all, but saw a perfectly good discarded comforter. She couldn’t resist taking it, even though she knew it wasn’t really a once in a lifetime opportunity. She grew up in a frugal family who taught her to never waste. And sometimes it does help (stocking up on cheap anchovy paste, using spare parts from a broken washing machine to fix her own machine etc).
Compulsive buyers tend to be young. Can have roots in addiction and impulsiveness, or more like a compulsion like in Jenny’s case.
Chapter 10: Compelled to do good
Like other compulsions, they do it to quell anxiety, but in this case other people happen to benefit too. In extreme cases, these people donate a kidney to a stranger. In a study of 20 donors and non donors, donors had a larger right amygdala on average, and was more active during viewing faces with expressions of fear. So maybe they’re unusually sensitive to the fear and distress of others, and this makes them act so altruistically.
Chapter 11: The compulsive brain
46 year old man had a ruptured aneurism, caused extensive damage to his left orbitofrontal cortex (planning and judgment) as well as to his caudate (mostly planning movement, but also involved in goal representation in general). He compulsively started collecting toy bullets at his local park, kept them in bottles. Patients with similar brain damage also started compulsively collecting things.
OCD circuit: in 1980’s, found that there was consistently elevated activity in three regions: orbitofrontal cortex, anterior cingulate, and striatum. When symptoms subside, these overactivations also subside. This is also called the worry circuit.
OFC: complex functions including risk assessment. Error detector, compares actual events to expected events (like if a reward you’re expecting doesn’t arrive), or if things are askew or out of order. So if you have chronically high activation in this area, you’re more prone to seeing errors and feeling emotionally affected by them.
Anterior cingulate: different kind of error detection, fires when you make a mistake.
Striatum: lots of connections to other regions, a hub. Involved in learning, goal directed behavior, voluntary movement, reward processing etc. In this case, the significant part is activity in the caudate nucleus. Caudate nucleus sends inhibitory axons to many other brain structures. So if this is overly active in OCD patients, this down the line quiets the thalamus too much, which is itself a silencing center, and so you actually get overactivity in thalamus etc.
OCD was an exemplar of a growing movement, abnormality in brain wiring, not neurochemical imbalances are behind mental disorders. But note, neuroimaging cannot reliably detect OCD. Only in 100 OCD brains on average.
Gene studies of OCD: 2012 study, GWAS (1,400 people with OCD, 5,000 controls). BTBD3 and DLGAP1 were biggest hits, both are related to neuronal wiring and migration. Another one popped up in 2014, PTPRD mutations related to OCD, related to neuronal growth. But many people with OCD don’t have these aberrant genes, and many people with the aberrant genes don’t have OCD. They just increase risk.
Environmental factors: these are even murkier. One theory is that compulsive behaviors are most likely to develop in people who had an unpredictable environment as a child, so they want to be able to control at least one thing.
Hoarding pops up in many patients with frontal lobe damage. It’s a disinhibition disorder. They also have reduced activity in anterior cingulate and insula. These form a salience network to help us decide what is important. They can’t tell what is important, so they just keep it all. VMPFC also involved, it is important for ambiguous decision making.
Dopamine: people on dopamine agonists for PD often started compulsively gambling, or obsessively doing other new compulsive behaviors. Behaviors go away once meds are stopped. But it is minority of such patients, and so far we don’t know how to predict who will develop compulsions on DA agonists, or what form the compulsions will take.
But the DA circuit is not the simple pleasure circuit we once thought. Famous experiment by Milner and Olds in 1954, inserted electrode into nucleus acumbens. Found that rats would press this level instead of eat, be in a comfortable temperature, and anything else. This has been interpreted as pleasure so intense it was more rewarding than anything else. But what if the rats were instead experiencing acute anxiety that could only be alleviated by pressing the lever? That doesn’t make any sense. Why would their baseline anxiety be so high? In humans, electrical stimulation of nucleus acumbens produces mildly pleasurable feeling, but not much. Now it’s thought that rather than a pleasure center, the DA circuit is more like a prediction machine. If reward is bigger than you expected it feels good, if it’s smaller or doesn’t come, you feel incomplete and anxious. Then NAc creates a feeling of wanting to try again. Compulsion arises from a need to make reality be in accord with your prediction. But if it is achieved, the result is not happiness as we often conceive it, but relief.
Primate experiment: green light means reward, red light means no reward. After they built the association, just the green light appearing triggered DA surge in VTA. There was no second spike when they actually consumed the reward.
So DA circuit fuels compulsion, this is checked or inhibited by areas of the cortex.
Mesolimbic DA path: VTA-striatum (includes NAc). Reward, reward prediction,
Notes:
One behavior can have roots in either addiction and impulsivity, or be a compulsion, and those people should be treated differently.