Finding the Right Balance–an OCD Problem.

It is possible to have too much of a good thing

Individuals who suffer from Obsessive-Compulsive Disorder (OCD) tend to see things in black or white. There is the proper way to do something—and there is everything else. So, some patients with this condition struggle to find the right way to walk along the sidewalk, the right number of times to brush their teeth, the right way to wash their hands and so on. Shoes have to be stored in a straight line. Clothes drawers have to be organized just so. Compulsive people may agonize about the “right clothes” to wear today– and every day.

Similarly, as there are good things, such as being organized and clean, there are bad things, such as germs. If something is good, the more of it the better. Exercising more and more and more is better. If something is bad a little, it is still bad. In such a way, all germs are considered bad. Putting aside the huge number of bacteria and other germs that do not threaten us at all, there are many others that actually help us to survive. Even the infectious bacteria that make children sick help them to develop their immune systems properly so that as adults they are less likely to become sick with auto-immune illnesses, such as multiple sclerosis, or the inflammatory bowel diseases. Some illnesses are worth getting. Mumps, although preventable now with an inoculation, is one condition of many that are more or less harmless in childhood, but serious in adults. This is a distinction that is impossible to make convincingly to those who have developed a particular view of the world: germs are no good; and that’s that.

People who are bothered by Health Anxiety develop all kinds of rigid ideas about good foods and bad foods. But bad foods are not bad in proper amounts; and good foods are not good in the wrong amounts (See my book, “The Stuff-Yourself Diet.”)  Some dieters believe in drinking a lot of water; but even water is not good when ingested in excessive amounts.

Some time ago, I was called to the emergency room of the hospital at which I was working to evaluate a woman who had evidently become psychotic. She was agitated and delusional. As I remember, she thought people were pursuing her. She heard voices. Although she had no history of schizophrenia, or any other serious mental disorder, I admitted her with a diagnosis of paranoid schizophrenia.

But she presented differently when I saw her on the psychiatric ward the following morning. She was in a delirium. A delirium, or “shifting levels of consciousness,” is marked by a confusional state. One minute, the patient is disoriented, unable to concentrate, unable to remember or interact meaningfully with others; a few minutes later the patient is more or less coherent and responsive. A delirium is characteristic of an “organic” state. If the individual is psychotic, it is termed an “organic” psychosis. The term “organic” is used to reflect an actual physical or chemical impairment of the brain, in contrast to the “functional” psychoses, such as schizophrenia or bipolar disease, which were thought at one time to represent merely a disturbance of brain function. This is a distinction that no longer makes sense. Still, the organic psychoses are different from the functional psychoses. One difference is that organic psychoses tend to cause visual hallucinations. Schizophrenia is marked by auditory hallucinations. The vivid, and frightening, hallucinations of insects and other animals that are common in delirium tremens, (D.T.s), are produced by withdrawal from an alcohol addiction. There are a great many other possible causes of an organic psychosis.

Here are only a few of the causes of an organic state: trauma to the head, infectious diseases of the brain (or a septic state from infection anywhere in the body,) tumors of the brain, a great variety of endocrine disorders, poisoning, metabolic diseases, auto-immune diseases, such as lupus, high fevers, stroke, and so on.

I was operated on a number of years ago and awoke from anesthesia to hear my daughter speaking in the next room. I called over to the nurse and asked her to bring my daughter in. She told me there was no one there, even though I could still hear her and thought I saw her standing to one side. I argued with the nurse until my daughter did come in some time later and told me she had just arrived. Anesthesia can produce an organic state.

Usually, the cause of a particular organic state is apparent from other physical signs and symptoms, and the medical history. These allow a particular diagnosis—but not always.

When it was not immediately obvious to me what was causing my patient’s organic state, I asked an internist and a neurologist to see her. The studies they ordered were innumerable and included a CAT scan of the brain, neurological testing, detailed blood studies, tests for occult infections, such as Lyme Disease, endocrine studies, the usual urine and liver studies, various X-rays, and electrolytes—and anything else they could think of —because the patient was not improving. She kept slipping in and out of a confusional state, and was intermittently agitated and delusional. And hallucinating. And she was not getting better. Anti-psychotic medicines calmed her down; but she was just as sick as ever. After two weeks she had not improved.

Finally, the two specialists came to me separately and said that if, indeed, she was delirious, they could not find the cause.  Neither could I think of anything further to do. But reviewing the woman’s chart still again, I noticed that her blood sodium level was somewhat low. I would not have thought twice about such a minor electrolyte imbalance except that many years before, by coincidence, I saw another woman who also had an organic psychosis and a slightly low sodium level. That other woman had become sick by drinking inordinate amounts of water. Water washes out sodium in the urine.

During one of those times when my patient was calm and coherent, I asked her if she had been drinking a lot of water.

“I never drink water,” she said.

During the third week of my patient’s intermittently relapsing, but un-resolving, condition, I asked her again.

“I told you, I never drink water,” she responded

Finally, about a week later she began to get better. I lowered the anti-psychotic medicine she was on, and in another few days she seemed entirely well. When I saw her in my office a week later, I told her that I did not expect that her illness would recur, but I would feel more comfortable if I knew what had provoked it in the first place.

“Are you sure you don’t drink lots of water sometimes?” I asked her again.

“I told you,” she said irritably, “I never drink water.”  She frowned at me for a moment. “I only drink coffee,” she added.

“Well, how much coffee do you drink?”

“I drink a pot before breakfast and a pot after breakfast, then some later on.”

It turned out that prior to her being admitted to the hospital she had been up practically all night for three nights in a row at a roof-top party drinking iced coffee. As far as we could figure, she had drunk gallons of the stuff. Coffee, of course, is mostly water—but, in terms of this condition, worse. Caffeine is a diuretic and causes even more sodium to be washed away.

This case history is an argument for a flexibility of mind. Things—including food—are not either good or bad. It is possible to look for shades of gray in matters that seem to be black and white.

I do not know how much water has to be ingested to produce an unsafe condition. It must surely be a great amount since I have only seen two cases of psychosis secondary to hyponatremia during all the time I have been in practice. I do not recommend drinking seven or eight glasses of water every day—as some people suggest—because I think doing so is unnecessary, rather than dangerous. I suggest drinking only when you get thirsty—unless you are about to run a marathon, or be somewhere where water will not be available. Thirst is the mechanism we have evolved—and other animals, too—to regulate the intake of water.

I’m afraid that this advice is not likely to satisfy those suffering from obsessive-compulsive disorder since they need to have a very detailed, exact, set of instructions to get through the day. I remember one man who had to know the exact number of times he should urinate during the day, and exactly what foods to eat. And precisely how much water he should drink. (c) Fredric Neuman 2013


Great read. The hard part is to pinpoint how many ways the ocd can manifest. I have it completely around using time effectively and about religion.
- Amir

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- Amir