James Greenblatt, MD
James Greenblatt, MD, founder and medical director, Comprehensive Psychiatric Resources, Inc., Waltham, Massachusetts, and author of Finally Focused. JamesGreenblattMD.com
It’s human nature to have occasional worried thoughts or to overanalyze important decisions. Normally, these thought patterns dissipate quickly, but in people suffering from obsessive compulsive disorder (OCD), letting go of repetitive thoughts isn’t so effortless. Instead, relentless ideas, impulses, or images inundate the brain, mentally imprisoning the individual in recurrent, irrational thought patterns.
These senseless obsessions often drive the individual to ritualistic behaviors or compulsions—like handwashing, hoarding, counting or hairpulling—in an attempt to temporarily relieve their anxiety. A person with OCD staggers through life with a sense of powerlessness—fully aware the behavior is abnormal, but unable to stop.
There are two standard treatment options: selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT). But even with these two treatments, only one out of five patients experiences complete recovery from OCD, and relapse is common. The reason for this failure: Conventional treatments don’t address the root cause of OCD.
Inflammation is a natural feature of the immune system. When there is a virus, bacteria, or other foreign invader, the immune system activates to neutralize the threat, producing the telltale redness, swelling, heat, and pain that are the signs of acute inflammation. But an immune system that is out of balance can generate low-grade, chronic inflammation—including inflammation in the brain (neuroinflammation). In the brain, cytokines produce an enzyme called IDO (indoleamine 2,3 dioxygenase). IDO decreases the level of serotonin, the neurotransmitter that regulates mood and anxiety. (Every medication approved for OCD works by increasing serotonin levels.)
Along with this biochemical understanding, there is a growing body of clinical and scientific evidence that immune dysregulation underlies OCD. Psychiatrists know that autoimmune disease—when the immune system attacks the body as if it were a foreign invader—is rampant among those with OCD. For example, a 2021 study in the International Journal of Environmental Research and Public Health showed that people with OCD had triple the risk of developing the autoimmune illness Sjogren’s Syndrome than the non-OCD population.
Researchers have identified two other neuroinflammatory disorders that play a role in OCD: pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS). In PANDAS, children who have had a streptococcal infection go on to rapidly develop OCD, practically overnight, because the immune system attacks the part of the brain (basal ganglia) where OCD is thought to originate. In PANS, other types of infections, such as Lyme disease, mononucleosis, and the flu, are also thought to quickly trigger OCD.
Along with neuroinflammation, a number of other factors affect serotonin levels, including genes, diet, stress, and neurotoxins. Those factors can be directly affected by nutritional therapy—a key treatment for OCD that is overlooked by conventional psychiatry.
Integrative psychiatrists, on the other hand, are open to both conventional and natural treatments for OCD. (You can find a list of integrative psychiatrists at www.psychiatryredefined.org/directory.)
An integrative psychiatrist may recommend one or more of the following commonly used supplements. Always talk to your physician before taking any new supplements.
5HTP. 5-hydroxtryptophan is a precursor of serotonin that has provided relief for many patients with OCD. The typical dose is 100 to 300 milligrams (mg). In some cases, doses as high as 600 mg may be needed.
Vitamin B12. A deficiency of this serotonin-boosting B vitamin is common in OCD. Although most conventional doctors consider blood levels between 200 to 1,100 picograms per millilitre (pg/mL) normal, Dr. Greenblatt considers any level under 500 pg/mL to be low. If a patient is low, he treats with weekly intramuscular B12 injections until the blood level reaches 900 pg/mL. Some patients experience a dramatic decrease in symptoms with just this treatment.
Folate. This B vitamin is crucial in the manufacture of serotonin, and it can boost the effectiveness of antidepressants. However, some people with OCD can’t metabolize folate because of a genetic abnormality. If you have OCD, consider having a methylenetetrahydrofolate reductase mutations (MTHFR) test to see if you lack the enzymes to process folate. If the test is positive, you may need to take one to 15 grams of folate daily.
Zinc. This mineral is a crucial cofactor in the production of serotonin. A zinc deficiency also can have a number of other negative consequences for health, such as depression, poor metabolism of essential fatty acids, lower melatonin, more vulnerability to stress, and digestive difficulties. Consider a dose of 30 mg daily.
Inositol. In some patients, supplementing with inositol—a vitamin-like compound that affects the serotonin receptors on cells—is the only treatment needed for OCD. Consider taking 5 to 10 grams (g) daily, starting off with 1 g and increasing by 1 g weekly. Taking too much inositol too quickly can cause gastrointestinal discomfort.
Omega-3 fatty acids. The brain is 60 percent fat, and optimal brain function requires healthy fats such as the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) found in fish oil. Consider a daily supplement containing 3 grams of omega-3 fatty acids with a slightly higher ratio of EPA to DHA.
N-acetylcysteine (NAC). This compound is a derivative of the amino acid cysteine and helps produce glutathione, a powerful anti-inflammatory antioxidant. In a study published in the Journal of Clinical Psychopharmacology, 36 women with OCD who didn’t respond to serotonin-boosting medication were divided into two groups: One group took NAC daily and one group took a placebo. A total of 53 percent of the NAC group had significant improvement in OCD symptoms, compared with 15 percent of the placebo group. Consider taking 2 to 3 g of NAC daily.
Glycine. This compound is a precursor to glutamine and gamma aminobutyric acid (GABA), two calming neurotransmitters that can inhibit obsessive thinking. Consider taking 3 to 6 g of glycine daily.
Vitamin D. This vitamin can lower neuroinflammation. Your doctor can test you for vitamin D deficiency (blood level below 30 nanograms per milliliter [ng/ml]). If you’re deficient, take 2,000 to 4,000 international units (IU) of vitamin D daily to bring levels to at least 50 ng/ml.
Magnesium. To cool inflammation, take 400 to 800 mg of magnesium citrate or glycinate daily, divided into two or three doses.
Several lifestyle factors can also affect OCD:
Poor sleep. Treat insomnia with improved sleep hygiene. Go to bed at the same time every night and get up at the same time every morning, giving yourself at least seven hours in bed.
Stress. Stress not only causes inflammation but also worsens the symptoms of OCD. Reduce stress by learning and practicing mindfulness-based stress reduction techniques.
Eliminate gluten and casein. People who are missing the digestive enzyme DPP-4 can’t adequately break down certain proteins from dairy (casein) and wheat (gluten), producing morphine-like compounds (casomorphin, gliadorphin) that can play a role in OCD. Taking the DPP-4 digestive enzyme, which breaks down gluten, and eliminating dairy and gluten-containing foods (wheat, rye, barley, oats) sometimes significantly or even completely resolves symptoms, particularly in children and adolescents with OCD. The Great Plains Laboratory tests for casomorphin and gliadorphin in the urine (www.greatplainslaboratory.com).
