Prof. Nevzat Tarhan: “Personalized Treatment in OCD Increases Success”

President of Üsküdar University, Psychiatrist Prof. Nevzat Tarhan was a live broadcast guest on AS TV Main News. In his evaluations on “Obsessive Compulsive Disorder (OCD)”, Tarhan explained that the disease has not only behavioral, but also biological and neuropsychological aspects. Explaining the formation mechanism of OCD, its relationship with the brain's reward system, and the interaction of thought-emotion, Tarhan drew attention to the importance of personalized treatment approaches. Referring to the place of the exposure and response prevention (ERP) method in treatment, Tarhan evaluated the contribution of the feeling of hope to the recovery process, the importance of strengthening decision-making skills, and the decisive role of coping with uncertainty in mental health. 

“The feeling of spiritual impurity is transformed into a feeling of material impurity”

President of Üsküdar University, Psychiatrist Prof. Nevzat Tarhan, explained the formation mechanism of obsessive-compulsive disorder, stating that thought and emotion do not operate independently but are often intertwined. Tarhan said; “In obsessive-compulsive disorder, a situation we call thought-emotion fusion occurs. That is, sometimes it starts with emotion, and thought emerges later. Sometimes there is thought, and emotion emerges later. Emotion and thought become intertwined. For example, a person has a compulsion related to hand washing. Obsession is always known as a thought, but in fact, there is also an emotion involved. The person has a feeling of psychological or spiritual impurity within them. It might be an experience from the past that aroused a feeling of guilt or made them feel bad. When the person cannot resolve this emotion in their mind, the brain converts the feeling of spiritual impurity into a feeling of material impurity and tries to relieve it by washing their hands. First, a thought or emotion comes, then the person acts, washes their hands, and feels relieved. The brain produces dopamine at that moment. Because dopamine is produced, a short-term feeling of relief and reward occurs. Then the person wants to repeat the same behavior. As they do it, the behavior increases. In the meaning disorder we have been discussing in recent years, the person catastrophizes or devalues a thought or emotion due to the meaning they attach to it.”

“Chemical degradation occurs”

Tarhan stated that permanent changes can occur in the brain's reward system over time in obsessive-compulsive disorder; “The reward pathways in the brain are like small paths formed by the reaction to thought and emotion. As one thinks, there is a brief relief. As one thinks again, after a while, these gain a material dimension in the brain. That is, chemical degradation occurs. From that point on, even the devil's whispers are no longer needed. The brain produces automatically. When we perform brain mapping, we can see that one region of the brain produces automatic erroneous thoughts differently from other regions. This therefore leads the person to say, ‘It’s as if there is a second person inside me.’ In genuine obsessive-compulsive disorder, the person believes that what they are doing is absurd and struggles against it. However, there are also obsessive-compulsive disorders that are consistent with one's personality, which are called ‘egosyntonic.’ In this case, the person accepts it as normal, lives with it, and does not want to change. This is a more serious condition, but if the person is still struggling, the potential for recovery is higher.”

“Our brain works with probability calculations”

Stating that the human brain works with probability calculations instead of certainty, Tarhan expressed that one of the biggest problems in obsessive-compulsive disorder is the search for certainty. Tarhan said; “When we talk about will, we are referring to the frontal region of the brain, which is the decision-making mechanism. Psychologist Geoffrey Hinton receiving the physics prize in 2024 is one of the important examples of this. Hinton, known as the godfather of artificial intelligence, worked for years on the cognitive psychology approach that viewed the brain as a computer and put forth the brain's computational model. As he himself stated, our brain works with probability calculations. That is, it's not black and white; it can evaluate many possibilities simultaneously. In obsessive-compulsive disorder, however, the person wants a possibility that comes to mind to be one hundred percent certain. Yet, the brain does not have such a capacity. The brain is not a structure that operates with one hundred percent certainty like Newtonian physics.”

“There is a constant war within them”

Drawing attention to the importance of a personalized treatment plan in obsessive-compulsive disorder, Tarhan said; “There is also a system in our brain that works like a computer's RAM. We call this the 'Salience Network'. Just as a computer gets blocked if too many files are open in this system that functions like a cache memory, in perfectionist individuals, this cache memory gets overloaded, and the same behaviors start repeating. After a while, the chemical pathways in the brain automatically deteriorate. For this reason, we do not give the same medication to everyone. We check for genetic polymorphism. We examine genes that affect liver drug metabolism, along with serotonin and dopamine genes. According to the genetic profile we create, we determine the most suitable medication for the person. Instead of trial and error, we apply treatment based on scientific data, and if necessary, we can go to higher doses by monitoring blood levels. Therefore, obsessive-compulsive disorder is truly a very difficult disease; those who haven't experienced it cannot know. There is a constant war within them. I know patients who cry when we show them that war in the brain and say, ‘This part of your brain causes this disease.’ Because most people have received advice like, ‘Don’t worry about it,’ ‘Go out and enjoy yourself, it will pass,’ ‘You're being anxious,’ ‘You're being obsessive.’ Yet, this is not something they can control.”

“When there is a feeling of hope, the brain’s internal pharmacy is activated”

Stating that the feeling of hope is one of the most important factors supporting recovery during the treatment process, Tarhan said; “In OCD, the most significant factor increasing other psychiatric illnesses is hopelessness. The brain's expectation of recovery and feeling of hope can create up to 40% improvement through a mechanism we call the placebo effect. The exact opposite of this is the nocebo effect. Research has shown that when people who had headaches without knowing they were taking a fake drug were given Naloxone, which eliminates the effect of morphine, their pain returned. This also shows that when a person believes in the medication, the doctor, and their recovery, the brain's internal pharmacy is activated, endorphins are secreted, and this contributes to the recovery process.”

“A highly effective method in mild cases”

Stating that the exposure and response prevention method yields effective results in the treatment of obsessive-compulsive disorder, Tarhan said; “In OCD, there is a treatment called ERP. 'Exposure Response Prevention,' which means exposure and response prevention method. For example, a person thinks their hands are dirty and constantly feels the need to wash them. In therapy, they are made to touch objects they consider dirty in a controlled manner. Normally, they want to go and wash their hands immediately because this behavior causes dopamine secretion and relaxation in the brain. With the therapist's accompaniment, the person is prevented from washing their hands. After a while, the desire to wash gradually decreases. If the person can achieve this, the recovery process of the disease begins. This method is particularly effective in mild cases. However, when the disease is very advanced, it can become difficult for the person even to approach objects they consider dirty.”

“The worst decision is better than indecision”

Tarhan stated that strengthening the decision-making mechanism in obsessive-compulsive disorder is an important part of treatment; “The feeling of control in life is very important in OCD. However, one must not overdo it. In the frontal region of our brain, there is, so to speak, a mental jury with a judge at its head. This structure evaluates incoming information, analyzing 'is it real or not', 'is it good or bad', 'is it useful or not', and finally makes a 'do' or 'don't do' decision. In people with OCD, this decision-making mechanism does not function healthily. They constantly remain indecisive, asking 'Is it this, or is it that?' In this situation, we use the principle 'The worst decision is better than indecision.' The person should choose the most suitable possibility, make their decision, and not constantly go back and re-question it. When a person determines their importance and priorities in life, and plans their day and future, the brain feels secure. Uncertainty, on the other hand, is perceived as a threat by the brain.”

“Managing uncertainty is a skill”

Tarhan stated that individuals who can cope with uncertainty develop strategic thinking skills; “Being able to manage uncertainty is a skill. People who can manage uncertainty become wise individuals, and good managers are trained. If panic occurs in the face of uncertainty, a second and third mistake also follows. For this, it is necessary to be prepared for a crisis. When a crisis comes, it is important to evaluate the options, make the most suitable decision, and not constantly go back and question the same thing. This is a mastery gained over time. We work on strategic thinking skills in individuals who have a self-development goal and define their roadmap. After the goal is determined, priorities should be listed, and time and energy should be managed accordingly. Just as success is in the details, the devil is also in the details. If a person knows their purpose, they grasp the useful detail and reach their goal. However, if their purpose is not clear, they get stuck in unnecessary details and miss their goal. Therefore, a person needs to develop the skill of managing their time and energy correctly.”