CHRIS AIKEN: Depression and anxiety occur on a spectrum, but can normal people have a little bit of OCD or psychosis? We're gonna trace that question from Carl Jung to a newly discovered neurologic trait. 

KELLIE NEWSOME: Welcome to The Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I'm Chris Aiken, the editor-in-chief of The Carlat Psychiatry Report.

KELLIE NEWSOME: And I'm Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. When we left Carl Jung last week, our hero was wrestling with psychotic symptoms and questioning his own sanity. Freud and his followers expelled him from their organization, dismissing the good Swiss doctor as paranoid, mentally deranged, and crazy. Freud used the Yiddish meshuga, but Jung did not seek treatment for these symptoms. Instead, he dove into the visions, recording them in an ornate journal,, The Red Book, that wasn't published until 2009.

CARL JUNG INTERVIEW AUDIO: My relation to reality was not particularly brilliant. I was often at variance with the reality of things.

CHRIS AIKEN: Psychosis is not like OCD. We don't treat it with exposure therapy, and I've never seen a patient come out of psychosis by diving into it. Usually, we advise them to ignore the paranoia and hallucinations as best they can while focusing on real life, eating, bathing, sleeping, and maybe moving toward work and relationships. But Carl Jung claims that he overcame his psychotic episode by diving into it. That's unusual, and historians have debated about whether the doctor had full bipolar or psychosis, or just a sensitive, creative temperament. It's a tough call. Every psychiatric symptom occurs on a spectrum. Naturally, depression, anxiety, inattention, and insomnia are part of everyday life, but so are more extreme symptoms like psychosis and OCD. Around 5% of people experience normal hallucinations at some point in their life that don't cause distress or impairment and are not associated with any psychiatric disorder, unlike clinical psychosis, these normal visions and voices are usually positive, like a bird telling you not to give up as you walk out of your apartment.

KELLIE NEWSOME: One explanation of these normal hallucinations is hyperphantasia, a condition where people have extremely vivid mental imagery, so vivid they can feel at times like they're actually seeing things they imagine.  Recent investigations suggest that this is what drove Jung’s visions rather than psychosis. Hyperphantasia is not a disorder, but it is thought to have a neurologic basis, with one study finding greater connectivity between the prefrontal cortices and the visual network. Around 3% of the population has hyperphantasia, and it may be more common in bipolar disorder. Studies find that people with bipolar tend to have expansive imaginations and strong visual thinking. Their moods are often affected by mental imagery in the same way that depression is driven by negative thoughts; there's even a psychotherapy for bipolar under development that harnesses this trait, helping patients to shift from negative to positive imagery just as a CBT therapist helps them shift away from negative thoughts.

CHRIS AIKEN: And maybe that's what Jung was doing as he shifted his relationship to these visions from one of fear and horror to one of meaningful mythological connection. Think about that in an upcoming episode where we talk about how acceptance and commitment therapy changes people's relationships to their symptoms. Regardless of what we think about Jung’s symptoms, understanding that mental illness occurs on a spectrum, including OCD and psychosis, does matter in everyday practice. Here's why you know, it used to be said that if a patient goes through all the rigamarole to get an appointment with you, that their symptoms must be causing distress, significant distress, and are worthy of a disorder. What if they came in because they heard about the symptoms on TikTok and wanted a professional opinion? If there's no significant distress or impairment, they don't have a mental illness, and they're better served with some behavioral advice, perhaps than with an SSRI. But even without TikTok, this idea has major holes. Take comorbidities. One patient started seeing me for depression. It was severe, and he needed medication. After he got better and his visits became more routine, he mentioned to me that he had a nervous habit he was curious about; whenever he said a curse word he had to say, “Father, have mercy,” to himself. He wasn't distressed by this compulsion. He thought it was amusing, and he wondered if he had OCD. But as we dug into it, there was no impairment. He could control the compulsion. It didn't take up much time, and he never had other OCD symptoms. His OCD symptom here was on the normal spectrum. It was mild, and it didn't need treatment. His depression may have brought him into my office, but his OCD was just a distraction.

KELLIE NEWSOME: Normal-spectrum OCD is even more common than normal-spectrum psychosis. Around 13% of people endorse some  symptoms of OCD without meeting the full criteria. They may have rituals or intrusive thoughts, but they don't get paralyzed by avoidance or compulsive behaviors, and it doesn't take up much time. In the standard structured interview for OCD, the MINI, they set a cutoff at one hour a day. That's how long the symptoms have to occupy the person to meet criteria.

CHRIS AIKEN: Carl Jung also had an OCD-spectrum symptom that changed his relationship to religion at the age of 12, just before his disappointing confirmation that turned him away from the church. Jung had a vision of God defecating on the chapel. He experienced this thought with all the fear, avoidance, and moral repulsion that characterizes OCD, even trying for a while to stop thinking about it until he finally gave in to the blasphemy. To his surprise and relief, nothing happened. He wasn't struck down from the heavens. It was a kind of exposure therapy that worked, and it also led to Jung's dualistic belief that good and evil, God and the devil, are both intertwined in the same being.

CARL JUNG INTERVIEW AUDIO: What sort of religious upbringing did your father give you? Oh, we were Swiss Reformed. And did he make you attend church regularly? Oh, well, that was quite natural, yes. Everybody went to church on Sunday. Yes. And did you believe in God? Oh, yes. Do you now believe in God? Now, difficult to answer. I know. I don't need to believe. I know. Well, do you think as man we need to have the concept of sin and evil to live with? Is this part of our nature? Well, obviously. And of a redeemer? That is an inevitable consequence. This is not a concept which will disappear as we become more rational. It's something which... Well, I don't believe that man ever will deviate from the original pattern of his being.

KELLIE NEWSOME: Let's pause for a preview of the CME quiz for this episode. Earn CME for each episode through the link in the show notes. 

Approximately what percent of people endorse sub-threshold symptoms of OCD that do not meet the clinical diagnosis?
A. 1 to 5%
B. 10 to 15%
C. 25 to 30%
D. 35 to 40%

In our last episode, we learned how Sigmund Freud elevated Jung to leadership, hoping that his Christian identity would save psychoanalysis from the anti-Semitic attacks it was facing. Instead, it was religion that ruptured their relationship.

CHRIS AIKEN: For Freud, spiritual faith was an immature defense mechanism, but for Jung, it was an essential part of psychological growth. Five years after they met, Jung published The Psychology of the Unconscious. In it, he argued against Freud's idea that the unconscious is shaped by early sexual conflicts. Instead, Jung's version of the unconscious was formed by spiritual forces, symbols, archetypes, and mythologies. And because the same archetypal images tend to show up across different cultures, you know, fire, floods, circles, and virgin births, Jung believed that we shared part of our unconscious with all of humankind, that it had both a personal and a collective layer, like Freud, Jung tried to ground this collective unconscious idea in biological terms, writing that these collective religious ideas arose from common brain pathways that were shaped by evolution, much like evolution shapes our basic instincts.

KELLIE NEWSOME: But Freud would have none of this. He saw this mystical turn as a professional betrayal and moved to expel Jung from the budding psychoanalytic profession. A year later, Jung resigned from his post as president of the International Psychoanalytic Association, and their friendship was never repaired. Jung retreated to the Swiss Alps, where he built a castle-like cottage on Lake Zurich, turning his unconscious archetypes into stone architecture, with a chimney that symbolizes the melding of earthly and physical space, spiral staircases that recall the descent into the unconscious, and a fortress-like tower where he could meditate with his imagination. And from this high tower, he came to a practical insight that is still with us today, something I see in the office at least once a week, more on that in next week's episode. But first, let's look at what the latest science says about psychoanalysis.

CARL JUNG INTERVIEW AUDIO: Tell me, did Freud himself ever analyze you? Uh, yeah. Oh, yes. I had submitted quite a lot of my dreams to him, and so did he. To you? Yes. Oh, yes, yes, yes. Do you remember now, at this distance of time, what were the significant features of Freud's dreams that you noted at the time? Well, that is rather indiscreet to ask. You know, there is such a thing as a professional secret. He's been dead these many years. Uh, yeah. Yes, but these regards last longer than life.

CHRIS AIKEN: Of all Freud's ideas, the one with the most empiric support is that of the unconscious. Although, as we found out last week, this wasn't really Freud's idea, the brain can process information outside of our conscious awareness, and this subconscious processing affects our emotions and behavior. We know this from experiments involving subliminal messages of sorts, where people are flashed words or pictures so fast that they're just out of conscious perception, but that influence their behavior later. But whether people can actively repress disturbing conflicts has proven more difficult to test. One breakthrough came in 2001, when Michael Anderson and Collin Green at the University of Oregon developed the think–no-think test. The experiment's a little complex, but to simplify here, they showed people pairs of unrelated words like “watermelon” and “hobby.” Later, they tested their recall of these word associations in various ways, and they found that if they instructed people to actively avoid thinking about the word pairing, like, “don't think about watermelon”, it would trigger them to forget the association with the unrelated word hobby. Now, that sounds kind of obvious, but what was remarkable was that the people went on to forget the word in other contexts. So they wouldn't just forget that watermelon was paired with hobby, they would also draw a blank on the obvious answer when asked to name a fruit that starts with “W”. The paper, published in Nature, was greeted as long-overdue proof of Freud's concept of repression. But does it really show that? It seems like a leap to go from repressing word associations to repressing psychosexual conflicts. But consider this fact: children who are abused by a parent , or a trusted caregiver , are more likely to forget the abuse than those abused by strangers. Why? They depend on that caregiver for their basic needs, from shelter to attachment, and they may feel a need to forget in order to survive, to repress, holding on tightly to whatever remnants of parental support they can piece together.

KELLIE NEWSOME: Difficult to Treat Depression is out in print or as an audiobook on Audible.com and Amazon. Here's what David Osser, associate professor at Harvard Medical School and author of Psychopharmacology Algorithms, had to say: “Dr. Aiken has collected and organized an astounding amount of information and distilled it into four to eight clearly written chapters, each of which is loaded with terrific and very practical advice. The answers to your questions are in here. You must get and use this remarkable book.”

CHRIS AIKEN: Our audio of Carl Jung was from his 1959 interview with the BBC.