Could nutritional ketosis unlock therapeutic breakthroughs in treatment-resistant obsessive-compulsive disorder (OCD)?
A newly published, peer-reviewed case report in Frontiers in Psychiatry unveils a potential missing link in the treatment of OCD. The report documents one individual’s complete and sustained remission from OCD without the use of medication, achieved through a combination of ketogenic metabolic therapy (KMT) and exposure and response prevention (ERP).
What makes this report particularly compelling is that symptom relief began before ERP was even introduced.
While ERP is a gold-standard treatment for OCD, it doesn’t work for everyone. By introducing ketogenic metabolic therapy first, is it possible that a ketogenic diet laid the neurological and biological foundation to enhance the efficacy of ERP?
In other words, this case study examines the potential for nutritional ketosis to stabilize brain function, thereby creating a more receptive environment for exposure and response prevention (ERP).
This raises a powerful question for the field of psychology: Could nutritional ketosis itself catalyze psychiatric recovery by calming the brain before therapy even begins? Let’s explore the case study in detail.
The Burden of OCD and the Limits of Standard Care
Obsessive-compulsive disorder (OCD) is a chronic mental health condition characterized by intrusive thoughts and repetitive behaviors or compulsions. Ranked among the top ten most disabling conditions worldwide, OCD can severely impact quality of life, and for many, can become profoundly debilitating.
Standard treatment typically involves exposure and response prevention (ERP) therapy and selective serotonin reuptake inhibitors (SSRIs). While ERP is considered a gold standard in psychotherapy for OCD, it doesn’t work for everyone. And when it comes to medication, the stats show that 40% to 60% of individuals treated with SSRIs fail to achieve complete remission or even a meaningful clinical response[*].
Why is it that these treatments are falling short? And what could be happening behind the scenes to drive obsessive-compulsive behaviors?
With the emerging research in ketogenic therapy pointing to metabolic roots in several mental health conditions, we have to ask: could the brain’s metabolism be a missing link in treatment resistance?
Case Overview: One Man’s Road to Recovery
Treatment-resistant OCD is not only debilitating, but when traditional therapies fail to provide relief, it can be incredibly discouraging, leaving the patient feeling helpless and alone.
These feelings are what drove a 26-year-old male with longstanding, treatment-resistant OCD to seek alternative therapies.
Beginning at the age of 10, he suffered from intrusive thoughts, obsessions, and compulsions. Some of the most debilitating behaviors included complex verbal rituals, averaging 30 to 120 minutes a day, with occasional peaks of well over three hours during stressful periods. He also experienced the need to maintain extreme order and symmetry in his living space and digital devices.
While he experienced partial benefit from medications, he never found full relief, and the side effects made it impossible for him to stay the course. Looking for a way out of his misery, he decided to pursue a ketogenic diet just prior to beginning ERP.
Intervention Design and Timeline
The patient’s self-guided ketogenic meal plan included macronutrient ratios set at a 1.5:1 (187 g fat, 150 g protein, 30g net carbohydrates). The average percentages of macronutrients were 71% fat, 24% protein, and 5% carbohydrates. Using a personal spreadsheet, he systematically tracked his daily dietary intake.
To ensure he was reaching and sustaining nutritional ketosis, he monitored his ketone levels daily to confirm they were equal to or above 0.8 mmol/L. He also engaged in daily symptom tracking.
After four weeks on the ketogenic diet, he initiated ERP with a therapist to address his physical compulsions.
Remarkably, by Week 3 (2 weeks before ERP began), he noticed significant shifts in his compulsive behaviors, with a decrease from 3 to 8 hours per day to less than 1 hour per day.
Outcomes That Inspire Hope
With a combination of KMT and ERP, his progress continued rapidly, with the Depression Anxiety Stress Scales (DASS-21) showing a sharp decline as depressive symptoms dropped from a score of 10 to 2, and anxiety plummeted from 12 to 2. These scores indicate an emotional equivalent of severe (11 or greater) to normal (4 or less) in just 12 weeks of treatment.
Furthermore, his self-reported OCD symptoms were nearly eliminated as indicated by the Dimensional Obsessive-Compulsive Scale (DOCS).
What makes these outcomes particularly remarkable?
First, the patient wasn’t on any psychiatric medications at the time of intervention.
Second, relief from psychological symptoms began two weeks before ERP treatment.
And third (perhaps most striking of all), the patient confirmed sustained remission at a 95-week follow-up. Nearly two years after his ERP treatment, he was still experiencing profound reductions in all symptoms as he continued to follow a ketogenic diet.
While it’s clear that the ketogenic diet offered symptom relief independently of ERP, given the treatment-resistant nature of his symptoms, it’s fair to question whether engaging in ketogenic therapy may have also helped stabilize his brain function for better outcomes once he began ERP. In his words:
“ERP taught me how to break decades of ‘habit’ [order & symmetry]. It gave me ‘permission’ to stop. The ketogenic diet, however, was the foundation of this recovery. It empowered me. It is extremely challenging to integrate counseling when your brain is not working properly.” He added, “I state with absolute certainty that the ketogenic diet saved my life.”
Moreover, he attributed several quality of life markers to the ketogenic diet, distinct from ERP’s focus on obsessive-compulsive behaviors. These include improved emotional regulation, stabilized energy, and enhanced sleep quality.
Possible Mechanisms: How KMT May Support OCD Recovery
To understand how ketogenic metabolic therapy (KMT) may support OCD recovery, we first need to look at the potential biological mechanisms behind OCD.
While there’s no definitive conclusion at this time, four biological processes have been associated with OCD: glutamate/GABA balance, neuroinflammation, oxidative stress, and impaired glucose metabolism.
The balance between the neurotransmitters glutamate and GABA presents an interesting theory behind many of OCD’s compulsive symptoms. Glutamate is an excitatory neurotransmitter, while GABA is an inhibitory neurotransmitter; when these two compounds are out of balance, glutamate can become overactive and lead to symptoms like anxiety, obsessive thoughts, and repetitive actions[*].
Unsurprisingly, studies show that people with OCD tend to have higher levels of glutamate in specific areas in the brain involved in emotion, decision-making, and movement[*].
Neuroinflammation and oxidative stress are two physiological processes that are thought to be involved in several mental health issues, including anxiety, depression, and OCD. While oxidative stress often results from impaired mitochondrial function, neuroinflammation may be triggered by stress, impaired immunity, or a variety of other factors.
Elevated neuroinflammation is often seen in OCD patients, particularly in areas of the brain associated with reward processing and cognitive functions[*]. Mitochondrial dysfunction is studied as a possible factor contributing to OCD symptoms, with mitochondrial modulators (nutrients that support mitochondrial health) being investigated as potential adjunct treatment[*].
Impaired glucose metabolism is another biological process indicated in many mental health conditions, including OCD. While the exact mechanism is unknown, there is a correlation between patients with OCD and insulin resistance, which results in the brain’s inability to properly use glucose for energy[*].
Where does ketogenic therapy fit in to address these concerns?
By offering ketones as an alternative fuel source, ketosis may help the body bypass impaired glucose metabolism, allowing the brain to receive sufficient nutrients for optimal function.
Ketones themselves are known to have anti-inflammatory and antioxidant activity, thus supporting the brain against neuroinflammation and oxidative stress. And due to the way ketones are used by mitochondria, burning ketones for fuel in place of glucose could help to repair mitochondrial dysfunction[*][*].
Finally, research shows that following a ketogenic diet may support a healthy balance of glutamate and GABA, naturally increasing GABA levels while mitigating overactivation of glutamate[*].
From Single Case to Emerging Trend
While this case study shows us an example of what could be possible when the ketogenic diet is used therapeutically for OCD, it’s essential to keep in mind that one case report can’t be taken as definitive proof.
With that said, it does add to a growing body of evidence supporting a link between metabolic health and OCD symptoms. Below are just a handful of cases where people struggling with OCD found relief with ketogenic therapy.
THINK+SMART community stories:
Looking Ahead: Reframing Psychiatry
The concept of stabilizing a patient’s biology to enhance psychotherapy outcomes is not a new one. In fact, this model is the reason that many OCD patients are given SSRIs in conjunction with cognitive behavioral therapy treatment.
The understanding of metabolic psychology brings a reframe for how we can support a patient’s biology to set them up for successful treatment. Is it possible that ketogenic therapy may be a more effective biological pillar than SSRIs for some patients?
From what we’ve seen so far, the evidence is compelling.
With so many people finding relief with ketogenic therapy alone, we have to ask: could nutritional ketosis itself catalyze psychiatric recovery, before therapy even begins?
As case reports and clinical trials focusing on ketogenic therapy and mental health continue to emerge, we’re seeing a growing body of evidence pointing to metabolic health as a key component to mental well-being.
Resources and Next Steps
For more details on the case report outlined in the article, check out the published paper in Frontiers in Psychiatry.
If you’re looking for a deeper understanding of KMT (ketogenic metabolic therapy) and how it can support OCD, head over to YouTube to watch this expert discussion with Dr. Chris Palmer.
If you or someone you care for is struggling with OCD, seek out mental health professionals trained in ketogenic therapy to explore metabolic approaches with guidance.
