Speaker 1: Oh hey, it's the bowl that's chipped, but not chipped
Speaker 1: enough to throw it away. Ali Ward, this is ologies,
Speaker 1: this is OCD. Okay. We asked y'all on Patreon your
Speaker 1: most desired episodes, and this was among the top, which
Speaker 1: was both a surprise. It was also a delight to me.
Speaker 1: Also a delight we got the world's most revered expert
Speaker 1: in OCD to talk to me for an hour. This
Speaker 1: person invented this scale by which OCD is measured. They've
Speaker 1: been working in this field for many, many decades and
Speaker 1: is pioneering a bunch of new treatment and research for it.
Speaker 1: They studied at Boston University and Yale School of Medicine.
Speaker 1: They've also been instrumental in nonprofit work for OCD treatment
Speaker 1: and research. They're now a professor and the chair at
Speaker 1: the manager Department of Psychiatry and Behavioral Sciences at Baylor
Speaker 1: College in Houston. And if you have OCD, or you
Speaker 1: know someone who does or might, their life is better
Speaker 1: because of this absolute OCD icon And just a content note,
Speaker 1: of course, we talk about some parts of OCD that
Speaker 1: are distressing to people, and that's part of why we're
Speaker 1: doing this to talk about it. But just to content
Speaker 1: warning up top that we do touch on self harm
Speaker 1: and some intrusive thoughts that might be a little disturbing
Speaker 1: to people. Now. I was nervous as hell to hop
Speaker 1: on this interview because I know their time is very limited,
Speaker 1: but we were able to cover so much, including questions
Speaker 1: from patrons at patreon dot com slash ologies, you also
Speaker 1: can ask questions before we record. You can join that
Speaker 1: for less than twenty five cents an episode. Also, Ologies
Speaker 1: Merch is available at ologiesmerch dot com should you need it,
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Speaker 1: Okay is OCD a niche condition. I would have thought so,
Speaker 1: since people don't talk about it a lot unless it's
Speaker 1: an offhand punchline or like an excuse for a complicated
Speaker 1: Starbucks order. But research reveals that OCD is now considered
Speaker 1: one of the most common psychiatric conditions, afflicting two to
Speaker 1: three percent of the general population. I did not know that.
Speaker 1: And because of the high demand for this episode, and
Speaker 1: because it's so close to my heart, surprise, we have
Speaker 1: a bonus episode coming out in a few days. We've
Speaker 1: been cooking up. It's all about lived experience. It's with
Speaker 1: a lovely neuroscientist, researcher, board certified mental health peer specialist,
Speaker 1: and mental health advocate UMA Chatterjy so Yes an extra
Speaker 1: episode this week. Enjoy. That's a great conversation. But for now,
Speaker 1: let's take a deep breath. Let's treat our brains to
Speaker 1: a feast of info on overt versus covert, perfectionism, obsessions
Speaker 1: versus compulsions, neurodivergence and OCD, pediatric illness induced OCD symptoms, ruminations, checking, counting, reassurance, seeking,
Speaker 1: a few famous folks who are helping break stigmas, medicines
Speaker 1: on the forefront some hopeful treatments in the future, finding
Speaker 1: a therapist, deep brain stimulation, genetic components overlap with trust syndrome,
Speaker 1: advice for loved ones, and the behavioral therapy that is
Speaker 1: the gold standard for OCD. With doctor, psychiatrist, researcher, advocate,
Speaker 1: and OCD neurobiologist, the doctor Wayne Goodman.
Speaker 4: I'm Wayne Goodman, he him. I'm a psychiatrist and I
Speaker 4: work at the Balacology of Medicine down in Houston, Texas.
Speaker 1: Really excited to talk to you. We've wanted to do
Speaker 1: this episode for literally years, and everyone we've talked to
Speaker 1: has said you are a perfect choice for this, so
Speaker 1: we're very excited to be speaking to you. Specifically, hundreds
Speaker 1: of papers last I saw on research Gate thirty six
Speaker 1: thousand citations to your work. I believe you started in
Speaker 1: the eighties.
Speaker 4: Yes, it's hard to believe. It was the nineteen eighty five,
Speaker 4: so forty years.
Speaker 1: Forty years. What got you started down this path?
Speaker 4: So I was at Yale doing my residency and starting
Speaker 4: a research fellowship, and I came across a patient with OCD,
Speaker 4: and it was the first patient I had seen with OCD,
Speaker 4: and started reading about it and I began to realize
Speaker 4: it wasn't that much known, particularly about the neurobiology or
Speaker 4: the treatment. So long story short, wound up launching the
Speaker 4: OCD program at Yale, and I've been focusing on OCD
Speaker 4: ever since.
Speaker 1: Was there something about this patient? Was it the level
Speaker 1: of suffering or the level of OCD that really hooked you?
Speaker 1: Were they particularly nice? Were they a patient you liked?
Speaker 4: Were he well, I like all my patients. But of
Speaker 4: course this patient had kind of a classic form of
Speaker 4: OCD involving contamination concerns and fear that if they didn't
Speaker 4: wash their hands carefully they would get somebody else sick,
Speaker 4: particularly somebody they loved. And they realized that whatever they
Speaker 4: were doing, whatever they were thinking about, was excessive. So
Speaker 4: that's what really struck me. You know, that this person
Speaker 4: was driven to the point that she used to have
Speaker 4: to use bleach on our hands. Her hands were red bleach,
Speaker 4: I mean it could be caustic because not only skin irritation,
Speaker 4: but actual damage. And she was consumed by these thoughts
Speaker 4: almost every hour the waking day. But yet again, she
Speaker 4: had complete insight into how absurd it was. And that's
Speaker 4: what struck me was that paradox between the irrationality of
Speaker 4: the thoughts, the excessiveness of the behaviors, and totally preserved
Speaker 4: insight and executive functioning.
Speaker 1: So this is a classic presentation of OCD and it's
Speaker 1: probably what people think of first because it's just easy
Speaker 1: to explain too. And according to the research, up to
Speaker 1: forty six percent of folks with OCD do deal with
Speaker 1: contamination fears, but the other fifty four percent, the majority,
Speaker 1: don't struggle with that. And at that time, were there
Speaker 1: scales to measure this? Was it something that was being
Speaker 1: treated with medicine? I know, the Yale Brown Obsessive Compulsive
Speaker 1: Scale is something that you pioneered, which among people who
Speaker 1: know OCD, they're like, WHOA that dud? Did the actual
Speaker 1: test OG? So the Yale Brown Obsessive Compulsive Scale, or
Speaker 1: y box as it's known, is a clinician administered ten
Speaker 1: items scale with each item rated from zero for no
Speaker 1: symptoms to four for extreme symptoms. So scores can run
Speaker 1: zero to forty. And it was developed in nineteen eighty
Speaker 1: nine by a Yale doctor and this OCD legend named
Speaker 1: Wayne Goodman, who we are talking to right now. What
Speaker 1: interventions are, what qualitative analysis was it back then.
Speaker 4: So at the time there were only case reports that
Speaker 4: one medication in particular was effective. It was a medication
Speaker 4: called clomipramine, which is still available, and it was one
Speaker 4: of the older medications with lots of side effects, and
Speaker 4: the case report suggested it was the only medication that
Speaker 4: seemed to work, and there was a theory that the
Speaker 4: reason it worked is because it had potent effects on
Speaker 4: the brain's serotonin system. Serotonin is one of the brain's
Speaker 4: neurotransmitters or neurochemicals, and my training at Yale really focused
Speaker 4: on trying to understand not only treatment but neurobiology. So
Speaker 4: that led me to want to test a newer generation
Speaker 4: of medications that were selective for their effects and serotonin.
Speaker 4: And then I looked around and back to your question
Speaker 4: about rating scales, there really weren't any gold standard scales.
Speaker 4: So I work with my colleagues on developing one.
Speaker 1: Is that something that a person can administer themselves or
Speaker 1: is that really something that you got to talk through
Speaker 1: with a doctor who can figure out, you know, very impacted,
Speaker 1: somewhat impacted. Can people self diagnosed OCDA? Yes?
Speaker 4: So the way the y box, that's the Yale Brown
Speaker 4: Obsessive Compulsive scale is administered, is it should be by
Speaker 4: a clinician who has experience in treating OCDA. There are
Speaker 4: forms of the scale that are self rated so that
Speaker 4: the patient fills them out, but really the diagnosis is
Speaker 4: left up to the clinician.
Speaker 1: We hear so often and I'm wondering how you feel
Speaker 1: about this when people say I'm so OCDA, Like I
Speaker 1: love to have all my pens in the same spot
Speaker 1: on my desk. People with OCD, from what I understand,
Speaker 1: hate that a lot.
Speaker 4: Yeah they do.
Speaker 1: Yeah, how do you feel as a professional and a
Speaker 1: clinician when you hear people say I'm so OCDA.
Speaker 4: Well, you know, I'm not judgmental. That's one of the
Speaker 4: good things that you need to be as a psychiatrist.
Speaker 4: But I do point out that that's not the same
Speaker 4: as OCD.
Speaker 1: Doctor Goodman says it's healthy and common to have certain
Speaker 1: preferences or routines.
Speaker 4: Sure, meaning being perfectionist, liking things orderly. Those are good,
Speaker 4: but it's not a disorder until it takes up a
Speaker 4: lot of time and by definition would be more than
Speaker 4: an hour a day. It would be distressing and for
Speaker 4: most of the patients. I treat and I focus on
Speaker 4: treatment resistant OCD. I focus on severe OCD. We're talking
Speaker 4: about patients that can't go sometimes fifteen minutes without having
Speaker 4: an intrusive thought or having to perform a compulsion.
Speaker 1: Well to find those in a moment, and our Surprise
Speaker 1: Owners episode out later this week with Uma goes into
Speaker 1: a ton of detail about lived experience.
Speaker 4: So that's very different from the people who are you know,
Speaker 4: have a little bit of OCD in them, like things
Speaker 4: orderly and are still able to work and lead a
Speaker 4: very productive life. People with very severe OCD can be incapacitated.
Speaker 4: Although many of my patients, despite their severe symptoms of
Speaker 4: figure out ways of still working around them, and a
Speaker 4: lot of patients. The other thing about patients with OCD
Speaker 4: is they're really good at camouflaging their symptoms.
Speaker 1: Now we'll get to kind of outward behavior versus inward,
Speaker 1: but you mentioned severe versus kind of high functioning or
Speaker 1: people who can function around it. Well, is it a
Speaker 1: spectrum like a lot of other conditions.
Speaker 4: Yeah. Yeah, So even on the Y box, the rating
Speaker 4: scale goes from zero to flority, and most patients that
Speaker 4: we treat in an outpaidation setting of first line treatments
Speaker 4: they discore around twenty, you know, like the midpoint, and
Speaker 4: those patients can continue to work, go to school, lead
Speaker 4: a very productive life. But the OCD is kind of
Speaker 4: annoying at them and interfering with their ability to be
Speaker 4: fully functional and fulfilling life.
Speaker 1: One thing that really surprised me about OCD is that
Speaker 1: it's not the same as an anxiety disorder. It's not
Speaker 1: underneath the umbrella of anxiety disorders. Is that correct?
Speaker 4: That's correct as of the DSM five, the Diagnostic Statistical Manual,
Speaker 4: fifth edition that came out in twenty thirteen. Before that,
Speaker 4: it was considered an anxiety disorder, and actually I'm not
Speaker 4: sure it was the right decision not to call it
Speaker 4: an anxiety disorder. It's now listed in this DSM five
Speaker 4: manual as in the obsessive, compulsive and related disorders. But
Speaker 4: anxiety is almost always a component of OCD.
Speaker 1: Does the anxiety tend to come from trying to control
Speaker 1: the OCD? Like people who have ADHD might have a
Speaker 1: lot of anxiety because executive function is difficult for them.
Speaker 1: Is the anxiety sometimes a byproduct?
Speaker 4: It comes in various forms, but OCD comes in various flavors.
Speaker 4: But all patients with OCD by definition have obsessions and compulsions,
Speaker 4: and the obsessions are the intrusive thoughts or images, and
Speaker 4: those by themselves are distressing kind of by definition, an
Speaker 4: obsession is something that is disturbing.
Speaker 1: More on these in a sec and in the bonus
Speaker 1: episode with uma. But these can again be the fear
Speaker 1: of getting sick and getting someone else sick, existential OCD
Speaker 1: about whether you really exist. There's a false memory OCD,
Speaker 1: perfectionism OCD relating to order and symmetry and counting that
Speaker 1: just feel off if incorrect. It's also harm OCD worrying
Speaker 1: that you might impulsively hurt yourself or others on accident
Speaker 1: or on purpose. And a very seldom discussed facet of
Speaker 1: OCD is pedophilia OCD. And this is a distressing worry
Speaker 1: that you will harm a child. But wait, there's more.
Speaker 1: There's moral scrupulosity, worrying about if you're a bad person
Speaker 1: who doesn't know it. There's checking OCD like with matters
Speaker 1: of safety like ovens or curling irons or locks, and
Speaker 1: there's reassurance seeking OCD. All of these obsessions can run
Speaker 1: like a ticker tape in your brain, and you would
Speaker 1: really like them to shut up. How do you do that? Compulsions?
Speaker 4: And then the compulsions are designed in a way to
Speaker 4: reduce the anxiety associated with that obsession. But sometimes the
Speaker 4: compulsions themselves can be so time consuming, so like the
Speaker 4: patient I mentioned before, you know, or even painful. I've
Speaker 4: had patients who took a shower so long that they
Speaker 4: ran out of hot water and they wound up taking
Speaker 4: the cold shower until they feel that they're clean enough.
Speaker 1: You mentioned your one of your first patients had contamination OCD,
Speaker 1: but I understand there's a lot of flavors. As you mentioned,
Speaker 1: there's pure OCD, there's moral scrupulosity, there's checking OCD numbers,
Speaker 1: there's reassurance seeking. So there's a lot of different ways
Speaker 1: that the obsessions and compulsions show up. Can you talk
Speaker 1: a little bit about pure OCD versus contamination versus moral.
Speaker 4: Well, yeah, so again going back to the Y box,
Speaker 4: we had this first part where we do the symptom checklist,
Speaker 4: and when I worked out that with my colleagues, we
Speaker 4: saw hundreds of patients together and came up with a
Speaker 4: list of different categories. So different categories of obsessions include contamination,
Speaker 4: but also, like you mentioned, scrupulosity is a big one.
Speaker 4: It could be about taboo thoughts about religion or sexuality,
Speaker 4: unwanted aggressive thoughts, you know, fear that you would be
Speaker 4: responsible for harming somebody or harming yourself even though you
Speaker 4: don't want to. And there's a whole bunch of miscellaneous
Speaker 4: ones that can occur as well.
Speaker 1: So in response to those thoughts.
Speaker 4: And the compulsions are generally designed. Again, design is probably
Speaker 4: not the right word, but they're functionally connected to the
Speaker 4: obsessions that try to reduce them, and they're not always
Speaker 4: in the form of something like washing or contamination that
Speaker 4: you can observe. They can be if say, somebody has
Speaker 4: an intrusive thought of something terrible happening to a loved one.
Speaker 4: They could recite something in their head, or they can
Speaker 4: review something in their head and you can't see that,
Speaker 4: but we would count that as a compulsion as well.
Speaker 1: And via the paper Prevalence and Clinical Characteristics of Mental
Speaker 1: Rituals and Longitudinal Clinical Sample of Obsessive Compulsive Disorder in
Speaker 1: the Journal Depression Anxiety, there are overt and physical, which
Speaker 1: you're probably more familiar with, but there are also covert
Speaker 1: or mental compulsions with no behavioral signs, and those types
Speaker 1: of compulsions include acts like silently repeating words or phrases,
Speaker 1: or praying or counting, or mental checking or thinking of
Speaker 1: good or safe thoughts to neutralize distressing mental images, among others. Now,
Speaker 1: that has to be a slim majority, right, that has
Speaker 1: the covert kind right. Nope. So this paper cites research
Speaker 1: suggesting that as many of sixty percent of OCD patients
Speaker 1: present without overt compulsions, meaning the majority of folks with
Speaker 1: OCD may just be struggling internally with mental compulsions, trying
Speaker 1: to undo the obsessive thoughts with other thoughts.
Speaker 4: Now you mentioned about pure obsessions. Yeah, there was a
Speaker 4: country star talking about did you see this about the
Speaker 4: pure ocday? Oh? Okay, Oh I want met the name,
Speaker 4: but you can look it up.
Speaker 1: Okay. It's Luke Comb's and he's been super public about it,
Speaker 1: and an article in NBC News reported that Combs hopes
Speaker 1: to use his platform to support others facing similar struggles,
Speaker 1: and in a recent interview with sixty Minutes Australia, Luke
Speaker 1: Combs explained his experience that it's thoughts essentially that you
Speaker 1: don't want to have, and then they cause you stress,
Speaker 1: and then you're stressed out, and then the stress causes
Speaker 1: you to have more of the thoughts, and then you
Speaker 1: don't understand why you're having them, and you're trying to
Speaker 1: get rid of them, but trying to get rid of
Speaker 1: them makes you have more of them. So what is
Speaker 1: pure O? Just obsessions?
Speaker 4: And said that he had the form of pure OCD.
Speaker 4: It's a controversial entity. Most of us in the field
Speaker 4: who have seen a lot of OCD can identify mental
Speaker 4: rituals that patients perform when they have their intrusive thoughts.
Speaker 4: So I don't think pure oc Well, pure O is
Speaker 4: actually that common. I think most patients who have really
Speaker 4: a real case of O and they may not perform
Speaker 4: overt rituals, but they're probably doing something mentally to try
Speaker 4: to ameliorate the anxiety associated with their thoughts or their images.
Speaker 1: Oh got it. So pure O is just the obsessions,
Speaker 1: is what they're saying without compulsion.
Speaker 4: Yes, it's just the obsessions. Yeah, and the vast majority
Speaker 4: of patients with OCD you have both.
Speaker 1: So Goodman is iffy on pure O because again, compulsions
Speaker 1: to stop the obsessions can be covert or mental and
Speaker 1: not outwardly behavioral. But usually yes, the ways that you
Speaker 1: try to stop the obsessions are compulsions. The O and
Speaker 1: the C are the buddy comedy that you never asked for.
Speaker 4: And they seem to be functionally connected.
Speaker 1: So is it possible that some people might not realize
Speaker 1: the compulsions that they're even doing, and they might just think, Oh,
Speaker 1: because I'm not doing something physical, then I don't have
Speaker 1: a compulsion, right.
Speaker 4: They might think they hit pure o, which they probably don't.
Speaker 1: Oh that's interesting, Okay, I wasn't sure about that.
Speaker 4: Yeah.
Speaker 1: Now, what are some of the more overlooked types of
Speaker 1: OCD that you feel like the general public doesn't know
Speaker 1: much about. I feel like the ones I hear about
Speaker 1: a lot are contamination and checking, making sure that the
Speaker 1: curling irons unplugged, that everything's stove is off, that the
Speaker 1: front door is locked. You have difficulty believing that you've
Speaker 1: done those things, and so you have to keep checking.
Speaker 1: But can you elaborate on some of the other, maybe
Speaker 1: more overlooked ones.
Speaker 4: Yeah, there's a category we sometimes refer as just se
Speaker 4: or just write OCD where people have to repeat something
Speaker 4: I have patient recently who was looking at the clock,
Speaker 4: and she really wasn't looking to see what time it was.
Speaker 4: She had superstitious concerns about she had to watch the
Speaker 4: second hand of the clock and see it hit twelve,
Speaker 4: because otherwise she had had this thought if she doesn't
Speaker 4: see the twelve, something bad is going to happen to her.
Speaker 4: And the other things that she would do could be
Speaker 4: really random. She could just repeatedly touch something or repeat
Speaker 4: something and you wouldn't notice it. And I would ask her,
Speaker 4: how do you know when it's done? How do you
Speaker 4: know when you've done enough of these performed enough of
Speaker 4: these compulsions, And she would say, and to it feels
Speaker 4: just right. So it's kind of the just right feeling,
Speaker 4: and people have a hard time articulating that, but that's
Speaker 4: a common form that's often overlooked and just full disclosure.
Speaker 1: I was diagnosed two years ago with OCD. Never realized
Speaker 1: that I had it. I don't have a super severe case,
Speaker 1: but I look back and I'm like, I had some
Speaker 1: stationary that I've had for twenty years, and I was like,
Speaker 1: if I use the last piece of the stationary, my
Speaker 1: dad will die. Things that I didn't tell anyone that
Speaker 1: I that I even thought because it sounded bonkers, but
Speaker 1: I was very afraid that if I use that something
Speaker 1: bad would happen. Or I have terrible procrastination problems. I'm
Speaker 1: really avoidant because I'm always afraid of making a mistake,
Speaker 1: and then it'll lead to my downfall. My career will
Speaker 1: be over if I make one mistake. And so there's
Speaker 1: there's like a certain kind of magical thinking.
Speaker 4: It feels like, yeah, that's a good category too. Yeah,
Speaker 4: magical thinking.
Speaker 1: This feeling that you can maybe control the outcome of
Speaker 1: bad things and avoid them if you do something concrete
Speaker 1: about it.
Speaker 4: Yeah, even though you know it doesn't make any.
Speaker 1: Sense, right, Yeah, it doesn't make any sense.
Speaker 4: But you don't want to take a chance, exactly because
Speaker 4: the stakes are too high. Stakes are high, and the
Speaker 4: OCD is telling you to do it.
Speaker 1: Oh yeah, or not to do it right exactly because
Speaker 1: if it landed on you, you can never forgive yourself.
Speaker 1: But I feel like, you know, when you mentioned the
Speaker 1: contamination OCD with one of your first patients, worried about
Speaker 1: she would hurt someone else. It feels like the avoidance
Speaker 1: of a bad outcome can fuel a lot of obsessions
Speaker 1: and compulsions. Do you find that with a lot of
Speaker 1: your patients.
Speaker 4: Yeah, I think that's a universal. So again, we talked
Speaker 4: about all the kind of different forms of flavors of OCD,
Speaker 4: but I think most of them have in common that
Speaker 4: patients with OCD are harm avoidant. They're worried about some outcome.
Speaker 4: That outcome, you know, could be something happening to themselves
Speaker 4: or their loved ones, you know, failing at work, you know,
Speaker 4: or having their career go up in smoke. And we've
Speaker 4: talked about scrupulosity. It maybe something that's most dear to
Speaker 4: that particular person is the thing that they're going to
Speaker 4: worry about most.
Speaker 1: That makes sense. And what about onset? When do you
Speaker 1: tend to see OCD become apparent enough? Because I'm sure
Speaker 1: a lot of people might have this as kids. I mean,
Speaker 1: don't step on a crack, You'll break your brother's back.
Speaker 4: I was going to mention that one. Yeah, that's that's
Speaker 4: the classic magical thinking one, but you actually do see it.
Speaker 1: Just a side note, this superstition has folkloric origins and
Speaker 1: it was a common and racist rhyme originally, and about
Speaker 1: five percent of adults still avoid cracks in the sidewalk.
Speaker 1: So let's just retire this one forever. Okay, good love that.
Speaker 1: I wonder how much that particular rhyme is responsible. Yeah,
Speaker 1: but what do you think the onset might typically be?
Speaker 4: So about half the cases of OCD have onset in childhood,
Speaker 4: and then there's another large group in early adulthood. So
Speaker 4: I actually I see a lot of people who first
Speaker 4: have onset of OCD after they go off to college.
Speaker 4: Oh so around that age range. It's unusual to see
Speaker 4: onset after age thirty five.
Speaker 1: Okay. Have you seen more people seeking treatment after the
Speaker 1: COVID pandemic hit with especially with contamination?
Speaker 4: You know, it's funny I should know the answers to that.
Speaker 4: In fact, I was on a paper that looked at it.
Speaker 4: I don't think it's had a huge impact. It just
Speaker 4: made it a little bit more confusing. For example, so
Speaker 4: I had a patient who I was treating with very
Speaker 4: severe OCD during the pandemic, and he used to wear
Speaker 4: three layers of gloves and a mask, and once the
Speaker 4: COVID struck, he didn't stand out anymore.
Speaker 5: Ah.
Speaker 4: He Actually he thought that was really really helpful in
Speaker 4: a way that it kind of normalized his appearance. Yeah,
Speaker 4: but I don't think so. It may have had a
Speaker 4: temporary impact, guess. I mean we were all concerned, but
Speaker 4: I don't think it really caused that many new cases
Speaker 4: of OCD.
Speaker 1: And for more on this you can see the twenty
Speaker 1: twenty three paper doctor Goodman co authored titled COVID nineteen
Speaker 1: Related Intrusive Thoughts and Associated Ritualistic Behaviors, which looked at
Speaker 1: a new thing you could have called CRB or COVID
Speaker 1: nineteen related Intrusive Thoughts and Associated Ritualistic Behaviors. But the study, however,
Speaker 1: concluded that while it's helpful and even critical for providers
Speaker 1: to see and take into account COVID related distress, it's
Speaker 1: likely a Chicken or the X situation. That is, if
Speaker 1: you only noticed obsessive compulsive traits after the COVID pandemic hit,
Speaker 1: chances are you already had a little bit of OCD
Speaker 1: before then. Also, there is a very baseline preoccupation with
Speaker 1: germs that came out of this. The September twenty twenty
Speaker 1: study COVID nineteen and OCD Potential Impact of Exposure and
Speaker 1: Response Prevention Therapy acknowledges right up top that the TSARS
Speaker 1: COVID two coronavirus disease nineteen pandemic is the greatest international
Speaker 1: health crisis in our modern era. So if you've been
Speaker 1: on edge about microbes, just about COVID, that's just kind
Speaker 1: of normal. This is a novel virus killing millions of people,
Speaker 1: And to this day, half of reported COVID deaths in
Speaker 1: the world are in the United States. The US has
Speaker 1: half the deaths, and because of truly unhinged politics, half
Speaker 1: the country won't wear masks or take a vaccine. So
Speaker 1: what the fuck? But yeah, there are rational precautions in
Speaker 1: a pandemic, and then there are OCD behaviors that prevent
Speaker 1: you from daily functioning And reading through doctor Goodman's list
Speaker 1: of published papers, so many of them, it's astonishing. I'm
Speaker 1: going to be real with you, I started crying. And
Speaker 1: how much work he's done in your research, which again
Speaker 1: you've done so much research neurochemistry versus neurobiology. You mentioned serotonin,
Speaker 1: You mentioned SSRIs as a treatment line or SNRIs have.
Speaker 4: We you know your stuff, by the way, Unite didn't
Speaker 4: really do.
Speaker 1: It's because I'm on one of them.
Speaker 5: I have.
Speaker 1: I've got put on lamicdall actually after I was diagnosed
Speaker 1: and it's been so I have questions about glutamate of
Speaker 1: course too. So limotogen brand named Lamikdahl was developed for
Speaker 1: the treatment of certain types of epilepsy because it slows
Speaker 1: bursts of electrical activity that could cause seizures. But some
Speaker 1: psychiatrists prescribe limotogene off label or depression associated with bipolar
Speaker 1: and also for things like fibromyalgia, certain types of migraines,
Speaker 1: panic disorder, binge eating disorder, and yep OCD. So the
Speaker 1: twenty fifteen paper Role of loamotrogen Augmentation and Treatment Resistant
Speaker 1: Obsessive Compulsive Disorder a Retrospective Case Review notes that genetic,
Speaker 1: behavioral and neuroimaging studies have shown evidence of abnormally high
Speaker 1: glutamaturgic concentrations in certain parts of the brains of people
Speaker 1: with OCD, and adds that resistance to pharmacotherapy is one
Speaker 1: of the major challenges in the management of OCD, but
Speaker 1: one avenue for that is glutamaturgic modulators like lamotrogen. So
Speaker 1: we're going to link a few other papers on our site,
Speaker 1: but just something to explore maybe with your doctor. And
Speaker 1: also because limotrogen can cause some severe allergic reactions in
Speaker 1: some people, and it needs to be closely monitored. It
Speaker 1: can also affect your white blood cell count. So talk
Speaker 1: to an actual doctor because I'm not one, and Doctor
Speaker 1: Goodman cannot treat or die ignows you from a podcast,
Speaker 1: nor can you take a transcript of this podcast to
Speaker 1: your pharmacist. But yeah, neurochemistry versus neurobiology is it a
Speaker 1: combination of both.
Speaker 4: So got through my own career, which we already established
Speaker 4: has gone on for a long time. The first half
Speaker 4: was more neurochemistry neurobiology, looking, for example, the role of serotonin,
Speaker 4: and I published a lot of negative studies looking to
Speaker 4: try to identify an abnormality in the brain the serotonin system,
Speaker 4: and that's proved elusive, not only for me, but for
Speaker 4: the whole field. And you mentioned glutamate. That's another neurotransmitter
Speaker 4: that's been implicated in OCD, and there's some interesting work
Speaker 4: on that and some medications that are being tried. But
Speaker 4: at some point I pivoted more to looking at OCD
Speaker 4: as a brain circuit disorder instead of a neurochemical disorder.
Speaker 4: Not that serotonin clearly plays a role in treatment, but
Speaker 4: it's not clear it plays a in the origins or
Speaker 4: pathophysiology of the illness. So I started getting involved more
Speaker 4: and looking at the brain circuits that mediate the symptoms
Speaker 4: of OCD.
Speaker 1: So he's been in the game so long, he's gone
Speaker 1: deeper into the actual brain, and even in twenty twelve
Speaker 1: published the study Deep Brain Stimulation for Intractable Psychiatric Disorders,
Speaker 1: exploring treatments for patients who had exhausted other avenues. And
Speaker 1: by helping these cases, he's also pioneering new understanding in
Speaker 1: the process, and.
Speaker 4: That's led me to different treatments, more neuromodulation, medical devices
Speaker 4: instead of drugs, not that there's still a role for drugs,
Speaker 4: and there's definitely The other thing we haven't touched on
Speaker 4: we need to is the role of behavior therapy. If
Speaker 4: I don't do that, my psychologist colleagues will be very
Speaker 4: upset with me.
Speaker 1: Damn right, Okay, So behavioral therapy, the right kind is huge.
Speaker 1: We're going to get into that, especially the gold standard,
Speaker 1: which is exposure response prevention or ERP therapy. And just
Speaker 1: a little bit, but I do. I want to give
Speaker 1: you some broad strokes of the neurobiology and the medication
Speaker 1: options for OCD. So let's start with SSRIs. SSRI. It
Speaker 1: stands for selective serotonin reuptake inhibitors, because these medications target
Speaker 1: serotonin and they prevent it from getting sucked back up
Speaker 1: into the brain cells, so there's more serotonin that stays
Speaker 1: floating between the nerve cells to relay messages between them.
Speaker 1: And there are a ton of other SSRIs on the
Speaker 1: market as well that go buy a lot of different names.
Speaker 1: Now SNRIs, they're not as selective as SNRI stands for
Speaker 1: serotonin and nor epinephrine reuptake inhibitors, and they work to
Speaker 1: keep more of both of those neurotransmitters between the cells,
Speaker 1: so SNRIs can have fewer side effects and some people
Speaker 1: than SSRIs do and SNRIs are sometimes prescribed for anxiety
Speaker 1: and nerve pain. And limiicdol or Lamotrogene is neither an
Speaker 1: SSRI or an SNRI. It's what's called a phenel triazine
Speaker 1: drug and it's used to prevent seizures in types of epilepsy.
Speaker 1: It's also used as a mood stabilizer, which can help
Speaker 1: with bipolar depression, and it's been shown to modulate those
Speaker 1: glutamate levels in the brain. We have a whole episode
Speaker 1: on neurotransmitters. It's called molecular neurobiology with doctor Brain aka
Speaker 1: doctor Crystal Delworth, which will link in the show notes.
Speaker 1: But let's put that skull juice to work to learn
Speaker 1: more about itself. Would you say that the majority of
Speaker 1: cases can be helped with medication or is it really
Speaker 1: a crapshoot?
Speaker 4: Depends who you ask, Okay, but you're asking me, so
Speaker 4: I would say, you know, it's really a lot up
Speaker 4: to the patient. I mean, if I'm seeing a patient
Speaker 4: who say I'm first diagnosing them with OCDA and they
Speaker 4: have moderate OCD not severe OCDA, well a moderate is
Speaker 4: through not great, I mean still can be quite distressing
Speaker 4: and empairing. I would outline, you know, you have two options.
Speaker 4: You can do the cognitive behavioral therapy, you can do
Speaker 4: the medications, and I'll give the pros and cons. A
Speaker 4: lot of patients will do well with one or the other,
Speaker 4: and sometimes you wind up doing a combination of both.
Speaker 1: Do SNRIs because they work in Europe and effort? Do
Speaker 1: those tend to help with the anxiety that can be
Speaker 1: a result of OCD.
Speaker 4: That's a good theory. I like that theory, but if
Speaker 4: you really want to be hardcore, and you look at
Speaker 4: randomized control trials and peer review publications, the only medications
Speaker 4: that have been shown effective or the SSRIs. The snri's
Speaker 4: based upon clinical experience are also effective, and perhaps the
Speaker 4: neurogenergic effects have some additional benefit, like you said, for anxiety.
Speaker 4: But I'm not totally convinced. Okay, but I'm even skeptical
Speaker 4: of my own work. You know, again, I've over the years,
Speaker 4: I've tried different medications in our patients, maybe even published
Speaker 4: a paper case report showing that it worked. But until
Speaker 4: you subjected to the rigor of a randomized control trial.
Speaker 4: And but I mean that, you know, a blinded study
Speaker 4: where you randomize patients to either the drug or the placebo,
Speaker 4: you don't really know the answer.
Speaker 1: Yeah, And you mentioned that your work involves people who
Speaker 1: have not been helped by what's typically administered. You do
Speaker 1: deep brain stimulation. Can you explain what that is?
Speaker 4: I work with brain surgeons, So the last twenty years,
Speaker 4: I've been working with neurosurgeons, and they you do the
Speaker 4: deep brain stimulation or DBS, and that's mostly a treatment
Speaker 4: for movement disorders, like treatment resistant Parkinson's disorder. But we've
Speaker 4: done studies together showing that it can be very effective
Speaker 4: in patients with treatment resistant severe OCDA.
Speaker 1: What is happening there? What are you stimulating? I picture
Speaker 1: there being this OCD rope that you just go in
Speaker 1: and cauterize, but I don't think that's how that works.
Speaker 1: What happens.
Speaker 4: It's a very complicated story and a very controversial one.
Speaker 4: There's been so called psychosurgery. I hate that term because
Speaker 4: it's brain surgery. It's not you know, nobody's operating on
Speaker 4: your psyche. They're operating on your brain. But before the
Speaker 4: introduction of deep brain stimulation, some surgeons at different centers,
Speaker 4: both in the US and the UK, we're doing what's
Speaker 4: called the blade of surgery. A blade of means actually
Speaker 4: making allsion a small hole. And the theory behind that
Speaker 4: is that there's this circuit, so let's identify those connections
Speaker 4: between those two areas, between the obsessions and the compulsions,
Speaker 4: and cut those connections and create allegiance. So that was
Speaker 4: the hypothesis, and there have been many case reports and
Speaker 4: case series showing that some of those patients with severe
Speaker 4: OCD did very well with very few side effects, not
Speaker 4: like the lobotomy era. You know, that's a totally different
Speaker 4: kind of procedure. So that led to the theory that
Speaker 4: you could use deep brain stimulation, which is not causing illsion,
Speaker 4: but it's stimulating an area of the brain at a
Speaker 4: high frequency that still interrupts those pathways. So the idea
Speaker 4: is still behind DBS is somehow it's interrupting the OCD circuit,
Speaker 4: this reverberating loot that's self reinforcing between obsessions and compulsions,
Speaker 4: because that's part of the problem and the basis of
Speaker 4: the exposure response prevention is the more a person performs
Speaker 4: the compulsions, and the more effective those compulsions are in
Speaker 4: reducing the angst associated with the obsessions, the more that's
Speaker 4: going to become habitual.
Speaker 1: Now is that kind of helpful in determining how genetic
Speaker 1: it is if you're looking at brain anatomy or I
Speaker 1: should just ask it straight up, but like how much
Speaker 1: of this is genetic?
Speaker 4: Yea, there's definitely a fair contribution of genetics. It's not simple. Yeah,
Speaker 4: it's not simple medellion genetics where it seems to be
Speaker 4: more genetic or in those patients that have both OCD
Speaker 4: and Tourette syndrome, Oh right, that seems to be a
Speaker 4: stronger genetic connection.
Speaker 1: And the twenty fourteen paper Touret Syndrome and Obsessive Compulsive
Speaker 1: disorder Compulsivity along the Continuum in the Journal of Obsessive
Speaker 1: Compulsive and Related Disorders recaps some previous research that revealed
Speaker 1: that genetic family studies have shown higher rates of OCD
Speaker 1: symptoms or OCD in relatives of individuals with Turet syndrome,
Speaker 1: and also research has shown higher rates of TICS or
Speaker 1: Turet syndrome in first degree relatives of patients with OCD,
Speaker 1: and the proportion of individuals with Thret syndrome who also
Speaker 1: have OCD is up to sixty three percent, rather than
Speaker 1: the general population rate of two to three percent. This
Speaker 1: study notes that, however, despite the significant genetic overlap between
Speaker 1: these disorders, Turet syndrome and OCD do have distinct genetic architectures,
Speaker 1: and deep brain stimulation has been used to treat conditions
Speaker 1: like Turet syndrome, Parkinson's disease, es central tremor epilepsy, and
Speaker 1: of course, the reason that we are all here obsessive
Speaker 1: compulsive disorder. I'm sorry, how though, does that work?
Speaker 4: Going back to your question, though about to how the
Speaker 4: DBS works. Yeah, I honestly don't. It's an area that
Speaker 4: we're studying. But where it's implanted in the brain is
Speaker 4: the reward circuitry, so the immediate effects. So I do
Speaker 4: the programming of the device, the surgeon does the implantation,
Speaker 4: and then after the recard from the surgery, which is
Speaker 4: just overnight a week later, I can interrogate the device.
Speaker 4: I can stimulate that area of the brain, and that
Speaker 4: area of the brain is part of the reward circuitry,
Speaker 4: and some of the immediate effects when I turn on
Speaker 4: the stimulation are the person feels happier, they feel more
Speaker 4: energetic and less anxious, and over time that leads to
Speaker 4: reduction in OCDA.
Speaker 1: How bad off do you have to be for? How
Speaker 1: long before you get bumped up to the Goodman level treatment?
Speaker 6: Yeah?
Speaker 4: Yeah, it's not just me the only one, but there aren't.
Speaker 4: It's not that many of us either. But you have
Speaker 4: to have OCD for at least five years. Has to
Speaker 4: be an adult. We won't do it in a kid.
Speaker 4: A child, and it's got to be a y box
Speaker 4: in the severe to extreme range, and they have to
Speaker 4: have had multiple medication trials and failed ERP exposure response prevention.
Speaker 1: Why does ERP work?
Speaker 4: And Ken, let me say, ERP is not my specialty.
Speaker 4: My psychologists colleagues are a specialist in that. But it
Speaker 4: breaks this cycle. And we've talked a little bit about
Speaker 4: OCD is kind of self reinforcing, and the idea is
Speaker 4: with the surgical ideas, you interrupt that, and I think
Speaker 4: with ERP you try to interrupt that too.
Speaker 1: So cognitive behavior therapy is a type of brain retraining
Speaker 1: and it comes in a lot of forms. One of
Speaker 1: those is ERP or exposure response prevention, which involves exposing
Speaker 1: yourself to the thoughts and confronting them and then the
Speaker 1: prevention or making a choice not to do a compulsive
Speaker 1: behavior wants the the anxiety or obsessions have been triggered.
Speaker 1: They say, so you're like, oh, okay, so just like
Speaker 1: don't do the thing, okay, cool, thanks, I promise. It's
Speaker 1: not that simple, of course, and working with a therapist
Speaker 1: trained an ERP, they'll help come up with a plan
Speaker 1: to take small steps to retrain your brain. And according
Speaker 1: to the International OCD Foundation, yes it's scary at first,
Speaker 1: and that's the point, but when you do ERP correctly,
Speaker 1: the following things happen, they say, you will feel an
Speaker 1: initial increase, an anxiety, uncertainty, and obsessional thoughts. You will
Speaker 1: find that these feelings and thoughts are distressing, but also
Speaker 1: that they can't hurt you. They're safe and manageable. When
Speaker 1: you stop fighting the obsessions and the anxiety, these feelings
Speaker 1: will eventually begin to subside. And this natural drop and
Speaker 1: anxiety that happens when you stay exposed and you prevent
Speaker 1: the compulsive response is called habituation. So just staying in
Speaker 1: it and confronting the fact that you're having these obsessive
Speaker 1: thoughts without doing the compulsive response, you get used to that.
Speaker 1: So you'll find that your fears are less likely to
Speaker 1: come true than you thought, and then you'll get better
Speaker 1: at managing everyday levels of risk and uncertainty. So doctor
Speaker 1: Goodman explains the clinician's role.
Speaker 4: What happens to people would have an obsession is they
Speaker 4: try to perform a compulsion to reduce the anxiety. So
Speaker 4: what you want to teach them in a behavior therapy
Speaker 4: session is, don't perform your compulsion. Let's just wait and
Speaker 4: tell me how how much distress you're feeling, maybe on
Speaker 4: a scale to one to ten. Maybe it starts off
Speaker 4: as an eight, but forty minutes later, even without performing compulsion,
Speaker 4: is maybe down to a four, and you didn't have
Speaker 4: to perform a compulsion. So you begin to teach the
Speaker 4: person over time that they shouldn't try to avoid the obsessions.
Speaker 4: They actually should try to let them come. So often
Speaker 4: a metaphor is like, don't fight the waves, ride those waves.
Speaker 4: The more you try to react to the OCD, the
Speaker 4: more it's going to take a grip on your life.
Speaker 1: And we've talked about the compulsions and what those look like,
Speaker 1: but can you describe how your patients describe the obsessions?
Speaker 1: How do other people describe them?
Speaker 4: It really varies, but it's definitely intrusive. It's always disturbing,
Speaker 4: and we may not have emphasized this enough. When we
Speaker 4: talk about obsessions and OCD, we're talking about thoughts, images,
Speaker 4: or unwanted impulses that are disturbing, and on the other
Speaker 4: side of the coin, with compulsions, they're never pleasurable. So
Speaker 4: we use the word compulsion very loosely, sometimes like compulsive eating,
Speaker 4: compulsive gambling, compulsive sexual activity. Now, even though all those
Speaker 4: could be problematic activities, especially like the gambling gets you
Speaker 4: in a lot of trouble, or some of the drug
Speaker 4: use can get you to some trouble. We may use
Speaker 4: the word compulsive, but we wouldn't say that that has
Speaker 4: any connection to OCD. At least at some point the
Speaker 4: gambling was pleasurable. You got some gratification from certainly when
Speaker 4: you want. In OCD, the compulsions are never gratifying. They
Speaker 4: may reduce tension, they may reduce the anxiety associated with
Speaker 4: the intrusive thoughts, but in and of themselves they're not
Speaker 4: inherently gratifying.
Speaker 1: So not like other compulsions. I'm like a less cool compulsion.
Speaker 1: And doctor Goodman says that one consistent issue that OCD
Speaker 1: sufferers have, no matter what the flavor is harm avoidance.
Speaker 1: Harm to yourself and others becomes so terrifying that the
Speaker 1: brain puts too much energy in trying to avoid it,
Speaker 1: ultimately doing a harm to you and your life. And
Speaker 1: I want to talk a little bit about comorbidities. And
Speaker 1: we have questions from listeners who have they know what
Speaker 1: you're coming on, and so they've submitted them ahead of time.
Speaker 1: We also donate to a cause of your choice of
Speaker 1: related cause, and I know there's an OCD walt coming
Speaker 1: IOCDF Oh okay, great, perfect. We will donate to them
Speaker 1: and shout them out and put a link for people
Speaker 1: IOCDF no hesitation. I love that the International OCD Foundation
Speaker 1: is a highly respected and core source for so much
Speaker 1: support and info for folks who have OCD or know
Speaker 1: someone who does. Their vision is that everyone impacted by
Speaker 1: OCD and related disorders has immediate access to effective treatment
Speaker 1: and support. And they provide up to date education and resources,
Speaker 1: quality professional training, and they advance groundbreaking research and as
Speaker 1: a leading nonprofit in the space. IOCDF has been around
Speaker 1: since nineteen eighty six. It was co founded by a
Speaker 1: guy named doctor Wayne Goodman. You may have heard of him. Also,
Speaker 1: he asked that his honorarium for this show also be
Speaker 1: donated to IOCDF dot org. So thank you to sponsors
Speaker 1: of the show for making that double donation possible. Get value.
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Speaker 1: So let's get in the mail bag of questions left
Speaker 1: at patroon dot com sash ologies, where for one hot
Speaker 1: dollar a month you can leave questions for the ologists
Speaker 1: before we record. So a lot of you, Megan Walker,
Speaker 1: are j Deutsche, Anonymous, Anastasia Press, Sarah Rose, Andy Pepper,
Speaker 1: Kyra Black, Sarah Cork Henderson. First time question askers Jessica
Speaker 1: Arrand and Benjamin Whiteley and Annie Eggelhoff asked well, Annie
Speaker 1: put it this way, asking Hi, I am autistic and
Speaker 1: have ADHD, OCD and dyslexia. Choosing the worst mental combo
Speaker 1: meal ever has me wondering why it's so common to
Speaker 1: have clusters of comorbidities like this as opposed to just
Speaker 1: one of these disorders. Okay, a lot of people had
Speaker 1: questions about co morbidities. Jessica Aaron said, as others are
Speaker 1: asking what disorders are commonly comorbid with OCD, Anton also
Speaker 1: asked how common is it for someone to just have OCD?
Speaker 1: And also are there a lot of misdiagnoses while people
Speaker 1: are trying to figure out what's going on?
Speaker 4: Yeah, that happens a lot. The most common comorbidity is depression. Yeah, bomber,
Speaker 4: particularly the more severe, the more treatment resistant, the longer
Speaker 4: it's lasted. It's very common for patients to present with depression.
Speaker 4: And that's what you know, I teach our residents our
Speaker 4: Traineese is if you have a patient that's presenting with
Speaker 4: either anxiety of course too as part of the syndrome
Speaker 4: presenting with depression, it really behooves you to ask questions.
Speaker 4: You know, do you have any behaviors that you feel
Speaker 4: you have to perform over and over or any rituals
Speaker 4: that you have to perform in order to reduce your anxiety?
Speaker 4: Because again, one things I mentioned earlier is patients with
Speaker 4: OCD by definition, have insight into the absurdity of their
Speaker 4: thoughts and excessiveness of their behaviors. I'll tell you one example,
Speaker 4: a patient of mine many years ago who came to
Speaker 4: me was a software engineer, a very logical guy. And
Speaker 4: he said, Doc, you're going to think I'm crazy. I've
Speaker 4: never told this to anybody, but and this goes back
Speaker 4: a few years. That's when you used to go to
Speaker 4: the mailbox and mail a letter. And he said, I
Speaker 4: can't mail a letter without wondering if my five year
Speaker 4: old daughter is inside. And I said, Doc, you're going
Speaker 4: to want to lock me up because I know you
Speaker 4: can't put a five year old in the door. But
Speaker 4: unless I check before I mail it, I worry something's
Speaker 4: going to happen to her. So it was kind of
Speaker 4: a metaphor for something happening to her. So it reached
Speaker 4: the point where it became very physical that he would
Speaker 4: have to look inside an envelope, he would have to
Speaker 4: look at billboards that make sure she wasn't in the billboard.
Speaker 4: And he actually did very well with treatment. But he
Speaker 4: was completely logical, kept this as a secret from his family,
Speaker 4: including his daughter.
Speaker 1: And I've read of other people who are so afraid
Speaker 1: that they hit someone on the road and didn't realize
Speaker 1: it that have to drive back and check several times.
Speaker 1: And it's interesting that harm avoidance is something that is
Speaker 1: so common with so many patients of it, And again
Speaker 1: we mentioned that the majority of compulsions can be covert
Speaker 1: and not related to any outward behavior or rituals. But
Speaker 1: what's the difference between strong preferences and compulsions? Patrons Jennifer
Speaker 1: Lemon Think, Alicia Henning, Amelia Phillips, Valerie Kirby, d Austin Broadwater,
Speaker 1: Mackenzie King, all of them asked, in the words of
Speaker 1: s first time question asker, how do you disentangle OCD
Speaker 1: from autism? Are they frequently comorbid when it comes to
Speaker 1: rituals and things like that? Do you see folks who
Speaker 1: are autistic who have trouble maybe understanding if it's OCD
Speaker 1: versus if it's just like a rigidity that's comfort.
Speaker 4: It's a great question, and it comes up a lot
Speaker 4: because if you have somebody with autism who may have
Speaker 4: some limited communication skills, they may have trouble explaining the obsessions,
Speaker 4: so you have to infer them. So if they're doing
Speaker 4: ritualized hand washing, or they're doing repeating getting in and
Speaker 4: out of a chair, you can probably infer that they
Speaker 4: have obsessions, even if you can't really identify them, and
Speaker 4: you wind up treating them in the same way as
Speaker 4: you would for OCD.
Speaker 1: And how about for people who are verbal and aware
Speaker 1: of their own rituals. Is there ever an overlap that
Speaker 1: gets misdiagnosed where people maybe don't realize they have OCD
Speaker 1: or don't realize that they have autism like eating the
Speaker 1: same meal, essay, or sitting in the same spot.
Speaker 4: It's somebody who's very ritualized. Yeah, yeah, that isn't necessarily OCD.
Speaker 4: The other thing I would say is, although you can
Speaker 4: have a monosymptomatic picture, meaning you know that maybe just
Speaker 4: one type of OCD, most patients with OCD check off
Speaker 4: different boxes. Sometimes when I'm not sure myself, I have
Speaker 4: more confidence in the diagnosis when I find that over
Speaker 4: time some of their obsessions and compulsions have changed and
Speaker 4: that they check off different ones.
Speaker 1: What about executive function and perfectionism or avoidance, things like
Speaker 1: that people who might have trouble Yeah, like for example,
Speaker 1: me getting set into worker work avoidance patrons Matt secafiin Crux,
Speaker 1: chimber Issa a perfectionist but not OCD Haver and Alex
Speaker 1: Rose first time question asker who asked, quite simply, why
Speaker 1: is perfection OCD such a bitch, Where is the line
Speaker 1: between perfectionism and OCD.
Speaker 4: There is another condition, obsessive compulsive personality disorder that sometimes
Speaker 4: it's hard to distinguish that from OCD, but that diagnosis
Speaker 4: implies more perfectionism and insistence that others kind of follow rules,
Speaker 4: and generally speaking, people with OCPD don't have a lot
Speaker 4: of insight. Generally, what I've found is that it's their
Speaker 4: family members who say, you really need to see somebody
Speaker 4: because you're driving me crazy with wanting to do things
Speaker 4: in your way all the time or in a certain
Speaker 4: way all the time. So there is some connection, but
Speaker 4: I think they're distinct most of the time.
Speaker 1: And other experts note that the core difference lies in
Speaker 1: the motivation behind perfectionist tendencies is that a high standard
Speaker 1: is there a certain goal in mind. OCD related perfectionism, however,
Speaker 1: may come from a place of extreme anxiety, catastrophizing, self criticism,
Speaker 1: and doubt. So one compulsion is avoidance, and a nineteen
Speaker 1: eighty four study titled Procrastination Tendencies among obsessive compulsives and
Speaker 1: their relatives did find a correlation between OCD and task avoidance.
Speaker 1: The author of that study is World renowned procrastination expert
Speaker 1: doctor Joseph Ferrari, and if you're like, you should do
Speaker 1: it izon with him, I did volitional psychology.
Speaker 5: We did it.
Speaker 1: It's linked in the show notes. His big advice is like,
Speaker 1: just do the thing. He even signed my copy of
Speaker 1: his book Still Procrastinating, the No Regrets Guide to Getting
Speaker 1: It done, with the scrawl just do it now all caps.
Speaker 1: At the time I was like, Joe, I can't, so
Speaker 1: fuck me, I guess, And then I learned much later
Speaker 1: that just do it now was just a little brusque
Speaker 1: and a less gentle type of exposure response prevention. Essentially,
Speaker 1: so until you stop procrastinating, you will not realize that
Speaker 1: procrastinating and compulsive avoidance is worse than the thing you're
Speaker 1: afraid to do poorly. And because of a therapist who
Speaker 1: understood ERP, I have since adopted two phrases which are
Speaker 1: essentially like bite sized takeaways that have helped me more
Speaker 1: than anything else to tackle my decades long plague of
Speaker 1: putting off the highest stakes tasks and avoiding them. So
Speaker 1: I used to know myself as a last minute person
Speaker 1: that was just like my vibe now when I see
Speaker 1: an email or a form or a thing I have
Speaker 1: to write, and I avoid it because what if I
Speaker 1: do it wrong? I tell myself, I'm a person who
Speaker 1: does things at the first minute, so that when a
Speaker 1: task or email or decision or a draft of something
Speaker 1: comes up, I decide or I started that first minute
Speaker 1: or that first day, do not let it grow mold.
Speaker 1: So I just say I'm a person who does things
Speaker 1: at the first minute, to have me just jump right
Speaker 1: into something. The other thing that exposure response prevention has
Speaker 1: taught me to say to myself all the time is
Speaker 1: worst things first, So what do you dread the most?
Speaker 1: Do it first? If you don't want to do it, well,
Speaker 1: it's therapy to get it done. And after a while
Speaker 1: you say, wow, Okay, I did a bunch of things
Speaker 1: I would have otherwise avoid. They did not kill me,
Speaker 1: and I did not do such a bad job that
Speaker 1: my whole life collapsed. So look, I made this episode,
Speaker 1: and so far I have not died or killed anyone
Speaker 1: in the process. Hooray. Now, speaking of putting some thoughts
Speaker 1: into our little meatball brains, what about the thoughts that
Speaker 1: we don't want around, the ones that barge into our
Speaker 1: lives like a dinosaur made out of a grizzly bear
Speaker 1: doing jazz hands through the wall like the Kool Aid Man.
Speaker 1: Well patron Audrey Keen wrote, can you ask about intrusive
Speaker 1: thoughts in OCD? I really do not want to drive
Speaker 1: my car into a tree or touch a hot stove,
Speaker 1: but in difficult times, my brain has yelled at me
Speaker 1: to do such things. Honestly relatable and patrons love to learn.
Speaker 1: Forty six Nicole Campbell, Ruby, Gordon Moss, Emily Staffer, and
Speaker 1: Nasty garden Rat's friend wanted to know about these kind
Speaker 1: of rude intrusions. Liliana, first time Questionascer wrote, sorry for
Speaker 1: a rather intense question. I know many people with OCD
Speaker 1: experience intrusive thoughts, and some, like my friend, have especially
Speaker 1: distressing ones, such as pedophilic intrusive thoughts, or fears of
Speaker 1: cheating or other scary and taboo topics. Could you speak
Speaker 1: about why OCD often involves such intrusive thoughts, what causes them,
Speaker 1: whether they're dangerous, and how people can manage them. We
Speaker 1: mentioned intrusive thoughts, and sometimes all thoughts feel intrusive, but
Speaker 1: can you explain exactly what an intrusive thought feels like
Speaker 1: or when you know that thought is unwanted. Why you
Speaker 1: can't just kind of swat it away.
Speaker 4: Well, I can just go by what my patients tell me.
Speaker 1: Yeah, and the other thing.
Speaker 4: As long as you're on that point. There are patients
Speaker 4: with psychotic conditions like schizophrenia may hear voices, right, They
Speaker 4: may have auditory hallucinations, so they may hear a voice
Speaker 4: that tells them something or tells them to do something.
Speaker 4: One of the distinctions we make when we're making the
Speaker 4: diagnosis of OCD. I'll ask the patient, well, it feels
Speaker 4: like there's a voice in your head. Is that from
Speaker 4: your own brain or you're actually hearing a voice? And
Speaker 4: if they have OCD, it's oh no, no, I know
Speaker 4: it's my brain, but it's like part of me is
Speaker 4: telling me that I need to be careful, that something
Speaker 4: terrible may happen, and until I do something about it,
Speaker 4: the terrible feeling is going to linger. So I think
Speaker 4: you're right. When I screened for somebody, I say, do
Speaker 4: you ever have intrusive thoughts? You have thoughts that come
Speaker 4: out of the blow and bother you. Everybody has them.
Speaker 4: That doesn't distinguish OCD. It's really the combination of having
Speaker 4: an intrusive thought that's unwanted, unpleasant, and the need to
Speaker 4: do something about it, either physically or in terms of
Speaker 4: a mental ritual.
Speaker 1: We had a great question from someone named Rena who
Speaker 1: very passionate requests. They say, can you talk about the
Speaker 1: intrusive grippy sock type of OCD. I don't know if
Speaker 1: you know that term, but grippysock vacation refers to an
Speaker 1: impatient stay. But this person said that they were having
Speaker 1: intrusive thoughts but they didn't seek help because they were
Speaker 1: afraid of getting hospitalized for saying it out loud. And
Speaker 1: they said, I think more people need to know the
Speaker 1: difference between say, suicidal ideation or intent versus intrusive OCD
Speaker 1: thoughts of self harm. How do clinicians parse that out?
Speaker 1: And does that happen a lot where someone is having
Speaker 1: intrusive thoughts without intent but it shoots them done the
Speaker 1: wrong thing.
Speaker 4: Yeah, that's a really good question too. So some patients
Speaker 4: may have an intrusive thought that they may hurt themselves,
Speaker 4: but what they'll tell me if they have OCDA is
Speaker 4: they really don't want to hurt themselves. They have no plan,
Speaker 4: they have no intent. It's the last thing I want
Speaker 4: to do. But they're worried that if they don't do something,
Speaker 4: perform some ritual, that somehow they're going to hurt themselves.
Speaker 4: More often people are worried that's going to hurt someone
Speaker 4: else rather than themselves. And when suicideality comes up, it's
Speaker 4: usually because the person is very depressed, they feel demoralized,
Speaker 4: they feel hopeless, maybe they feel embarrassed about their symptoms.
Speaker 4: That's when suicideality comes to fruition.
Speaker 1: We have an entire episode called Suicideology with suicidologists doctor
Speaker 1: de Quincy Mayfriend Lazine, which we'll link for you in
Speaker 1: the show notes.
Speaker 4: And let me say something about a year of harming others.
Speaker 4: That's a very common one, and there the questions come up. Well, say,
Speaker 4: if you're an inexperienced clinician and somebody comes to you
Speaker 4: and they're afraid they're gonna hurt somebody, I mean, what
Speaker 4: you find out first? Do they ever hurt anybody you know? Intentionally?
Speaker 4: And who are they afraid of hurting? Are they afraid
Speaker 4: of hurting their boss who they hate? I don't know.
Speaker 4: Well maybe that's not Elday, I will to kill you
Speaker 4: right now, but we're they afraid of they can't babysit
Speaker 4: for their grandchild anymore because they're afraid they're gonna put
Speaker 4: their grandchild in the microwave. And they said, that's crazy,
Speaker 4: But I'm afraid they instead of baking the cake, I'm
Speaker 4: gonna put my grandchild in the microwave. So I can't
Speaker 4: babysit anymore. That's OCDA.
Speaker 1: When you mentioned harm others versus self, Mallory Albie wanted
Speaker 1: to know, is OCD associated with things like skin picking
Speaker 1: or hair pulling things like that? Is that under the
Speaker 1: OCD umbrella?
Speaker 4: The skin picking and hair pulling, trickletail and me is
Speaker 4: under this larger category, larger umbrella of OCD and related disorders,
Speaker 4: but they're considered distinct from OCD. You do see some coomorbidity,
Speaker 4: but they're separate and sometimes require different treatments.
Speaker 1: What about eating Deanna Day, Zoey Dunham, Mie Geoback and
Speaker 1: in Matt Secafan's words, what's known of the relationship between
Speaker 1: eating disorders and OCD? Same with disordered eating at all? Yeah.
Speaker 4: In terms of the relationship between eating disorders and OCD,
Speaker 4: the one where I see the strongest connection in some
Speaker 4: patients between anorexia nervosa and OCD. In fact, I've seen
Speaker 4: some patients over the years who may have started with
Speaker 4: anorexia nervosa with a focus has been more on their weight,
Speaker 4: and then they develop some rituals and other obsessions unrelated
Speaker 4: to their weight. So I see some connection there the
Speaker 4: idea of compulsive eating or belie. I don't see a
Speaker 4: strong connection between that and OCD. That's, in my mind,
Speaker 4: a misuse of the term compulsive.
Speaker 1: Okay, that's good to know. Some people wanted to know
Speaker 1: about infections, and Kapy Verregal asked how often is the
Speaker 1: onset of OCD preceded by an illness or infection, And
Speaker 1: a lot of people wanted to ask about PANDAS, which
Speaker 1: is a I'll put it in an aside pediatric autoimmune
Speaker 1: neuropsychiatric disorders associated with streptococcal infections, or say that three
Speaker 1: times fast, I cannot or pans. Okay, So PANTS stands
Speaker 1: for pediatric acute onset neuropsychiatric syndrome, and it's related to pandas.
Speaker 1: Cute names horrible conditions, and PANDAS stands for pediatric autoimmune
Speaker 1: neuropsychiatric disorders associated with streptococcal infections. No, I'm not going
Speaker 1: to say that three times. I just said it twice.
Speaker 1: That was hard enough. But according to the National Institute
Speaker 1: of Mental Health, these conditions affecting kiddos involve autoimmune encephalopathy
Speaker 1: or brain inflammation causing sudden and severe onset of OCD
Speaker 1: or restrictive eating disorder in children, and mood behavior and
Speaker 1: sensory and motor function can also be affected. But what
Speaker 1: doctors suspect triggers this are infections like PANDAS involves strap
Speaker 1: or scarlet fever, and in general, PANS may be triggered
Speaker 1: by immune system issues or illness or even environmental factors,
Speaker 1: and the conditions may start or stop suddenly. And for
Speaker 1: a while there was a lot of controversy on whether
Speaker 1: PANS or PANDAS were even real, and in twenty twelve
Speaker 1: Stanford University became the first academic institution to start treating it. Now,
Speaker 1: patrons including Anastasia Press, Aaron Sorenson, Nicholas Randall, Rayna William Russell,
Speaker 1: they all asked if PANDAS or PANS is the same
Speaker 1: as OCD, does treatment differ, and what's doctor Goodman's take
Speaker 1: on it? And Nicholas Randall echoed, Oh gosh, the pantas
Speaker 1: question would be so good to hear an answer to.
Speaker 1: But yeah, a lot of people wanted to know about this.
Speaker 1: It's something that typically the general population knows very little
Speaker 1: about unless you've known someone that has it. But can
Speaker 1: you talk about that and like sudden onsetting kids.
Speaker 4: Yeah, I've done some research on and some of my
Speaker 4: colleagues a more expert than I am. But it goes
Speaker 4: back to the reason when if you have a child
Speaker 4: then they have a sore throat. The reason you want
Speaker 4: to make sure it gets treated is you want to
Speaker 4: make sure it's not beta hemolytic STRAP, a strep infection,
Speaker 4: because with STRAP, this is unrelated to OCDAY, but I'll
Speaker 4: make the connection. The concern there is that some patients,
Speaker 4: if you failed to treat the STRAP infection adequately, you
Speaker 4: can get a complication called Sydenham's korea, which is auto
Speaker 4: antibodies directed against the brain. And Sue Sweeto, who came
Speaker 4: up with the idea of pannas many years ago, had
Speaker 4: identified a subpopulation of patients with OCD where they had
Speaker 4: a strep infection and instead of developing what was korea,
Speaker 4: Sinnham's korea, which is a certain type of movement disorder.
Speaker 4: They develop ticks or OCD symptoms out of the blue,
Speaker 4: kind of overnight. So it's a very interest, very fascinating.
Speaker 4: It's still controversial entity, but I think it does exist.
Speaker 4: It's hard to diagnose, and it's been expanded now to consideration.
Speaker 4: As you mentioned with PANS, not just focus on the strap,
Speaker 4: but maybe other infectious agents cause a autoimmune response where
Speaker 4: the antibodies attack your own brain and instead of producing
Speaker 4: Sinham's korea, you get ticks or OCD.
Speaker 1: Is the treatment for that still something serotonin or behavioral
Speaker 1: therapy or I've heard globulent therapy can be helpful for that.
Speaker 4: Yeah, I know there's some I'm not as up to
Speaker 4: date on the literature there, so I'm going to be
Speaker 4: a little bit careful about what I say about the latest.
Speaker 4: A lot of the patients that I see who are
Speaker 4: adults will raise questions about that they had OCD when
Speaker 4: they were a child, and could that be related to
Speaker 4: PANNED As it's possible if it's say five ten years,
Speaker 4: if transpired, I'm probably not going to try an immunal
Speaker 4: therapy because probably what even if there was an insult
Speaker 4: and an activation of the immune system. That inflammation is
Speaker 4: long gone, so we generally would treat it OCD kind
Speaker 4: of independent of whatever we think caused it, including PANDAS,
Speaker 4: so it would be the same treatments of behavior therapy
Speaker 4: or SSRIs for the most part.
Speaker 1: So yes, treatment varies depending on the case, but some
Speaker 1: first line therapies are treating the underlying STREP infection if
Speaker 1: that's still active, and going after the OCD challenges using
Speaker 1: cognitive behavioral therapy, perhaps also trying SSRIs or According to
Speaker 1: the twenty seventeen paper Clinical Management of Pediatric Acute on
Speaker 1: st Neuropsychiatric Syndrome, Part two, use of immunomodulatory therapies, immune
Speaker 1: abnormalities in seventy five to eighty percent of patients occur
Speaker 1: as inflammatory and post infectious autoimmune presentations, and that oral
Speaker 1: or IV cordico steroids may help, but IVY immunoglobulins or
Speaker 1: antibodies are the preferred treatment now for very severe cases.
Speaker 1: The paper continued, Therapeutic plasma exchange is the first line therapy,
Speaker 1: sometimes combined with immunoglobulins and the high doses of steroids
Speaker 1: and possibly retuximop which is an antibody medication used to
Speaker 1: treat certain autoimmune diseases like rheumatoid arthritis and cancers like
Speaker 1: non hodgkinslomphoma. And on the topic of neuroinflammation triggered by knowllness,
Speaker 1: we have a two part long COVID episode that just
Speaker 1: went up a few months ago with this amazing doctor,
Speaker 1: doctor Wes Eley, that will link in the show notes.
Speaker 1: And we also have an episode on multiple sclerosis coming
Speaker 1: up very soon. But I'm grateful to say I have
Speaker 1: some kiddos in my life who have had pandas went
Speaker 1: to this exact Stanford Pants clinic and are doing amazing.
Speaker 1: So if anyone from that clinic Stanford is listening, thank
Speaker 1: you from the bottom of this lady's heart. It's really
Speaker 1: challenging to find doctors who are looking at different times
Speaker 1: of treatment for this, but it's heartening to see that
Speaker 1: it's become more widely known and treated now. If you
Speaker 1: think that your kid is struggling with this, the National
Speaker 1: Institute of Mental Health recommends that you reach out to
Speaker 1: the wonderful International OCD Foundation or the Panda's Physicians Network
Speaker 1: to find a healthcare provider who may be knowledgeable about
Speaker 1: pants and pandas we'll link that on our website. And
Speaker 1: you know, we talked about a little bit about like
Speaker 1: a childhood situation. I know we're throwing around a lot
Speaker 1: of letters when it comes to complex BTSD. Some folks,
Speaker 1: Jordan Iron's, Kayla Tozier, Will Clark, Alex miner Orlsur Reese
Speaker 1: Perini wanted to know is OCD, in Reese's words, sometimes
Speaker 1: trauma induced. Do you see that in any patients? Kyla
Speaker 1: wanted to know who childhood trauma lye to OCD.
Speaker 4: I've seen some cases over the years where I thought
Speaker 4: that there was a direct connection between a traumatic life
Speaker 4: event and the OCDA, but it's not all that common
Speaker 4: in my experience. I remember one patient I treated who
Speaker 4: was a combat veteran and he had an awful job
Speaker 4: of This was in the Vietnam era of doing body counts.
Speaker 4: Oh and it was obviously a very traumatic experience and
Speaker 4: he developed OCD after that, and I thought it was
Speaker 4: definitely a connection.
Speaker 1: Well, well, well look at that. A twenty twenty four
Speaker 1: study titled exploring the Interplay between complex post traumatic stress
Speaker 1: Disorder and obsessive compulsive disorder severity Implications for Clinical Practice,
Speaker 1: which opens with a banger of a sentence. Traumatic events
Speaker 1: adversely affect the clinical course of obsessive compulsive disorder, and
Speaker 1: the paper concludes that the coexistence of CPTSD in OCD
Speaker 1: exacerbates obsessive compulsive symptoms and increases the burden of anxiety. So, yeah,
Speaker 1: you know you're not imagining that. And here I just
Speaker 1: have to shout out one of my favorite musicians, Alison Pontier,
Speaker 1: who not only has the voice of an angel. You
Speaker 1: may have heard her EPs Faking my own death and
Speaker 1: shaking hands with Elvis the last few years, or her
Speaker 1: feature on Lord Here on song.
Speaker 5: Eyeled Bucks of jobs.
Speaker 1: But also last week released an essay on substack about
Speaker 1: her OCD titled Manifesting but Evil What I couldn't tell anyone,
Speaker 1: and I'll link it on our website, but it opens
Speaker 1: around age eleven, I discovered that if I made deals
Speaker 1: with God, my stomach wouldn't hurt anymore, at least until
Speaker 1: the next time it happened. God isn't big on money
Speaker 1: or favors. He's mostly interested in meaningless tasks performed in
Speaker 1: exchange for a few minutes of relief Now. On Allison's
Speaker 1: Instagram post about it, the comments flooded in like ex
Speaker 1: Religious OCD, Eva's rise up and religious OCD plus magical
Speaker 1: thinking OCD were rude and I was really moved by
Speaker 1: her essay and I found it relatable as well. Hell
Speaker 1: and Olivia Lester wanted to know if there's a correlation
Speaker 1: between OCD and Judaism. I was personally raised Catholic, and
Speaker 1: if there's ever an obsessive in convulsion, Catholicism is like,
Speaker 1: you will go to Hell unless you say this rosary
Speaker 1: the exact number of times, you know what I mean,
Speaker 1: Like that they send you to penance. So do you
Speaker 1: ever see people with maybe religious backgrounds that.
Speaker 4: Are oh yeah, yeah all the time. And definitely a
Speaker 4: lot of Catholics for sure. In fact, some of the earliest,
Speaker 4: probably some of the earliest descriptions of OCD that correspond
Speaker 4: to our current definitions go back to the Catholic Church
Speaker 4: referring to scrupulosity. In fact, I don't know if it
Speaker 4: still exists, but there's a treatment center in the Midwest
Speaker 4: for priests who were scrupulous. They were taking the biblical
Speaker 4: studies too literally, and so one of the things when
Speaker 4: I I'm Jewish, and I certainly I've had Jewish and
Speaker 4: Catholic and people from all walks of life, all religions
Speaker 4: who have had OCD, and some of them do involve
Speaker 4: religious ideation. And what I will ask him is have
Speaker 4: you have you sought out your priest, your rabbi, and
Speaker 4: have they tried to reassure you that you're over interpreting
Speaker 4: these concerns And usually that doesn't work. My experience is
Speaker 4: that that kind of reassurance doesn't cure the OCD.
Speaker 1: The priest is like, no, yeah, you do have to
Speaker 1: do this. That's interesting that Catholic literature some of the
Speaker 1: first but Keithan Newman and Linda English wanted to know
Speaker 1: about hoarding. Does it ever bother you when you see
Speaker 1: shows like or hear of shows like Quarters where they're like,
Speaker 1: we're just going to come in and clean up your
Speaker 1: house and you're going to be fine, When it's so
Speaker 1: much deeper than that. Is that under the OCD umbrella again.
Speaker 4: It's separate against under the same umbrella of OCD and
Speaker 4: related to sourders. Sometimes they're connected, other times hoardings is separate.
Speaker 4: I'll give you an anecdote patient. This years ago gotten
Speaker 4: to the point where she collected her cat litter in
Speaker 4: bags because she was afraid that the cat would ingest
Speaker 4: something valuable. And she pointed out that she really didn't
Speaker 4: own anything valuable, but nevertheless, she was worried that something
Speaker 4: would be thrown out in the trash that was valuable,
Speaker 4: including the in the cat letter. And you can imagine,
Speaker 4: you know, collecting bags of cat litter in your base.
Speaker 4: So her husband took advantage of a weekend when she
Speaker 4: was visiting her sister, brought in a dumpster and he
Speaker 4: and his friends decide to clear out the house. She
Speaker 4: came home early and she did a dumpster dive. So
Speaker 4: it did not work. That approach doesn't work.
Speaker 1: Just a fun side note. We have an episode on
Speaker 1: decluttering called Oecology and the expert in it is named
Speaker 1: Jamie Hord. But simply Marie, condoing your house is not
Speaker 1: going to do the full trick. Results on medical trials
Speaker 1: for hoarding disorder have been a little mostly focused on
Speaker 1: SSRIs which have been a little effective, although SNRIs and
Speaker 1: glutamate modulators or ADHD medications may show some promise, but
Speaker 1: a ton more research is needed, so for now, the
Speaker 1: best treatment for hoarding disorder seems to be cognitive behavioral
Speaker 1: therapy and usually a lot of support from caregivers or
Speaker 1: loved ones. And hoarding disorder, remember isn't OCD, although some
Speaker 1: folks can struggle with both. Now, what if some of
Speaker 1: this OCD info is hitting a little too close to home?
Speaker 1: But you also don't want to diagnose yourself from a
Speaker 1: one hour long podcast episode? Do you have any advice
Speaker 1: for someone who suspects that they might have OCD in
Speaker 1: terms of how to seek help and how to how
Speaker 1: to really recognize the impact that it's having.
Speaker 4: So I want to put a blog in for the
Speaker 4: International OCD Foundation that I was a co founder of
Speaker 4: that organization back in the eighties. Go to their website.
Speaker 4: They have a lot of great information. They identify different
Speaker 4: places where you can seek treatment. So I think that's
Speaker 4: a good starting point.
Speaker 1: What about for people who's loved ones might have OCD?
Speaker 1: Anonymous wanted to know about living with someone with OCD,
Speaker 1: both in ways to help and ways to cope, and
Speaker 1: Elena Grilla also wanted to know any tips on coping,
Speaker 1: how to support but also not enable too many compulsions.
Speaker 4: Yeah, you know, that's a tough struggle for love one
Speaker 4: ones you talk about enabling, you don't want to enable.
Speaker 4: But also if you have a loved one who's in distressed,
Speaker 4: or you have to make it to a dinner date
Speaker 4: together and they say, well, you got a check, or
Speaker 4: they're asking for your reassurance that they did something correctly,
Speaker 4: or that they have to check the locks again or
Speaker 4: the stove, or.
Speaker 1: In the case of say moral scrupulosity OCD involving ruminations
Speaker 1: worrying that you're not a good or moral person or
Speaker 1: that you're always harming people. Reassurance seeking may come in
Speaker 1: the form of asking loved ones over and over if
Speaker 1: you've done anything wrong. Now, with a therapist who doesn't
Speaker 1: specialize in OCD, you may just run around in circles
Speaker 1: treatment wise, just asking your therapist for reassurance and getting it,
Speaker 1: but not getting to the root of the issue or
Speaker 1: confronting those obsessions and compulsions. And also, I said enable,
Speaker 1: but I meant accommodate. My brain did not do a word.
Speaker 4: Well, it's easy just to give into it because that's
Speaker 4: the most parsimonious thing to do. So it's there's no
Speaker 4: one script. I think if somebody is going for exposure
Speaker 4: response prevention. It's really important for the family members to
Speaker 4: participate so that they're not inadverently accommodating the symptoms, but
Speaker 4: also not looking like they show feeling no empathy for
Speaker 4: the person's feelings. It's easy to say from the outside
Speaker 4: just stop it, yeah, but it isn't for the patient
Speaker 4: who has OCD.
Speaker 1: Especially if the stakes are typically so high where you're
Speaker 1: asking someone.
Speaker 4: To or like going to going to hell, yeah, going
Speaker 4: to hell.
Speaker 1: Or giving someone an illness that could kill them. Just
Speaker 1: this notion that like if I don't do this correctly,
Speaker 1: I could kill someone. It's not as easy as just
Speaker 1: not doing it, you know. And any biggest myths, last questions,
Speaker 1: any biggest myths that you want to stand on a
Speaker 1: soapbox and flim flamm you.
Speaker 2: On a bust.
Speaker 4: Again, this goes back to sometimes you know, they are
Speaker 4: family members who are very supportive and understanding, and some
Speaker 4: who feel that the person it just doesn't work hard
Speaker 4: enough to control their behaviors. And that's if somebody with
Speaker 4: OCD it was so easy to just stop it, people
Speaker 4: would they wouldn't need treatment. So I think one of
Speaker 4: the mess is that it's a weakness. The other is
Speaker 4: I see it really as a brain based disorder. I mean,
Speaker 4: there's just so much evidence that this is the disorder
Speaker 4: of the brain, and it certainly has manifestations or behavioral
Speaker 4: but it's a brain based illness. And even the behavior
Speaker 4: therapy is acting to retrain the brain.
Speaker 1: Again, exposure and response prevention therapy. Huge, huge, huge love
Speaker 1: hate doing it, love that it's helped me so much.
Speaker 1: What do you feel is the hardest part about your job.
Speaker 4: The patients who don't get better? Yeah, I mean, and
Speaker 4: so I've never told the patient that I can't think
Speaker 4: of something else that we can do, and so I've
Speaker 4: always taken that position. I never give up on somebody.
Speaker 1: What about your favorite what's the most rewarding doing the deep.
Speaker 4: Brain stimulation and patients who have had OCD and for
Speaker 4: twenty years and within a few months they're back to
Speaker 4: living a normal life. It's just incredible.
Speaker 1: Do you ever cry about it? I'm about to start crying.
Speaker 4: No, I don't cry, you don't. But in the operating
Speaker 4: room it's interesting. So I mean again into detail, but
Speaker 4: we wake up the patients in the operating room to
Speaker 4: test the stimulation and sometimes you know what we look
Speaker 4: for is that they feel happy and when we turn
Speaker 4: on the stimulation. And we had one patient who in
Speaker 4: the middle of the operating room says, I feel happy.
Speaker 4: In fact, we asked her, what does it feel like?
Speaker 4: It feels like love in my chest for everyone else
Speaker 4: and almost everybody, maybe not me, start to tear up
Speaker 4: in the operating room, and she did very well. She
Speaker 4: went on to do very very well.
Speaker 1: Do you ever lie about crying? For example, right now.
Speaker 4: I'll cry sometimes the movies. I'm not a big crier.
Speaker 1: I'm crying about it. I don't even know this person. Well,
Speaker 1: the work you're doing so important, and it's really such
Speaker 1: a privilege to talk to you. Anyone who has knowledge
Speaker 1: of OCD is like, whoa, wait, good man, that's amazing,
Speaker 1: including me, So this is really cool.
Speaker 4: You know your stuff too, Ali, I'm impressed.
Speaker 1: Thank you so much for doing this.
Speaker 4: That's my pleasure.
Speaker 1: So consult an expert about your curiosities when it comes
Speaker 1: to getting treated. Please remember that an evaluation is really important.
Speaker 1: Some conditions look like others and they overlap and treatment
Speaker 1: can be really different. So find a specialist at the
Speaker 1: link in the show notes or on our website at
Speaker 1: aliward dot com, slash Ologies slash OCD Neurobiology, which we've
Speaker 1: also linked in the show notes, so you don't have
Speaker 1: to write that down right now now come back in
Speaker 1: a few days. Should be up this weekend for a
Speaker 1: bonus episode all about lived experience and more research and
Speaker 1: tips for loved ones and folks with OCD as I
Speaker 1: chat with researcher and OCD havever and mental health advocate
Speaker 1: Uma Chatterjee, who's amazing, And thank you so so much
Speaker 1: to doctor Wayne Goodman for the decades of tireless work
Speaker 1: to make this condition better understood and to improve the
Speaker 1: lives of people who have it, and for founding the
Speaker 1: International OCD Foundation, the charity of choice this week and
Speaker 1: we'll link them in the show notes as well. We're
Speaker 1: at Ologies on Blue Sky and Instagram. I'm at Aliward
Speaker 1: on both. We have weekly kid friendly episodes called Smologies
Speaker 1: available wherever you get podcasts. Just look for Asmologies, sm
Speaker 1: l O g I E S swear free shorter versions.
Speaker 1: Ologies Merch is available at ologiesmerch dot com, and to
Speaker 1: support the show and sending questions for upcoming episodes, you
Speaker 1: can sign up at Patreon dot com. Slash Ologies Aaron
Speaker 1: Talbert is our Ologies podcast Facebook admin Big Hugs to
Speaker 1: the whole Campbell Clan. This week a whale of a
Speaker 1: hug to Mike. Aveline Malick makes our professional transcripts. Kelly
Speaker 1: ar Dwyer does the Way Paige Noel Dilworth is our
Speaker 1: scheduling producer. Susan Hale managing directs the whole show. Jake
Speaker 1: Chafee is one wonderful editor and lead editor. Up top
Speaker 1: is Mercedes Maitland of Maitland Audio. Nick Thorburn wrote the
Speaker 1: theme music and if you stick around to the end
Speaker 1: of the episode, I tell you secret and if you
Speaker 1: heard the ADHD episodes. For a while, my chronic procrastination
Speaker 1: looked a lot like ADHD, and one doctor said it's possible.
Speaker 1: But a short trial of ADHD meds with me was
Speaker 1: like trying to coax a terrified chihuahua out from under
Speaker 1: a car by injecting it with espresso. Did not help me.
Speaker 1: Further evaluation revealed, hey, bitch, thinking NonStop that everyone might
Speaker 1: hate you because you made a minor mistake, and procrastinating
Speaker 1: to the point of panic because you're avoiding something so hard.
Speaker 1: We have a therapy for that. It's called exposure, and
Speaker 1: it will suck so hard, but then your brain will say, Okay,
Speaker 1: this is not so bad. It's like a jump from
Speaker 1: a high dive or a plunge into an ice bath.
Speaker 1: It is scary, it's not comfortable, it's not as bad
Speaker 1: as you thought, and then it's much easier to do
Speaker 1: the next time, and you'll be like, holy shit, I
Speaker 1: did that. So if you're listening to this because you
Speaker 1: have a loved one going through it, or you were,
Speaker 1: like me, diagnosed with OCD in the last couple of years,
Speaker 1: I hope you get it a little bit more. Let
Speaker 1: me tell you there are brighter days ahead. You got this. Also.
Speaker 1: The second secret is that sometimes I have a hard
Speaker 1: time not scrolling, and I don't get a lot of
Speaker 1: stuff done. And my friend Simone told me about this
Speaker 1: thing called a brick. It's like fifty bucks. It's a
Speaker 1: physical object you use to brick certain apps on your phone.
Speaker 1: You keep it on the fridge or somewhere that's not
Speaker 1: your hand. If Brick wants to advertise, I love them,
Speaker 1: but here I am just giving it to them for free.
Speaker 1: But yeah, this thing called a brick has helped me
Speaker 1: stop scrolling. So much when I'm avoiding things. Okay, I
Speaker 1: hope this episode helped in some way. Stay tuned. We're
Speaker 1: going to talk to um in a couple of days.
Speaker 1: That's a great combo too. Thank you for hearing about
Speaker 1: all of my mental health issues. I feel like we
Speaker 1: all have them. I just tell you about them. Well,
Speaker 1: I hope it helps, Okay.
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