WEBVTT 1 00:00:00.280 --> 00:00:02.720 Oh hey, it's the bowl that's chipped, but not chipped 2 00:00:02.799 --> 00:00:05.160 enough to throw it away. Ali Ward, this is ologies, 3 00:00:05.200 --> 00:00:08.640 this is OCD. Okay. We asked y'all on Patreon your 4 00:00:08.679 --> 00:00:11.640 most desired episodes, and this was among the top, which 5 00:00:11.679 --> 00:00:14.279 was both a surprise. It was also a delight to me. 6 00:00:15.080 --> 00:00:18.920 Also a delight we got the world's most revered expert 7 00:00:19.239 --> 00:00:21.839 in OCD to talk to me for an hour. This 8 00:00:21.879 --> 00:00:26.280 person invented this scale by which OCD is measured. They've 9 00:00:26.280 --> 00:00:29.920 been working in this field for many, many decades and 10 00:00:30.440 --> 00:00:33.039 is pioneering a bunch of new treatment and research for it. 11 00:00:33.320 --> 00:00:36.560 They studied at Boston University and Yale School of Medicine. 12 00:00:36.640 --> 00:00:40.520 They've also been instrumental in nonprofit work for OCD treatment 13 00:00:40.560 --> 00:00:43.280 and research. They're now a professor and the chair at 14 00:00:43.320 --> 00:00:46.799 the manager Department of Psychiatry and Behavioral Sciences at Baylor 15 00:00:46.840 --> 00:00:49.359 College in Houston. And if you have OCD, or you 16 00:00:49.439 --> 00:00:52.679 know someone who does or might, their life is better 17 00:00:52.799 --> 00:00:57.560 because of this absolute OCD icon And just a content note, 18 00:00:57.640 --> 00:01:00.200 of course, we talk about some parts of OCD that 19 00:01:00.280 --> 00:01:03.159 are distressing to people, and that's part of why we're 20 00:01:03.200 --> 00:01:05.719 doing this to talk about it. But just to content 21 00:01:05.799 --> 00:01:08.599 warning up top that we do touch on self harm 22 00:01:08.640 --> 00:01:11.359 and some intrusive thoughts that might be a little disturbing 23 00:01:11.400 --> 00:01:13.519 to people. Now. I was nervous as hell to hop 24 00:01:13.560 --> 00:01:17.159 on this interview because I know their time is very limited, 25 00:01:17.400 --> 00:01:19.719 but we were able to cover so much, including questions 26 00:01:19.760 --> 00:01:22.680 from patrons at patreon dot com slash ologies, you also 27 00:01:22.719 --> 00:01:25.519 can ask questions before we record. You can join that 28 00:01:25.560 --> 00:01:28.439 for less than twenty five cents an episode. Also, Ologies 29 00:01:28.480 --> 00:01:31.040 Merch is available at ologiesmerch dot com should you need it, 30 00:01:31.400 --> 00:01:33.680 and for no dollars. You can support the show just 31 00:01:33.719 --> 00:01:35.439 by leaving a review and I read them all and 32 00:01:35.439 --> 00:01:37.840 then I pick freshy to read, such as this one 33 00:01:37.920 --> 00:01:39.959 this week from Mishar, who wrote, if you were a 34 00:01:40.040 --> 00:01:42.920 kid who went to these Scholastic book fairs looking for 35 00:01:43.079 --> 00:01:46.439 nonfiction books or fun facts books, this is the podcast 36 00:01:46.599 --> 00:01:50.040 for you, Meshar. Let's crack into the catalog. Let's get 37 00:01:50.079 --> 00:01:52.560 some mo CD but verse. Also thanks to sponsors of 38 00:01:52.599 --> 00:01:54.680 the show for making it possible to donate to a 39 00:01:54.760 --> 00:01:57.359 cause of the ologist choosing get value. 40 00:01:57.400 --> 00:02:00.439 You can't argue with Optesco with their amazing club card rices. 41 00:02:00.719 --> 00:02:03.159 Serve up something special with our finest meal deal for 42 00:02:03.200 --> 00:02:05.840 two starring one main, two sides and dessert for only 43 00:02:05.840 --> 00:02:09.400 sixteen euro Like Succulent Board be approved rush Angus Striploin 44 00:02:09.439 --> 00:02:13.360 steaks with peppercorn butter or Delicious Virus Chicken Parmesana served 45 00:02:13.400 --> 00:02:16.000 with creamy potato gretam and her mix of rainbow root 46 00:02:16.120 --> 00:02:20.599 vegetables and enjoy Goozillionaire or Salder caramel cheesecake. 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I would have thought so, 61 00:03:01.120 --> 00:03:03.800 since people don't talk about it a lot unless it's 62 00:03:03.960 --> 00:03:08.039 an offhand punchline or like an excuse for a complicated 63 00:03:08.120 --> 00:03:12.000 Starbucks order. But research reveals that OCD is now considered 64 00:03:12.039 --> 00:03:15.479 one of the most common psychiatric conditions, afflicting two to 65 00:03:15.520 --> 00:03:18.599 three percent of the general population. I did not know that. 66 00:03:18.840 --> 00:03:21.199 And because of the high demand for this episode, and 67 00:03:21.240 --> 00:03:24.039 because it's so close to my heart, surprise, we have 68 00:03:24.080 --> 00:03:26.560 a bonus episode coming out in a few days. We've 69 00:03:26.599 --> 00:03:29.520 been cooking up. It's all about lived experience. It's with 70 00:03:29.599 --> 00:03:34.639 a lovely neuroscientist, researcher, board certified mental health peer specialist, 71 00:03:34.639 --> 00:03:38.159 and mental health advocate UMA Chatterjy so Yes an extra 72 00:03:38.240 --> 00:03:41.680 episode this week. Enjoy. That's a great conversation. But for now, 73 00:03:41.719 --> 00:03:44.400 let's take a deep breath. Let's treat our brains to 74 00:03:44.520 --> 00:03:49.759 a feast of info on overt versus covert, perfectionism, obsessions 75 00:03:49.879 --> 00:03:59.879 versus compulsions, neurodivergence and OCD, pediatric illness induced OCD symptoms, ruminations, checking, counting, reassurance, seeking, 76 00:04:00.280 --> 00:04:03.599 a few famous folks who are helping break stigmas, medicines 77 00:04:03.719 --> 00:04:07.520 on the forefront some hopeful treatments in the future, finding 78 00:04:07.520 --> 00:04:12.199 a therapist, deep brain stimulation, genetic components overlap with trust syndrome, 79 00:04:12.360 --> 00:04:15.400 advice for loved ones, and the behavioral therapy that is 80 00:04:15.439 --> 00:04:20.439 the gold standard for OCD. With doctor, psychiatrist, researcher, advocate, 81 00:04:20.560 --> 00:04:24.879 and OCD neurobiologist, the doctor Wayne Goodman. 82 00:04:43.759 --> 00:04:48.680 I'm Wayne Goodman, he him. I'm a psychiatrist and I 83 00:04:48.759 --> 00:04:52.399 work at the Balacology of Medicine down in Houston, Texas. 84 00:04:52.879 --> 00:04:55.199 Really excited to talk to you. We've wanted to do 85 00:04:55.480 --> 00:04:59.480 this episode for literally years, and everyone we've talked to 86 00:04:59.560 --> 00:05:01.800 has said you are a perfect choice for this, so 87 00:05:02.000 --> 00:05:06.519 we're very excited to be speaking to you. Specifically, hundreds 88 00:05:06.560 --> 00:05:09.920 of papers last I saw on research Gate thirty six 89 00:05:10.000 --> 00:05:13.160 thousand citations to your work. I believe you started in 90 00:05:13.160 --> 00:05:13.720 the eighties. 91 00:05:15.439 --> 00:05:18.480 Yes, it's hard to believe. It was the nineteen eighty five, 92 00:05:18.959 --> 00:05:20.600 so forty years. 93 00:05:20.680 --> 00:05:24.040 Forty years. What got you started down this path? 94 00:05:25.240 --> 00:05:29.439 So I was at Yale doing my residency and starting 95 00:05:29.519 --> 00:05:35.160 a research fellowship, and I came across a patient with OCD, 96 00:05:35.439 --> 00:05:37.680 and it was the first patient I had seen with OCD, 97 00:05:38.839 --> 00:05:42.120 and started reading about it and I began to realize 98 00:05:42.439 --> 00:05:45.519 it wasn't that much known, particularly about the neurobiology or 99 00:05:45.560 --> 00:05:50.199 the treatment. So long story short, wound up launching the 100 00:05:50.240 --> 00:05:54.319 OCD program at Yale, and I've been focusing on OCD 101 00:05:54.439 --> 00:05:55.000 ever since. 102 00:05:56.240 --> 00:05:59.319 Was there something about this patient? Was it the level 103 00:05:59.360 --> 00:06:04.079 of suffering or the level of OCD that really hooked you? 104 00:06:04.800 --> 00:06:07.639 Were they particularly nice? Were they a patient you liked? 105 00:06:07.639 --> 00:06:10.879 Were he well, I like all my patients. But of 106 00:06:10.920 --> 00:06:14.720 course this patient had kind of a classic form of 107 00:06:14.720 --> 00:06:19.680 OCD involving contamination concerns and fear that if they didn't 108 00:06:19.839 --> 00:06:22.720 wash their hands carefully they would get somebody else sick, 109 00:06:22.800 --> 00:06:27.199 particularly somebody they loved. And they realized that whatever they 110 00:06:27.240 --> 00:06:30.879 were doing, whatever they were thinking about, was excessive. So 111 00:06:31.040 --> 00:06:34.040 that's what really struck me. You know, that this person 112 00:06:34.160 --> 00:06:37.160 was driven to the point that she used to have 113 00:06:37.240 --> 00:06:41.560 to use bleach on our hands. Her hands were red bleach, 114 00:06:41.639 --> 00:06:45.040 I mean it could be caustic because not only skin irritation, 115 00:06:45.120 --> 00:06:49.079 but actual damage. And she was consumed by these thoughts 116 00:06:49.720 --> 00:06:53.319 almost every hour the waking day. But yet again, she 117 00:06:53.480 --> 00:06:57.639 had complete insight into how absurd it was. And that's 118 00:06:57.639 --> 00:07:02.000 what struck me was that paradox between the irrationality of 119 00:07:02.040 --> 00:07:07.759 the thoughts, the excessiveness of the behaviors, and totally preserved 120 00:07:07.800 --> 00:07:09.639 insight and executive functioning. 121 00:07:10.040 --> 00:07:12.240 So this is a classic presentation of OCD and it's 122 00:07:12.279 --> 00:07:15.279 probably what people think of first because it's just easy 123 00:07:15.319 --> 00:07:17.720 to explain too. And according to the research, up to 124 00:07:17.800 --> 00:07:20.959 forty six percent of folks with OCD do deal with 125 00:07:21.000 --> 00:07:25.040 contamination fears, but the other fifty four percent, the majority, 126 00:07:25.279 --> 00:07:28.639 don't struggle with that. And at that time, were there 127 00:07:29.040 --> 00:07:32.519 scales to measure this? Was it something that was being 128 00:07:32.920 --> 00:07:36.920 treated with medicine? I know, the Yale Brown Obsessive Compulsive 129 00:07:36.920 --> 00:07:41.720 Scale is something that you pioneered, which among people who 130 00:07:41.800 --> 00:07:45.680 know OCD, they're like, WHOA that dud? Did the actual 131 00:07:45.839 --> 00:07:51.240 test OG? So the Yale Brown Obsessive Compulsive Scale, or 132 00:07:51.439 --> 00:07:54.839 y box as it's known, is a clinician administered ten 133 00:07:54.920 --> 00:07:58.680 items scale with each item rated from zero for no 134 00:07:58.800 --> 00:08:02.360 symptoms to four for extreme symptoms. So scores can run 135 00:08:02.759 --> 00:08:05.680 zero to forty. And it was developed in nineteen eighty 136 00:08:05.800 --> 00:08:10.040 nine by a Yale doctor and this OCD legend named 137 00:08:10.079 --> 00:08:13.519 Wayne Goodman, who we are talking to right now. What 138 00:08:13.600 --> 00:08:17.199 interventions are, what qualitative analysis was it back then. 139 00:08:17.360 --> 00:08:20.480 So at the time there were only case reports that 140 00:08:20.560 --> 00:08:24.959 one medication in particular was effective. It was a medication 141 00:08:25.040 --> 00:08:29.800 called clomipramine, which is still available, and it was one 142 00:08:29.800 --> 00:08:33.519 of the older medications with lots of side effects, and 143 00:08:33.799 --> 00:08:36.440 the case report suggested it was the only medication that 144 00:08:36.480 --> 00:08:40.559 seemed to work, and there was a theory that the 145 00:08:40.600 --> 00:08:43.799 reason it worked is because it had potent effects on 146 00:08:43.840 --> 00:08:47.720 the brain's serotonin system. Serotonin is one of the brain's 147 00:08:47.799 --> 00:08:52.919 neurotransmitters or neurochemicals, and my training at Yale really focused 148 00:08:52.960 --> 00:08:56.960 on trying to understand not only treatment but neurobiology. So 149 00:08:57.039 --> 00:09:01.200 that led me to want to test a newer generation 150 00:09:01.320 --> 00:09:05.320 of medications that were selective for their effects and serotonin. 151 00:09:06.320 --> 00:09:08.879 And then I looked around and back to your question 152 00:09:08.919 --> 00:09:13.799 about rating scales, there really weren't any gold standard scales. 153 00:09:13.840 --> 00:09:16.639 So I work with my colleagues on developing one. 154 00:09:17.320 --> 00:09:20.519 Is that something that a person can administer themselves or 155 00:09:20.559 --> 00:09:22.360 is that really something that you got to talk through 156 00:09:22.399 --> 00:09:25.879 with a doctor who can figure out, you know, very impacted, 157 00:09:26.080 --> 00:09:29.799 somewhat impacted. Can people self diagnosed OCDA? Yes? 158 00:09:29.960 --> 00:09:32.559 So the way the y box, that's the Yale Brown 159 00:09:32.559 --> 00:09:36.080 Obsessive Compulsive scale is administered, is it should be by 160 00:09:36.120 --> 00:09:40.759 a clinician who has experience in treating OCDA. There are 161 00:09:40.960 --> 00:09:43.919 forms of the scale that are self rated so that 162 00:09:43.960 --> 00:09:48.320 the patient fills them out, but really the diagnosis is 163 00:09:48.399 --> 00:09:49.639 left up to the clinician. 164 00:09:50.399 --> 00:09:53.879 We hear so often and I'm wondering how you feel 165 00:09:53.879 --> 00:09:56.559 about this when people say I'm so OCDA, Like I 166 00:09:56.679 --> 00:09:59.360 love to have all my pens in the same spot 167 00:09:59.360 --> 00:10:02.679 on my desk. People with OCD, from what I understand, 168 00:10:03.080 --> 00:10:04.080 hate that a lot. 169 00:10:04.240 --> 00:10:04.840 Yeah they do. 170 00:10:05.159 --> 00:10:08.679 Yeah, how do you feel as a professional and a 171 00:10:08.720 --> 00:10:11.000 clinician when you hear people say I'm so OCDA. 172 00:10:11.799 --> 00:10:14.200 Well, you know, I'm not judgmental. That's one of the 173 00:10:14.360 --> 00:10:16.399 good things that you need to be as a psychiatrist. 174 00:10:17.159 --> 00:10:20.480 But I do point out that that's not the same 175 00:10:20.519 --> 00:10:21.039 as OCD. 176 00:10:21.639 --> 00:10:24.559 Doctor Goodman says it's healthy and common to have certain 177 00:10:24.679 --> 00:10:26.759 preferences or routines. 178 00:10:26.440 --> 00:10:32.440 Sure, meaning being perfectionist, liking things orderly. Those are good, 179 00:10:33.080 --> 00:10:36.919 but it's not a disorder until it takes up a 180 00:10:37.000 --> 00:10:39.679 lot of time and by definition would be more than 181 00:10:39.759 --> 00:10:44.120 an hour a day. It would be distressing and for 182 00:10:44.399 --> 00:10:46.480 most of the patients. I treat and I focus on 183 00:10:46.559 --> 00:10:50.840 treatment resistant OCD. I focus on severe OCD. We're talking 184 00:10:50.879 --> 00:10:56.120 about patients that can't go sometimes fifteen minutes without having 185 00:10:56.120 --> 00:10:58.600 an intrusive thought or having to perform a compulsion. 186 00:10:58.960 --> 00:11:00.879 Well to find those in a moment, and our Surprise 187 00:11:00.960 --> 00:11:03.799 Owners episode out later this week with Uma goes into 188 00:11:03.879 --> 00:11:06.320 a ton of detail about lived experience. 189 00:11:06.840 --> 00:11:09.639 So that's very different from the people who are you know, 190 00:11:09.759 --> 00:11:12.159 have a little bit of OCD in them, like things 191 00:11:12.320 --> 00:11:15.519 orderly and are still able to work and lead a 192 00:11:15.639 --> 00:11:19.720 very productive life. People with very severe OCD can be incapacitated. 193 00:11:20.120 --> 00:11:23.600 Although many of my patients, despite their severe symptoms of 194 00:11:24.159 --> 00:11:27.759 figure out ways of still working around them, and a 195 00:11:27.840 --> 00:11:30.000 lot of patients. The other thing about patients with OCD 196 00:11:30.440 --> 00:11:33.039 is they're really good at camouflaging their symptoms. 197 00:11:33.879 --> 00:11:38.080 Now we'll get to kind of outward behavior versus inward, 198 00:11:38.759 --> 00:11:43.679 but you mentioned severe versus kind of high functioning or 199 00:11:43.720 --> 00:11:47.240 people who can function around it. Well, is it a 200 00:11:47.360 --> 00:11:50.360 spectrum like a lot of other conditions. 201 00:11:51.320 --> 00:11:54.480 Yeah. Yeah, So even on the Y box, the rating 202 00:11:54.559 --> 00:11:58.600 scale goes from zero to flority, and most patients that 203 00:11:58.720 --> 00:12:02.279 we treat in an outpaidation setting of first line treatments 204 00:12:02.519 --> 00:12:06.240 they discore around twenty, you know, like the midpoint, and 205 00:12:06.360 --> 00:12:09.639 those patients can continue to work, go to school, lead 206 00:12:09.679 --> 00:12:13.320 a very productive life. But the OCD is kind of 207 00:12:13.320 --> 00:12:17.000 annoying at them and interfering with their ability to be 208 00:12:17.399 --> 00:12:20.120 fully functional and fulfilling life. 209 00:12:20.919 --> 00:12:23.840 One thing that really surprised me about OCD is that 210 00:12:24.000 --> 00:12:27.080 it's not the same as an anxiety disorder. It's not 211 00:12:28.000 --> 00:12:30.639 underneath the umbrella of anxiety disorders. Is that correct? 212 00:12:31.399 --> 00:12:35.960 That's correct as of the DSM five, the Diagnostic Statistical Manual, 213 00:12:36.200 --> 00:12:39.759 fifth edition that came out in twenty thirteen. Before that, 214 00:12:40.039 --> 00:12:44.360 it was considered an anxiety disorder, and actually I'm not 215 00:12:44.480 --> 00:12:47.960 sure it was the right decision not to call it 216 00:12:48.039 --> 00:12:52.480 an anxiety disorder. It's now listed in this DSM five 217 00:12:52.639 --> 00:12:57.679 manual as in the obsessive, compulsive and related disorders. But 218 00:12:57.799 --> 00:13:01.639 anxiety is almost always a component of OCD. 219 00:13:02.759 --> 00:13:06.320 Does the anxiety tend to come from trying to control 220 00:13:06.399 --> 00:13:10.559 the OCD? Like people who have ADHD might have a 221 00:13:10.639 --> 00:13:14.039 lot of anxiety because executive function is difficult for them. 222 00:13:14.320 --> 00:13:16.559 Is the anxiety sometimes a byproduct? 223 00:13:17.399 --> 00:13:21.159 It comes in various forms, but OCD comes in various flavors. 224 00:13:21.279 --> 00:13:27.039 But all patients with OCD by definition have obsessions and compulsions, 225 00:13:27.120 --> 00:13:31.919 and the obsessions are the intrusive thoughts or images, and 226 00:13:32.039 --> 00:13:35.720 those by themselves are distressing kind of by definition, an 227 00:13:35.759 --> 00:13:38.320 obsession is something that is disturbing. 228 00:13:38.799 --> 00:13:40.879 More on these in a sec and in the bonus 229 00:13:40.919 --> 00:13:44.159 episode with uma. But these can again be the fear 230 00:13:44.240 --> 00:13:48.039 of getting sick and getting someone else sick, existential OCD 231 00:13:48.360 --> 00:13:52.159 about whether you really exist. There's a false memory OCD, 232 00:13:52.840 --> 00:13:57.360 perfectionism OCD relating to order and symmetry and counting that 233 00:13:57.600 --> 00:14:01.799 just feel off if incorrect. It's also harm OCD worrying 234 00:14:01.919 --> 00:14:04.960 that you might impulsively hurt yourself or others on accident 235 00:14:05.080 --> 00:14:08.600 or on purpose. And a very seldom discussed facet of 236 00:14:08.679 --> 00:14:12.559 OCD is pedophilia OCD. And this is a distressing worry 237 00:14:12.639 --> 00:14:15.639 that you will harm a child. But wait, there's more. 238 00:14:15.879 --> 00:14:19.279 There's moral scrupulosity, worrying about if you're a bad person 239 00:14:19.399 --> 00:14:22.679 who doesn't know it. There's checking OCD like with matters 240 00:14:22.720 --> 00:14:26.279 of safety like ovens or curling irons or locks, and 241 00:14:26.399 --> 00:14:30.799 there's reassurance seeking OCD. All of these obsessions can run 242 00:14:31.240 --> 00:14:34.080 like a ticker tape in your brain, and you would 243 00:14:34.200 --> 00:14:38.279 really like them to shut up. How do you do that? Compulsions? 244 00:14:38.840 --> 00:14:43.919 And then the compulsions are designed in a way to 245 00:14:44.080 --> 00:14:48.200 reduce the anxiety associated with that obsession. But sometimes the 246 00:14:48.279 --> 00:14:52.519 compulsions themselves can be so time consuming, so like the 247 00:14:52.639 --> 00:14:56.159 patient I mentioned before, you know, or even painful. I've 248 00:14:56.200 --> 00:14:58.879 had patients who took a shower so long that they 249 00:14:58.960 --> 00:15:02.039 ran out of hot water and they wound up taking 250 00:15:02.080 --> 00:15:05.080 the cold shower until they feel that they're clean enough. 251 00:15:05.519 --> 00:15:11.039 You mentioned your one of your first patients had contamination OCD, 252 00:15:11.600 --> 00:15:15.799 but I understand there's a lot of flavors. As you mentioned, 253 00:15:15.840 --> 00:15:21.399 there's pure OCD, there's moral scrupulosity, there's checking OCD numbers, 254 00:15:21.519 --> 00:15:24.639 there's reassurance seeking. So there's a lot of different ways 255 00:15:24.679 --> 00:15:28.240 that the obsessions and compulsions show up. Can you talk 256 00:15:28.320 --> 00:15:34.360 a little bit about pure OCD versus contamination versus moral. 257 00:15:34.879 --> 00:15:37.000 Well, yeah, so again going back to the Y box, 258 00:15:37.080 --> 00:15:40.559 we had this first part where we do the symptom checklist, 259 00:15:40.679 --> 00:15:43.000 and when I worked out that with my colleagues, we 260 00:15:43.080 --> 00:15:46.759 saw hundreds of patients together and came up with a 261 00:15:46.840 --> 00:15:51.080 list of different categories. So different categories of obsessions include contamination, 262 00:15:52.000 --> 00:15:54.600 but also, like you mentioned, scrupulosity is a big one. 263 00:15:55.000 --> 00:15:59.039 It could be about taboo thoughts about religion or sexuality, 264 00:16:00.080 --> 00:16:03.200 unwanted aggressive thoughts, you know, fear that you would be 265 00:16:03.279 --> 00:16:06.840 responsible for harming somebody or harming yourself even though you 266 00:16:06.919 --> 00:16:10.759 don't want to. And there's a whole bunch of miscellaneous 267 00:16:10.840 --> 00:16:12.559 ones that can occur as well. 268 00:16:12.919 --> 00:16:14.799 So in response to those thoughts. 269 00:16:15.120 --> 00:16:20.159 And the compulsions are generally designed. Again, design is probably 270 00:16:20.200 --> 00:16:24.200 not the right word, but they're functionally connected to the 271 00:16:24.320 --> 00:16:27.840 obsessions that try to reduce them, and they're not always 272 00:16:27.879 --> 00:16:31.279 in the form of something like washing or contamination that 273 00:16:31.399 --> 00:16:34.480 you can observe. They can be if say, somebody has 274 00:16:34.559 --> 00:16:38.360 an intrusive thought of something terrible happening to a loved one. 275 00:16:39.200 --> 00:16:41.519 They could recite something in their head, or they can 276 00:16:41.639 --> 00:16:44.639 review something in their head and you can't see that, 277 00:16:45.159 --> 00:16:47.320 but we would count that as a compulsion as well. 278 00:16:47.919 --> 00:16:51.720 And via the paper Prevalence and Clinical Characteristics of Mental 279 00:16:51.840 --> 00:16:55.639 Rituals and Longitudinal Clinical Sample of Obsessive Compulsive Disorder in 280 00:16:55.720 --> 00:17:00.759 the Journal Depression Anxiety, there are overt and physical, which 281 00:17:00.759 --> 00:17:04.119 you're probably more familiar with, but there are also covert 282 00:17:04.440 --> 00:17:09.400 or mental compulsions with no behavioral signs, and those types 283 00:17:09.519 --> 00:17:14.160 of compulsions include acts like silently repeating words or phrases, 284 00:17:14.480 --> 00:17:18.519 or praying or counting, or mental checking or thinking of 285 00:17:18.720 --> 00:17:24.920 good or safe thoughts to neutralize distressing mental images, among others. Now, 286 00:17:25.640 --> 00:17:27.759 that has to be a slim majority, right, that has 287 00:17:27.839 --> 00:17:31.720 the covert kind right. Nope. So this paper cites research 288 00:17:31.920 --> 00:17:35.480 suggesting that as many of sixty percent of OCD patients 289 00:17:35.559 --> 00:17:40.440 present without overt compulsions, meaning the majority of folks with 290 00:17:40.559 --> 00:17:45.559 OCD may just be struggling internally with mental compulsions, trying 291 00:17:45.599 --> 00:17:48.920 to undo the obsessive thoughts with other thoughts. 292 00:17:49.559 --> 00:17:52.880 Now you mentioned about pure obsessions. Yeah, there was a 293 00:17:53.519 --> 00:17:56.799 country star talking about did you see this about the 294 00:17:56.920 --> 00:18:00.400 pure ocday? Oh? Okay, Oh I want met the name, 295 00:18:00.440 --> 00:18:01.160 but you can look it up. 296 00:18:01.400 --> 00:18:04.920 Okay. It's Luke Comb's and he's been super public about it, 297 00:18:05.119 --> 00:18:08.119 and an article in NBC News reported that Combs hopes 298 00:18:08.160 --> 00:18:11.599 to use his platform to support others facing similar struggles, 299 00:18:11.880 --> 00:18:14.799 and in a recent interview with sixty Minutes Australia, Luke 300 00:18:14.880 --> 00:18:18.599 Combs explained his experience that it's thoughts essentially that you 301 00:18:18.759 --> 00:18:21.079 don't want to have, and then they cause you stress, 302 00:18:21.160 --> 00:18:23.480 and then you're stressed out, and then the stress causes 303 00:18:23.519 --> 00:18:25.079 you to have more of the thoughts, and then you 304 00:18:25.200 --> 00:18:27.680 don't understand why you're having them, and you're trying to 305 00:18:27.720 --> 00:18:29.640 get rid of them, but trying to get rid of 306 00:18:29.720 --> 00:18:32.400 them makes you have more of them. So what is 307 00:18:32.720 --> 00:18:34.359 pure O? Just obsessions? 308 00:18:35.000 --> 00:18:37.640 And said that he had the form of pure OCD. 309 00:18:39.279 --> 00:18:43.119 It's a controversial entity. Most of us in the field 310 00:18:43.160 --> 00:18:47.920 who have seen a lot of OCD can identify mental 311 00:18:48.079 --> 00:18:51.519 rituals that patients perform when they have their intrusive thoughts. 312 00:18:51.519 --> 00:18:54.920 So I don't think pure oc Well, pure O is 313 00:18:55.000 --> 00:18:58.880 actually that common. I think most patients who have really 314 00:18:59.039 --> 00:19:02.799 a real case of O and they may not perform 315 00:19:03.119 --> 00:19:08.200 overt rituals, but they're probably doing something mentally to try 316 00:19:08.279 --> 00:19:13.200 to ameliorate the anxiety associated with their thoughts or their images. 317 00:19:13.799 --> 00:19:16.359 Oh got it. So pure O is just the obsessions, 318 00:19:16.839 --> 00:19:18.240 is what they're saying without compulsion. 319 00:19:18.480 --> 00:19:21.960 Yes, it's just the obsessions. Yeah, and the vast majority 320 00:19:22.039 --> 00:19:23.720 of patients with OCD you have both. 321 00:19:24.440 --> 00:19:28.400 So Goodman is iffy on pure O because again, compulsions 322 00:19:28.519 --> 00:19:31.720 to stop the obsessions can be covert or mental and 323 00:19:31.839 --> 00:19:36.039 not outwardly behavioral. But usually yes, the ways that you 324 00:19:36.319 --> 00:19:40.039 try to stop the obsessions are compulsions. The O and 325 00:19:40.119 --> 00:19:43.400 the C are the buddy comedy that you never asked for. 326 00:19:43.839 --> 00:19:45.839 And they seem to be functionally connected. 327 00:19:47.039 --> 00:19:49.839 So is it possible that some people might not realize 328 00:19:50.119 --> 00:19:54.000 the compulsions that they're even doing, and they might just think, Oh, 329 00:19:54.039 --> 00:19:57.880 because I'm not doing something physical, then I don't have 330 00:19:58.000 --> 00:19:59.400 a compulsion, right. 331 00:19:59.640 --> 00:20:02.400 They might think they hit pure o, which they probably don't. 332 00:20:02.960 --> 00:20:05.039 Oh that's interesting, Okay, I wasn't sure about that. 333 00:20:05.200 --> 00:20:05.400 Yeah. 334 00:20:05.559 --> 00:20:10.440 Now, what are some of the more overlooked types of 335 00:20:10.519 --> 00:20:13.799 OCD that you feel like the general public doesn't know 336 00:20:13.920 --> 00:20:16.559 much about. I feel like the ones I hear about 337 00:20:16.640 --> 00:20:19.680 a lot are contamination and checking, making sure that the 338 00:20:19.759 --> 00:20:23.359 curling irons unplugged, that everything's stove is off, that the 339 00:20:23.440 --> 00:20:26.640 front door is locked. You have difficulty believing that you've 340 00:20:26.759 --> 00:20:28.640 done those things, and so you have to keep checking. 341 00:20:29.119 --> 00:20:32.400 But can you elaborate on some of the other, maybe 342 00:20:32.519 --> 00:20:33.640 more overlooked ones. 343 00:20:34.319 --> 00:20:37.799 Yeah, there's a category we sometimes refer as just se 344 00:20:38.039 --> 00:20:42.240 or just write OCD where people have to repeat something 345 00:20:42.279 --> 00:20:45.839 I have patient recently who was looking at the clock, 346 00:20:45.960 --> 00:20:48.359 and she really wasn't looking to see what time it was. 347 00:20:49.119 --> 00:20:53.599 She had superstitious concerns about she had to watch the 348 00:20:53.720 --> 00:20:56.720 second hand of the clock and see it hit twelve, 349 00:20:57.559 --> 00:21:00.599 because otherwise she had had this thought if she doesn't 350 00:21:00.599 --> 00:21:04.000 see the twelve, something bad is going to happen to her. 351 00:21:04.960 --> 00:21:06.880 And the other things that she would do could be 352 00:21:07.079 --> 00:21:10.759 really random. She could just repeatedly touch something or repeat 353 00:21:10.839 --> 00:21:14.480 something and you wouldn't notice it. And I would ask her, 354 00:21:14.559 --> 00:21:16.759 how do you know when it's done? How do you 355 00:21:16.920 --> 00:21:19.920 know when you've done enough of these performed enough of 356 00:21:20.000 --> 00:21:23.039 these compulsions, And she would say, and to it feels 357 00:21:23.200 --> 00:21:26.680 just right. So it's kind of the just right feeling, 358 00:21:27.359 --> 00:21:30.680 and people have a hard time articulating that, but that's 359 00:21:30.720 --> 00:21:35.519 a common form that's often overlooked and just full disclosure. 360 00:21:35.640 --> 00:21:39.799 I was diagnosed two years ago with OCD. Never realized 361 00:21:39.839 --> 00:21:42.680 that I had it. I don't have a super severe case, 362 00:21:42.720 --> 00:21:44.240 but I look back and I'm like, I had some 363 00:21:44.440 --> 00:21:48.000 stationary that I've had for twenty years, and I was like, 364 00:21:48.119 --> 00:21:50.079 if I use the last piece of the stationary, my 365 00:21:50.160 --> 00:21:54.200 dad will die. Things that I didn't tell anyone that 366 00:21:54.319 --> 00:21:57.240 I that I even thought because it sounded bonkers, but 367 00:21:57.519 --> 00:21:59.480 I was very afraid that if I use that something 368 00:21:59.519 --> 00:22:03.160 bad would happen. Or I have terrible procrastination problems. I'm 369 00:22:03.240 --> 00:22:06.559 really avoidant because I'm always afraid of making a mistake, 370 00:22:06.599 --> 00:22:09.359 and then it'll lead to my downfall. My career will 371 00:22:09.400 --> 00:22:11.920 be over if I make one mistake. And so there's 372 00:22:12.279 --> 00:22:14.960 there's like a certain kind of magical thinking. 373 00:22:15.079 --> 00:22:18.200 It feels like, yeah, that's a good category too. Yeah, 374 00:22:18.319 --> 00:22:19.359 magical thinking. 375 00:22:19.960 --> 00:22:23.480 This feeling that you can maybe control the outcome of 376 00:22:23.559 --> 00:22:26.839 bad things and avoid them if you do something concrete 377 00:22:26.839 --> 00:22:27.200 about it. 378 00:22:27.440 --> 00:22:29.640 Yeah, even though you know it doesn't make any. 379 00:22:29.559 --> 00:22:31.640 Sense, right, Yeah, it doesn't make any sense. 380 00:22:31.680 --> 00:22:33.960 But you don't want to take a chance, exactly because 381 00:22:33.960 --> 00:22:36.599 the stakes are too high. Stakes are high, and the 382 00:22:36.720 --> 00:22:38.839 OCD is telling you to do it. 383 00:22:39.440 --> 00:22:42.200 Oh yeah, or not to do it right exactly because 384 00:22:42.480 --> 00:22:45.200 if it landed on you, you can never forgive yourself. 385 00:22:45.720 --> 00:22:47.400 But I feel like, you know, when you mentioned the 386 00:22:47.440 --> 00:22:49.920 contamination OCD with one of your first patients, worried about 387 00:22:49.960 --> 00:22:54.759 she would hurt someone else. It feels like the avoidance 388 00:22:54.799 --> 00:22:59.160 of a bad outcome can fuel a lot of obsessions 389 00:22:59.200 --> 00:23:02.119 and compulsions. Do you find that with a lot of 390 00:23:02.160 --> 00:23:02.720 your patients. 391 00:23:03.039 --> 00:23:05.839 Yeah, I think that's a universal. So again, we talked 392 00:23:05.839 --> 00:23:08.559 about all the kind of different forms of flavors of OCD, 393 00:23:09.400 --> 00:23:12.160 but I think most of them have in common that 394 00:23:12.480 --> 00:23:17.240 patients with OCD are harm avoidant. They're worried about some outcome. 395 00:23:17.359 --> 00:23:19.960 That outcome, you know, could be something happening to themselves 396 00:23:20.119 --> 00:23:23.400 or their loved ones, you know, failing at work, you know, 397 00:23:23.680 --> 00:23:27.559 or having their career go up in smoke. And we've 398 00:23:27.599 --> 00:23:30.720 talked about scrupulosity. It maybe something that's most dear to 399 00:23:30.839 --> 00:23:33.200 that particular person is the thing that they're going to 400 00:23:33.279 --> 00:23:34.160 worry about most. 401 00:23:34.759 --> 00:23:38.920