Good morning, Dr. Malesburg.
Good morning.
There's some tension in there, isn't there?
Oh, big time.
We won't talk about what it's about, but maybe the gentle and well-perceiving reader-listener can figure it out.
What's been going on? We just got into a screaming match, and I think I accidentally recorded it. Not for artistic reasons, but because I just hit play before we popped on.
Well, you could always make it into something artistic. But what are we talking about today?
Well, I think the purpose of our... One of the main theses of our podcast is a move away towards medications. Or not a move away towards medications, but not the artificial dichotomy of like our medications versus other interventions were better. But for some reason, there's a huge pull for us to do pharmacological episodes.
That's right. No matter how much... I'd prefer to not do that. You know, I did not think there's going to be so many people immediately going like, oh, yeah, OCD, psychopharmacology. But that's what happened. And there was even a comment expressing they felt robbed a bit last week, last couple weeks.
We did. I would say 95 percent of the comments were do do a pharmacological episode.
Mm hmm. Well, the people have spoken.
You know, it's funny. I actually, one of the main reasons I made Psychopharm, or at least my goal was to do pharmacology so well that I outdid a few of the other pharmacological things and then be like, I don't think medications are that, that good. Setting it up to knock it down. I'm exaggerating. I'm saying I, then just prioritizing the limitations of medications as I saw them.
Yeah.
Well, on that note, I was listening to the NEI podcast, and one way to draw viewers is to create conflict. So I did want to bash NEI, who I do really appreciate. I think they do great work. But they're farm heavy. And I was listening, and they were talking about the Sigma-1 receptor. And some direct quotes are, the Sigma-1 receptor is sexy. And one of the people there has an unnatural love for the Sigma-1 receptor.
And that gets me heated.
You know, I've been surprised how few residents actually know about the whole Sigma grind set thing, because I've tried to bring it up as a joke and mnemonic for Luvox fluvoxamine, given its unique Sigma receptor action. But majority of residents are not terminally online. They had no idea what that meant even. So it didn't work.
Yeah. Can you walk us through what the Sigma grind set is?
I mean, I don't know for sure, but my understanding is that it's from the people online who believe a lot in alpha versus beta males, you know, some kind of a ranking of males, kind of like how the wolves supposedly have certain roles where there's alpha wolf, beta wolf, whatever. And then they came up with some kind of sigma role in society where you're kind of this cool, aloof outsider type who goes his own way, but is also still cool and awesome, even though he's not real alpha.
Well, I guess that's the fluvoxamine SSRIs.
Yeah, I mean, it fits perfect because for the listeners, Sigma-1's a receptor that's like in a few random medications and no one has any clue what the hell it does. And now all of a sudden they're talking about it as if it's like this sexy receptor. And I was telling you my crackpot theories is whenever I hear them like talking up this receptor is like this sleek, sexy, cognitive receptor, there's going to be an antipsychotic release that hits it.
And someone's got a lot of money in it.
Oh, yeah. Well, you know, I always get excited for a new antipsychotic anyway, even though it means that I won't be able to use it for another seven to eight years until some kind of a generic form hits. Though actually, more recently, community mental health centers seem like they've been negotiating with the companies to get early access to some of the, you know, non-generic medications like cobenphy is actually accessible uh with minimal fuss uh in my area for my community mental health center
Yeah, I mean, that'd be super exciting to be able to use that in any patient. Have you used it yet? I haven't used it yet. I've seen one patient on it that I didn't put them on, but I assessed them.
I was asked to opine on it by a judge just right after release. Had to use generalities, no personal experience.
Just very, very vague. Mm-hmm. i do want to talk the reason why i have an issue with why you know the sigma 1 receptor is sexy or why 5ht7 is a cognitive enhancer there's something called Algernon's Law. And this is like not a serious thing, but you know, it's that any major biological tweak that looks unambiguously beneficial must pay a hidden cost or evolution would have installed it.
And the gist is that when it comes to receptors, there's no such thing as a free lunch. Like you can't, there's not a receptor that like, oh, you just, you flick this on or you block this receptor and it's all benefits. There has to be trade-offs for anything. Otherwise, evolution would have installed it in us.
You know, that's interesting. I think a lot of people don't think about conflict systems that way. It can explain a lot of ideology out there that There's a group of people who think that a complex system is a certain way, a bad way, because of the actions of you small people and that if you shift those actions, if you just make certain steps, everything can and will be better, right?
And then there are people who believe that complex systems are the way they are because that's pretty much the, let's call it, lowest level. It's the lowest stable configuration for that system without having to put in more energy or having to shift energy or directionality around. Right. Just like how a bubble is the structure that forms because it's the lowest energy state. we can have a long debate with probably very different people than us about which one is to correct the view.
But I am of the camp that systems are the way they are for a reason. And so anytime you make a change, there's some kind of sacrifice. There's a balance, exactly as you said.
Yeah. To expand what you're saying, there's major feedback loops that keep the system in homeostasis. And it's not ever... These are nodes with top-down... Bottom-up input, top-down change. Like, there's no one little knob that you flick it and everything works. There's a ton of mechanisms and things built in so that... Yeah. Yeah. And any particular node is a part, like you said, part of a much bigger system that you address.
Some listeners like when we reference Lacan, it reminds me of the objet petit A, right? We always imagine that there's this one thing. If we get it, everything's going to be whole and good. But if something always drops out, man, it's never going to be complete. I'm pessimistic. Okay, I think this has been too much philosophy. Should we get to the medication?
All right, right, right, right. So let's talk. We'll start how we do in general where I give you the super basic algorithm and then we jazz on it. Okay. So I guess let's just general medication principles for OCD. First, you tend to continue treatment for about a year after you start any sort of medication. Higher doses tend to work better. A little bit controversial. We got a little pushback on that, but we're sticking to it.
A trial for OCD is a little bit longer than in depression. Typically, you want to wait about eight weeks to see a full effect. There's no need to extend unnecessarily, but the gist is that response might be a little bit longer than you would see for depression. This is a big one, expectations for medications. So... People need to be taught, both clinicians and patients, that OCD medications are expected to reduce symptoms somewhere in the range of 30 to 40 percent.
We're not curing OCD. We're not getting rid of their symptoms. We're reducing them so they can better engage in therapeutic interventions.
Absolutely. From a Y-Box standpoint, if I see a six to eight point reduction, I'm very happy. You know, yeah, we got a lot of dissent, I think, from the last episode about the classic super therapeutic dosing that is above the FDA general levels dosing of SSRIs in OCD. I'm still a believer of this, but I think we should have a caveat. It's a problem to be up titrating medications up to the FDA limits or even beyond for any class if you are not being relatively regimented, in my opinion, about assessing for symptoms.
And so no matter your... psychopathology that you're treating, I do suggest that you use some kind of a objectively subjective measure. So for OCD, please get a Weibach score of some kind, track it across visits, see if it's changing over time with increased doses, even though it takes a longer time, maybe for anxiety and OCD to respond to SSRI medication. I suggest that you still should expect some improvement.
within the first four to eight weeks for each dose step.
Yeah, and maybe to expand, whenever we're talking about like, I expect higher doses or this is responsive at low doses, the patient in front of you is all that matters. So you don't, if I say, when I say OCD might require higher doses, that doesn't mean you instinctively titrate straight to the higher dose. You're following comments. It's just in populations of people. In general, OCD will require a higher dose than depression.
And you still have to follow common sense regarding side effects and tolerability. And as we know, like 100 milligrams of Zoloft is not the same across different people. There's people who 50 milligrams of Zoloft is their blood level is higher than other people at a much, much higher dose. So it's just in terms of expectations and how to approach. I've had tons of patients who have been on the lowest minimal effective dose of an SSRI and had incredible results.
So the point is like this has to do with your expectations and your willingness to continue increasing the dose. It doesn't mean you instinctively just plow right through it.
Yeah, exactly. And I guess one more caveat while we're on the first step of medication treatment for OCD is to reemphasize. Don't mistake the medication for the treatment. The medication facilitates the treatment. It reduces the symptoms. The primary treatment is psychological behavioral for OCD as far as we know it. ERP, whatever, some kind of a targeted psychotherapy that directly addresses obsessions and compulsions. Or you may be leading patient into further disability and impairment based on the OCD.
To repeat that in just different language, the first step of my algorithm is always that exposure response prevention is first step and med equations should be used if the symptoms are severe or the patient is unwilling to do therapy. And I'm not just throwing lip service to that. I've had a lot of my intakes end with me not prescribing a medication and end with me saying, I appreciate that you met with me as a psychiatrist.
Let's find you a therapist. I'll assist you in finding a therapist. And if that fails or there's issues, you give me a call back and we get you back in an appointment. Some patients or some some providers think like, oh, well, no, I need to. No, you don't need to prescribe a medication. You do what's right for the patient. If you're at a clinic where they say you need to prescribe a medication or the patient has OCD, they need a medication.
Get the hell out of that clinic.
Or at least try to see if you can shift how they think about it, I suppose.
Of course.
Should we mention inference-based CBT? There's like one guy on Reddit who always posts about it.
Yeah, give us some of it.
So inference-based CBT is this interesting new version of CBT that is supposed to be geared towards the treatment of OCD specifically, but without exposure and response prevention. The idea is to identify the incorrect thoughts that generate the obsession. I'm not trained in this, by the way. This is what I picked up from reading about it. Identify the incorrect thoughts that generate the obsession and then find the deeper fundamental assumptions, biases, ways of viewing the self and others that generate those errors and that obsession.
Amusingly to me, one of the websites about inference-based CBT features a picture of an iceberg, which if you've received any education in psychodynamic psychotherapy and psychoanalysis, it's the classic figure to demonstrate the unconscious. And personally, I find that this particular approach bears suspicious resemblance to psychodynamic psychotherapy for ocd uh but you know whatever the more modalities that we can train people in to help people i'm happy so you could consider it for somebody who is not able or willing to engage in erp inference-based cbt if you can find a practitioner near you you know i think you
might have even made this joke it just feels like a lot of um like trauma and CBT, like they're reverse engineering psychodynamics and psychoanalytic principles. And they're building them from new parts and then acting as if it's something different.
Yeah. Though I think psychoanalysis is not to be spared from criticism here. I think that this happens because theorists, analysts, clinicians in that field got way too entrenched in their particular area. almost got into kind of like an arms race of being esoteric and special in order to be more recognized and seen as intellectual. I think there's a dearth of discussion of psychodynamic principles in plain language and for ordinary people.
And that's why the field probably moved away and went into CBT.
Absolutely. And you experience that. I mean, if you're ever inpatient and call a entrenched psychoanalytic practitioner and you give them a call and they say, you really need to work on their mother complex. And you're like, you don't get it.
Only in New York. Only in New York. Okay.
Back to psychophoncology. Step one. Yeah. Therapy is typically better than medications. We reserve medications for when symptoms are severe or the patient is unwilling to do therapy. I actually don't like to use the word unwilling. Patient, for whatever reason, their values makes it so they want to try a medication before, you know, instead of fully engaging in therapy. After that, your initial medication, SSRI is first line.
In terms of the... I mean, should I talk about the FDA approved options? I feel like that gives like...
I'd rather not. Maybe we should just say what we like to use first. Similarly to anxiety and depressive disorders, I like to use Zoloft or Lexapro because they tend to have less med-med interactions, but really any SSRI is fine. I avoid Paxil because Paxil tends to cause weight gain.
Yep, and I have the exact same approach.
Now, how about the Sigma Grindset SSRI? It is Luvox. Is Luvox more effective in OCD? Fluvoxamine for the international viewers.
No matter what we say, we're going to get pushback.
That's true. But what do you think the evidence shows, Dr. Malesberg?
I think that the evidence can be pushed either way in terms of when you look at the different studies. Like I can... I can argue for either of them, but people who are smarter than me and have more experience in this area tend to believe in Luvox. So whenever I feel like the data is equivocal, I look at people who do this more than often, who see more patients than me and emulate what they do.
Yeah. You know, I do a funny thing. I don't believe that's more effective across studies. Yet, when my patient with OCD has failed one or two SSRIs, I go to Lubox. Oh, yeah. So it's like I don't believe in it, but I still practice it. I suspect that it's because... just whatever process they engaged in to set the fda maximum for luvox allows us to get to a reasonable dose for ocd treatment compared to other ones other ssris which are their dose ranges are tailored by the fda for depression anxiety um so yeah
let's let's talk about Okay, so you mentioned, yeah, I think we actually talked about last time that my typical algorithm is use an SSRI. If that doesn't work, then you have a few options. So let's say you start off with a Zoloft. And if you have a partial response, you can consider raising to a super therapeutic dose. Yeah. If you feel like you want to switch for whatever reason, then I typically switch to Luvox.
So I typically go, yeah, Zoloft, your Lexapro, then Luvox is my typical algorithm. But again, it's impossible to give a perfect one because it's like, let's say there's a partial response and I want to keep pushing up to higher doses versus I get to a reasonable dose and I see nothing, then I would just switch to Luvox.
Now, what do you think we should talk about next? Augmentation strategies or approaches to unique comorbidities?
let's why don't i i'll do a quick like augmentation strategy and then uh we can riff and then you can talk about comorbidities okay um sounds good so let's say you have a partial response or you want to augment like you you know you've tried zoloft then you're at luvox and the patients you still want to do something um there's a here we're moving away from evidence in regards to what you pick like it's kind of as you said like this isn't there's not an evidence-based clear next step uh you have a few options um
We're in Wild West land. I think everyone has a different tree algorithm tree for how to approach treatment resistant, so to speak, OCD.
So I'm going to I'm just going to give all the reasonable options because whatever if you if you made an algorithm, you're going to get a pushback. One option is TMS. And that, in my opinion, is that that's probably the direction I would go. I don't know if I now work at a TMS clinic, so I probably have some biases towards using TMS.
As someone without the bias, I think I'll give a caveat. It has to be a TMS clinic that is sufficiently sophisticated that they use the right kind of TMS. I believe that the more modern TMS strategy is the one that has any efficacy in OCD compared to the traditional one. So if you're with a TMS clinic that only uses the older machines and protocol, I don't think it'll work.
Correct me if I'm wrong. Do you know about this? I only know about this vaguely from a few grand rounds.
Yeah, maybe maybe I'll give a quick three minute cap so that people understand this.
Yeah.
So so when it comes to so you don't just say like TMS, TMS would be like saying like, oh, does does schizophrenia require medication like TMS when it comes to FDA clearance? It's actually not FDA approval. It's clearance because it's a device. The clearance has to do with a particular protocol and a particular machine. So it's not that TMS is approved for OCD. It's actually a Brainsway H7 coil.
that's used at a certain protocol with an ERP intervention. And I can like break down everything I kind of just said a little bit slower. So the H7 coil, there's different coils that you put on your head for different TMS machines. H7 is a helmet and it does what's called deep TMS. So it penetrates a little bit deeper than your other other machines. The FDA clearance is as an adjunct treatment of OCD in adults.
So it's adjunctive for the FDA clearance. The protocol includes a small little ERP intervention. So the patient is supposed to be guided to do something that triggers their obsessions while refraining from doing any ritual. So you're supposed to get them to a SUDS, the subjective unit of distress, to a four to a seven and then have them not engage in the ritual that they do for whatever that distressing thing is.
And you do that for three to five minutes before the TMS treatment. As you said, this is a particular type of TMS and it needs to be done well at a particular clinic. It's not just like equal that like you just throw them in TMS and they get it done.
yeah can't just go to the random tms clinic opened by an anesthesiologist downtown
correct um all right uh medications oh okay so one other little axe to grind in residency tms to me was grouped in like the like psychosurgery category it's like you can have a lobotomy or tms and it's like tms is infinitely more safe and infinitely less invasive to uh psychosurgery um So to me, after, you know, the first, the SSRIs don't work, Luvox doesn't work. I think TMS is next, but that's, again, I might be a little bit biased.
Other options.
Not available in a lot of areas though, unfortunately.
Other options for augmentation, second gen antipsychotics. We're usually talking about low doses of Abilify or Risperidone. One thing that's super important to keep in mind, and I think we're planning on talking about it later, is that antipsychotics, especially the pines. So I'm talking about like clozapine, olanzapine, can exacerbate or cause new onset OCD symptoms. And I looked it up. It's much higher than I expected.
Compulsive symptoms.
The percentages, I saw one thing that's a 25% of claspine treated patients experience new onset OCD symptoms, which is crazy.
Yeah, it's a mysterious thing. It's a mysterious thing. I kind of wonder, I'm not all that convinced that it's the medication effect. Obviously, the data suggests it. I sort of wonder if it's actually from the general comorbidity of psychotic disorders, bipolar disorders, autism and OCD that if you look at forget what they're being treated with, the incidence of obsessions and compulsions is higher in people with a primary psychotic disorder.
Right. The people with the most severe primary psychotic disorders are going to be treated with the pines. olanzapine clozapine right i i wonder if it's a confounding like that that's hard to pick out the data but we don't really know you should be careful um there's a likelihood that it can worsen compulsions compulsive behaviors so you should monitor for that
awesome um so that's the so we talked about tms second gen antipsychotics other option is clomipramine um which is yeah i would have put that one before the antipsychotics person yeah and it's yeah i apologize i'm glad you said that because
this is a lot of people and i would say that say that is common practice in community that people reach for antipsychotic first because they're so used to it now right we're all primed to using the antipsychotic as augmentation depression anxiety even Uh, that people are really comfortable with it. And by the way, I guess I should mention you can use things other than Abilify and Risperbol, right?
You almost, we don't know how these work. I like to use the ones that have bipolar depression advocacy, um, out of almost a cargo fault, like, uh, feeling that maybe it'll help them because depression is often comorbid mostly deep, but yeah, uh, Bilify is a relatively safe choice. Um, I usually reach for that one first.
Yeah, and as you said, clomipramine is very... I feel like now residents are just more comfortable using antipsychotics, and the quote-unquote older medications of the TCAs and MAOIs were just less comfortable using. So it's natural that it's used less, but I think that's unfortunate. Yeah. So maybe I can... Now... Should I give a little spiel about clomipramine? Yeah, yeah, let's do that. So the TCAs, I'm trying to think of how much I want to go into the TCAs.
So clomipramine is the most serotonergic TCA. So it consists of clomipramine, and then it's broken down by CYP1A2 into norclomipramine. So... Norclomiprimine is a secondary TCA, so it's less serotonergic. And maybe I can give a little spiel, a little memory thing to help people understand secondary first tertiary. I don't think this will make sense the first time you hear it, but once you get it, I think this will be helpful.
So there's secondary and tertiary TCAs. The secondary TCAs are mostly noradrenergic. And that's why you, and it also has the names, the nor prefix. So nor clomipramine, nor tryptaline. I think of them as essentially it's norepinephrine dominant SNRIs. Tertiary TCAs are hit the noradrenergic and other receptors. So I think of like three is bigger than two. So it's like the secondary TCA with additional mechanisms. So it also has more serotonergic activity, histaminergic, cholinergic, and alpha adrenergic.
then chlamypramine is the most serotonergic of the tertiary TCAs. Yeah, I don't know if that's my little spiel.
Nothing's good. Good mnemonic. I'll be honest with you. I probably forgot most of that stuff after boards. I just reached for a clomipramine because, as you say, it's the most serotonergic understood to be. I think that if you're not improving on clomipramine, either as an add-on or as a monotherapy, you're probably not going to respond to the other TCAs anyway, and we should probably avoid the side effects because lots of side effects to the TCAs.
Strong anticholinergic effects, QTC prolongation, very sedating. weight gain. So not necessarily the greatest choice, but if it's viable, you can consider it. Some people augment with it. They add to an SSRI. I'm not a believer in that. I will switch off and only give the TCA, give it a good trial. If it's not considerably better in the Y box compared to other things, personally, I will just try to go back to SSRI and make do with other augmentation strategies and psychotherapy.
Yeah, I guess the reason I bring it up, and this might be actually clinically helpful. So the tertiary TCAs are broken down into the secondary TCAs. So clomipramine is broken down into norclomipramine. And it's that, because we know OCD responds to more serotonergic mechanisms, there's a push to wanting to keep it as clomipramine. And that's the logic behind adding fluvox. So fluvoxamine is a CYP1A2 inhibitor. So if you inhibit CYP1A2, you're going to increase the ratio of the serotonergic clomipramine and theoretically get more of that serotonergic activity that's better for OCD.
So some people combine the clomipramine with the Luvox with the intention of increasing that serotonergic mechanism. Now, if this is the first time you're hearing about it, it's a very risky combination. You're using two serotonergic medications. Listening to this podcast does not prepare you to use that medication.
Yes. But thank you for mentioning it. I forgot that that is the one SSRI and TCA combo that I would say has at least a mechanistic rationale for that you can consider use of. I still consider this kind of thing a little bit um you know iffy personally for my practice i don't know if it's worth it but for a very refractory case as an ocd specialist i'm sure it's bread and butter uh just monitor carefully and warn and monitor for serotonin syndrome you know you can see signs of serotonergic overload even without a full serotonin syndrome you know things like tremors clonus uh you can do that on a physical exam Awesome.
So, so far we talked about TMS, we talked about the second gen antipsychotics, we talked about clomipramine plus or minus Luvox. The next set of potential augmentation options are the, you know, quote unquote novel mechanisms, which tends to be glutaminergic. So there, Lamotrigine is a reasonable option. N-acetylcysteine is particularly good, especially with skin picking. That's a supplement. It's not a prescribed medication. I've been reading more and more about Ondansetron as potentially one of the most effective add-ons for OCD.
Don't forget good old Buspar. You know, we're Buspar fans here.
I saw, I think, I'm not quite, maybe it was CanMat. Was it CanMat or something else? But they said the ones that were not recommended and that, like, there's evidence against them working are buspirone, benzos, lithium, and gabapentin.
I don't know about the signal for the BUSPAR. I'm going to have to look at those studies. But I think mechanistically and experientially, totally worth an add-on for almost any kind of neurotic illness. It's very low risk and within the FDA limits and relatively well-tolerated, not a lot of side effects. So I would disagree with that unless I see some pretty strong evidence. We should name the glutamatergic meds, right?
People don't know them necessarily.
So, yeah, I included Lamotrigine and NSEL cysteine in terms of they have some glutaminergic mechanisms, but also Memantine, Amantadine, and then a medication that I remember as from you probably don't know what Sketchy Farm is, but Reluzol, which is used for ALS, which I've obviously never used because I can't even pronounce it. And I doubt I'll ever use it.
Yeah. Personally, I draw back a little bit from using meds that I don't use in other contexts. I've used, so I am comfortable with NAC. I'm comfortable with Memantine. I'm comfortable with Modansetron and Buspirone. Personally, I would have to look into or or however you say it. But again, we're shooting in the dark here. This is beyond the typical, this is for a patient who really isn't responding.
It's something to consider. And personally, when it comes to augmentation, I actually would probably, I like to think it along two lines. You have your primary treatment med for the OCD and then you have augmentation. So for me, clomipramine and Luvox are still within the primary treatment arm. And then for augmentation, I like to go from least harmful to most harmful. So that's why I would start with things like NAC, Buspar, Odansetron, and then I would end with things like the antipsychotics.
But people, you can take your pick about how you're going to approach this.
And then the only other thing I think is worth mentioning, not medication, is moderate intensity aerobic exercise. That's really good data. Obviously, not an easy thing to get people to do, but worth mentioning for sure.
We should probably talk about how to get NAC and how to dose it.
Actually, my partner made a wonderful little one-page sheet that I can include in terms of like it's a little, you know, it's almost like a stall-esque kind of thing on how to use it.
Yeah, put it in the description, but we should talk about it too, right?
Yeah. Also, maybe another plug. Whenever there's a supplement and I'm not 100% how to use it or what the best supplement is, Chris Aiken's website just has spectacular resources. He's got nice little one-page sheets that review how to use it and then his recommendation for which one to order on Amazon.
Yeah. So you got to identify a reliable source and this is going to just change year to year. Right. I don't know. These days I'm a little suspicious of Amazon, even though I'm a shareholder when I buy my own supplements, if any. I will get them from iHerb or some other website. I just go on Reddit and see what the supplement fans are buying from. In terms of dosing, I go off of the available studies for NAC and OCD, and I usually target something between
4 to 3 grams of NAC. I have had patients complain of the taste or smell, though, so... some people may not tolerate it i don't want people buying huge amounts of a supplement that may not help them or they may not tolerate so i usually recommend that they find the smaller supply of it and add it on i also recommend that for supplements you pick and stick with one brand because it's a highly unregulated area You don't know what you're getting necessarily.
You should try to just normalize things and keep it steady the best you can. So pick one brand. Hopefully it's reliable. You can look for consumer labs that I've tested them and see where it goes and track that white box.
Yeah, it's been a minute since I've looked in to the best supplements, but I tend to use for NAC the Now Foods 600 milligram. I usually start with two of the 600 milligrams and then go up to 1,200 milligrams twice a day after a few weeks once it's tolerated.
Yep. You know, we should talk about adverse effects, I guess, if no one's tried NAC before. Other than smell and taste, there's not a whole lot of adverse effects from NAC. The main risk is allergy, like any other medication, allergic reaction. So as long as it's tolerated, you know, it should be relatively fine to dose up to the standard range.
Now, see, I, I've seen a lot of GI distress and I've read about like, and I don't even know if I haven't looked into the depth of this, but like histaminergic, uh, response, like for these, these are very like unscientific things, but people who have like histaminergic intolerance, um, having like flushing and just general like histamine response.
Yeah, I mean, that is possible. I haven't seen it personally, but I don't know if that's the NAC or it's like the preparation or the capsules or something. It's so unregulated. So, yeah, I mean, standard principles. If someone's not tolerating a medication, don't keep pushing it. Don't keep trying it. And I guess in a way, NAC is a little bit less preferred because you've got to go out of pocket for it, right?
If you can get Ondansetran and you're comfortable prescribing it, i believe it's six eight milligrams for augmentation uh might be better idea um i
think we covered all the major strategies um my brain just randomly popped up and i think you watch probably less uh true crime documentaries than i do i just remembered um i don't find it worth mentioning do you have a nexium the keith ranieri cult
Oh, not in any specifics, just by name.
Tell us more. I didn't say this with a prepared response that makes any sense, but I just remember they were using... neurolinguistic programming, which I think is some like CBT offshoot. And they cured people's OCD.
Oh, I don't think we should call that CBT offshoot. That's slandering CBT. I don't think it is a CBT offshoot. I remember being popular because pickup artist culture was into it back in the 2000s or something, maybe.
Yeah, I don't know. I just I thought if any of its efficacy came from its use of CBT principles and everything else was pseudoscience. That was my very superficial understanding of what it was.
Wait, but how's that related to OCD pharmacology?
The documentary I watched, the Nexium, which was a horrific cult, they drew people in by curing OCD through the neuro-linguistic programming.
Oh, really? That's quite interesting. Specifically OCD?
Whatever it was, I think they just had one spokesperson who had their... I thought it was OCD. Maybe it was Tourette's. I think it was just that kind of... Tick disorders? Yeah.
Well, that's just awful.
That's just terrible. Third line is join a cult.
I think the real third line is deep brain stimulation. Psychosurgery. I do not recommend it.
Should I explicitly say don't join a cult? Don't join a cult.
Do not join a cult, please. But yeah, like you can do really in the era of deep brain TMS, I think you really do that first. Go looking for that if you're bad enough. But yeah, there are people with extremely severe OCD, you know, almost basically stuck at home. They require home visits from therapists. You know, when we're getting to that level of impairment, you do begin to consider, you know, implant treatments or vagal nerve stimulation type stuff.
I believe there's vagal nerve stimulation for OCD, isn't there?
I don't have experience in this.
Yeah, this is not my area. Look at that, folks. Look at that.
Have you seen the have you seen anyone get deep brain stimulation?
I haven't seen it personally. Yeah. It's it's it's neurosurgery area and I don't know any neurosurgeons. It is possible. They've done studies. You could. There are side effects.
Yeah.
Be careful.
All right. Now, I think you want to I want to circle back to what you mentioned earlier is the thinking more about comorbidities.
Oh, yes. I was thinking that we're done. But no, common challenging comorbidities. I think one of the ones that you can see is where the person that has OCD has near delusional lack of insight and maybe even some flattened affect. And you begin to wonder, is there a psychotic disorder? Right. And sometimes they do develop a psychotic disorder. I have seen that. This is a challenging area.
I think, again, we are touching upon our inability as a field to correctly capture the crossover genetic risk between psychotic disorders, bipolar disorders, OCD and autism. I would just do a careful eval on those. Um, very possible to have comorbidity. I would try to track the course of illness and see if there's any particular thing that seems primary. Did you miss or did people miss autistic traits or disorder, uh, early on?
When was the onset of the OCD? Does there seem to be a developing psychotic or mood disorder component on top of that? Uh, Unfortunately, for this particular group, antipsychotic augmentation or antipsychotic and mood stabilizer primary treatment, if it seems to be a bipolar consideration, may be necessary. And be extra careful about what we mentioned earlier, the induction of compulsive behaviors or compulsivity or obsessionality with antipsychotic treatments.
So I guess you're saying if you were to dive into it deeper and feel that the OCD was somewhat secondary, you should be treating the primary psychotic or mood disorder like that. Thinking through that approach more so than thinking through the OCD approach.
Mm-hmm. Yeah. And then when you have a clear diagnosable bipolar disorder, that's when we get into an awkward situation. I'm of the camp that anyone with a manic depressive illness bipolar disorder, regardless of their comorbidities, should not be treated with an SRI whenever possible. Okay, whenever possible. Unfortunately, sometimes you can give antipsychotic and mood stabilization regimen for these patients, and they're still going to be quite symptomatic with their OCD symptoms.
But a lot of the time, I have found that if you adequately treat both poles of the bipolar disorder, the OCD becomes pretty mild. Even if it still remains, it may even not meet criteria for OCD anymore, or it can be OCD mild and you can definitely address it once they're mood stable with ERP or another psychotherapy. That's what I usually recommend. But if you must, you can trial low doses of serotonergic medication.
But only, in my opinion, on top of a adequately mood stabilized picture, usually a good mood stabilizer plus a bipolar depression active antipsychotic or Abilify, again, because it's a pretty decent one in the evidence. or not decent, at least has some evidence in OCD. But be careful. Reassess, reassess. Look for the sleep patterns. Look for any agitation. You might need to pull off the serotonergic medication. I'd rather do buce bar, personally.
To repeat that, which I feel like I'm repeating the same thing I said before, if you have a patient with bipolar and you see emerging OCD symptoms, really make sure to look at the underlying mood potential stuff going on and make sure that's treated. And often, once you take care of that stuff, the OCD stuff will clear on its own. Now, let's say you've looked in, there's none of that underlying mood stuff.
If a patient is well controlled or has good mood stabilizers on board, you can consider a low SSRI. SSRI at the lowest dose possible.
And maybe temporary. What about apparent obsessionality that may be better attributed to a personality disorder?
What about it?
What would you do with that?
Oh, God.
Well, I think most people miss the personality component, attribute all of it to OCD proper, which, again, in my opinion, is more of a neurobiological illness, and then just slam a bunch of medications on there. I think you need to be sensitive to the possibility of personality pathology as a real comorbidity or even as the main cause of obsessionality. I see this most often in reported obsessions.
People with cluster B pathology or other kinds of pathology may report having a lot of obsessions and compulsions, but if you actually drill down and examine in detail the time spent, the cognition surrounding, impulses surrounding these obsessions and compulsions, they are not really OCD. OCD properly should have recurrent intrusive obsessions that are paired to some kind of a mental or physically acting compulsion that is not satisfying know or minimally satisfying or requires a lot of repetition and often takes at least an hour a day of the obsessions and compulsions when there's personality pathology let's take for example obsessive compulsive personality disorder they're pretty satisfied they don't have to repeat very much they may be rigid but they're quite satisfied alternatively um for borderline conditions i find that the obsessions and compulsions are over reported almost as a way of communicating distress to the clinician and if you look at how much time is being spent on it it's there but it's relatively minimal almost to the range of normal and what's really causing the impairments and the problems and the distress are other kinds of symptoms that are related to their perception of themselves and their interactions with others
Yeah, this actually reminds me, everyone's got different failure modes. And as you kind of say, if you're too steeped into one way of thinking, then everyone's got a failure mode. And I think I talked a little bit about a case of OCD that I missed. And I think my failure mode is the... inverse of what you were saying and that i conceptualized him as prime i'm going to change the details very a ton of the details so that it's not actually the you know the gist of the case is true um i conceptualized him as a personality disorder he was a very violent guy with a violent history and he kept reporting um having intrusive thoughts of wanting to beat people up on the street and because i conceptualized him so much as a personality disorder i uh didn't i don't think i gave those symptoms the uh attention that they deserved because i i in my head was like oh these are these are violent impulses um this is this is you know this is a part of his personality and then it was only a few years i i think a lot about my cases and like a year after the case um i thought more about it and i was treating someone else with ocd and and the symptoms like were so similar to that other person that i was like oh i think i probably missed addressing those ocd symptoms because i had such a And again, we're kind of talking...
I agree with you that most people don't include personality nearly enough in their formulations. I think my failure mode is sometimes to do it too much.
Yeah, absolutely. And, you know, very easy for any condition, for any condition to make that kind of error. Our priors completely dictate what we can or can't perceive. Generally speaking, what I would say is that... people who have a lot of violent impulses that is fundamentally related to personality tends to be ego syntonic it tends to be ego syntonic you should examine when there seems to be some kind of a distress or if there's not a clear link to a secondary gain Uh, or if it's not fitting that kind of intermittent explosive picture.
Um, yeah, that's the thing about obsessions and compulsions. There's so many different ones and they can seem like other conditions as well.
Yeah. Um, I think we're getting close to wrapping up on time. Was there any other, um, you know, major concepts you wanted to discuss or other comorbidities you wanted to discuss?
not that comes to mind and i think that covers it for most of what people do for psychopharm stuff again beyond the standard ssri treatment we don't have a lot of good evidence you know and as we've seen certain uh commenters don't even believe in the traditional super therapeutic dosing even though i do i think you do as well um evaluate and treat the patient and friendly
is of course the standard fantastic all right um i think let's call it
All right. See you next time.
Later.