Are you more of a cat or a dog person?
Cat or dog person? Where's this one going? Cat, I would say. Sorry to the dog people. I love dogs as well. But don't you feel like there's a certain psychological relationship with a dog that doesn't exist with a cat?
In what way?
I'm not going to elaborate. I think it would be offensive.
That's funny because I was thinking that about the relationship with horses and it was going to be even more offensive.
That's a completely different topic. We're definitely not going to go there.
We're not going to. And then yesterday I was watching The Shark Whisperer. And Ocean Ramsey has this weird relationship with sharks. Okay. That's for another day, too. We don't want to be offensive.
I didn't know you could whisper to sharks. Can you whisper underwater?
You can whisper. But I bring this up because the last two weeks we've been taking care of a cat. And it scratches at the door in the morning. to try to wake us up and we've intentionally been ignoring its scratches and i feel like it's a very nice metaphor for one of our topic today how so well so it scratches at our door at like 5 m and we choose not to open the door and ignore it and over time it's been scratching at the door less and it's been come we haven't been waking up and it's
And that's a metaphor for exposure and response prevention?
I don't know if that's enough.
Well, we'll talk about why.
Oh, come on. You never give me anything.
I give you some things. You give me some things. I give you some things.
You give me some things, but it doesn't feel good because you overcompensate. Like, I'll say something that's totally average and you'll go, like, great job. And I'll go, like, you're just making up for giving me s*** for something that wasn't that bad of a job.
Well, I don't think that's what's happening. Maybe those things that you find mundane are excellent.
So what are we talking about today? We're talking about OCD.
Obsessive compulsive disorder. Often misunderstood, often not detected, difficult to treat, contentious area. What are your thoughts on OCD?
Yeah, I agree. I think it's partially overdiagnosed, partially underdiagnosed. Yeah. I had a few cases that it was blaring OCD and I missed them. And that like in residency, looking back, it's like, I'm like, how did I like if you have a formulation that's different from OCD, you can kind of get wrapped up into, you know, totally missing something that's very obvious.
For the cases where you think you missed it, did you change your mind about the OCD while still in treatment with the patient? Or is that a retrospective review?
Retrospective review.
I'd like to hear about that. I think it's important to note that you touch on something very important. I don't know if anyone has seen the video where, I mean, this is going to spoil it, but you watch for how many times these people are passing a basketball, right? And then afterwards, you're asked to watch again, and then you will notice that there's a dude in that gorilla suit throughout that whole video that you wouldn't have seen the first time.
almost all experience seems to work that way, that our prior expectations actually gate what we are able to even perceive in the first place. So I think that in many areas there's insufficient education on OCD and its diagnosis, and that basically makes it hide in plain sight for many, many cases. It's extremely common. I believe there have been a couple of studies showing that the time from first contact with a mental health professional to diagnosis in OCD is about seven years, seven or eight years.
Very long time.
Yeah, I remember watching that little, you know, the gorilla that comes in while the ball is passing. It's like 101 class. Yeah, I missed him. I missed the gorilla.
Yeah, we miss gorillas all the time. We got to be aware of that.
So why don't I start off with just the basic, kind of going over the DSM and adding a little bit of flavor to it so it's not just the boring DSM thing. Does that work for you? Sure, yeah. So DSM 5, the criteria is the presence of obsessions, compulsions, or both. Obsessions, there's two components, and it's the second component that I think is especially important. So the first is recurrent and persistent thoughts, urges, or images.
And the second part, and this is the part that I think is the crux of OCD, is the individual attempts to ignore or suppress these thoughts, urges, or images and or neutralize them with some other thought or action. So, you know, I was saying I have a lot of patients that they just have the recurrent persistent thoughts, but the crux to me is that attempt to ignore or suppress or some sort of ritual that is done in response to the thoughts.
So it's those two components. Compulsions have two components. The first is repetitive behaviors or mental acts that a person feels driven to in response to an obsession and according to rules that must be applied. And the second part is that the behaviors are aimed at preventing or reducing anxiety or preventing some dreaded event. It's usually it's not connected in a realistic way with what they're trying to neutralize or it's clearly excessive.
And it's worth noting in that point, sometimes young kids aren't able to articulate the aims of the behaviors, the mental acts. So adults will, you will hear like, you know, I know, you know, my house isn't going to burn down. I know it's ridiculous if I don't do this, that my house won't burn down, but I feel compelled to do it. Ending part of the criteria has to cause significant distress or take more than one hour in a day, not the result of a substance or medical condition and not explained better by another disorder.
I don't have a problem with the one hour cutoff, but isn't that so arbitrary?
You got to pick something.
I know you got to pick something, but I wonder how that popped in.
If it was like there were people who were like, I'm not distressed. And then they found out they were doing it for two hours and it's like, it doesn't matter.
Yeah, I'm actually not aware if there's a study like that. I would love if there was where they actually kind of mapped distress and time spent and figured out some kind of impairment thing. I wonder if that happened. I have no idea, actually.
Other little components. So there is a specifier of insight. So there's the DSM five has three different insights that you can specify. So with good or fair insight is the first one, then with poor insight. And then the third is absent or delusional insight. And then the second specifier you can add is tick related. I also think it's worth mentioning the things that were dropped from the DSM four.
So I'm actually, I, As I was talking about, I do see that overdiagnosis, and I can't help but wonder if this being dropped is a part of it. So it used to say that the thoughts, images, or impulses are not simply excessive worries about real-life problems. Now, for the DSM-5, the definition is focused on the obsession being intrusive, unwanted, or hard to suppress, rather than the content of the thought.
And to my point earlier about the over-diagnosis, I wonder if some of these patients are just experiencing anxious thoughts, and because this specifier is dropped, they feel like OCD could fit.
You know, it's an interesting debate. I have no problem with the DSM-5 version of it. I could live with or without dropping the not simply worries aspect. It is true that obsessions are not simply worries. You have to differentiate that. But I think that we're running into an area where it's that the DSM tries to be ideology neutral, but the difference between OCD and another disorder like GAD is what is driving it, not the manifestation of it.
And we use our rudimentary knowledge about how these two different conditions seem to manifest to try to tell them apart. And they can occur together. And it's very hard to figure out. I think overall it's an okay thing to have dropped. I don't really see over diagnosis, at least in my area. I only see under diagnosis. But of course, over or under diagnosis is in the population and in the hands of the diagnostician.
So who knows?
You mentioned that the difference is what's driving it. I do have some things I want to comment on in regards to what's driving OCD, but I'm curious if you have an answer to the difference between what's driving, for example, generalized anxiety disorder versus OCD. Okay.
Yeah, I mean, it's a big area. Before I move on to that, I guess I'll say that aspect in DSM-IV is preserved in the criterion D of OCD and DSM-V, right? Not better explained by. And so the problem with that, though, is that it expects the diagnostician to have a very good understanding of all the other conditions and how to diagnose them and how they work, right?
So on that topic, what is there, what is the difference between OCD and, let's say, another anxiety disorder, GAD? Why are they different? To me, I would have to be tautological. They're different because they're caused by different things. How do we know that? Well, we don't fundamentally know that, but we believe it very strongly. Why do we believe it very strongly? Because the life course and degree of dysfunction and characteristics of these groups seem to be rather different unless you can find people that seem to have both.
So in brief, I would say that a GAD, an anxiety disorder that seems more primary, seems to just be an exaggeration of normal neurotic tendencies that you can see across almost all the population. And obsessionality that turns into OCD is sort of an exaggeration of a mental symptom or a phenomenon that in an isolated and specific way becomes extremely impairing. Okay, and it's not worrying. So I guess we have to drill down to the difference between worrying and an obsessive and compulsive loop.
And this gets also very murky because obsessions and compulsions are symptoms that are present. There are symptoms and traits that are present in a variety of other conditions. But when we say OCD, we mean this relatively unique form of obsessions and compulsions that tend to come together and repeat and are substantially impairing.
That makes me think that in my head I make a distinction between OCD and OCD symptoms. So OCD symptoms are a variant of a normal thing occurring. So OCD symptoms occur in like 25% of adults and in kids there are developmentally appropriate rituals and superstitions. Whereas OCD proper is only in about like 1-2% in the population and is very disabling. So you know, it's normal to have OCD type symptoms and OCD develops when there's an insidious progression of these symptoms.
So oftentimes when you hear the, the life course of someone with an OCD, it starts relatively innocently. Like they're double checking something, you know, they, they look at the clock and they need to make sure it ends in a five, something relatively minor. And then over time it becomes more and more developed. It becomes a more rigid and compulsive cycle. Um, So, you know, I think it's important to distinguish between OCD symptoms and the diagnosis of OCD.
Yeah, I prefer to call it obsessionality as sort of a character trait or just a feature of humanity that can be present more or less than some. And then obsessive compulsive disorder, which is sort of the full blown syndrome. But I think that. It's an interesting area. OCD is the best treatment of psychological. It's behavioral psychological. And so it's mostly recognized and treated by psychology oriented types, people who are more interested in the psychology of the mind rather than biology.
But personally, I am convinced that OCD proper is a neurobiological issue, much more so than a psychological. I think most people think that, well, this is a group of people for whatever reason, they progressed from having this obsessionality psychologically, and then they got into some bad habits and it progressed and progressed and became OCD. I don't really see it that way. I categorize OCD and I personally understand it more within the realm of things that sort of happen to people.
Things like a real autism spectrum disorder, schizophrenia, bipolar disorder.
Interesting. I have it more classified. I think a good thing to compare it to is addiction, where I think people have a neurobiological predisposition. And for some people, that predisposition is so high that even the smallest environmental... trauma or trigger could set it off. And then there's some patients that have such a developmentally difficult history that even a very tiny predisposition sets it off.
It's a reasonable way to think of it. I think many people think of it that way. It's just that i see so much similarity um you know between autism ocd and schizophrenia and comorbidity i think it's my patient population that i i do see it as something that's imposed upon the person from genetics and biology versus something that's being willfully engaged in That could coexist with the vulnerability hypothesis, but I just don't see much will being involved in the process.
I don't think anything willful happens that causes somebody to be spending eight hours a day on obsessions and compulsions. It's just beyond... my conceptualization anyway and in particular because of how you can tamp down and reduce the severity using medications you don't see that happening in my opinion on conditions that are more psychologically driven interesting you know it's curious
to me that you you like because i also don't agree with you in regards to i don't think it's a willful process i think it's um But I also do, you know, it's not as if something's biological, then it's not willful. Or if it's psychological, it is willful. I feel like that's almost an artificial distinction.
Well, it's very murky, very murky. I don't know if it's artificial distinction. I think it's a chicken and egg question that we can't confirm or disconfirm.
And actually, sorry, one thing that makes it a little more confusing is that for OCD, treatment is willful. And that's an interesting thing to put side by side in that the development of it is not willful, but the treatment, of course, is.
Yeah, yeah. Let me try to kind of paint out two lines here. It's very complicated because the origin of something can be biological, but then that can produce psychological habits that then need to be treated psychologically. Right. And then you can also have the origin of something be psychological and then that can produce biological sequelae, you know, bad effects or even good effects that you could then treat using a biological treatment that goes back to the secondary.
I don't know, this might be a diagram. But because these two issues, the biological and the psychological, are completely intertwined and completely interdependent, etiology does not imply treatment.
Yeah, I like that.
I think we just need to keep that in mind. Yeah, we're definitely delving, I think, to philosophically.
All right. All right. So let me let me let me go through. Let me walk through what I think of as the anatomy of OCD and walk through what I think of as like the five steps or the loop of OCD. I think this might be helpful for thinking through what's occurring. So the first step is a trigger. So it's some sort of internal or external cue that leads to the second thing, which is an intrusive thought or image or urge.
And this intrusive thought is actually normal in a sense and i say it's normal in the sense that the intrusive thought is not the quote-unquote problem the person suffering from ocd often experiences the intrusive thought as the quote-unquote problem but it's normal to have intrusive relatively bizarre uh ego dystonic thoughts that are upsetting to the individual but the person who doesn't have ocd And again, we're not saying this is willful, but they notice that intrusive thought, they tolerate the minor discomfort, and the thought fades away.
But for a person with OCD, this isn't the end of the cycle. So this intrusive thought turns into step three, which is the catastrophic appraisal or the worried belief about the thought. And this to me is the quote unquote problem with the person with OCD. So the person with OCD assigns inappropriate seriousness and meaning to the intrusive thought. So their brain implicitly or explicitly says, this thought is important and dangerous and we have to do something.
So again, this is the misinterpretation or the misappraisal of normal intrusions. This leads to step four, which is distress. So it leads to an intense emotion that's tough to tolerate. Fear, doubt, guilt, shame, anxiety. The classic, the amygdala goes online, the frontal lobe shuts off, there's a big spike of anxiety or disgust or fear. The pivotal feeling, if you were to put it into words, is that something's just not quite right.
And that leads to number five, which is the compulsion. And this is some sort of ritual, whether it's a physical compulsion like checking or a mental ritual that temporarily neutralizes the distress. So this little ritual brings relief and it reinforces, the relief reinforces through negative reinforcement that this was something that helped with the anxiety. So when we're thinking about the cycle, the amygdala is stupid and it thinks that the compulsion that I did, that's what decreased the distress.
That works great. Let's do it again next time. And this is why it's so hard to stop because the distress activates the amygdala, which interprets the thought as a threat. This turns the frontal lobes offline. So it makes it really, really hard to resist the compulsion. And then the amygdala says, like, let's find the thing that worked last time to make this threat go away. And then you do the compulsion and the behavior is reinforced.
So in a sense, the performing the compulsion is feeding the urge. So, you know, I like to think of like a little this is something more common in addiction, but I think applies to OCD. There's like a little urge monster that feeds on compulsions. And ERP is tolerating the urge and not doing the compulsions. So you're starving that little urge monster who just gets bigger and bigger the more compulsions that you do.
Yeah, it's a good framework for it. There's some areas where I diverge. And I think we have to emphasize that we don't really know how this works. So it's just a matter of opinion. For me, it's actually the repetition itself that is the driver. That's how I see it. It's that people who develop OCD versus people who have obsessionality, it's not a matter of getting pleasure or relief.
Because for me, there are too many people with OCD who get no pleasure or relief from repeating, you know, no discernible subjective pleasure or relief. There's also too many people with low insight OCD that don't get distress from the initial cue, right? They get almost an enjoyment out of the initial cue and its related behavior. think it's right or they feel that's a good thing to be doing so it's it's interesting the the framework you're presenting if we want to relate that to kind of freudian theory it's kind of a pleasure principle theory right it's saying that we fundamentally do things to either enjoy or to ward off pain but what i'm referring to here is that Fundamentally, neurons that fire together wire together.
If you repeat an action, it will become stronger in the neural network, in the neural system. And if your system, for whatever reason, is out of whack in a way that makes you repeat things, repeating those things makes it stronger. And that's all. So if we're going to translate that into a psychological interpretation, analogy, metaphor for OCD, I prefer one of the interpretations of OCD as, and of course this is based on my training, Not tolerating uncertainty.
Not tolerating whatever it is that you feel or experience. The state between the obsession and the compulsion. Not tolerating that. Okay. And so if that's the psychological problem that's being experienced, then that's what you target. I don't know if that's clear at all, but this is extremely murky, the way I'm talking about it.
What you said, though, I'll be able to link in because I do want to talk about ERP and how it works. And I think the tolerating uncertainty part will make maybe more sense when I when I dive into that. I do want to you know, I don't know why my brain just keeps making associations to the process of addiction in terms of when you're talking. Because you were saying the person doesn't experience relief and that it's almost like this compulsive behavior that's developed because it's almost innocent.
As you said, it developed because it developed. But I hear something similar with patients with addiction that they're using the substance and not getting any pleasure out of it. It's almost like they feel a pull to do it and there's not... you know, a pleasure or a relief being experienced.
But I still, but I do think that's the thing. I don't believe in a pure pleasure principle explanation of addiction either. And by the way, I'm not saying that there's no relief in all people of OCD, right? I'm saying that there are some subtypes here, some cases that sort of violate that rule. And so I think that we need to go beyond the pleasure principle when we think about repetitive behaviors.
And I think what I'm arguing is that this is how it starts. And how it starts is different than how it continues.
We think that's how it starts. It may start that way in many people. I'm saying in the severe cases, I'm not sure that's really how it starts. I think that there is some neurobiological tendency to repetition that we rationalize around with the conscious mind, because that's just what makes sense. If we are compelled to do something as human beings from our biology, we will build a emotional, psychological explanation for it automatically.
And to me, that's part of the meaning-making function that we have. I don't know if it's necessarily true to life.
You're, in a sense, mirroring Freud's progression from the pleasure principle to the repetition compulsion in OCD. Right.
Yes.
Interesting.
I think that the discovery of repetition compulsion and the death drive is important to the understanding of certain forms of biological illnesses like OCD.
Where does the death drive come into play here?
Well, the death drive is... inaptly named, you can argue, because it's not about necessarily death. Some people think it is about death and destruction. You could argue it's about repetition, that it's about not progressing, not going beyond and growing and moving on, but staying in place. This is definitely too theoretical, but I guess this kind of OCD is interesting, isn't it? It just touches on so many different things.
You can have people who are fully neurotic with OCD. You can have people who are fully psychotic with OCD. But yeah, the more severe cases, I really think that you can't knock out with a run through an ERP workbook. I think those cases are biological. I think that's what I'm going to say. I'm really reminded of a case I saw early in my career where we had an intake of this lady who was...
on her third rhinoplasty okay nose look great by the way okay not that she believed it her presentation was high functioning person with body dysmorphic disorder and for those of you that don't know body dysmorphic disorder is not in the eating disorder chapter it is in the ocd chapter because definitionally it is about repetitive checking of the body in some fashion so she fit that like a glove OK, she also had the basic psychological body image and weight issues that we'd expect for a woman of her age.
OK, fine. Great. No problem. Right. Treat it with high dose SSRI and ERP. Well, not ERP. Have it reversal training. OK. Two years later, started getting prodromal and developed schizoaffective disorder. Mm hmm. And I've seen that comorbidity. You can look into the research and clinically there's a comorbidity between OCD and psychosis often enough that that's what's kind of tipped me over to some kind of understanding that there's a brain circuitry processing problem for a lot of these people.
Interesting. So maybe I should spend this time talking about ERP a little bit.
Okay, yes. Enough talking about ideology, philosophy. You can recognize OCD, but should we talk about treatment, ERP, before we talk about practical recognition?
No, I think practical recognition and screener questions would be helpful.
Shall we do that first? Yeah, of course. Okay, so you might ask yourself, how am I supposed to detect this? If everybody out there is getting seven years into each case to detect OCD, it's tough. I would say that you need a good understanding of the psychology of the obsessional neurotic. Somebody that has OCD, you need to know how they kind of live their lives and work.
I would say that the thing to sharpen your senses for, to listen carefully for, is any indication that someone is, again, intolerant of uncertainty, that they always want to be sure of things, that they want to be extra sure of things, and they even check things multiple times. Again, this is a finding that you're going to see in a lot of people without a CT. but it's certainly not finding obsessionality that you find in everybody.
And if you have somebody coming in with anxiety, concentration problems, problems with being effective at work or school, and you begin to detect signs and symptoms of obsessionality, that is a warning sign. If you hear that they do anything repetitively without feeling satisfaction or certainty from it, began to suspect OCD. I find that directly questioning about OCD is relatively low yield. It's not sensitive or specific if you just ask SCID type questions with the DSM criteria.
People with OCD will not recognize their behaviors as obsessions or compulsions. People without OCD with worries, repetitive worries, will answer it in affirmative. Okay, so you can spend a lot of time in a standard outpatient interview, a lot wasted time, simply first starting with OCD type screener questions. I personally think that the best way to do it is actually to get a sense of the natural course and trajectory of OCD, what kinds of features that people will come in with.
I don't have a specific listing for you. It's honestly almost implicit in my opinion. practice. But if you get a sniff of some kind of OCD risk, have them do a Y-Box. That's the Yale Brown obsessive compulsive scale. There are many different versions of it online, but simply have them fill out a Y-Box and then go off of that. Don't take the Y-Box as diagnostic. It's a screener.
But if they have multiple marked obsessions and compulsions, Then go off of those. Don't say, tell me how this is obsession or compulsion. Say, I noticed you marked that this is something that you've experienced or you are experiencing. Tell me about that. What do you do with it? What happens through the day? How much time do you spend on it? What would happen if you didn't do that?
What do you imagine would happen if you didn't do that? That's the best way in my experience to get to a real OCD diagnosis. Detecting it, just detecting the risk factors. getting a Y box and then specifically getting a narrative around whatever they screen possible for in the Y box. But yes, do not use the Y box as a diagnostic. I've had patients without OCD who marked every single one.
And I've had patients with OCD who've only marked one or two. The full Y box, right, is both the symptom checklist and also the score form. I will use the Sporiform to track OCD treatment in somebody once I've started treating them. But when I say do the white box initially, I mean the whole thing. I want to do the whole thing. And we're not using it diagnostically.
We're using it as a screener. Interpret it through a clinical interview after.
Okay, awesome. Yeah, I just want to clarify because the scale itself is not helpful to as a screener. It is helpful once you have a diagnosis for monitoring treatment. But it's not helpful for kind of getting a picture or understanding if they have or don't have OCD. The symptom checklist is the one that's just a ton of different questions that you ask if they currently or in the past have experienced.
And I think to your point is the point of going through that checklist isn't to just get current or past, but to get a narrative of how they relate to those different things. Yeah.
Yeah, because OCD can be and often is so illogical. Sometimes there is a logic. You can find some kind of psychological reasoning for it, but it can be so illogical and it can just emerge in very small ways, almost like a psychotic disorder that you want to just figure out what could be emerging and then check on that, flesh it out to get a sense of it.
By the way, if you are going to be using it for your longitudinal treatment monitoring, obsessional people being such role followers, make sure to tell them you don't need to fill out the symptom checklist every time. Okay, just the numerical one we're monitoring. I've had many patients fill out the entire thing every time until I start saying, hey, in the future, just the score mark as we do the treatment.
Now, one thing I'm struggling with is because I feel like I see a full spectrum of behavior. And I like your focus on getting a full narrative to understand the patient and make the diagnosis. But I still have a tough time with where that cutoff is for when it is or isn't OCD. And I'm curious if you have any tidbits for that.
It's unfortunately a big judgment call. And if someone is not... is low insight, then that judgment must lie with the clinician more. If someone is, let's face it, more of a hypochondriac in any way motivated to identify OCD, That could be an over exaggeration on the part of the patient. I just stick with DSM rules. OK, does it bother you or impair your life in some way?
Remember that for many people, they have no feeling of being bothered by their OCD in their day to day subjective experience, but their family hates it. Do you really have to pray every single time before you eat?
One magical hour.
Well, of course I have to pray every time. And also before I wash my hands. And also if I do this thing wrong. And that's a good thing because nothing bad is going to happen to me. Why would I stop doing that? Oh, yeah, but my wife really gets on my case about it. So you really have to get a sense of the day-to-day functioning and interpersonal functioning.
to accurately make the OCD diagnosis. And some people aren't really paying attention. It's such a big part of their lives to how long they're really taking on this stuff. Some people will totally diminish and say, oh, really, I'm not taking very long at all. No more than 10 minutes a day. And then you talk to family. So it's a tough... area but just try to get as much information as you can think about how does this patient compare to the average person in terms of engaging with these activities uh how much does this seem to be directly impacting their interpersonal and occupational functioning and then you'll just have to make that call maybe maybe if
you wouldn't mind i'm gonna move to just paying attention to time maybe move to a little bit about erp that work for you absolutely we should talk about treatment So ERP is first line and ERP is exposure response prevention. And the mechanism, as you were saying earlier, is tolerating uncertainty. And ERP is one of those things that gets thrown out a lot. So it's important if you have a patient that isn't getting better and they're saying they're doing ERP, investigate what kind of ERP is being done and what the patient's doing.
Mm-hmm. I'll just put that out there and I'll keep moving on.
So why is ERP? No, I don't think we should move on. This is such a niche area, but it's important. Because when you engage some people of OCD and ERP, what can happen if you're not experienced is that they will just develop different compulsions than what they were doing before. And you might not notice it at all. And that can be a reason why they're not getting better because all they're doing is suppressing the initial compulsions with a new compulsion.
With a CBT-flavored compulsion.
Yeah, exactly. We're just trying to keep people... for as long as they are willing to tolerate in the space between the onset of the obsession and the action of the compulsion. And I call that intolerance of uncertainty because that is what I was taught and it fits maybe 90% of OCD cases. It doesn't fit the other 10%, but what we're really looking for is existing in that space before the compulsion and not doing any compulsions for as long as possible and then moving on to other tasks.
That's kind of the goal.
Bingo. And a core concept of ERP is that it's uncomfortable. Because if a patient... It's not fun. Patients should not enjoy ERP because it involves slow and deliberate exposure to the distress and tolerating and accepting discomfort. And what we're saying is... coping or calming skills don't treat the OCD like breathing techniques. Um, you know, like, uh, that's another example. Um, you know, a lot of things that are encouraged for anxiety in regards to, you know, breathing techniques or, or cognitive reframing that, that goes directly counter to ERP.
Um, So again, the focus is on distress tolerance skills. And the purpose is to do the opposite of what the OCD is demanding. So it's resisting the compulsion. It's embracing the discomfort. And it's building confidence in the ability to tolerate the discomfort. I read one person's motto in their head. For OCD is maybe, maybe not. So if they have an intrusive thought like, you know, my house is going to burn down if I don't check the stove, they're not trying to breathe through it.
They're not trying to think of cognitive reframing of I didn't check the stove the last 10 times and it didn't occur because, as you said, that that is a can be transformed into reassurance or compulsion or obsession. So the person's not trying to reassure themselves. They're not going to the therapist or the psychiatrist for reassurance. They're tolerating the uncertain. Maybe the house will burn down. Maybe not.
I don't know. And, you know, an important thing is so ERP differs from CBT because OCD is not a thinking problem because the issue isn't what the person's thinking. The issue is how the brain is responding to the thoughts.
Or the process of the thinking and behaviors.
So it's driven more by the secondary emotions and the maladaptive behavioral responses. So positive framing or rational evidence testing is problematic. And I think you kind of mentioned this, like OCD has its own logic. So patients know the compulsions don't make sense often, but overwhelmingly in the moment they fear it.
yeah uh one thing to know i will say um that's the very classical approach to erp i've come to a point though where um some level of comfort is nice uh there's there's just a subset of people of ocd maybe they're even a plurality or even the majority they're very self uh effacing and they have a lot of depressive tendencies they're really mean to themselves basically And that can be an impediment to doing the ERP properly because they're too self-critical, too harsh, and can't just do the maybe, maybe not and let things go.
It almost becomes an exercise of sadomasochism for some of these patients. So I've stopped. So classically, I've recommended in terms of for self-help, people who can't find a properly trained ERP therapist and engage with it. I recommended reading Freedom from Obsessive Compulsive Disorder by Jonathan Graveson, because it's structured as a self-help book, and it's pretty good. It's very good. But... might be a little too mean uh in turn or harsh or disciplined uh for some people who are already overly harsh and disciplined and uh for patients where i detect that i want to start now with the self-compassion workbook for ocd so mindfulness and calming techniques again not used to diffuse the anxiety from the uh space between obsession and compulsion but, uh, utilized in order to help you tolerate as long as possible that space.
Yeah. And I, you know, I think it's helpful for, you know, cause I think probably a large part of our audience is, uh, psychiatric clinicians, um, Some patients, the best case scenario is they have a therapist who's doing good ERP. That said, as you're kind of saying, workbooks do work for highly motivated and particular subset of OCD patients. And I also think... For that subset of patients that I identify, I do walk through and explain ERP and then give them the workbooks.
If you wouldn't mind, maybe I'll just walk through the gist of ERP. Yeah, go for it. So again, this is like, you know, the basic overview, just so you have an idea of what it looks like. So when you're doing ERP, and you can do this in medication management appointments. But acknowledge that it's not the same thing as like a therapist who's doing good ERP.
And there's some risk if you're not trained in creating challenges or exposures that are actually reinforcing. But I think it's still overall a positive to try to work with the patient who's not in formal ERP to put up little challenges or exposures in their day-to-day life.
Yeah, but I think to your point, there is a risk of someone having developing negative associations because you tried something and it didn't work. And then it makes it harder for them to engage in better ERP. But yeah, the gist is first you identify all the person's triggers and compulsions. And you create a menu, like a hierarchy of sorts. So what you typically do is like you get all the different triggers and you rank them from least to the most anxiety provoking.
There's something called the SUDS, which is acronym for subjective unit of distress. So for each trigger, you go from zero to 100 to how distressing that trigger is. And then you rank them and you work to create exposures to the triggers. So you can be creative. A common one is to create scripts. So you write the worst case scenario paragraph of your intrusive thoughts and then the patient will read it out loud while practicing response prevention.
Or you can do image rehearsal or watch videos. Essentially, there's a ton of different creative ways that you can create triggers that are tolerable. And in this list of triggers, you should work on having things that are videos, real-life triggers, in vivo tasks. And remember that when you're doing the response prevention, the goal isn't necessarily to stop all compulsions. The goal is to have... Focus on, you know, seeing how long you can prolong until you do a compulsion or reducing.
How long can you stay in the space in between the uncertain space? And if you have to do the compulsion, fine, but better yet, move on to another part of your day.
And the instruction that you're providing for the patient during the exposures is they should be trying to notice the urges, the sensations and discomfort. You can use distress tolerance techniques leading into the discomfort, opening up around the discomfort, urge surfing or riding the wave. These are there's a DBT workbook work thing that has this list. You know, try to be curious about the anxiety, try to watch the anxiety.
And again, reinforcing that ERP is distress tolerance and it's not distraction. It's not calming yourself. It's tolerating the distress.
Yeah. I like to call them challenges, you know, or technically exposures in the response prevention, but I call them, what are some challenges we can plan before the next visit? And keep in mind these, this approach that I'm doing is really an adjunct to medication management and patients who are essentially refusing formal ERP. Okay. Uh, which is, again, the gold standard treatment. And unfortunately, yes, the use of medications can cause patients to feel that they're justified in not engaging in the true treatment, the psychological treatment.
But you have to work with what people are willing to do or able to do based on their constraints and their finances. Some examples of ones I have used in the last few years are Well, what I usually do is I say, what do you think you spend the most time on? Or what's causing the most problems right now in your life? Is it hand washing? Is it the checking in on your family not being dead?
Is it your thoughts of jumping in front of a train? Is it thinking or wondering if your husband is cheating on you? So, for example, jumping in front of a train, you said, okay, how many times a week are you willing to go to the train station and just sit in the platform for as long as you can take it? Are you willing to do that? Okay, if you're not willing to do that, how about imagining?
Okay, or how about watching YouTube videos of people on a train platform? Okay, of course you have to have knowledge of what their actual compulsion is to know how to not engage with it. So you have to know their compulsions and compulsions can be subtle, they can be mental only. Another example of a challenge exposure that people do might be Well, why don't you write a story about your husband having a coffee with a platonic female friend?
Right. That's a low level exposure because she felt she could not handle an exposure of the husband actually cheating, even imagining. Sometimes you just have to do harm mitigation to one of them was let's try this week only shaking your duvet cover 30 times instead of 60 times. Right. So it should be tailored to the patient and their willingness.
And, you know, one other thing that I think is important, psycho ed surrounding doing these things is sometimes patients want that they're doing. We talked a little bit about in terms of meditation, like the motivation. Well, for ERP, the motivation is not to stop or remove the intrusive thoughts or the feelings. ERP doesn't remove the thoughts or the feelings. So I teach patients they shouldn't be doing it with the hope that they'll be cured or that they'll stop having the thoughts.
The goal is to start is to not view those thoughts as threatening and to not be doing the compulsive behaviors. This is important because if in terms of we're talking about like success, if someone is doing these exercises with the hope that these things are going to go away, they're going to feel really discouraged when they don't. And if they understand the purpose of it, they'll see things as more as wins and progressions that are how we're viewing treatment.
Yeah, incredibly important point. We need to let people know about a realistic view of how this works and what the treatment is like. We're not here where it's impossible to try to remove any particular aspect of yourself from your life entirely. You can expect, just like with trauma memories, that these are just going to come back once in a while. You know, that is the repetitive nature of the mind.
The difference is that we want you to live around that, past it, through it. Live the life that you want to live beyond that. And we also have to let people know that if you notice things getting worse, that's okay. That's normal. Sometimes things are going to get better. Sometimes things are going to get worse. If it gets worse in a way that you can't handle, it's really getting in your way.
That's the time to talk to a professional again about changing something with the treatment plan.
Absolutely. And telling patients that OCD is a chronic condition. It's not something that is cured. So, you know, patients who have successful rounds of ERP, it's expected to have setbacks. It's expected when there's a stressful period, you know, death of a loved one, hard loss of a job or something. It's normal to have recurrence of symptoms. And it's not a reason to get frustrated and say it doesn't work.
That's expected. And there are, you know, quote unquote, relapses in regards to the compulsions. And that's OK. And you just continue with the ERP and it improves. And it comes.
back yeah and i hope this doesn't sound overly pessimistic i want to emphasize that uh you know the before and after of appropriate treatment of ocd is night and day in terms of the level of distress and disability that you can uh remove from the life of these patients if they get into the treatments appropriately um now talking about we mentioned very briefly medication tweaks again i think i think we do a
whole episode on it
No, I don't want to do a whole episode again just talking about SSRIs. No, I refuse for that. It's not. Okay, prescribers, you must know that OCD treatment with SSRIs has been tested, and the evidence shows that, generally speaking, for true OCD, especially moderate to severe, it is warranted to increase the SSRI dose beyond the FDA maximum that we are used to for major depressive disorders. Okay, so we're talking Zoloft 300 or even 400, Lexapro 30 to 40.
I always get an EKG with that, that kind of thing. Of course, there's Clomipramine and Luvox, Fluvoxamine as third or fourth line, first line agents. People like them as first line agents, but let's face it, you're not going to start with those. But don't make this mistake. It is not the primary treatment. It's a symptom reducer, but often very important. Sometimes the symptoms are so disabling, distressing, you do need medications to help people get into the ERP.
We could easily do a full episode on this.
I know, but the problem is this. Okay. Beyond increasing SSRIs past FDA limit, I think the evidence base is so poor that it's a little irresponsible to talk about the options. You honestly just throw stuff at the wall and see what sticks. And it's so case by case. I don't want to... even imply that we know what we're doing beyond giving SSRIs. One extra note, I generally don't recommend giving the SSRIs for people who have comorbid bipolar disorder and OCD.
You're going to have to use sleep support in the second generation as a psychotic. Some people can tolerate SSRI. I don't know.
There's so much we could be going into. We could be talking about clomipramine and how Luvox 1A2 inhibition, and there's so much we could be diving into.
Okay. If there are at least five comments expressing interest in a OCD psychopharmacology episode, I'll consider it with no promises.
All right. So after the OCD, does the cat scratching at the door and us not responding to it make more sense?
No, I don't think so. The cat has no problems with uncertainty. The cat is simply trying to get a response.
If anything, that's like a personality issue. What I'm saying is me in the bed is the person, not the cat out there.
You're saying you felt a compulsion to respond to the cat. Oh, my God. I don't get it. I'm sorry. What are we saying the death drive is?
Because I'm experiencing it towards you.
I think it's a nice metaphor for standard pleasure principle neurotic issues. That's all. It's not a death drive issue.
No, I'm experiencing the death drive issue right now. Unrelated. All right. Have a good one.
All right. Until next time.
Thank you.