Key moments, in order
OCD hides in plain sight because of poor education about it. It is extremely common, and studies suggest about seven years pass from first contact with a mental health professional to diagnosis.
Compulsions are repetitive behaviors or mental acts the person feels driven to perform in response to an obsession, by rules, aimed at reducing anxiety or preventing a dreaded event.
DSM-5 specifiers are insight (good or fair, poor, or absent or delusional) and tic-related.
GAD looks like an exaggeration of normal neurotic tendencies seen across the population. OCD is a specific, isolated mental phenomenon that becomes extremely impairing.
OCD symptoms are a variant of something normal, seen in about 25 percent of adults and as developmentally normal rituals in children. OCD proper affects only about 1 to 2 percent and is very disabling.
We are convinced OCD proper is much more a neurobiological problem than a psychological one, not just obsessionality that grew into bad habits. The more severe cases cannot be knocked out with a run through an ERP workbook.
Etiology does not imply treatment. The biological and the psychological are completely intertwined.
Intrusive, bizarre, ego-dystonic thoughts are normal. A person without OCD notices the thought, tolerates the minor discomfort, and the thought fades.
In OCD the compulsion lowers distress, so the amygdala learns to do it again next time. That is why it is so hard to stop.
Another view: neurons that fire together wire together. If the system is out of whack in a way that makes you repeat things, the repetition itself makes it stronger.
Body dysmorphic disorder is in the OCD chapter, not the eating disorders chapter, because by definition it is about repetitive checking of the body.
Listen for intolerance of uncertainty: always wanting to be sure, extra sure, checking things multiple times.
Get family input. Many people are not bothered by their OCD day to day, but their family hates it.
ERP is the first step in the OCD algorithm. Medications come in when symptoms are severe or the patient is unwilling to do therapy.
Patients can develop different compulsions than before and you might not notice at all. That can be a reason they are not getting better, because they are only suppressing the initial compulsion with a new one.
Patients should not enjoy ERP. It is slow, deliberate exposure to distress, and breathing techniques and calming skills do not treat the OCD.
Patients should not enjoy ERP. Coping and calming skills such as breathing techniques do not treat OCD, because OCD is not a thinking problem: the issue is how the brain responds to the thoughts.
A subset of patients, maybe most, are self-critical and harsh with themselves, and that can get in the way of doing ERP properly.
For a highly motivated subset without access to formal ERP, explain ERP in the medication visit and give them workbooks.
List the triggers and rank them from least to most distressing, rating each 0 to 100 on subjective units of distress (SUDS).
During exposures, coach them to be curious about the anxiety and watch it. ERP is distress tolerance, not distraction and not calming yourself.
Target what matters most now: ask what they spend the most time on or what causes the most problems, whether hand washing, checking that family is not dead, or thoughts of jumping in front of a train.
ERP does not remove the thoughts or feelings. Teach patients not to do it hoping to be cured or to stop having the thoughts.
Tell patients OCD is chronic, not cured. Setbacks are expected after successful ERP, especially in stressful periods such as a death or a job loss.
Anyone with bipolar disorder, whatever the comorbidities, should not get an SSRI whenever possible. With bipolar disorder plus OCD, use sleep support and a second-generation antipsychotic, though some people can tolerate an SSRI.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.