What we’ve said about OCD

“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”

“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”

“because these two issues, the biological and the psychological, are completely intertwined and completely interdependent, etiology does not imply treatment”

“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”

“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”

“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”

“I think there's some question about validity of post-traumatic stress disorder, whether it's as valid as something like schizophrenia. I forgot obsessive compulsive disorder. That's highly valid. Classic autism. Which is a bit different than Autism Spectrum Disorder. Addiction”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“you can have a totally positive Yale Brown, and it's not OCD, and you can have a one or two positive Yale Brown, and it is OCD. But by doing the screener, it at least gives you an anchor to start inquiring in a narrative fashion”

“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”

“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”

“people are actually engaging in mental or School work based obsessions and compulsions reading and rereading note-taking editing essays Just in the process of doing homework many different manifestations of obsessions and compulsions can come through”

“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”

“That's probably why a lot of people will call Jerry obsessive compulsive. But that's obsessive compulsive personality. There's really no evidence of obsessions or compulsions from OCD throughout the series”

“At the borderline and psychotic levels, you have all those rituals and compulsions, but they tend to be egocentronic. In other words, you tend to think of them as natural and you don't know any other way to be”

“The neurotic range of obsessive-compulsive would be somebody who has ritualistic practices that they know are crazy. They know it involves internal anxiety that they have to do something about. They can make a good relationship with a therapist”

“unlike Obsessive Compulsive Disorder. They do not respond well to ERP and SSRI treatment. Why? Because I think what's happening in this subset of patients is that the underlying problem is the self and other relating, the personality functioning problem”

“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”

“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”

“People can have thoughts about suicide as part of the obsessive and compulsive disorder type process. Properly, it will be called a ego dystonic obsession with matching compulsions”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“it inhibits especially CYP1A2 and then basically all of them, 2C9, 2C19, CYP3A4. I think it was studied a little bit for like COVID”

“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”

“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”

“Strong anticholinergic effects, QTC prolongation, very sedating. weight gain. So not necessarily the greatest choice, but if it's viable, you can consider it”

“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”

“I go off of the available studies for NAC and OCD, and I usually target something between 2.4 to 3 grams of NAC. I have had patients complain of the taste or smell, though”

“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”

“Other detail about risperidone, pretty decent for OCD augmentation. They're usually using it in a lower range, like two to three milligrams”

“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”

“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”

“some of the antipsychotics can actually worsen OCD. I think clozapine and olanzapine are the most likely”

“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”

“do not be afraid also to use mood stabilizers. We don't understand these categories as much as we think. And I think the reality is that there's probably a lot of genetic and pathophysiological crossover between the bipolar disorders and the schizophrenia and sometimes OCD, ADHD, autism”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“the concept of intrusive thoughts provides a container for their experience to help understand what's going on so it doesn't feel like all these wild, called unexplainable thoughts, and in a sense, contains them and makes them feel much better”

“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”

“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”

“This problem of concentration you have, this problem focusing and not being able to get the schoolwork done, I'm not so sure it's ADHD. It really does seem like that it's your high level of obsessions, compulsions and related anxiety”

“we thought together of maybe it's something else going on other than OCD type symptoms and that this patient is putting us in this crazy situation of making this really complicated. Unlocated psychopharmacological switch”