HealthyGamerGG - Let's Talk About OCD

Episode Date: February 14, 2023

OCD affects us all differently, but the impact can be overwhelming 💔. Join Dr. K in this episode as he delves into the world of OCD and how to manage it 🧠 Learn more about your ad choices. Visit megaphone.fm/adchoices

And essentially what's going on here is that I have a thought. It leads to a particular action. And since the action relieves my mental stress, that behavior actually gets reinforced. So the tricky thing about OCD is that the more that we give in to our compulsions, the stronger the compulsions become. And this is actually what's so devastating about it is we get stuck in the cycle because the only way that we know how to fix this thing is actually by giving into it. seeing in your future something that is transformative, helpful, and fun.

I don't know what it is, but maybe it is down in the link in the description, nah? So I want to talk to you all today a little bit about OCD or obsessive-compulsive disorder. And I think that this is really important because one of the things I've noticed is that people sort of increasingly have anxiety and people are also like somewhat perfectionistic. So a lot of times people ask me questions about, you know, I'm anxious all the time or I'm very perfectionistic, like, how do I deal with those kinds of things? And one of the things that I found as a psychiatrist is that people don't really know what obsessive compulsive disorder is. And oftentimes, what we'll kind of do is mislabel it. And by mislabeling it, what we end up doing is sort of making

it difficult for us to, like, get the appropriate treatment or help for it. So I'd love to talk to you all a little bit today about OCD. And the other reason that this is important is because I think OCD has some of the most unusual psychotherapy involved with it. So in my experience, sort of treating people with OCD, the angle I take in psychotherapy is actually quite different from how I do psychotherapy for basically everyone else. And the reason that I think this is important is because I think that psychotherapy for OCD gives us an insight into a fundamental skill that is probably the most important thing for all people. So if I had to take one skill that I teach people, that I teach people, in psychotherapy, and if I had to teach, or if I could teach that to every human being on the planet,

what I'd actually do is draw that skill from psychotherapy for OCD. And the reason for that is because OCD is this disease, which we'll dive into in a second, which is all about obsessions. So we have particular thoughts that are kind of intrusive, unwanted, or don't sit well with us, and compulsions. So compulsions are actions that we take in response to thought. So even if you look at the neuroscience, of OCD, what we sort of know about the neuroscience of OCD is it's caused by this particular part of the brain that starts with sort of where our attention goes. So it's a disorder of attention. So certain thoughts will dominate our mind. And then furthermore, those thoughts, once they start to dominate our mind, will lead to behavior. And these are what we call compulsions. And these

compulsions are so severe that they'll sometimes end up hurting us. So for example, like a really classic thing that people are familiar with is excessive handwashing. So I'm so concerned about having germs, I have this thought in my head. Oh my God, my hands are dirty, my hands are dirty, my hands are dirty. And even if I know it's irrational, I can't control that thought. And the only way I can get rid of that thought is to wash my hands with blistering hot water and soap seven times in a row to the point where my hands are peeling, they're cracked. Sometimes people will even get infections from excessive hand washing, which then launches the OCD into a whole different cycle. So if we really look at the-

OCD, what we sort of know is that in the brain, it's kind of involved in this set of circuitry that sort of dictates the connection between thoughts and actions. And specifically what happens in OCD is people have thoughts that are so strong that they lose control of their actions. And so the most important thing about treatment for OCD is that we want to teach people how to not be controlled by their thoughts, how to sever the link between thoughts and actions. And the reason this is important for everyone is if there's one core skill that I could teach every human being on the planet, it would be how to separate your thoughts from your actions,

how to act independent of the way that you're thinking or feeling, and also how to have particular thoughts and feelings, which make you feel bad and not be kind of beholden to them and force yourself into action. So a really good example of this is, you know, unhealthy coping mechanisms. So if I have particular thoughts or particular feelings, let's say I'm feeling lonely, let's say I'm feeling unlovable, in order to get rid of those thoughts and feelings, I may do something like Colin X, who's always down to, you know, hang out or whatever, even though they're really toxic for me. So what we sort of see is that a lot of what we struggle with in life, like, I want to play video games today, I feel bored, I don't feel like working. So we have all of

these internal impulses, and then we give into those internal impulses. So oddly enough, I think if you had to summarize the goal of OCD treatment, it's almost to like make people disciplined. And so what that sort of means is that this is a scientifically verified technique that helps about 83% of people separate their thoughts from their actions. And keep in mind, these are thoughts that are so powerful and so overwhelming that they will lead to major problems in these people's lives. So we're going to kind of, that's part of the reason that I want to teach about OCD. And let's kind of dive into a little bit more detail. So the first question is, what is OCD. So like I mentioned earlier, OCD is characterized by thoughts or obsessions

and compulsions. So obsessions are basically thoughts that have a couple of key features. The first is generally speaking, they're intrusive, i.e. you don't want to think about them, right? So you're going about your day and you kind of like are enjoying yourself and then suddenly certain kinds of thoughts will crop up. So good examples, like the most common forms of OCD intrusive thoughts are things related to contamination and high. hygiene. So sometimes people will kind of feel dirty. Other times it'll be something related to danger. So you'll have intrusive thoughts about people kind of getting hurt or having accidents or things like that. One way and part of the reason that I think this is important to discuss is because a lot of times

people will come in and will say, I'm anxious about, you know, my kids getting hurt or I'm always worried about bad things happening to other people. That's not really an anxiety disorder. For a lot of those people, what that really is is OCD. So a preoccupation with particular people getting hurt, yourself getting hurt, bad things happening, things like that. Another really important part of OCD is that oftentimes the obsessional thoughts, the intrusive thoughts, are very, like, immoral in nature. So you'll have thoughts about hurting other people. Sometimes they're sexual in nature. So you sort of have these thoughts that we would kind of associate with being very immoral or being a degenerate in some way. So those are some of the really common ways in which

obsessions will actually manifest. So we're concerned about danger. We're concerned about hurting other people. We're concerned about kind of, you know, forbidden thoughts, thoughts of contamination, things like that. So the other aspect that's important to talk about, actually, is that the other way that people with OCD will kind of manifest is with thoughts around symmetry or organization. And this is where we have to draw a really big distinction between OCD and OCPD. So OCD is obsessive-compulsive disorder. And OCPD is basically what we call being a control freak. So people with OCPD, which is obsessive-compulsive personality disorder, is actually completely different from OCD. A lot of times nowadays, especially on social media, people will use statements like, oh my God, I'm so OCD.

If anyone rearranges the shoes in my house, I get completely bent out of shape, or I need my bathroom organized a certain way, or I need the kitchen organized a certain way. And people who are essentially control freaks and need to have something done in a particular. particular way, those people are OCD. OCD, once again, is a little bit different. They may be not obsessed, they may be sort of very focused on symmetry or organization, but there's a big difference, which is that usually OCD people know, or people with OCD, know that what they're asking is irrational. They kind of recognize that these thoughts are intrusive, and I don't want it. I wish I could be okay with some of this stuff. Whereas OCP people are, are, are, completely fine with their OCPD. They actually want everyone to conform to their way of thinking.

Their thoughts are not intrusive. They're not trying to get rid of their thoughts. They genuinely think that this is the way that things should be and everyone should listen to me. So this is a key feature which in psychiatry we call egosintonic or ego dystonic, which means is it okay with you? Do you think that this is actually good or do you actually want to get rid of it? In the case of OCD, this is ego dystonic, which means that people with OCD usually don't like. the thoughts. They don't like having the thoughts. They try to actually make the thoughts go away. And people who are OCPD are egosentonic, which means that they actually, they don't, they don't think that anything's wrong with them. They actually think that everything is wrong

with other people. The shoes need to be arranged this way. And it's the fact that other people are so disorganized and barbaric that they don't want shoes arranged this way. But this is the right way to do it. So that's a key differentiating feature. So going back to OCD, so we know that we've got kind of obsessions that have four particular types, right? So contamination, symmetry, thoughts of danger and sometimes kind of like forbidden or blasphemous or kind of scandalous thoughts. The other things about these thoughts are that they tend to be, as we mentioned, intrusive, which means that you're kind of going about your day and you don't want to have those thoughts. The thoughts can also be so severe that they're like, they impair your focus. So once an obsession actually crops into your mind,

like you're not able to focus on other things. And this is what really makes OCD like a bad disorder is that along with the obsessions, there tend to be compulsions. So compulsions are behaviors that we engage in, which we may recognize are irrational. So we know like logically that washing my hands seven times, washing my hands once should be enough. Like logically, I know that if I use soap and water, like that should be sufficient. But a key thing about all these compulsions is that they're sort of like, even though they're illogical or sometimes they'll even be sort of magical in nature. So I'll give you all an example.

So I had a patient who anytime their family was taking some kind of long distance journey, like a car ride that was over about an hour and a half or any kind of plane or something like that, they had to repeat some kind of like mental, magical spell in their mind. And if they said a particular statement to themselves seven times in a row, that would mean that whatever kind of dangers their family was like exposed to would be staved off. And if they didn't repeat this prayer seven times in a row for each person that's traveling, by the way, then something bad was going to happen. And even if you ask this person like, hey, what do you think about that? They'd say, you know, I know it makes no sense. Like there's no way that the thoughts that I have in my head are going to determine whether a plane crashes or not.

But I really have to do it because if I don't, they're playing will crash. So there's some amount of understanding that the compulsions don't actually, like, relate to what people are doing or it's some sort of weird, magical or mystical connection. So compulsions are repetitive behaviors that we use that may be a little bit illogical, but we feel sort of out of control with them, right? We have a compulsion to do them. And the key feature here is that the compulsions actually reduce our mental stress. So if we look at the purpose of compulsions, if you talk to someone who has OCD, they have particular thoughts.

And then the only way they can get relief from those thoughts, the only way they can calm down the thoughts, the only way they can go back to studying, the only way they can enjoy a movie is if they go through the compulsions. So engaging in the compulsion, whether it's a physical compulsion of like, you know, turning on and off the stove seven times, that's a really classic thing, or arranging things in a particular way, or sometimes we forget that compulsion. can be mental in nature too, so they don't even have to be outward acts. That we have to engage in the compulsion, and then what happens is once we engage in the compulsion, then the obsession kind of calms down, relaxes, or goes away. And so this is sort of in a nutshell what OCD is. And we're going to tunnel down kind of a little bit further into understanding why this is such a problem and kind of what's going on here, okay? So the first thing that I kind of want to touch on is that we sort of know that OCD comes from this part of the brain called the corticostriatal thalamic circuit. So there's a particular

part of our brain, which is, it's a circuit that involves three or four regions. And this thing forms a circuit that basically governs attention with action and reward. So what we're thinking about, what we do, and what we end up the benefit that we get from it. And the tricky thing about OCD is that once I have these obsessional thoughts, once I have all these negative thoughts, let's say they're like kind of forbidden sexual thoughts or something like that. I don't want them. They're intrusive. They're distracting me from studying. And I feel bad about myself for having them. So that's another thing that happens with OCD is that people will start to make judgments about themselves for having the thought. So if I'm having like kind of forbidden sexual thoughts,

I think of myself as a degenerate or a pervert. That in turn can induce things. like shame and can even lead to some amount of things like suicidality. So if I'm sort of having these thoughts that I can't control, then what I sort of discover is that I feel so bad for having these thoughts. Whereas if I take a shower, if I'm having obsessive, intrusive sexual thoughts, if I shower three times, that'll wash away the impurity or wash away the sin. And then what happens is I'm sitting there studying and I have to go into the shower and then I have to wash three times and I leave, I come back, and then I end up like studying for a little while. And then the thoughts come back and then I have to go back and I have to shower. So if we kind of look at what's going on

in the brain here, we have a particular amount of mental distress and our brain learns that in order to relieve the mental distress, what I have to do is engage in the compulsion. And so this is why this corticostriatosothothelamic circuit of our brain kind of gets bent out of shape. We know that this circuit in our brain becomes hyperactive in people with OCD. And essentially what's going on here is that I have a thought, it leads to a particular action. And since the action relieves my mental stress, that behavior actually gets reinforced. So the tricky thing about OCD is that the more that we give into our compulsions, the stronger the compulsions become. And this is actually what's so devastating about it is we get stuck in the cycle because the only way that we know how to fix this thing is

actually by giving into it. So this is what makes psychotherapy for OCD actually a little bit different. When I look at most of my patients that I do psychotherapy for, part of what I sort of think about is I want them to understand themselves, right? We want to understand, okay, what is the origin of your feelings? How did you come to feel this way? You know, what do you believe about yourself? There's all kinds of stuff around identity and the past and sort of like understanding like how your mind developed in this way. But with OCD, it's actually a little bit different because in psychotherapy for OCD, we actually don't care about the content. So we don't care that you have, let's say, an obsession around cleanliness or you have these intrusive thoughts

that are harmful in nature or sexual in nature. There are some areas of psychotherapy that will do that kind of work. Like so psychoanalytic, psychoanalytic perspectives will kind of focus on that kind of perspective on OCD. But generally speaking, what I found to work the best is not to dig into the content of your thoughts. So whatever the thought is, like we don't really care in a sense, right? So whether you're worried about cleanliness or whether you're worried about hurting other people

or whether you're afraid that other people are going to, like, their planes are going to crash. The content of your OCD, the content of your obsessions is not actually the important thing. The important thing that we try to teach in psychotherapy for OCD is actually the ability to tolerate your negative emotions and not give into the compulsions. And the reason that I think,

that's incredibly important is because that fundamental skill is actually the skill that the Buddha, yogis, and monks try to entrain in India. So for thousands of years, we've had this spiritual tradition that is trying to separate out our actions from our thoughts. And so what we try to do in psychotherapy for OCD is as these thoughts start to arise within you, you start to feel particular things, right? So if I, let's say I have a forbidden sexual thought. So as this thought arises, I make certain judgments about myself. I feel bad. I have difficulty focusing. I start to think of myself as a bad person. And my brain has kind of figured out that there's one thing I can do to make these thoughts go away, which is, let's say, shower three times. The tricky thing is that if I shower

three times, it works, right? So if I go into the shower, soap up, everything, wash everything off, and then go through that two more times, I may start to get raw skin. My skin may start to dry out, but the thoughts get relieved. And this is the problem with OCD is that essentially what we end up doing is harming ourselves through relieving our obsessions. The only way we know how to calm down our mental struggle or our mental anguish

is by going through these behaviors. And so essentially what we want to teach is the ability to tolerate that negative emotion and not give in to the behavior. And the reason that I think this is important even if you don't have OCD is because this is a fundamental skill that everyone needs to learn.

Right? If we really think about it, what causes us problems in life? It's essentially a lot of mental anguish, right? So if I don't want to go to a party because I feel embarrassed, if I don't want to go to a party because there's someone there that I asked out a week ago, and it's going to feel awkward. So what do I end up doing? I end up not going to the party. I end up using an avoidance strategy to avoid triggering that negative emotion. And so then, and people with OCD do the same thing, one of the key hall. marks of the actual diagnosis is the development of avoidance behaviors. So if certain things will trigger obsessional thoughts and then I have to go shower three times, then I can't watch any TV or anything like that that could trigger even a remotely sexual thought. And so then what happens with people with OCD is they start to build walls around their life. And they're not able to actually like live a full life because they're so terrified of triggering the OCD that they start to avoid particular.

aspects. And we see that in normal people as well, that when I start to avoid negative thoughts, when I start to avoid particular situations, when I start to avoid putting myself in an uncomfortable state, I start to close off the doors of opportunity in my life. At the end of the day, OCD, I think, is something that's horribly, horribly misunderstood. You know, at the top of the list, the most important thing that's kind of like relevant to OCD is that it's not OCD. So, one of the biggest misnomer's is that being a control freak is not really what OCD is. OCD is characterized by having intrusive, persistent thoughts that are ego-distonic, i.e., I don't want to have the thoughts. I don't think they're good thoughts. I don't think they're logical thoughts.

I wish they would just go away. And the second consequence of OCD or the second piece of it is some kind of compulsion, that our brain figures out that we can either go through a mental process or a physical process, some kind of action, even if the action is mental, like repeat, something to myself over and over and over again in my head. I can engage in some kind of action that will relieve the obsession. The reason that I think this is really important is because if you actually ask someone who has OCD, what do you feel? They'll describe anxiety. So they'll describe, oh, I feel really worried, I'm terrified. They'll describe a lot of anxiety and fear. So a lot of times what they think is that they've got an anxiety disorder or their anxiety is really bad. Truly what it is

is OCD. The other problem with OCD is that as human beings tend to do, we develop our own intuitive adaptations to the OCD. And the problem with those adaptations is that those adaptations actually cause oftentimes more damage than the OCD itself. If I'm, you know, if I'm kind of like triggered by particular things in my surroundings, that triggers kind of the obsessional thoughts and then the only way I can get rid of them as the compulsions, the best strategy for me is to avoid big parts of life in general, because then I don't have to, if the thoughts don't get triggered, then I don't have to worry about the compulsions, and it's the only way that I can feel safe. The other big problem with OCD is that oftentimes this whole cycle leads to a lot of shame.

So this is where people with OCD will come into my office and they'll describe to me, oh, I'm depressed, I'm suicidal. But the more that I do a diagnostic evaluation in them, the more I discover, oh, this is not a mood disorder. This is actually a consequence of untreated OCD, which is intense shame for these intrusive thoughts that we never asked for. But since I'm having these thoughts all the time, it must make me a bad person, right? I must be a degenerate. And the only thing that I can think of is to take my own life to provide relief and protect the world from how awful I am. So OCD oftentimes masquerades is lots of other things. The last thing to consider is that in terms of psychotherapy for OCD, I think it's really important because the skills that we teach

in psychotherapy for OCD, I think, are the most generalizable to the rest of the population. And what we really kind of target or focus on is this idea that if you feel mentally unwell within your being, that there are always actions in the outside world that you can take. And those actions that you take in the outside world can actually relieve the mental distress within. right? So if I'm feeling mentally unwell or if I'm bothered by the asymmetry of my workplace, I can spend 15 minutes organizing everything. And that makes me feel better. The problem is that every time I do that, what I'm essentially training my mind to do is to solve internal discomfort with external actions. Right. I'm training my mind that the only way to get rid of this

internal feeling is to act in a particular way. And we see this a lot in our community. Let's say like, I'm procrastinating, right? I feel bad about myself. I feel bad that I'm not studying and I should be studying and I want an A. And the only way I can manage these emotions is to engage in some kind of unhealthy behavior. So I'm going to spend the day gaming. I'm going to procrastinate and binge watch some anime.

I'm going to do something. I'm going to spend some time on Twitter or social media. I'm going to do anything but the work that I need to do. And so if you look at like this fun. fundamental idea of, okay, if you do this, what is your brain, what is your corticostriatothelamic portion of your brain? What does that circuit learn about the solution to feeling bad on the inside? What it learns is that, oh, the next time we feel bad, we should actually just start playing a video game, because that's what fixes our problems, right? That's what leads to a relief. If you think about it,

there's a reward circuitry involved here. I'm feeling bad. And if I engage in a behavior, that behavior gets reinforced because the reward is really good. I don't feel bad about myself if I start playing a video game. And so what we actually end up doing is reinforcing the negative behavior. And that circuit seems to be what's hyperactive in OCD. So this has been kind of a really quick overview of OCD. There's a lot more that we could talk about in terms of the details of like what psychotherapy for OCD is like.

The neuroscience of OCD is really fascinating. Even psychoanalytic perspectives on OCD are really fascinating. But this is kind of a quick overview. that I really wanted to share with y'all to really help you understand a little bit about what OCD is, why it's so devastating, and a little bit about even how treatment for OCD can be useful for every human being on the planet. I saw that...