HealthyGamerGG - What People Don't Understand About OCD

Episode Date: October 4, 2022

Dr. K dives into OCD, compulsions, treatments, being obsessive about self-improvement, and more! Support this podcast at — https://redcircle.com/healthygamergg/donationsAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy Learn more about your ad choices. Visit megaphone.fm/adchoices

If you do particular things as a patient, you will no longer need the medication to do that job for you. So what we're going to do now is we're going to talk a little bit about OCD. So we're going to talk a little bit about what OCD is, what it isn't, what are some of the key features of OCD. And lastly, we're going to talk about three things that people get wrong when it comes to OCD. So let's start by taking a quick look at the post. Okay. OCD is the most misunderstood mental illness. Every single person I've seen thinks it's about organizing and always joking they have it because they're clean and organized.

They don't understand that there's many types of OCD. And for most people, it's not like that at all. That's sometimes a coping method for some. I've convinced myself I have cancer. Someone's going to break in and hurt my pets. And I have to make sure it's not happening and keep on checking. The checking compulsions have also ruined my life. They're as bad if not worse than the obsessive thoughts.

Every mistake I make haunts me, and even when it affected no one, even if it's a small mistake like accidentally stepping on something, the guilt eats me up. It hurts me so much. I want to change my whole life. I can't live like this. I've convinced myself I have every cancer before. I convinced myself I have something or am something new so often. I research about it nonstop and it matches my symptoms and then it's a whole cycle.

I can't take it. The fact that it's so misunderstood makes it worse. I get so pissed when people constantly say how it blessed them or I have OCD because I'm organized. Even teachers say that. Shame on them. And they haven't been diagnosed and say that. Like, shut up, seriously. So I think it's super challenging, but OCD is actually one of the most misunderstood illnesses.

So what we're going to do today is talk a little bit about why. it's misunderstood, talk a little bit about what it is, and then three really common mistakes that people make. So let's start with why it's misunderstood. So the first thing that we're going to talk about is OCD versus OCP. So OCD is obsessive compulsive disorder, and OCPD is obsessive-compulsive personality disorder. Now, what's the difference between these two things? So we tend to use the phrase OCD colloquially. We'll say, oh my God, I'm so OCD, I have to have everything in the right place. I'm so OCD, everything has to be organized. I'm so OCD, everything has to be on time. And when people are talking about OCD, what they basically mean is

I'm a control freak, right? I need everything organized. I need everything symmetrical. But being a control freak isn't OCD. It's actually something completely different, which is what we tend to call OCPD, which is obsessive-compulsive personality disorder. So in the case of OCPD, people are control freaks to the extent where it actually negatively impacts their function and their relationships, usually to a drastic extent. If people are talking about being so OCD on social media because they have to arrange all their bookshelves in a particular way, chances are they're not actually true OCPD. I mean, very few, a small percentage of the population, maybe one or two percent of the population

really has OCPD. So what people tend to, usually what that means is that they have a high tendency for organization. They're more rigid. they're lower on sort of the openness or lower on the agreeableness scale from a personality perspective. And everyone calls this OCD. And so as we've started calling basically being a control freak or being like more rigid in our thinking, OCD, what it's started to do is actually confuse a lot of people about what real OCD is. So let's talk a little bit about what true OCD is.

So the first thing to understand is that OCD is composed of two things. obsessions and compulsions. So obsessions are usually thoughts that have the following characteristics. The first is that they're intrusive. So what that means is that I can be going about my day and then a thought will like force its way into my head. Frequently, the intrusive thoughts are also unwanted. So that sort of means I don't want to be thinking about this, right?

So if I'm going to a wedding and I'm having a good time and I'm like, I'm there at the wedding to have fun. but if I have OCD, I can start thinking all these sort of negative and intrusive and unwanted things. I may start thinking, oh, my God, what if the groom dies? What if the groom dies? What if the groom dies? Or I may start thinking a little bit about getting infected with COVID, and then I can't stop those kinds of thoughts. Or I can even eat a piece of, like, I can eat an appetizer and I get a weird sensation in my stomach,

and I get this persistent thought that maybe I've got stomach cancer. So that's the third quality of. obsessions, which is that they're persistent. So no matter what I do, they always tend to come back, come back, come back. So in the cases of people who have, for example, like, let's say body dysmorphia, which is a kind of OCD, I'll look at my face and I'll think, oh my God, my face is flawed. I need to fix it. And then no matter how much I try to fix it, even to the extent of maybe wearing makeup or going and getting surgery and then I need more surgeries and more surgeries and more surgeries. Because the key thing about the obsession from

OCD is that it's persistent. And even fixing things on the outside doesn't make the thoughts go away. So obsessions are intrusive, unwanted, and persistent. The other thing about obsessions, and this is kind of important to understand, is that they don't make me happy. So even though I may act in accordance with them, it's not like making me happy to give into my OCD. In fact, quite the opposite frequently for many people, is that I want the thoughts to go

away. I don't like it. And if we look at people who are control freaks, they get really, really happy when everyone listens to them and they get their way, right? So this is a key difference between OCD and OCPD. In psychiatry, we call this phrase egosentonic, which basically means does it jive with you or not? And in the case of OCD, when people have true OCD, they want their OCD to go away.

When people have OCPD, they don't want their OCPD to go away because they're right. and the rest of the world is wrong. And the rest of the world really needs to do things the way that I do them. We really need to objectively organize the knives, the forks, and the spoons this way because it's better. So in OCD, people really dislike the thoughts they have. They dislike the obsessions. And in OCPD, they tend to be like very, very controlling and they think that they're good and better than what everyone else thinks. So just for the sake of completeness, oftentimes obsessions focus on a couple of different things.

So they can focus on things like cleaning or being concerned about germs or kind of being a germaphobe or neat freak or something like that. They can be focused on symmetry. And this is where things get a little bit conflicting with OCPD or muddy, I should say with OCPD. Because oftentimes OCPD can be very, people can be rigid and organized as well. So obsessions are frequently about cleaning. They're frequently about symmetry, right? So I need things arranged in a particular way. They're also frequently about what we call taboo thoughts.

So people will have intrusive and unwanted thoughts that are very, very negative. Like we judge them very harshly. So people can have thoughts about inappropriate kind of sexual relationships. They can have just all kinds of thoughts that they feel guilty for. They're very taboo or forbidden. And the last common type of OCPD actually has to do with intrusive thoughts of harm. So this can be actually incredibly distressing because this. Despite not wanting to hurt anyone, you will sometimes have visions of harming other people in particular ways.

And those visions are, once again, intrusive, unwanted. They don't agree with you. You don't think they're right. And they can be very, very distressing. So that's obsessions, which are intrusive, unwanted, and persistent thoughts. The other key thing about OCD is that frequently what people will discover is ways to calm those obsessions down. So if I'm having a particular taboo thought, right, I'm thinking something that I shouldn't be thinking, what people with OCP will discover is ways to alleviate the tension in the mind.

And those are what we call compulsions. So if, for example, I'm a germaphobe, if I wash my hands for 90 seconds under scaldingly hot water, then my fear of germs will calm down. And so I'll engage in a compulsive behavior. So here are the key things about compulsions. They're oftentimes behaviors, but they can also sometimes be thoughts. So sometimes I've met people with OCD who will, like, think particular things. So I was working with someone who once every time a loved one was traveling, they had to say some kind of like magical spell in their mind.

And if they said these thoughts, this person is going to leave on time and they'll be arrive on time, they'll leave, they'll be safe when they leave and they'll be safe when they'll they arrive. They'll be alive when they leave and they'll be alive when they arrive. They'll sort of come up with this almost like mantra in their head that they sort of have to say in order to feel better about that person actually leaving. And unless they go through the compulsion, the tension of the obsessive thought actually persists. And it's actually incredibly terrifying. So compulsions are behaviors or even mental behaviors that we do to alleviate the obsessions. The other tricky thing about the compulsions is that they will also oftentimes be damaging. in and of themselves.

So in the case of the germaphobe, that's something that we can understand. I've seen patients who have, you know, very, like, raw hands that are actually getting infected because they've broken down parts of the skin from excessive washing and excessive scrubbing, and now they're prone to infection, which makes the OCD even worse,

and they want to keep washing and keep washing and keep washing. So engaging in the compulsions can actually be damaging to people. So that's kind of what true OCD is. We see it's a huge impairment to function. So what are some of the common things that people get wrong when it comes to OCD. The first, we've already talked about a fair amount,

which is that people confuse OCD with OCD. They confuse being a control freak with OCD. But what we learn from real OCD is that it's obsessions that are intrusive, persistent, and unwanted. And compulsions that make that kind of stuff go away, even though you don't want to do it. And oftentimes people recognize that the compulsions are actually very irrational. So that's the first thing.

OCD isn't what people think it is. The second thing that people oftentimes forget about OCD is that the compulsions don't have to be what the media represents. The compulsions don't have to be turning on and off the lights or turning on and off the stove. The compulsions can be completely non-visible or even not behaviors at all. They can be thoughts.

They can be things that you do in your head. And when I've worked with some people who have debilitating OCD, you would never see it from the outside. Because essentially every time they do something, they have to run through this whole litany in their head. So every time I start studying, I have to go through some kind of like process in my head before I pull a single notebook out. Every time I flip the page, I have to go through some sort of process in my head before I can flip the page. Otherwise, I will lose kind of the information in the page. And the last thing that we have to really focus on that people don't really get about OCD is that you can't really control it.

So this is for people who have OCD as well as people who are in relationships with people who have OCD, which is that we'll assume that this person can somehow control it. So sometimes I've seen people with OCD get treated very, very harshly by parents, by friends, by romantic partners, because they're like, why can't you just stop doing it? There's this assumption that OCD can be controlled, and it really can't. It's like this automatic, persistent, unwanted, and intrusive process. that it doesn't mean that it can't be treated, but there's sort of this idea that like if people tried harder,

they could make the OCD go away. Just don't wash your hands. Easy, right? Just be satisfied in the way that you look and stop getting surgeries and getting your nose, like getting a rhinoplasty and Botox injections and all this kind of stuff. Some of the most terrible OCD I've actually worked with is actually with people who are bodybuilders

and who are so obsessional about a particular part of their body that they'll work out for four hours, five hours, six hours a day, and aren't really able to function in other parts of their life. So these are the three things that people really get wrong with OCD, which is why it makes it such a misunderstood illness. The first is that having OCD is not being a control freak. In fact, they're completely different. Even when being a control freak rises to the level of a diagnosis, which is what we call

OCD, that's still like, you know, very, very rare. second thing is that obsessions and compulsions are not necessarily physical behaviors. A lot of OCD can happen purely in your head. And the third thing is it's not something that you can just control. And so a lot of times when I work with patients with OCD, they recognize that these thoughts are unwanted. Remember, they're ego dystonic. So I don't want to have them. It doesn't make me happy to have these thoughts.

And so I try to control it. I try to control it. I try to use willpower, but that's not how it works. There are absolutely places where willpower becomes a, important, but that's where good OCD treatment comes in, because we figured out that this can actually be helped. You just have to approach it in sort of an evidence-based and scientifically valid way, which is not brute forcing it through willpower or blaming someone for having these kinds of symptoms. So it's unfortunate that OCD is so misunderstood, and hopefully by sort of

going over some of the basics of obsessions and compulsions, we can understand really what it is and also understand what we get wrong about it. Questions? Yeah, I didn't, I didn't, I didn't we need an iPad. We may bust it out, but. So a lot of good questions here. Could it be possible that having OCD is beneficial in some way? Possibly, but remember that when we're doing the dividing line between whether something is a psychiatric illness or not, the dividing line is whether it impairs function. So generally speaking, when we talk about OCD, these are people for whom it is so severe that it kind of by definition impairs them more than that. it helps them. Are there levels of OCPD? Absolutely. Right? So just like any other personality

disorder, there are people with severe OCPD and people with mild OCPD. And there are even people with what I would call subclinical OCPD. So these are people who are like control freaks, who have trouble in their interpersonal relationships, but they're not such bad control freaks that they can't maintain a job, they can maintain a healthy, or they can maintain, you know, a romantic relationship, et cetera. Can OCD worsen anxiety disorders if you have both? Absolutely. So there's actually a high level of comorbidity between anxiety disorders and OCD.

So there seems to be, it seems to be that like it's not a purely independent process. What about the compulsion to smoke cigarettes? So great question. So we can have, we can be have behaviors that are compulsive, which don't necessarily have to do with OCD. So if I feel like I need to smoke a cigarette, that could be due to a biological or physiological dependence that's making me kind of feel that way. That's part of the reason that when I talk about compulsions and OCD, what we really look for, this is somewhat of an oversimplification because, you know, if you really want to understand what we look for, you've got to go to medical school and then become a psychiatrist or psychologist or whatever. But basically what we look for is that the compulsion relieves the mental tension. of the obsession. This is a key part of OCD, that the reason that I wash my hands over and over and

over and over again is because it's the only way that I can stop worrying about being infected. Because the thoughts of being infected are so intrusive, so persistent, and so unwanted that I can't do anything. I can't play video games. I can't talk to people. I can't pay attention in class because I'm constantly thinking about, oh my God, this is, I'm, germs, germs, germs, germs. And the only way that I can start to live life is by washing my hands 15 times so that that thought finally calms down. The problem is that it's just going to come back. Tomorrow, later today, if someone touches me, it just comes back and then the cycle repeats itself, which is why OCD is so debilitating. Good questions. How,

easy is it to diagnose? I'd say it's not hard to diagnose if you're a competent clinician, for the most part. Sometimes the tricky thing about OCD is that it can look like other things, and also patients are, the reason we're educating on this, y'all on this stuff is so, because a lot of times what will happen is that patients will not volunteer particular information because they think it's normal or they don't think it's what their vision of OCD is. So that's why, for example, like I've met some patients who the diagnosis has been missed because, you know, in the screening, clinicians will ask them questions like, oh, do you have checking behaviors? They'll talk about behaviors of OCD, whereas they won't ask about mental compulsions. So sometimes it can be missed.

It can oftentimes look like anxiety or things like that. Or since people have OCD and anxiety, the anxiety is like what we pick up first, right? So there are like reasons why it can be missed, but generally speaking, I wouldn't say it's hard to diagnose. Are OCD and OCPD mutually exclusive? No, they're not mutually exclusive, but they still look very, very different. People are asking about ADHD and OCD. I don't know that there is a very tight comorbidity between the two. What I've seen is very, very frustrating for people who have OCD and ADHD.

This is devastating. is that in ADHD, it's easy to get distracted. And OCD loves to dominate your mind. So what I've seen in the two, which can be very hard to deal with, is when I've got OCD and ADHD, let's say I wash my hands 10 times, and then I'm sitting down to study, and I'm no longer thinking about germs.

The problem is that once I sit down to study, 15 minutes, 20 minutes, 30 minutes, maybe an hour goes by, maybe 90 minutes go by, maybe three hours go by, before I think about drugs again, in a neurotypical person. When you throw ADHD into the mix, it's easier to get distracted.

Right? So now that I get distracted, the OCD is like, oh, thank you for opening the door. Let me come in with my intrusive, unwanted, and persistent thoughts, and let's go back to square one. So sometimes I can see the two

really kind of synergize in a very negative way, but I haven't seen a lot of data that shows that they're very highly comorbid. Good questions. Can people be obsessive over self-improvement? sure. So this is also where obsessiveness is not exclusively OCD. The key thing about obsessiveness is that it usually has obsessions and compulsions. So we'll see obsessiveness as a quality that is a part

of all kinds of things. So it can also be a part of other mental illnesses. So for example, like people on the autism spectrum can sometimes be obsessive about particular things. things. That's something that we call more something like perseverance, which is the inability to let go of a particular thought. Sometimes we'll also see obsessiveness in things like psychotic disorders or delusional disorders, right, where someone becomes very like delusionally obsessed with something and they can't stop thinking about it, can't stop talking about it. But it doesn't mean that you have OCD. The other thing is that sometimes obsessiveness has nothing to do with a psychiatric illness. Sometimes people just get obsessed and it can be almost more of a

personality characteristic where they really tunnel down into one thing, or they can sort of foster a certain kind of infatuation or things like that, where you may be able to diagnose someone who is like, you know, a stalker with something, right? Because there's something not right there. But sometimes you can have obsession outside of psychiatric illness. So if this resonates with y'all, so I'm noticing one person is saying, I count all the time, how can I stop, I can control a few things and started fighting against a few things, I would say you should get clinically evaluated. what the reason that we have these kinds of educational segments. So Brian Gou is asking in private spaces, I'm a mess, but in public spaces, I have to leave things exactly as before I

displaced them, is this OCD? So that's not a question that I can answer. So just a, you know, a couple of things. When we say we're not doing, you know, nothing, this is medical advice, we don't diagnose or treat people over the internet. But it's not just, it's not just that we're not doing that for medical legal reasons. It's because, you know, getting a diagnosis and determining whether something is OCD involves a thorough diagnostic process. So when I'm evaluating someone for OCD, it's not a yes or no question about one feature. That's where, because remember, OCD can look like other things. And that's why when you do a diagnostic evaluation for OCD, a part of that diagnostic process is actually ruling out all kinds of other stuff.

So before I can diagnose someone with OCD, I have to not only assess the OCD symptoms, but also make sure. that it's not something that looks like OCD. So make sure it's not an anxiety disorder. Make sure it's not body dysmorphia. Make sure it's not, for example, you know, bullying. Like if you were, you know, grew up in a household, for example, where your parents were like, made sure everything was in order because you all had to keep up appearances.

And so if you go out, you have to keep everything neat and tidy because of, you know, what your parents, the way they raised you. That may not be OCD. So a diagnostic evaluation is not just about checking. boxes, it's also about making sure that it's not something else. So diagnostic evaluation involves diagnostic criteria, as well as assessing for other conditions and ruling out those conditions. That's how you make a real medical diagnosis. So does OCD act in similar ways to Tourette syndrome? There are some correlations there. In fact, I think some of these tick disorders

are considered in the OCD family. So I'm not an expert in those disorders, but there's definitely some overlap there or some common starting point according to a lot of people. So we do tend to lump them together. Like we kind of say, okay, these things seem similar to us. So it seems like a lot of people are,

okay, so let me ask you all a question now. So someone's asking, can someone suddenly develop OCD, OCP, later in their lives, like in their 30s, they can. So just to give you all some statistics, I want to say that the average age of onset for OCD, I'm rusty here,

is I think 19 years old. So most people who have OCD will experience it early in life. Now, they may not get diagnosed with it, but I have seen, I've certainly seen, like, weird cases. So this is the advantage of training at a place like Massachusetts General Hospital or McLean Hospital. So these are like

world-renowned institutions and people will like get referred from all over the world. So sometimes you see some weird stuff. So I've seen like weird cases of post-infectious like development of OCD. But just because I've seen it doesn't mean it's common. In fact, when you work at a place like MGH or McLean, by definition, you see a lot of stuff that is the least common because like people, you know, it's not run-of-the-mill OCD. This is a weird kind of OCD. So, like, your community psychiatrists will actually send them from a different state to the OCD at McLean, the OCD Institute at McLean Hospital. Because that's where, like, people are experts in OCD.

So you can see it later, but it's not common. Yeah, it's kind of weird. So, like, I love training there. But it's like, I also saw, I think, a case of familial fatal insanity. insomnia, which is fascinating, but also like exceedingly rare. Like, I'll probably never see another case of it in my lifetime, and I doubt, I mean, most psychiatrists will never see a case of familial fatal insomnia, hopefully. Yeah, familial fatal insomnia is a preon disease.

We've done a lecture on it before. Actually, this is kind of interesting. We did a playthrough of, I mean, we started playing disco elysium, and there was some guy who was like make like talking like just in some dialogue thing and I was like oh this sounds like the familial fatal insomnia and then we did like a quick lecture on it and then sure enough like later on in dialogue he's like actually mentioned and I was like oh wow these people really did their research once you get diagnosed with OCD do you have it forever or can it dissipate over time what a great question so this we actually have another post about so we're going to talk about

general treatments for psychiatric stuff we're going to focus a little bit about on ADHD for a second, but a lot of this applies to, oh, no, iPad, we don't need Netflix. My iPad is trying to open Netflix. Okay. So let's talk about, so people have some questions about treatments, right? So short answer is there are all kinds of treatments for OCD. Medication, there are medication treatment, psychotherapy treatments. The two are not mutually exclusive.

I've seen cases where people can end up in sustained remission from OCD. it basically does not affect them at all. That's the goal of psychiatric treatment. It doesn't mean that they don't still sometimes have intrusive thoughts, but they're basically able to function completely normally, and it doesn't really cause them much to stress. Some of those people can do it without medication. Some people sort of find medication to be easier.

It just depends on the person. But let's talk a little bit more about treatment. Okay. My doctor just told me I've become dependent on ADHD medication. What does that even mean? I got off the phone with my doctor just now to get my Adderall prescription refilled. During the call, he asked me, do you take it every day or as needed? So I told him, honestly, I take it every day because I feel I need it every day.

My ADHD doesn't just vanish. But on the odd day that I forget to take it, I do just fine. It's when I forget for multiple days that it becomes an issue. And he said, it sounds to me like you've become dependent on stimulates. Okay. So I told him that I actually was planning on visiting a proper psychiatrist. My prescription was given by a GP and seeing about altering my prescription. Maybe a non-stimulant would work or a lower dosage.

And he replied, no, stimulants work best for ADHD symptoms. So now I'm very confused as to what he's going on about, to be honest. I shouldn't take my medication if I don't need it because I'll become dependent on stimulants, but I also need to take stimulants because it helps me the most, therefore making me dependent. It's really confusing logic, and I don't know how I feel about it. He didn't really elaborate either. No concerns about my blood pressure or anything.

He just said, hey, you're dependent, just letting you know your prescription is ready for you to pick up. It's just really confusing, and I'm paranoid about my health as it stands. So this is really tough, because especially if you've got ADHD, like anyone who's taking psychiatric medication usually has a concern. that they're going to become dependent on it. I've seen this whether people have OCD, whether I have major depressive disorder, whether they have bipolar disorder, whether I have ADHD.

People are afraid of becoming dependent on medication. And then sometimes you'll have clinicians who will be like, oh yeah, you're dependent on this medication now. Like a doctor is telling you this. And that's kind of terrifying. Isn't dependency on medication like a bad thing? And then you're like not really sure.

And sometimes you'll even ask your doctor like, hey, like, is there some way to get off the medication? And they'll say, like, no, this is the most effective treatment. So I disagree with a lot of what this GP says. I'm pretty sure the evidence backs me up better than it backs the GP up. We'll talk about that for a second. But what I'd love to do is talk to you all today about what medication dependence means. Is it okay?

Is it not okay? And how people wind up being dependent on medication. And is that scary? So the first thing to understand is that the reason we prescribe medication is to sustainably help people, right? So I'm going to ask you all a question. Let's say I have a heart transplant. And as part of my heart transplant, I have to take immunosuppressive medication every single day. Why do I have to take immunosuppressive medication?

So let's do a quick jaunt into physiology and transplant rejection. not what y'all were expecting today, but let's explain this principle. So I have a body. My body has an immune system. My immune system learns what is me and what is not me. And then what the immune system does is starts to attack things that are not me, right? Pretty easy. Turns out that I got a bum ticker and I need a heart transplant.

So what I'm going to do is I'm going to get a heart transplant. And in order for my immune system to not destroy the transplanted heart because it comes from another person, I have to take immunosuppressive medication. Now, this begs the question, am I now dependent on immunosuppressive medication? Like, sort of, right? I'm not, I mean, like, I guess I could stop taking it. It's just that, so this is the key thing to understand. Medication is there to accomplish a particular goal.

That's really the beginning and the end of it, right? We'll add a little bit of nuance in a second. But in terms of whether you're going to become quote-unquote dependent on a particular psychiatric medication, the first question is, is it doing what it's supposed to do? And do you want it to continue doing what it's supposed to do? So when people take an antidepressant medication or anti-anxiety medication, for example, they're like, do I have to be on this the rest of my life? That's usually like one of the earliest questions they ask. And the short answer is you don't have to be, and we'll get to that in a second. But this is where I'd say the purpose of medication, whether it's cholesterol medication, immunosuppressive medication, weight loss medication, or ADHD medication or depression medication, the goal is the same. It's to try to keep you healthy. Now, just like with many of those medications, if you do particular things as a patient, you will no longer need the medication to do that job for you. So let's say I have type 2 diabetes, which means that due to the number of adipocytes or fat cells that I have in my body, this is an oversimplication, my body has become resistant to insulin.

And so since it's resistant to insulin, I can take certain medications that will increase my insulin sensitivity. Fix the problem. And what I can also do is adjust my diet, reduce the level of my adipocytes, right? Start to exercise and do other kinds of physiologic things that make it so that I no longer need the medication. So am I going to be dependent on this medication for the rest of my life? well, that depends on my other behaviors and what else I do. So let's talk a little bit about ADHD medication. So do people become dependent on it? So some people with ADHD require medication on a daily basis.

Generally speaking, stimulant medication for most people that are prescribed for ADHD, I will actually recommend it on a daily basis. So the goal with people with ADHD is generally speaking, the ADHD kind of screws up their life. Right. If I go to work every day and I need to pay. attention every day, I don't want to be like missing some days and be like okay other days. Like if I show up three hours late to work once a month because I didn't take my ADHD medication

every single day, like, I'm going to lose my job. So what I found is a psychiatrist working with people with ADHD is you can't afford to have ADHD, you know, 20% of the time. Like you can't treat 80% of it. You're still going to get screwed if you, like you're 20% If your ADHD is active 20% of the time. There are some cases where, for example, like if people don't need it for work, what they'll do is they'll not take their ADHD medication on the weekends or things like that. There are individual plans that you can kind of come up with. But it's okay to take ADHD medication every single day.

Does that build dependence? Before we go on. So people are asking about weekends. So like, here's the thing. Sometimes you need your ADHD medication on the weekend as well. Why? Because you have to do all the crap that you don't get to do during the week on the weekend. Like, you've got to do laundry, you've got to pick up groceries, you got to drop off packages to return to Amazon, you got to pick up birthday cards, you've got to be on time to social events.

So it's fine to use ADHD medication every single day. So does that mean you become dependent? Well, there's two issues to consider with ADHD medication. The first is that there may be a physiologic dependence. So this is neither good nor bad. It's not a value judgment. It just means that if your body develops a physiologic tolerance and dependence on a particular chemical substance, that means if you don't take it, you're going to have withdrawal symptoms, and that could be bad.

So we develop different kinds of symptoms with ADHD, I mean, different kinds of tolerance with ADHD medications. That's not necessarily a bad thing. It's just something that you need to be aware of, almost from a safety standpoint. So that's where, like, we can become dependent on caffeine. Does that mean that morally we're bad people and we're addicts? Not necessarily. It just means that if you don't have caffeine, you may have a headache. That's it. It's just to understand the physiology of it. Now, the second thing about dependence is, do I have to take this medication for the rest of my life? That's what basically people are asking when they're saying, am I dependent on this medication? And that's where that depends.

It depends. And then you may say, well, Dr. Kay, that's weird. Like, how can you say that depends? What does it depend on? Just like any other medical illness, or not any, but many other medical illnesses, how long you need to be on medication, the dose of the medication, that all depends on whatever. else you are willing to do as a patient. So let's go back to our diabetes example.

If I start exercising every day, if I eat low glycemic index foods, if I start, you know, doing other particular things like doing yoga or other practices that support type 2 diabetes and stuff like that, then I may not need to be on the medication for the rest of my life, right? So if I can like get to where I need to go without the medication, then I won't be dependent on the medication. I won't need it. So the question is, okay, what does that mean for ADHD?

What's the equivalent of eating healthy and exercising for ADHD? First of all, eating healthy and exercising both do help ADHD. We go into some of that stuff in the guide that we've got hopefully coming out in about a month on ADHD. So we'll go over a lot of different treatment options and stuff like that in more detail. The key thing to remember about ADHD, let's talk about science. What does the evidence-based data suggest? So first thing that evidence-based data suggests is that medication and psychotherapy are equally effective, roughly, in terms of effect size.

What does that mean? That means that if I have 100 people with ADHD and I put 50 of them into psychotherapy and 50 of them into medication or give them medication, the symptom reduction that they get in terms of ADHD is the same. Okay? You actually don't need a pill. You can just go to therapy and you will get roughly the same. effect size. Now, people may ask, like, how do you get therapy for ADHD? It gets complicated.

There's also a bunch of info on this in the guide, but basically, a lot of the psychotherapy for ADHD is developing structures and systems to account for your ADHD, essentially putting up guard rails so that your ADHD does not negatively impact your life. It is literally teaching people things like how to organize, how to prioritize, how to set alarms, how to set reminders. we go into a lot of detail about how to develop a good organizational system in the guide. But it teaches people these kinds of skills. And so just like any other psychiatric illness, there are certain skills you can learn that will mitigate or prevent the illness from harming you.

So a simple example of that is anxiety and meditation. So if I have an anxiety disorder and I'm feeling very anxious and I learn to meditate, that can reduce the symptoms of anxiety and reduce my quote-unquote dependence. dependence on anxiety medication. ADHD is no different. We can learn particular skills. That's what psychotherapy teaches us. Now, here's where the data gets interesting. So when you take people who have been given psychotherapy and people who have been given ADHD medication, effect size is roughly the same. Difference is duration of benefit after ending treatment. Here's where the dependence comes in. So when I take ADHD,

medication, if I stop the ADHD medication, I'm more likely to go back to square one. Whereas the cool thing about psychotherapy is if I do psychotherapy for, let's say, 20 weeks, and I'm done seeing my psychotherapist, I will still get the benefit of that therapy for a year, two years, maybe even three years, or even somewhat, quote, quote, permanently. Depends on the person. But what we know is that the benefits of ADHD medication even last after you've done taking the medication. So people will still get positive benefits for six months and

nine months after stopping medication. So their symptoms don't return back to normal right away, necessarily, over long, you know, large populations and longitudinal studies. So the duration of psychotherapy far outweighs the duration of medication, which is an important consideration. So when people ask me, am I going to be on medication for the rest of my life, it's like, well, that depends on whether you develop an organizational system that will protect you from your ADHD.

And if you can learn how to organize, if you can learn how to prioritize, if you learn all these things, chances are you don't need medication. Next point. So the GP said stimulant medication works the best. So there's something really tricky about stimulant medication, which is not necessarily that it works the best. So there are head-to-head studies that show that non-stimulent medications and stimulant medications basically work the same in terms of the effect size. The big difference between stimulant and non-stimulant medication is, first of all, stimulants work faster than non-stimulants. So there's a medication called buproprione, for example, that is just about as effective as stimulants.

The difference is that buproprione takes like a month to really kick in, whereas stimulants, you'll feel the benefit within 24, 48, or 72 hours. So stimulants are better in terms of acting fast, but they don't necessarily work. They don't reduce your ADHD symptoms more than non-stimulant medications, on the whole. The second thing about stimulants that makes them feel like they work the best, and I'm not surprised to hear that from a GP, is that patients think they work the best. So there's a very simple principle in our brain that the more rapid the reinforcement, the more behavioral reinforcement we see.

Sorry, the more rapid the benefit, the more behavioral reinforcement we see. So for example, like stimulants work instantly. So what happens from a patient perspective is patients will tell you stimulants work the best for me, nothing else works. And why do they say that? it's because they notice the benefit immediately, whereas non-stimulate medication takes days or weeks to really kick in, so people don't notice it.

But if you actually do studies where I take 100 people on stimulant medication, 100 people on non-stimulant medication, and I measure objectively how bad their ADHD is, let's say three months after they started medication, what I'm going to find is they're both equally effective. But the subjective experience of the two patients is going to be very, very different. The subjective experience is going to be any day I miss my medication with a with a stimulant, people notice it right away.

So there isn't a difference in efficacy. What there is is a difference in sort of noticing or kind of like an awareness bias where you can really feel the difference of the medication. Whereas when you're on a slower acting medication, you don't quite feel it as much. So that's part of the reason why people say stimulants, quote, quote, work the best. I don't think they actually, the data suggests that they don't work substantially better than non-stimulants. It's just the difference is a lot more noticeable

and therefore is much more likely to reinforce the behavior, right? So a lot of people are genuinely concerned about, am I going to be dependent on my ADHD medication? And like, the answer is maybe, right? So what I tend to see as a clinician is that a lot of people will find it very convenient to just take a medication every day because they don't have the time or the energy or wherewithal to learn organization, prioritization, whatever.

Especially if we're talking about people who are students, right? So sometimes, like, I'll get someone who's like a sophomore who's coming in during midterms. And they're like, you know, you can teach me organization and planning. But in the two months it takes me to like figure out how to use a calendar effectively, like my midterms are going to be gone and I'll have failed them. So sometimes people will need medication because it's the easiest thing to do. Now, how dependent on it you become, not just from a physiologic perspective, but we're talking

like long term, do you need to take a medication for the rest of your life? The answer is that depends. It depends on the severity of your ADHD. It depends on what other kinds of things you're willing to try. So we also know, for example, that meditation strengthens frontal lobe function, and the goal is going to be over time to literally, like, reduce your mind's distractibility through practices like meditation, the more of that kind of stuff you do, the less dependent you're going to become on your medication.

And the last thing about people sort of saying stimulants work best, well, I think they work fastest, and they work most noticeably. But fastest and most noticeable does not technically mean best, but it oftentimes looks like best. Because think about it from the GP's perspective. When I give someone a non-stimulant medication, they come back in two weeks and they say the medication isn't working, I'm still having. having problems. Then as a general practitioner, I switch them from a non-stimulant to a stimulant.

They call me the next day and they're like, this medication has changed my life. And so then as a GP, I don't blame the GP for, you know, they can't stay experts in everything. You know, I don't blame them, but they'll sort of say like, oh, okay, so it seems like stimulants work better. And then what happens to the GP is the next time someone comes in with ADHD, I just start them on the stimulant. And then I don't ever hear from them again, except when it's time from refill. I ask them, how's the medication working? They say it's working great. So these kinds of biases, not really the GP's fault in a sense, right? Because there's very natural ways why GPs will get to that conclusion.

Last thing that I kind of want to say is that if your doctor uses terms with you, that you don't understand or terrify you, like they say like, oh, yeah, you're dependent on this, by the way. That may mean something different to them than it does to you. And if your doctor says things that scare you, ask them to explain themselves. Be like, what do you mean by that? What does that mean? What are the implications of being dependent on ADHD medication? Is this a bad thing?

Like, what do I do about it? Second thing is, by all means, get a second opinion. If a doctor is not talking to you enough. If they are not explaining things enough, then by all means, get a second opinion. Explain to them that you need more explanation. And also, by all means, go see a specialist. So someone's asking, how does one's life,

Vly 2-915 is asking how does one's life change if they get diagnosed with ADHD? Chances are their life gets substantially better. So that's kind of a weird thing to say. Because remember, getting diagnosed with ADHD or not getting diagnosed, like you have the ADHD, whether it's diagnosed or not. It's affecting you whether you have the ADHD or, I mean, whether you have the diagnosis or not. You've got ADHD either way.

It's impairing your function. whether you have a diagnosis or don't have a diagnosis. The only thing that the diagnosis, hopefully the main thing that the diagnosis does is gives you the opportunity to do something about it. Engage in treatment. Now, what we do know is that living a life of untreated ADHD leads to all kinds of problems. We've probably got a lecture that we're going to share with you all in about a week or two about this, about the ADHD iceberg.

But for example, we need to be a lot of. know that something like 50 to 70% of people with ADHD. No, let me think about this statistic. That sounds high even to me. I think I may be misquoting this. But if you look at the comorbidity of ADHD and depression, three to five percent of people with depression will grow up to later be diagnosed with ADHD. But of the people who have both, 50 to 70 percent of people with ADHD will be, will

also have depression later in life for that comorbid population. So what does that mean? Does that mean that if you've got ADHD, you have a 50% chance of getting depression? No. There's four people who have both. If you take that subset of people who already have both, what you see is that there is a causal relationship between ADHD leading to depression. And it doesn't go the other way. It's not just correlated. One causes the other. And why is that? It's because growing up with ADHD, especially untreated ADHD, shapes your life to be depressed later. So I'll give you all a simple example of this.

Very fascinating study that found that kids with ADHD are less likely to be invited to birthday parties than neurotypical kids. Think about that for a second. So if I'm an ADHD kid, why does it mean I'm going to be less? less likely to be invited. It's because I don't pay attention. So all the other kids are talking about Pokemon cards and I start randomly talking about something that's completely unrelated. The kids all look at me like I'm weird because I'm highly distractible. I can't keep pace with the conversation. I also don't pay attention when they're talking to me. Right? So over time, like those kids aren't

going to want to invite me to their birthday party. And then over time, if I stop getting invited to birthday parties, what does that mean for the development of my social skills? I don't get opportunities to, like, develop my social skills because I get invited less. Can't level up if you don't zone into where the fighting is, right? Like, you can't get any XP if you're not invited to the game. And so over time, kids with ADHD experience more social isolation and loneliness. Rusty social skills, which in turn makes it harder for them to get promoted at work. Because a lot of getting promoted at work has to do with social skills. And so what we tend to see with kids with ADHD, especially when it's undiagnosed and untreated,

is that living a life of undiagnosed ADHD predisposes you to depression through features like underperforming in an academic sense. So there's underachievement academically for kids with ADHD. There's lack of social opportunities, which leads to isolation and loan. There are all these different factors where you can almost, this is what we do in the lecture that, there's a whole lecture about this, and Dr. Kay's guide to ADHD and doing stuff, where you can map it out how growing up with ADHD leads to particular factors which later in life lead to depression. Because what ADHD does is all of these factors over here are risk factors for depression later in life. So hopefully getting diagnosed changes your life for the better.