HealthyGamerGG - Why OCD Is Deeper Thank You Think

Episode Date: April 29, 2025

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I'm Dr. Al-O. Knoja, but you can call me Dr. K. I'm a psychiatrist gamer and co-founder of Healthy Gamer. On this podcast, we explore mental health and life in the digital age, breaking down big ideas to help you better understand yourself and the world around you. So let's dive right in. Hey, everyone. My name is Dr. Aolo Kanoja. I'm a Harvard-trained psychiatrist, and today we're going to talk about OCD. So obsessive-compulsive disorder is characterized by two things, obsessions, which are intrusive, unwarial, and repetitive thoughts, and compulsions, which are behaviors or mental reactions, which we engage in to reduce the anxiety from our obsessions. Compulsions can be repetitive behaviors, things like washing my hands seven times when I'm afraid I have germs, or they can even be mental reactions, like repeating certain thoughts

in your head over and over and over again until that feeling of anxiety goes away. The scariest thing about OCD is that you may have it and never realize it. And even if you see a mental health professional, there is a very, very good chance that you will get misdiagnosed with something like an anxiety disorder. Let's take a look at a couple of really quick statistics. 90% of lifetime respondents with OCD met the criteria for another lifetime disorder. 79.2% of cases of OCD began after comorbid anxiety disorders. Only a minority of severe cases received treatment for OCD. So this diagnosis is incredibly easy to miss.

Why is that? Because OCD feels like really bad anxiety. Sixty-five percent of people with OCD rank as severely impaired on a disability scale. So why is that? So let's understand something, okay? We have two kinds of psychiatric illnesses. We have the psychiatric illnesses that we give names to based on how they feel like major depressive disorder or generalized anxiety disorder. And we have other psychiatric diagnoses like OCDs. in schizophrenia that are named based on what causes them. So I know that sounds kind of confusing, so let me just explain, okay? So if we have something called a myocardial infarction, this is a heart attack, this means that there is a part of my heart that is not receiving adequate blood supply. Maybe I have a blocked coronary artery, so there's a part of my heart that is essentially suffocating. So myocardial infarction doesn't describe what it feels like.

So when someone has an MI or a heart attack, you know, it feels like, crushing sub-sternal chest pain. So you feel like there's an elephant sitting on your chest. So myocardial infarction is a good example of a diagnosis that is a technical diagnosis and what it feels like to a patient. If we look at the psychiatric illnesses, they also fall into those categories. So major depressive disorder feels like you're depressed all the time. Generalized anxiety disorder. Feels like you're really anxious. Social anxiety disorder. Feels like you're anxious in social situations. And then we have obsessive compulsive disorder, which, based on social media portrayals and things like that, everyone's like, oh my God, I'm so OCD. Oh my God, I'm so OCD because

I have to have my pens arranged in a particular way. That's not what OCD feels like. OCD feels like crippling anxiety, anxiety that won't go away no matter what you do, except for the one thing that actually makes it go away. So if you're someone who has crippling anxiety and there's one thing that works, you should seriously consider getting evaluated for OCD. Like I've said, one of the most frustrating things about OCD is how often it gets misdiagnosed. People can spend years trying to manage anxiety, depression, or even something else entirely without realizing that underneath it all, it might actually be OCD. And because it's so misunderstood, it gets missed. Another study showed something like 50% of people with OCD get misdiagnosed at first, which means they don't get

the right kind of support early on. And even when it is diagnosed, not every therapist is trained in the specific treatment that is effective for OCD, like exposure and response prevention or ERP. But here's the real challenge. There's a shortage of OCD specialists out there. That's where our sponsor, NoCD, comes in. It's a telehealth platform that connects you with licensed therapists who are trained specifically in ERP. Our scientific advisory board spent some time digging into NoCD's clinical approach and how they handle things like safety and escalation. And they were genuinely impressed by the level of rigor and understanding there. So if you're dealing with intrusive thoughts or you find yourself stuck in loops of obsessive thinking or repetitive behaviors,

it might be worth talking to someone who really knows what to look for. 155 million Americans have insurance that covers the cost of their sessions, making it an affordable option for therapy. They even offer in-app support when you need help between sessions, so you're never alone. You can schedule a free 15-minute call with no CD using the link in the description below. So what we're going to start with is someone who is lucky enough to not have OCD. So here's you. Let's hope that you don't have OCD. So what happens is you're in a particular situation, and the situation creates a thought. The thought will create an emotion.

So let's say that the situation is that my partner, who I'm in a long-distance relationship, is boarding a plane and is going to come visit me. So the situation is a visit. And then I have a thought. I hope that the plane doesn't crash. I hope they're safe. I hope everything is okay. And then this thought leads to anxiety.

Now, in a normal brain, someone without OCD, there are a couple of different things that can happen to this anxiety. The first thing, as I'm sure y'all are aware, is that we can habituate to it. So we have to explain this for a second, okay? Anytime we have a negative experience within our body or our mind, like let's say I feel hungry. We don't feel hungry forever, right? We feel hungry for a little while, and then my brain sort of my body figures out,

okay, we're not going to get food right now, so we're going to suppress hunger signals for some amount of time. If you wait an hour or two hours later, the hunger signals will come back, but our brain and our body basically suppress negative signals after a little while. Another really great example of this is like body odor. So sometimes you step into a place where like someone is a little bit smelly or you step into a place that's smelly. And then it smells really bad for the first few seconds. And then over time, the badness kind of goes down, right? It's not that you ever forget the smell, but that you habituate to it.

So you kind of get used to it. This can be true of temperature, it can be true of smell, it can be true of hunger, it can even be true of anxiety. So if you're lucky enough to not have OCD, you'll feel anxious about something and the anxiety will naturally decrease. The second thing that we do with anxiety is that we tend to distract ourselves. So this one is my favorite. It's the funnest way to deal with your anxiety. We can do things like I've had patients who enjoy when they're feeling anxious, getting high and playing video games. We have all these devices that give us dopamine that allow us to distract ourselves,

from our anxiety. Let's say I have a test on Friday and today is Monday. So the test is in four days. So I think to myself, oh my God, I need to study. I'm anxious about the test. Instead, I'm going to just play video games all day. So Tuesday rolls around and I'm like, oh my God, I still have this test, but I feel anxious about it. So I'm going to get high and play video games again. So I'm going to use certain mechanisms to regulate my emotions, right? So I feel bad. I'm going to do something to make the feelings go away. But then if I'm lucky, Wednesday rolls around, and this is really important. Now I've wasted two days, and then I have something that works, right? I can get high and play video games. But Wednesday rolls around, and I think to myself,

you know, that's not really a great idea. I really should study for this test. And you all may know this, that there are certain days that you do the wrong thing, but there's a voice inside you that then inhibits the wrong thing. So we call this response inhibition, right? So we call this response inhibition. Right? So what we're going to do is we are going to stop the emotional regulation that is unhealthy. So we'll distract ourselves for a little while. Maybe we'll spend 15 minutes on our phone, but then eventually we inhibit that response and we get back to what we should be doing. And so then hopefully what happens is once I'm inhibiting my response, then I end up taking appropriate action. So I end up basically fixing it. So this is the brain of someone who does not

have OCD. We have a situation. We have a thought. We have an emotion. And we have three ways that we sort of deal with the emotion. We habituate to it. We distract ourselves or regulate that emotion. And then even if we're regulating that emotion, eventually we learn how to stop regulating that emotion in that way. And we take definitive action to fix our problem. So how is the brain of someone with OCD different? So the first thing that happens is the situation. So already, already we know that one, thing is different. People with OCD have an overestimation of threat. Okay? So there's a situation. Someone is boarding a flight. If I were to ask you, are you worried that the plane will crash? A normal person may say, or a person without OCD may say, yeah, you know, I'm worried about it.

What do you think the chances are? Oh, I think the chances are less than 1%. But for someone with OCD, the chances of a plane crash are 10%. Or, I know this sounds a little bit crazy, no pun intended, and not trying to offend anyone, or the chances may be 100%. If you're someone who has a thought of a potential danger that feels like it is going to happen, 100%, unless you do something about it, you may have OCD. So this creates a thought, and then this creates anxiety. So we also know that there are changes in the amygdala of people of OCD. This is our fear and threat center of the brain, and it tends to get ramped up.

very easily. So we are overestimating the threat and our amygdala is hyperactive, which means that we feel an intense, intense amount of anxiety. Remember, this anxiety is so bad that it is severely disabling for 65% of people. Then we get to another problem. So remember how we habituate to negative things, like we're in a smelly, we step into the restroom, smells really bad, but then slowly the smell kind of goes away. And then when we step out, we feel really good, but we're not tortured while we're in the bathroom the whole time. So we know that in the brains of OCD, people fail to habituate. So whereas a neurotypical brain may get used to a bad smell, a feeling of anxiety, it'll kind of tone things down. The brains of people with OCD, they fail to

habituate, so they don't habituate nearly as easily. So that function doesn't work. The other thing is that they have a lot of difficulty even distracting themselves. They can try, but there is a lack of called cognitive flexibility in OCD. So what does this mean? So when I'm worried about something, let's say I'm worried about my test on Friday, in order to distract myself with video games, my brain needs to stop thinking about the test and start thinking about video games. Even this degree of cognitive flexibility is impaired in OCD.

So usually my patients with OCD will feel like once a thought gets stuck in their head or a thought gets stuck, really lodged in there. It's like a pit bull that is bitten on to something and refuses to let go. So whereas your friends may be able to distract themselves pretty easily, they can forget about it in a way that seems completely foreign to you. You get stuck in this almost obsessive degree of anxiety. So distractions don't really work as well. And this is also associated with emotional regulation deficits. So our capacity to calm down the amygdala is impaired. Okay? So it's hard for us to calm ourselves down.

It's hard for us to distract ourselves. So there's an emotional regulation deficit. Now here's the worst part of the illness. Remember how we talked about response inhibition? So remember that, okay, so for the first two days on Monday and Tuesday, I'm going to get high. test it on Friday, it's not that big of video, whatever. I'll figure out later. Wednesday rolls around, I'm like, you know, that is not a good idea.

I basically did something for a couple of days, and then I inhibit that response and start studying. This is the most critical thing that is impaired in OCD, because once someone with OCD finds something that works, they continue to engage in that behavior no matter the cost. So this is impaired, okay? So I'll have some kind of thought. like, oh my God, I'm going to get HIV if I touch anything in a public restroom.

So they feel an intense, intense anxiety. The anxiety is crippling. It doesn't go away. I try to distract myself. It doesn't really work. And then what happens is I wash my hands. I'm like, oh, my God, I feel so anxious. I feel so anxious.

So I'm going to wash my hands. I'm going to wash my hands. And then what happens when I wash my hands is my anxiety improves. This is really important understand. It is the only thing that makes my anxiety feel bad. Remember that thought sticks in your mind doesn't actually go away. The anxiety is still there. So I think to myself, okay, let me wash him again. And then I wash him again. And now I feel, oh my God, I feel 75% better. I feel so much better. Let me make sure. Then I wash him a third time.

Oh my God, that feels so much better. Now I'm 90% better. Let me watch them a fourth time, fifth time, six times. So OCD is actually a deficit of learning. Okay. So there is anxiety and or uncertainty with goal-directed behaviors, and then a compulsivity with habitual behaviors. So our brain learns that this thing is going to work. Their brain changes as a consequence, as a cause and consequence of OCD. So now let's talk a little bit about what obsessions actually look like. So the one that we've used today is an obsession with contamination. So this is incredibly common where people are germophobes. They feel like they have to wash their hands. They can't touch particular things. They maybe need to shower excessively. I've seen really bad cases of that. The second obsession that's

really common is danger towards yourself or others. So this can look like the scenario that we talked about where your, you know, your partner is boarding a plane. You're afraid that the plane will crash. I've had patients who will be worried every time a loved one gets into a car and has to drive somewhere. They're afraid that there'll be a crash. You know, there'll be some kind of accident. People can be, oh, something that people are more familiar with are like concerns about a danger about the house burning down. So this is why people will turn off and on the stove seven times, or people will turn off and on light switches.

But what's going on in their head? Unless I make sure that the light is off, maybe there's some kind of electrical signal that will cause a spark and my house will burn down. So they will have a lot of concerns around danger. I had a patient who any time a loved one was in transit, they would have to say a prayer in their head. It was almost like a magical protective spell

where they would say the sequence of things, this person is leaving this place, they will be safe, and they will arrive on time or something like that. They would say some kind of prayer. And they would say that in their head seven times every time a loved one was getting into a car or a plane or anything like that. So I hope you all can imagine how debilitating this is, because every day when 5 p.m. rolls around and everyone is leaving work, they have to stop whatever they are doing and say this prayer seven times for every person who they know who they care about. Oh my God, this person is boarding a flight, they would set an alarm, repeat the prayer in their head. So compulsions can absolutely be in your head. Other forms of obsessions involve things like checking and counting.

We've sort of talked about that a little bit. So what a lot of people don't realize is that obsessions can be like really nasty. So I've had patients who will have intrusive thoughts about hurting other people. I've had patients who have intrusive thoughts about sexual acts. So sometimes obsessions can be sexual in nature. They can also. be towards really inappropriate people. So I've unfortunately had to work with patients, I mean, unfortunate for them, that, you know, they'll have intrusive sexual thoughts about their parents. And this is why OCD is like so hard to diagnose, because when someone has really negative thoughts, they feel like a really bad person. So if you think every day about having a sexual

relationship with someone that's really inappropriate, you feel really guilty, you feel like am I really screwed up, am I a sociopath? The number of people with OCD, who I've worked with who think that they're like a sociopath is astronomical. But remember, the nature of OCD is that an obsession is not that you're like obsessed with something like, oh my God, I'm so obsessed with this celebrity or this influencer. That's not what we're talking about. You didn't want this. It doesn't say anything about you.

You don't care about it. You don't like it. Most of the time what people with OCD want is they want their obsessions to go away more than anything else. So if you have a persistent, intrusive thought that you. you don't like, and you tend to have some kind of ritualistic behavior, that's behavior that you repeat over and over and over again in response to the thought. That's really what characterizes OCD. So if you have OCD, what do you do about it? So this is where OCD is one of the most under-treated disorders. Remember, only 30.9% of people with OCD actually receive OCD-specific

treatment. A lot of people will misdiagnose OCD as a severe anxiety disorder, and they actually get treatment for anxiety. OCD responds really well to biological treatments. Now, what do I mean by that? So if we look at psychiatric illness, there are kind of like two sources of psychiatric illness. It can come from your brain or it can come from your mind. Okay. So if we look at like diseases that come for, let's say, from your mind, I mean, they still come from the brain in some way. But if we look at something like, let's say a mood disorder like major depressive disorder, only about one-third of people with major depressive disorder respond really well with medication. What we know about major depressive disorder is that a lot of psychotherapy can be incredibly effective.

You can treat depression by targeting your thoughts, changing the way that you think without necessarily doing anything to your brain, right? So we don't have to take a pill or do electrocumdulsive therapy or have some kind of surgery for our brain in order to treat depression. We can treat it using psychotherapy. Now, this is also true of something like generalized anxiety disorder or socialized anxiety disorder, especially if we look at these illnesses like narcissistic personality disorder. There are really no medications that help with your personality. The personality sort of exists within your mind so we can do psychotherapy to help you with your mind. There are some psychiatric illnesses, however, that I think are a lot more in the brain.

So the number one example of this is something like dementia. So when someone has dementia and they have Alzheimer's disease and they have all these like plaques in their brain when their brain tissue is kind of deteriorating, I just realized how terrible this is to talk about in the video about OCD, I'm not trying to freak y'all out. But what I mean is that there are some illnesses where there are changes in the brain

which then affect the way that we feel and affect the way that we think. So I think OCD is more in the brain than it is in the mind. So we know that there are all these neuroscientific changes that we know, like, for example, failures of habituation, inability to distract yourself, sort of repetitive learning, habitual learning towards one thing, the compulsion, which is the only thing that relieves your anxiety, but there are a couple of other indicators. For example, 40% of OCD is basically heritable, which means that we know that about 40% of the illness

has to do with your genetics. Some of the most interesting literature at the intersection of OCD neurology is that describing obsessive compulsive symptoms that are precipitated by streptococcal, infection, so-called pediatric autoimmune neuropsychiatric disorders associated with streptococcus. Pandas. So what does this mean? This means that some children who get a streptococcal infection will have an autoimmune reaction that will alter the way that their brain kind of functions, and they will actually develop OCD. But we just have a lot of data that suggests that OCD can be related to things like infections in childhood. That may be how you develop it. Most people develop OCD between the ages of 18 and 29, but there are cases that it kind of gets developed in childhood.

And if you're past 30, the likelihood that you will develop OCD is really low. The likelihood that if you're past 30 and you think you've had anxiety that has not responded really well to treatment or therapy hasn't worked great, and there's a decent chance that you may have OCD, so get that reevaluated. So first line treatment for OCD tends to be medication. We have some medications that tend to work pretty well. about 50% of people who take medication for OCD will not have a great or sufficient response. It can be kind of a stubborn illness.

But this is also where I love it because there are particular modes of psychotherapy. So my favorite thing to prescribe to patients, I don't do it very much, is something called exposure and response prevention. So the cool thing is we have tailored certain kinds of psychotherapy specifically to OCD. And instead of going to a therapist and talk, about your feelings, which there are absolutely that can work. There are good papers that suggest that psychodynamic therapy can be very effective for OCD. But I personally like really like when patients do exposure and response prevention. So what does that look like? Remember,

we had this diagram. So what exposure and response prevention does is it trains you to stop this. You train this in therapy where you like train your mind. It's like doing pushups for your brain and your mind, where when you have a certain situation, the situation, the situation will, an exposure, will create a response, right? So that response can be cognitive, it can be a thought, it can be emotional, which is anxiety, and then it can be, the response can also have a behavior or a compulsion. So how do we uncouple and relearn how to deal with these situations in a healthy way? Because remember that OCD is an illness of essentially inappropriate learning, where our brain learns that only one thing, if I feel like I'm afraid I have a contamination

on my hands. The only thing that helps is washing my hands seven times. So what we actually do an exposure and response prevention is we expose ourselves to the scary thing, but we do it in a graduated manner where we can basically handle the degree of thought or obsession that arises, and then we can stop washing our hands in a very damaging way. And then the cool thing about that is once you stop relying on the compulsion to manage your anxiety, you can start to develop other ways to manage your anxiety. And the coolest thing that I've seen in my patients is they will start to develop habituation. Once they stop relying on washing their hands, their anxiety, they feel really anxious, and then the anxiety actually habituates and it just goes away on its

own. So there are a lot of, we've shared a, we're going to show a quick treatment algorithm. As you all can see, it's long, it's complex. But the truth of the matter is it works incredibly well and you can get better from OCD. But the good news is that if you get tailored treatment to OCD, there's a really good chance that you can get substantially better. And you do not have to live with severely impairing anxiety anymore. Thanks for joining us today. We're here to help you understand your mind and live a better life.

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