Ologies with Alie Ward - Obsessive-Compulsive Neurobiology (OCD) with Wayne Goodman
Episode Date: July 23, 2025Ruminations and reassurances. Checking and counting. Suffering and stigmas. It’s OCD, babes! OCD is now considered one of the most common psychiatric conditions, afflicting 2% to 3% of the general p...opulation, and this episode is among our top-requested topics. So we snagged a top-shelf ologist: psychiatrist, researcher, advocate and OCD Neurobiologist, *the* Dr. Wayne Goodman. We cover myths, misconceptions, diagnosis and treatment options for OCD, as well as advice for loved ones. Also: PANDAS, famous folks who are helping break the silence on it, intrusive thoughts, deep brain stimulation, genetic components, links to Tourette’s Syndrome, finding the right doctor, and the behavioral therapy that is the gold standard for OCD. And surprise! Later this week we’ll have a bonus episode on OCD lived experience with neuroscientist, mental health advocate and OCD-haver, Uma Chatterjee. View Dr. Goodman’s publications on ResearchGate and follow him on Google ScholarA donation went to International OCD FoundationFind more episodes you'll like at Ologies.comMore episode sources and linksSmologies (short, classroom-safe) episodesOther episodes you may enjoy: Attention-Deficit Neuropsychology (ADHD), Molecular Neurobiology (BRAIN CHEMICALS), Volitional Psychology (PROCRASTINATION), Suicidology (SUICIDE PREVENTION & AWARENESS), Post-Viral Epidemiology (LONG COVID), Disability Sociology (DISABILITY PRIDE), Gustology (TASTE), Oikology (DECLUTTERING)Sponsors of OlogiesTranscripts and bleeped episodesBecome a patron of Ologies for as little as a buck a monthOlogiesMerch.com has hats, shirts, hoodies, totes!Follow Ologies on Instagram and BlueskyFollow Alie Ward on Instagram and TikTokEditing by Mercedes Maitland of Maitland Audio Productions and Jake ChaffeeManaging Director: Susan HaleScheduling Producer: Noel DilworthTranscripts by Aveline Malek Website by Kelly R. DwyerTheme song by Nick Thorburn
Transcript
Discussion (0)
Oh hey, it's the bowl that's chipped, but not chipped enough to throw it away.
Allie Ward, this is all a G. This is OCD.
Okay, we asked y'all on Patreon your most desired episodes, and this was among the top,
which was both a surprise, it was also a delight to me.
Also a delight, we got the world's most revered expert in OCD to talk to me for an hour.
This person invented the scale by which OCD is measured.
They've been working in this field for many, many decades
and is pioneering a bunch of new treatment
and research for it.
They studied at Boston University
and Yale School of Medicine.
They've also been instrumental in nonprofit work
for OCD treatment and research.
They're now a professor and the chair
at the manager department of psychiatry and behavioral sciences at Baylor College in Houston.
And if you have OCD or you know someone who does or might, their life is better
because of this absolute OCD icon. And just a content note, of course we talk
about some parts of OCD that are distressing to people and that's part of
why we're doing this to talk about it. But just a content warning up top that we do touch on self-harm and
some intrusive thoughts that might be a little disturbing to people. Now I was
nervous as hell to hop on this interview because I know their time is very limited,
but we were able to cover so much including questions from patrons at
patreon.com slash Ologies. You also can ask questions before we record. You can join
that for less than 25 cents an episode. Also, ologies merch is available at ologiesmerch.com
should you need it. And for no dollars, you can support the show just by leaving a review.
And I read them all and then I pick a freshie to read, such as this one this week from Mish
R who wrote, if you were a kid who went to the Scholastic Book Fairs looking for nonfiction
books or fun facts
books, this is the podcast for you.
Mish R, let's crack into the catalog, let's get some OCD.
But first, also thanks to sponsors of the show for making it possible to donate to a
cause of theologist's choosing.
Okay, is OCD a niche condition?
I would have thought so, since people don't talk about it a lot unless it's an offhand
punchline or like an excuse for a complicated Starbucks order.
But research reveals that OCD is now considered one of the most common psychiatric conditions,
afflicting 2 to 3% of the general population.
I did not know that.
And because of the high demand for this episode and because it's so close to my heart, surprise,
we have a bonus episode coming
out in a few days. We've been cooking up. It's all about lived experience. It's with a lovely
neuroscientist, researcher, board-certified mental health peer specialist and mental health advocate,
Uma Chatterjee. So yes, an extra episode this week. Enjoy. That's a great conversation. But
for now, let's take a deep breath. Let's treat our brains to a feast of info on overt versus covert, perfectionism, obsessions versus
compulsions, neurodivergence and OCD, pediatric illness-induced OCD symptoms,
ruminations, checking, counting, reassurance seeking, a few famous folks
who are helping break stigmas, medicines on the forefront, some hopeful treatments
in the future, finding a therapist, deep brain stimulation, genetic components, overlap with
Tourette's syndrome, advice for loved ones, and the behavioral therapy that is the gold
standard for OCD with doctor, psychiatrist, researcher, advocate, and OCD neurobiologist,
the Dr. Wayne Goodman, he, him.
I'm a psychiatrist and I work at the Baylor College of Medicine down in Houston, Texas.
Really excited to talk to you.
We've wanted to do this episode for literally years and everyone we've talked to has said
that you are a perfect choice for this.
So we're very excited to be speaking to you specifically.
Hundreds of papers. Last I saw on ResearchGate, 36,000 citations to your work.
I believe you started in the 80s?
Yes, it's hard to believe.
It was the 1985.
So 40 years.
40 years.
What got you started down this path?
So I was at Yale doing my residency and starting a research fellowship and I came across a
patient with OCD and it was the first patient I had seen with OCD and started reading about
it and I began to realize that it wasn't that much known, particularly about the neurobiology
or the treatment.
So long story short, we ended up launching the OCD program at Yale and I've been focusing
on OCD ever since.
Was there something about this patient?
Was it the level of suffering or the level of OCD that really hooked you?
Were they particularly nice?
Were they a patient you liked working with?
Well, I like all my patients.
But of course.
This patient had kind of a classic form of OCD
involving contamination concerns
and fear that if they didn't wash their hands carefully,
they would get somebody else sick,
particularly somebody they loved.
And they realized that whatever they were doing,
whatever they were thinking about was excessive.
That's what really struck me,
this person was driven to the point that
she used to have to use bleach on our hands.
Her hands were red, bleach,
I mean, it could be caustic cause not only
skin irritation but actual
damage.
And she was consumed by these thoughts almost every hour of the waking day.
But yet again, she had complete insight into how absurd it was.
And that's what struck me was that paradox between the irrationality of the thoughts,
the excessiveness of the behaviors, and totally preserved insight
and executive functioning.
So this is a classic presentation of OCD, and it's probably what people think of first
because it's just easy to explain too.
And according to the research, up to 46% of folks with OCD do deal with contamination
fears, but the other 54%, the majority, don't struggle with that.
And at that time, were there scales to measure this? Was it something that was being treated
with medicine? I know the Yale Brown Obsessive Compulsive Scale is something that you pioneered,
which among people who know OCD, they're like, whoa, that dude did the actual test.
Like, he's OG.
So the Yale Brown Obsessive Compulsive Scale,
or Y-Box as it's known,
is a clinician administered 10 item scale
with each item rated from zero for no symptoms
to four for extreme symptoms.
So scores can run zero to 40.
And it was developed in 1989 by a Yale doctor
and this OCD legend named Wayne Goodman, who we are talking to right now. What interventions
or what qualitative analyses was it back then?
So at the time, there were only case reports that one medication in particular was effective. It was a medication called clomipramine, which is
still available. And it was one of the older medications with lots of side effects. And the
case report suggested it was the only medication that seemed to work. And there was a theory that
the reason it worked is because it had potent effects on the brain's serotonin system.
Serotonin is one of the brain's neurotransmitters or neurochemicals.
My training at Yale really focused on trying to understand not only treatment but neurobiology.
That led me to want to test a newer generation of medications that were selective for their
effects on serotonin.
And then I looked around and back to your question about rating scales, there really
weren't any gold standard scales.
So I worked with my colleagues on developing one.
Is that something that a person can administer themselves or is that really something that
you got to talk through with a doctor who can figure out, you know, very impacted, somewhat impacted?
Can people self-diagnose OCD?
Yes.
So the way the Y-Box, that's the Yale Brown Obsessive Compulsive Scale is administered
is it should be by a clinician who has experience in treating OCD.
There are forms of the scale that are self-rated so that the patient fills them out, but really,
the diagnosis is left up to the clinician. We hear so often, and I'm wondering how you feel
about this, when people say, I'm so OCD. I love to have all my pens in the same spot on my desk.
People with OCD, from what I understand, hate that a lot.
Yeah, they do. Yeah. how do you feel as a professional and a clinician
when you hear people say, I'm so OCD?
Well, I'm not judgmental.
That's one of the things that you need to be
as a psychiatrist, but I do point out
that that's not the same as OCD.
Dr. Goodman says it's healthy and common
to have certain preferences or routines, sure.
Meaning being perfectionistic,
liking things orderly, those are good.
But it's not a disorder until it takes up a lot of time
and by definition would be more than an hour a day.
It would be distressing.
And for most of the patients I treat,
and I focus on treatment resistant OCD,
I focus on severe OCD, we're talking about patients
that can't go sometimes 15 minutes
without having an intrusive thought
or having to perform a compulsion.
We'll define those in a moment.
And our surprise bonus episode out later this week
with Uma goes into a ton of detail about lived experience.
So that's very different from the people who are,
you know, have a little bit of OCD in them,
like things orderly and are still able to work
and lead a very productive life.
People with very severe OCD can be incapacitated.
Although many of my patients,
despite their severe symptoms,
figure out ways of still working around them.
And a lot of patients, the other thing about patients
with OCD is they're really good
at camouflaging their symptoms.
Now, we'll get to kind of outward behavior versus inward,
but you mentioned severe versus kind of high functioning
or people who can function around it well.
Is it a spectrum like a lot of other conditions? Yeah, yeah. So even on the Y
box, the rating scale goes from 0 to 40 and most patients that we treat in an
outpatient setting with first-line treatments, they score around 20, you
know, like a midpoint.
Those patients can, you know, continue to work, go to school, lead a very productive life, but
the OCD is kind of gnawing at them and interfering with their ability to be fully functional
and fulfilling life. One thing that really surprised me about OCD is that it's not the same as an anxiety disorder.
It's not underneath the umbrella of anxiety disorders.
Is that correct?
That's correct as of the DSM-5, the Diagnostic Statistical Manual, fifth edition that came
out in 2013.
Before that, it was considered an anxiety disorder.
And actually, I'm not sure that it was the right decision not to call it an anxiety disorder. And actually, I'm not sure that it was the right decision
not to call it an anxiety disorder.
It's now listed in the DSM-5 manual
as in the obsessive compulsive and related disorders.
But anxiety is almost always a component of OCD.
Does the anxiety tend to come from trying to control the OCD? Like people who have ADHD
might have a lot of anxiety because executive function is difficult for them. Is the anxiety
sometimes a byproduct? It comes in various forms, but OCD comes in various flavors,
but all patients with OCD by definition have obsessions and compulsions.
The obsessions are the intrusive thoughts or images, and those by themselves are distressing.
By definition, an obsession is something that is disturbing.
More on these in a sec and in the bonus episode with Uma, But these can, again, be the fear of getting sick and getting someone else sick, existential OCD
about whether you really exist.
There's false memory OCD, perfectionism OCD
relating to order and symmetry and counting
that just feel off if incorrect.
There's also harm OCD, worrying that you might impulsively
hurt yourself or others on accident or on
purpose. And a very seldom discussed facet of OCD is pedophilia OCD. And this is a distressing
worry that you will harm a child. But wait, there's more. There's moral scrupulosity
worrying about if you're a bad person who doesn't know it. There's checking OCD, like
with matters of safety like ovens or curling irons or locks,
and there's reassurance seeking OCD. All of these obsessions can run like a ticker tape in your
brain and you would really like them to shut up. How do you do that? The compulsions.
And then the compulsions are designed in a way to reduce the anxiety associated with that obsession.
But sometimes the compulsions themselves can be so time consuming, like the patient I mentioned
before, or even painful.
I've had patients who took a shower so long that they ran out of hot water, and they went
up taking the cold shower until they feel that they're clean enough.
You mentioned one of your first patients had contamination OCD, but I understand there's
a lot of flavors.
As you mentioned, there's pure OCD, there's moral scrupulosity, there's checking OCD numbers,
there's reassurance seeking.
So there's a lot of different ways that the obsessions
and compulsions show up.
Can you talk a little bit about pure OCD
versus contamination versus moral?
Well, yeah, so again, going back to the Y-Box,
we has this first part where we do the symptom checklist.
And when I worked on that with my colleagues,
we saw hundreds of patients together and came up
with a list of different categories. The different categories of obsessions include contamination,
but also like you mentioned, scrupulosity is a big one. It could be about taboo thoughts about
religion or sexuality, unwanted aggressive thoughts, fear that you would be responsible
for harming somebody or harming yourself even though you don't want to. And there's a whole bunch of
miscellaneous ones that can occur as well.
So in response to those thoughts...
And the compulsions are generally designed, again, design is probably not the right word,
but they're functionally connected to the obsessions that try to reduce them.
And they're not always in the form of something like washing or contamination that you can observe.
They can be, if say somebody has an intrusive thought of something terrible happening to a
loved one, they could recite something in their head or they can review something in their head
and you can't see that, but we would count that as a compulsion as well. And via the paper
prevalence and clinical characteristics of mental rituals in longitudinal
clinical sample of obsessive compulsive disorder in the journal Depression
Anxiety there are overt and physical compulsions which you're probably more
familiar with but there are also covert or mental compulsions with no behavioral signs and
those types of compulsions include acts like
silently repeating words or phrases or praying or counting or mental checking or thinking of good or safe thoughts
to neutralize distressing mental images among others. Now,
that has to be a slim majority, right, that has the covert kind, right?
Nope.
So this paper cites research suggesting
that as many as 60% of OCD patients present
without overt compulsions,
meaning the majority of folks with OCD
may just be struggling internally with mental compulsions,
trying to undo the
obsessive thoughts with other thoughts. Now you mentioned about pure obsessions.
Yeah. There was a country star talking about,
do you see this, about pure OCD? No.
Oh, okay. I won't mention the name, but you can look it up.
Okay. It's Luke Combs, and he's been super public about it. And an article in NBC News
reported that Combs hopes to use his platform to support others facing similar struggles.
And in a recent interview with 60 Minutes Australia, Luke Combs explained his experience
that it's thoughts, essentially, that you don't want to have, and then they cause you
stress and then you're stressed out. And then the stress causes you to have more of the
thoughts and then you don't understand why you're
having them and you're trying to get rid of them but trying to get rid of them
makes you have more of them. So what is Pure O? Just obsessions? And said that
the form of Pure OCD, it's a controversial entity. Most of us in the
field who've seen a lot of OCD can identify mental
rituals that patients perform when they have their intrusive thoughts. So I don't
think pure OC or pure O is actually that common. I think most patients who have
really a real case of OCD and they may not perform overt rituals, but they're probably doing something mentally
to try to ameliorate the anxiety associated with their thoughts or their images.
Oh, got it.
So Pure O is just the obsessions is what they're saying without compulsion.
Yes, it's just the obsessions.
And the vast majority of patients with OCD have both.
So Goodman is iffy on pure O, because again, compulsions
to stop the obsessions can be covert or mental
and not outwardly behavioral.
But usually, yes.
The ways that you try to stop the obsessions are compulsions.
The O and the C are the buddy comedy that you never asked for.
And they seem to be functionally connected.
So is it possible that some people might not realize
the compulsions that they're even doing
and they might just think,
oh, because I'm not doing something physical,
then I don't have a compulsion.
Right, they might think they have pure O,
which they probably don't.
Oh, that's interesting.
Okay, I wasn't sure about that. they hit pure O, which they probably don't. Yeah. That's interesting. Okay.
I wasn't sure about that.
Now, what are some of the more overlooked types of OCD that you feel like the general
public doesn't know much about?
I feel like the ones I hear about a lot are contamination and checking, making sure that
the curling iron is unplugged, that everything's stove is off, that the front door is locked.
You have difficulty believing that you've done those things,
and so you have to keep checking.
But can you elaborate on some of the other, maybe more overlooked ones?
Yeah, there's a category we sometimes refer as just so or just right OCD,
where people have to repeat something.
I have a patient recently who was looking at the clock
and she really wasn't looking to see what time it was.
She had superstitious concerns about,
she had to watch the second hand of the clock
and see it hit 12.
Because otherwise she had had this thought
that if she doesn't see the 12,
something bad is gonna happen to her.
And the other things that she would do could be really random.
She could just repeatedly touch something or repeat something and you wouldn't notice
it.
And I would ask her, how do you know when it's done?
How do you know when you've done enough of these, performed enough of these compulsions?
And she would say, until it feels just right.
So it's kind of a just right feeling.
And people have a hard time articulating that, but that's a common form that's often overlooked.
And just full disclosure, I was diagnosed two years ago with OCD, never realized that
I had it.
I don't have a super severe case, but I look back and I'm like, I had some stationary that I've
had for 20 years and I was like, if I use the last piece of the stationary, my dad will die.
Things that I didn't tell anyone that I even thought because it sounded bonkers, but I was
very afraid that if I used that, something bad would happen or I have terrible procrastination
problems. I'm really avoidant because I'm always afraid
of making a mistake and then it'll lead to my downfall,
my career will be over if I make one mistake.
And so there's like a certain kind of magical thinking
it feels like.
Yeah, that's a good category too.
Yeah, magical thinking.
This feeling that you can maybe control the outcome
of bad things and avoid them
if you do something concrete about it.
Yeah, even though you know it doesn't make any sense, right?
Yeah, doesn't make any sense. But you don't want to take a chance. Exactly. Because the stakes are too high.
Stakes are high. And the OCD is telling you to do it. Oh, yeah, or not to do it. Right, exactly.
Because if it landed on you, you could never forgive yourself.
But I feel like, you know, when you mentioned the contamination of OCD with one of your first patients worried
about she would hurt someone else, it feels like the avoidance of a bad outcome can fuel a lot of
obsessions and compulsions. Do you find that with a lot of your patients? Yeah, I think that's a
universal. So again, we talked about all the kind of different forms of flavors of OCD.
But I think most of them have in common that patients with OCD are harm avoidant.
They're worried about some outcome.
That outcome could be something happening to themselves or their loved ones,
failing at work or having their career go up in
smoke.
And we've talked about scrupulosity.
It may be something that's most dear to that particular person is the thing that they're
going to worry about most.
That makes sense.
And what about onset?
When do you tend to see OCD become apparent enough?
Because I'm sure a lot of people might have this as kids.
I mean, don't step on a crack,
you'll break your mother's back.
I was going to mention that one.
Yeah, that's the classic magical thinking one.
But you actually do see it.
Just a side note,
this superstition has folkloric origins
and it was a common and incredibly racist rhyme originally.
And about 5% of adults still avoid cracks in
the sidewalk so let's just retire this one forever okay good love that I wonder
how much that particular rhyme is responsible for patterns but what do you
think the onset might typically be so about half the cases of OCD have onset
in childhood and then there's another large group in early adulthood.
So I actually see a lot of people who first have onset
of OCD after they go off to college.
So around that age range.
It's unusual to see onset after age 35.
Okay.
Have you seen more people seeking treatment
after the COVID pandemic hit, especially with
contamination?
You know, it's funny, I should know the answer to that.
In fact, I was on a paper that looked at it.
I don't think it's had a huge impact.
It just made it a little bit more confusing.
For example, I had a patient who I was treating with very severe OCD during the pandemic.
He used to wear three layers of gloves and a mask.
Once the COVID struck,
he didn't stand out anymore.
He thought that was really helpful in a way,
that it normalized his appearance.
Yeah.
But I don't think so.
It may have had a temporary impact,
because I mean, we were all concerned, but I don't think it really caused that many new cases of OCD.
And for more on this, you can see the 2023 paper Dr. Goodman co-authored titled COVID-19 Related
Intrusive Thoughts and Associated Ritualistic Behaviors, which looks at a new thing you could have called CITRB, or COVID-19-related
intrusive thoughts and associated ritualistic behaviors.
But the study, however, concluded that while it's helpful and even critical for providers
to see and take into account COVID-related distress, it's likely a chicken or the
egg situation.
That is, if you only noticed obsessive compulsive traits
after the COVID pandemic hit, chances
are you already had a little bit of OCD before then.
Also, there is a very baseline preoccupation
with germs that came out of this.
The September 2020 study COVID-19 and OCD,
Potential Impact of Exposure and Response Prevention Therapy acknowledges right up top that the SARS-CoV-2 coronavirus COVID-19 and OCD, potential impact of exposure and response prevention therapy,
acknowledges right up top that the SARS-CoV-2
coronavirus disease 19 pandemic
is the greatest international health crisis
in our modern era.
So if you've been on edge about microbes,
just about COVID, that's just kind of normal.
This is a novel virus killing millions of people.
And to this day, half of reported COVID deaths in the world
are in the United States.
The US has half the deaths.
And because of truly unhinged politics,
half the country won't wear masks or take a vaccine.
So what the fuck?
But yeah, there are rational precautions in a pandemic.
And then there are OCD behaviors that prevent you
from daily functioning.
And reading through Dr. Goodman's list
of published papers, so many of them, it's astonishing.
I'm gonna be real with you, I started crying
at how much work he's done.
In your research, which again, you've done so much research,
neurochemistry versus neurobiology,
you mentioned serotonin, you mentioned SSRIs as a
treatment line or SNRIs
Have we you know your stuff by the way
I've got put on Lamictal actually after I was diagnosed and it's been so I have questions about glutamate of course too. So limotrigine brand name limictol was developed for the treatment
of certain types of epilepsy because it slows bursts of electrical activity that
could cause seizures but some psychiatrists prescribe limotrigine off
label for depression associated with bipolar and also for things like
fibromyalgia, certain types
of migraines, panic disorder, binge eating disorder, and yep, OCD.
So the 2015 paper, Role of Lamotrigine Augmentation in Treatment-Resistant Obsessive Compulsive
Disorder, a retrospective case review, notes that genetic, behavioral, and neuroimaging
studies have shown evidence of abnormally high glutamatergic concentrations
in certain parts of the brains of people with OCD and adds that resistance to pharmacotherapy
is one of the major challenges in the management of OCD. But one avenue for that is glutamatergic
modulators like lamotrigine. So we're going to link a few other papers on our site, but
just something to explore maybe with your doctor. And also because lamotrigine. So we're going to link a few other papers on our site, but just something to explore maybe with your doctor.
And also because lamotrigine can cause
some severe allergic reactions in some people,
and it needs to be closely monitored.
It can also affect your white blood cell count.
So talk to an actual doctor, because I'm not one,
and Dr. Goodman cannot treat or diagnose you from a podcast,
nor can you take a transcript of this podcast
to your pharmacist.
But yeah, neurochemistry versus neurobiology. Is it a combination of both?
So going through my own career, which we already established has gone on for a long time, the
first half was more neurochemistry, neurobiology, looking, for example, at the role of serotonin.
And I published a lot of negative studies looking to try to
identify an abnormality in the brain,
in the serotonin system and that's proved elusive,
not only for me but for the whole field.
You mentioned glutamate, that's
another neurotransmitter that's been implicated in OCD.
There's some interesting work on that
and some medications that are being tried.
But at some point,
I pivoted more to looking at OCD as a brain circuit disorder instead of a neurochemical disorder.
Not that serotonin clearly plays a role in treatment,
but it's not clear it plays a role in the origins or pathophysiology of the illness.
So I started getting involved more
in looking at the brain circuits
that mediate the symptoms of OCD.
So he's been in the game so long,
he's gone deeper into the actual brain,
and even in 2012 published the study,
Deep Brain Stimulation for Intractable Psychiatric Disorders,
exploring treatments for patients
who had exhausted other avenues.
And by helping these cases, he's also pioneering new understanding in the process.
And that's led me to different treatments, more neuromodulation, medical devices,
instead of drugs.
There's still a role for drugs, and there's definitely, the thing we haven't touched on, we need to,
is the role of behavior therapy.
If I don't do that, my psychologist colleagues will be very upset with me.
Damn right.
Okay.
So behavioral therapy, the right kind is huge.
We're going to get into that, especially the gold standard, which is exposure response
prevention or ERP therapy in just a little bit.
But I do want to give you some broad strokes of the neurobiology of and the medication
options for OCD.
So let's start with SSRIs.
SSRI, it stands for Selective Serotonin Reuptake Inhibitors because these medications target
serotonin and they prevent it from getting sucked back up into the brain cells.
So there's more serotonin that stays floating between the nerve cells to relay messages
between them. And there are a ton of other SSRIs on the market as well that go by a lot of
different names. Now SNRIs, they're not as selective as SNRI stands for serotonin
and norepinephrine reuptake inhibitors and they work to keep more of both of
those neurotransmitters between the cells. So SNRIs can have
fewer side effects in some people than SSRIs do and SNRIs are sometimes
prescribed for anxiety and nerve pain and Lemictal or Lamotrigine is neither
an SSRI or an SNRI. It's what's called a phenyltriazine drug and it's used to
prevent seizures and types of epilepsy. It's also used as a mood stabilizer,
which can help with bipolar depression,
and it's been shown to modulate
those glutamate levels in the brain.
We have a whole episode on neurotransmitters.
It's called Molecular Neurobiology with Dr. Brain,
aka Dr. Crystal Dilworth, which we'll link in the show notes.
But let's put that skull juice to work
to learn more about itself.
Would you say that the majority of cases can be helped with medication or is it really
a crap shoot?
Depends who you ask.
Okay.
But you're asking me.
Okay.
So I would say, you know, it's really a lot up to the patient.
I mean, you know, if I'm seeing a patient who say I'm first diagnosing them with OCD,
and they have moderate OCD, not severe OCD, well, the moderate is still not great. I mean,
it still can be quite distressing and impairing. I would outline, you know, you have two options.
You can have to do the cognitive behavioral therapy, you can do the medications, and I'll
give the pros and cons. A lot of patients will do well with one or the other and sometimes you wind up doing a combination of both.
Do SNRIs, because they work in norepinephrine, do those tend to help with the
anxiety that can be a result of OCD?
That's a good theory. I like that theory. But if you really want to be hardcore
and you look at randomized control trials and
peer-reviewed publications, the only medications that have been shown effective are the SSRIs.
The SNRIs, based upon clinical experience, are also effective.
And perhaps the neurodegenerative effects have some additional benefit, like you said,
for anxiety.
But I'm not totally convinced.
Okay.
But I'm even skeptical of my own work.
You know, again, I've, over the years,
I've tried, you know, different medications in our patients,
maybe even published a paper, you know,
case report showing that it worked.
But until you subject it to the rigor
of a randomized controlled trial,
by I mean that, you know, a blinded
study where you randomize patients to either the drug or the placebo, you don't really
know the answer.
Yeah.
And you mentioned that your work involves people who have not been helped by what's
typically administered.
You do deep brain stimulation.
Can you explain what that is?
I work with brain surgeons.
So the last 20 years, I've been working with neurosurgeons.
And they do the deep brain stimulation or DBS.
And that's mostly a treatment for movement disorders,
like treatment resistant Parkinson's disorder.
But we've done studies together showing that it can be very
effective in patients with treatment resistant severe OCD. What is happening there? What are you
stimulating? I picture there being this OCD rope that you just go in and cauterize, but I don't
think that's how that works. What happens? It's a very complicated story and a very controversial one.
There's been so-called psychosurgery.
I hate that term because it's brain surgery.
Nobody's operating on your psyche.
They're operating on your brain.
But before the introduction of deep brain stimulation, some surgeons at different centers,
both in the US and the UK, were doing what's called a blight of surgery.
A blight of means actually making a lesion, a small hole.
The theory behind that was that there's a circuit.
Let's identify those connections between those two areas,
between the obsessions and the compulsions,
and cut those connections and create a lesion.
That was the hypothesis.
There have been many case reports and case theories showing that some of those patients
with severe OCD did very well with very few side effects, not like the lobotomy error.
That's a totally different kind of procedure.
So that led to the theory that you could use deep brain stimulation, which is not causing
a lesion, but is stimulating an area of the brain
at a high frequency that still interrupts those pathways.
So the idea is still behind DBS is somehow
it's interrupting the OCD circuit,
this reverberating loop that's self-reinforcing
between obsessions and compulsions,
because that's part of the problem.
And the basis of the exposure response prevention
is the more a person performs the compulsions
and the more effective those compulsions are
in reducing the angst associated with the obsessions,
the more that's gonna become habitual.
Now, is that kind of helpful in determining
how genetic it is if you're looking at brain anatomy?
Or I should just ask straight up,
but how much of this is genetic?
Yeah, there's definitely a fair contribution of genetics.
It's not simple.
It's not simple, medullion genetics.
Where it seems to be more genetic are in those patients
that have both OCD and Tourette syndrome.
Oh, right.
And it seems to be a stronger genetic connection.
And the 2014 paper, Tourette Syndrome and Obsessive-Compulsive Disorder, Compulsivity
Along the Continuum in the Journal of Obsessive, Compulsive, and Related Disorders, recaps
some previous research that revealed that genetic family studies have shown higher rates
of OCD symptoms or OCD in relatives of individuals with Tourette syndrome. And also research has shown higher rates of ticks or Tourette syndrome in first degree
relatives of patients with OCD.
And the proportion of individuals with Tourette syndrome who also have OCD is up to 63% rather
than the general population rate of 2 to 3%.
This study notes that, however, despite the significant genetic overlap between these
disorders, Tourette syndrome and OCD do have distinct genetic architectures.
And deep brain stimulation has been used to treat conditions like Tourette syndrome, Parkinson's
disease, essential tremor, epilepsy, and of course the reason that we are all here, obsessive
compulsive disorder.
I'm sorry, how though does that work?
Going back to your question though about how the DBS works, I honestly don't, it's an area
that we're studying.
Yeah.
But where it's implanted in the brain is the reward circuitry.
So the immediate effects, so I do the programming of the device, the surgeon does the implantation,
and then after the recur recovered from the surgery,
which is just overnight, a week later,
I can interrogate the device,
I can stimulate that area of the brain,
and that area of the brain is part of the reward circuitry,
and some of the immediate effects
when I turn on the stimulation are the person feels happier,
they feel more energetic and less anxious.
And over time, that leads
to reduction in OCD.
How bad off do you have to be for how long before you get bumped up to the Goodman level
treatment?
Yeah, yeah. It's not just me. I'm not the only one, but there aren't, there's not that
many of us either. But you have to have OCD for at least five years.
It has to be an adult.
We won't do it in a kid, a child.
And it's gotta be a Y box in the severe to extreme range.
And they have to have had multiple medication trials
and failed ERP, exposure response prevention.
Why does ERP work?
And again, let me say ERP is not my specialty.
My psychologist colleagues are specialists in that,
but it breaks this cycle.
We've talked a little bit about OCD
as kind of self-reinforcing,
and the ideas, with the surgical ideas, you interrupt that.
And I think with ERP, you try to interrupt that too.
So cognitive behavior therapy is a type of brain retraining,
and it comes in a lot of forms.
One of those is ERP or exposure response prevention, which involves exposing yourself to the thoughts
and confronting them and then the prevention or making a choice not to do a compulsive
behavior once the anxiety or obsessions have been triggered, they say.
So you're like, oh, okay, so just like don't do the thing.
Okay, cool, thanks.
I promise it's not that simple, of course.
And working with a therapist trained in ERP,
they'll help come up with a plan
to take small steps to retrain your brain.
And according to the International OCD Foundation,
yes, it's scary at first, and that's the point.
But when you do ERP correctly,
the following things happen.
They say, you will feel an initial increase in anxiety,
uncertainty, and obsessional thoughts.
You will find that these feelings and thoughts
are distressing, but also that they can't hurt you.
They're safe and manageable.
When you stop fighting the obsessions and the anxiety,
these feelings will eventually begin to subside.
And this natural drop in anxiety that happens when you stay exposed and you prevent the
compulsive response is called habituation.
So just staying in it and confronting the fact that you're having these obsessive thoughts
without doing the compulsive response, you get used to that.
So you'll find that your fears are less likely to come true than you thought,
and then you'll get better at managing everyday levels of risk and uncertainty.
So Dr. Goodman explains the clinician's role.
What happens to people who have an obsession is they try to perform a compulsion to reduce the
anxiety. So what you want to teach them in a behavior therapy
session is don't perform your compulsion, let's just wait and tell me how much distress you're
feeling. Maybe on a scale of one to ten, maybe it starts off as an eight, but 40 minutes later,
even without performing compulsion, it's maybe down to a four. And you didn't have to perform a compulsion.
So you begin to teach the person over time that they shouldn't try to avoid the obsessions,
they actually should try to let them come.
So often a metaphor is like, don't fight the waves, ride those waves.
The more you try to react to the OCD, the more it's going to take a grip on your life.
And we've talked about the compulsions and what those look like,
but can you describe how your patients describe the obsessions?
How do other people describe them?
It really varies, but it's definitely intrusive, it's always disturbing.
I mean, we may not have emphasized this enough.
When we talk about obsessions in OCD, we're talking about thoughts, images,
or unwanted impulses that are disturbing.
On the other side of the coin with compulsions, they're never pleasurable.
We use the word compulsion very loosely sometimes, like compulsive eating, compulsive gambling,
compulsive sexual activity.
Now, even though all those could be problematic activities, especially like the gambling, compulsive sexual activity. Now, even though all those could be problematic activities,
especially like the gambling,
gets you in a lot of trouble or
some drug use can get you into some trouble.
We may use the word compulsive,
but we wouldn't say that that has any connection to OCD.
Because at least at some point,
the gambling was pleasurable.
You got some gratification from it, certainly when you won.
In OCD, the compulsions are never gratifying.
They may reduce tension, they may reduce the anxiety
associated with the intrusive thoughts,
but in and of themselves, they're not inherently gratifying.
So not like other compulsions,
I'm like a less cool compulsion.
And Dr. Goodman says that one consistent issue
that OCD sufferers have,
no matter what the flavor, is harm avoidance.
Harm to yourself and others becomes so terrifying
that the brain puts too much energy in trying to avoid it,
ultimately doing a harm to you and your life.
And I want to talk a little bit about comorbidities.
And we have questions from listeners who have, they know you're coming on.
And so they've submitted them ahead of time.
We also donate to a cause of your choice, a related cause.
And I know there's an OCD walk coming up.
IOCDF.
Oh, okay, great.
Perfect.
We will donate to them and shout them out and put a link for people.
IOCDF, no hesitation.
I love that.
The International OCD Foundation is a highly respected and core source for so much support
and info for folks who have OCD or know someone who does.
Their vision is that everyone impacted by OCD and related disorders has immediate access
to effective treatment and support, and they provide up-to-date education and resources, quality professional training,
and they advance groundbreaking research.
And as a leading nonprofit in the space, IOCDF has been around since 1986.
It was co-founded by a guy named Dr. Wayne Goodman.
You may have heard of him.
Also, he asked that his honorarium for this show also be donated to iocdf.org.
So thank you to sponsors of the show for making that double donation possible.
So let's get into the mailbag of questions left at patreon.com slash ologies, where for
one hot dollar a month, you can leave questions for the ologist before we record. So a lot
of you, Megan Walker, RJ Deutsch, Anonymous, Anastasia Press, Sarah Rose, Annie Pepper, Kyra Black, Sarah Corkhenderson, first-time question askers
Jessica Aarond and Benjamin Whiteley, and Annie Egelhoff asked, well Annie put it
this way, asking, hi I am autistic and have ADHD, OCD, and dyslexia. Choosing the
worst mental combo meal ever has me wondering why it's so common to have
clusters of comorbidities
like this as opposed to just one of these disorders.
Okay, a lot of people had questions about comorbidities.
Jessica Aron said, as others are asking, what disorders are commonly comorbid with OCD?
Anton also asked, how common is it for someone to just have OCD?
And also, are there a lot of misdiagnoses while people are trying to figure out what's going on? Yeah that
happens a lot. The most common comorbidity is depression. Yeah. Dumb.
Particularly the more severe the more treatment resistant the longer it's
lasted it's very common for patients to present with depression and that's
what you know I teach our residents are trying to use is if you have a patient that's presenting with.
Either anxiety of course to is a part of the syndrome of the presenting with depression it really behooves you to ask questions you know do you have any.
feel you have to perform over and over or any rituals that you have to perform in order to reduce your anxiety.
Again, one thing I mentioned earlier is patients with OCD by definition have insight into the
absurdity of their thoughts and excessiveness of their behaviors.
I'll tell you one example.
A patient of mine many years ago who came to me was a software engineer, a very logical guy, and he said,
Doc, you're gonna think I'm crazy.
I've never told this to anybody,
but, and this goes back a few years,
this is when you used to go to the mailbox
and mail a letter, and he said,
I can't mail a letter without wondering
if my five-year-old daughter is inside.
And I said, Doc, you're gonna wanna lock me up,
because I know you can't put a five-year-old in the door. But unless I check before I mail it, I worry something's
going to happen to her. So it was kind of a metaphor for something happening to her. So
it reached the point where it became very physical that he would have to look inside an envelope.
He would have to look at billboards to make sure she wasn't in the billboard.
And he actually did very well with treatment.
But he was completely logical, kept this as a secret from his family, including his daughter.
And I've read of other people who are so afraid that they hit someone on the road and didn't
realize it, that have to drive back and check several times.
And it's interesting that harm avoidance is something that is so common with
so many patients of it. And again, we mentioned that the majority of compulsions can be covert
and not related to any outward behavior or rituals. But what's the difference between
strong preferences and compulsions? Patrons Jennifer Lemon, Zink, Alicia Henning, Amelia Phillips,
Valerie Kirby, Dee, Austin Broadwater, Mackenzie King,
all of them asked in the words of S,
first time question asker,
how do you disentangle OCD from autism?
Are they frequently comorbid?
When it comes to rituals and things like that,
do you see folks who are autistic who have trouble
maybe understanding if it's OCD versus if it's just
like a rigidity that's comfort?
It's a great question and it comes up a lot because if you have somebody with autism who may have some limited communication skills
They may have trouble
Explaining the obsession so you have to infer them. So if they're doing
Ritualized hand washing or they're doing repeating getting in and out of a chair you can probably infer that they have obsessions even if you can't really identify them
and you wind up treating them in the same way as you would for OCD.
And how about for people who are verbal and aware of their own rituals is there
ever an overlap that gets misdiagnosed where people maybe don't realize they
have OCD or don't realize that they have autism, like eating the same meal, say, or sitting in the same
spot.
It's somebody who's very ritualized.
Yeah.
Yeah.
That isn't necessarily OCD.
The other thing I would say is although you can have a monosymptomatic picture, meaning
that maybe just one type of OCD, most patients with OCD check off different boxes.
Sometimes when I'm not sure myself,
I have more confidence in the diagnosis
when I find that over time,
some of their obsessions and compulsions have changed
and that they check off different ones.
What about executive function and perfectionism
or avoidance, things like that. People who
might have trouble, yeah, like for example me, getting set into work or work avoidance.
Patrons Matt Sekofian, Krux Jimber, Isa, a perfectionist but not OCD haver, and Alex Rose,
first-time question asker, who asked quite simply, why is perfection OCD such a bitch?
Where is the line between perfectionism and OCD?
There's another condition,
obsessive compulsive personality disorder
that sometimes it's hard to distinguish that from OCD,
but that diagnosis implies more perfectionism
and insistence that others kind of follow rules. And generally
speaking, people with OCPD don't have a lot of insight. Generally what I've found is that
it's their family members who would say, you really need to see somebody because you're
driving me crazy with wanting to do things in your way all the time or in a certain way all the time.
So there is some connection, but I think they're distinct most of the time.
And other experts note that the core difference lies in the motivation behind perfectionist
tendencies.
Is it a high standard?
Is there a certain goal in mind?
OCD-related perfectionism, however, may come from a place of extreme anxiety,
catastrophizing, self-criticism, and doubt. So one compulsion is avoidance. And a 1994
study titled Procrastination Tendencies Among Obsessive Compulsives and Their Relatives
did find a correlation between OCD and task avoidance. The author of that study is world renowned
procrastination expert, Dr. Joseph Ferrari.
And if you're like, you should do an episode with him,
I did, volitional psychology.
We did it, it's linked in the show notes.
His big advice is like, just do the thing.
He even signed my copy of his book,
Still Procrastinating, the No Regrets Guide
to Getting It Done with the scrawl,
just do it now, all
caps. At the time, I was like, Joe, I can't, so fuck me, I guess. And then I learned much
later that just do it now was just a little brusque and a less gentle type of exposure
response prevention, essentially. So until you stop procrastinating, you will not realize
that procrastinating and compulsive avoidance is worse than the thing you're afraid to do poorly.
And because of a therapist who understood ERP, I have since adopted two phrases, which are essentially like bite-sized takeaways that have helped me more than anything else to tackle my decades-long plague of putting off the highest stakes tasks and avoiding them.
So I used to know myself as a last-minute person.
That was just like my vibe.
Now when I see an email or a form or a thing I have to write and I avoid it because what
if I do it wrong?
I tell myself, I'm a person who does things at the first minute so that when a task or
email or decision or a draft of something comes up, I decide or I start at the first minute so that when a task or email or decision or a draft of something
comes up, I decide or I start it that first minute or that first day.
Do not let it grow mold.
So I just say, I'm a person who does things at the first minute to have me just jump right
into something.
The other thing that exposure response prevention has taught me to say to myself all the time
is worst things first.
So what do you dread the most? Do it first. If you don't want to do it, well it's therapy to
get it done. And after a while you say, wow okay I did a bunch of things I would
have otherwise avoid, they did not kill me, and I did not do such a bad job that
my whole life collapsed. So look, I made this episode and so far I have not died
or killed
anyone in the process. Hooray! Now speaking of putting some thoughts into
our little meatball brains, what about the thoughts that we don't want around?
The ones that barge into our lives like a dinosaur made out of a grizzly bear
doing jazz hands through the wall like the Kool-Aid man. Well, patron Audrey
Keane wrote, can you ask about intrusive thoughts in OCD? I really do not want to
drive my car into a tree or touch a hot stove, but in difficult times my brain
has yelled at me to do such things. Honestly? Relatable. And patrons Love2Learn46,
Nicole Campbell, Ruby Gordon, Moss, Emily Stauffer, and Nasty Garden Rat's friend
wanted to know about these kind of rude intrusions, Liliana, first time question asked, wrote,
Sorry for a rather intense question.
I know many people with OCD experience intrusive thoughts, and some, like my friend, have especially
distressing ones, such as pedophilic intrusive thoughts, or fears of cheating, or other scary
and taboo topics.
Could you speak about why OCD often involves such intrusive thoughts,
what causes them, whether they're dangerous, and how people can manage them?
We mentioned intrusive thoughts, and sometimes all thoughts feel intrusive. But can you explain
exactly what an intrusive thought feels like or when you know that thought is
unwanted, why you can't just kind of swat it away?
Well, I can just go by what my patients tell me.
Yeah.
And the other thing, as long as you're on that point,
there are patients with psychotic conditions
like schizophrenia may hear voices, right?
They may have auditory hallucinations.
So they may hear a voice that tells them something
or tells them to do something.
One of the distinctions we make when we're making a diagnosis of OCD, I'll ask the patient,
well, it feels like there's a voice in your head.
Is that from your own brain or are you actually hearing a voice?
And if they have OCD, they say, oh, no, no, I know it's my brain.
But it's like part of me is telling me that I need to be careful, that something terrible
may happen.
And until I do something about it, that terrible feeling is going to linger.
So I think you're right.
When I screen for somebody, I say, do you ever have intrusive thoughts?
You ever have thoughts that come out of the blue and bother you?
Everybody has them.
That doesn't distinguish OCD.
It's really the combination of having an intrusive thought that's unwanted, unpleasant,
and the need to do something about it, either physically or in terms of a mental ritual.
We had a great question from someone named Reina who, a very passionate request, they say,
can you talk about the intrusive grippy sock type of OCD? I don't know if you know that term,
but grippy sock vacation refers to like an impatient stay. But this person said that they were having intrusive thoughts, but they didn't
seek help because they were afraid of getting hospitalized for saying it out loud. And they
said, I think more people need to know the difference between say suicidal ideation or
intent versus intrusive OCD thoughts of self-harm. How do clinicians parse that out?
And does that happen a lot where someone is having intrusive thoughts without intent,
but it shoots them down the wrong thing?
Yeah, that's a really good question too.
So some patients may have an intrusive thought that they may hurt themselves.
But what they'll tell me if they have OCD is they really
don't want to hurt themselves. They have no plan. They have no intent. It's the last thing
they want to do, but they're worried that if they don't do something, perform some ritual,
that somehow they're going to hurt themselves. More often, people are worried that they're
going to hurt someone else rather than themselves. And when suicidality comes up,
it's usually because the person is very depressed,
they feel demoralized, they feel hopeless,
maybe they feel embarrassed about their symptoms.
That's when suicidality comes to fruition.
We have an entire episode called Suicidology
with suicideologist, Dr. DeQuincy Mayfran Lazeen, which we'll link
for you in the show notes. Let me say something about a fear of harming others.
That's a very common one. And there the questions come up, well say if you're an
inexperienced clinician and somebody comes to you and they're afraid they're
gonna hurt somebody. I mean what you find out first, do they ever hurt anybody?
You know intentionally. And who are they afraid of hurting? Are they afraid of afraid they're going to hurt somebody. I mean, what you find out first, do they ever hurt anybody intentionally?
Who are they afraid of hurting?
Are they afraid of hurting their boss who they hate?
I don't know. Well, maybe that's not LCD.
I'm well within my rights to kill you right now.
But what are they afraid of?
They can't babysit for their grandchild anymore because they're
afraid they're going to put their grandchild in the microwave.
They said, that's crazy. But I'm afraid that instead of baking the cake, because they're afraid they're going to put their grandchild in the microwave.
And they said, that's crazy, but I'm afraid that instead of baking the cake, I'm going
to put my grandchild in the microwave.
So I can't babysit anymore.
That's OCD.
When you mentioned harm of others versus self, Mallory Albee wanted to know, is OCD associated
with things like skin picking or hair pulling, things like that?
Is that under the OCD associated with things like skin picking or hair pulling, things like that? Is that under the OCD umbrella?
The skin picking and hair pulling trichotillomania is under this larger category, larger umbrella
of OCD and related disorders, but they are considered distinct from OCD.
You do see some comorbidity, but they're separate and sometimes require different treatments.
What about eating? Deanna Day, Zoe Dunham, Mia, Geo Beck,
and in Matt Seckafan's words,
what's known of the relationship
between eating disorders and OCD?
Same with disordered eating at all?
Yeah, in terms of the relationship
between eating disorders and OCD,
the one where I see the strongest connection
in some patients between anorexia nervosa and OCD, the one where I see the strongest connection in some patients
between anorexia nervosa and OCD. In fact, I've seen some patients over the years who
may have started with anorexia nervosa with a focus has been more on their weight, and then
they develop some rituals and other obsessions unrelated to their weight.
So I see some connection there.
The idea of compulsive eating or bulimia, I don't see a strong connection between that
and OCD.
That's in my mind a misuse of the term compulsive.
Okay.
That's good to know.
Some people wanted to know about infections and Kapi Virigal asked how often is the onset
of OCD preceded
by an illness or infection and a lot of people wanted to ask about PANDAS, which is a, I'll
put it in a side, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections
or- Say that three times fast.
I cannot.
Or PANS.
Okay. fast. I cannot. Or PANS. Okay, so PANS stands for pediatric acute onset neuropsychiatric syndrome
and it's related to PANDAS. Cute names, horrible conditions, and PANDAS stands for pediatric
autoimmune neuropsychiatric disorders associated with streptococcal infections. No, I'm not going
to say that three times. I just said it twice, that was hard enough.
But according to the National Institute of Mental Health, these conditions affecting
kiddos involve autoimmune encephalopathy or brain inflammation causing sudden and severe
onset of OCD or restrictive eating disorder in children.
And mood, behavior, and sensory and motor function can also be affected.
But what doctors suspect triggers this are infections,
like pandas involve strep or scarlet fever.
And in general, pans may be triggered by immune system issues
or illness or even environmental factors.
And the conditions may start or stop suddenly,
and for a while there was a lot of controversy on whether PANS or
PANDAS were even real. And in 2012, Stanford University became the first academic institution
to start treating it. Now patrons, including Anastasia Press, Aaron Sorensen, Nicholas
Randall, Reina, William Russell, they all asked if PANDAS or PANS is the same as OCD,
does treatment differ and what's Dr. Goodman's take on it?
And Nicholas Randall echoed,
oh gosh, the pandas question would be so good
to hear an answer to.
But yeah, a lot of people wanted to know about this.
It's something that typically the general population
knows very little about
unless you've known someone that has it.
But can you talk about that and like sudden onset in kids?
Yeah, I've done some research on it.
Some of my colleagues are more expert than I am.
But it goes back to the reason when if you have a child and they have a sore throat,
the reason you want to make sure it gets treated is you want to make sure it's not beta hemolytic
strep, a strep infection.
Because with strep, this is unrelated to OCD, but I'll make the connection.
The concern there is that some patients, if you fail to treat the strep infection adequately,
you can get a complication called Sydenham's Korea, which is autoantibodies directed against
the brain.
And Sue Swedo, who came up with the idea of pandas many years ago, had identified a subpopulation
of patients with OCD where they had a strep infection,
and instead of developing what was Correo,
Sineham's Correo, which is a certain type of movement disorder,
they develop ticks or OCD symptoms out of the blue overnight.
It's a very interesting,
very fascinating and still controversial entity.
But I think it does exist.
It's hard to diagnose and it's been expanded now to consideration as you mentioned with
PANS not just focus on strep but maybe other infectious agents cause a autoimmune response
where the antibodies attack your own brain and instead of producing synhamscaria, you
get ticks or OCD.
Is the treatment for that still something serotonin or behavioral therapy or I've heard
immunoglobulin therapy can be helpful for that?
Yeah, no, there are some.
I'm not as up to date on the literature there, so I'm going to be a little bit careful about
what I say about the latest.
A lot of the patients that I see who are adults will raise questions about that they had OCD
when they were a child and could
that be related to pandas? It's possible, but if it's say five, 10 years have transpired,
I'm probably not going to try an immunotherapy because probably what even if there was an insult
and an activation of the immune system, that inflammation is long gone. So we generally would treat it OCD kind of independent
of whatever we think caused it, including pandas.
So it would be the same treatments of behavior therapy
or SSRIs for the most part.
So yes, treatment varies depending on the case,
but some first line therapies
are treating the underlying strep infection
if that's still active and going after
the OCD challenges using cognitive behavioral therapy. Perhaps also trying SSRIs or according
the 2017 paper, Clinical Management of Pediatric Acute Onset Neuropsychiatric Syndrome, Part 2,
Use of Immunomodulatory Therapies. Immune abnormalities in 75 to 80 percent of patients occur as
inflammatory and post-infectious autoimmune presentations. And that oral
or IV corticosteroids may help, but IV immunoglobulins or antibodies are the
preferred treatment. Now for very severe cases, the paper continued, therapeutic
plasma exchange is the first line therapy, sometimes combined
with immunoglobulins and the high doses of steroids and possibly rituximab, which is
an antibody medication used to treat certain autoimmune diseases like rheumatoid arthritis
and cancers like non-Hodgkin's lymphoma.
And on the topic of neuroinflammation triggered by an illness, we have a two-part long COVID
episode that just went up a few months ago with this amazing doctor, Dr. Wes Ely, that we'll link in the show notes.
And we also have an episode on multiple sclerosis coming up very soon.
But I'm grateful to say I have some kiddos in my life who have had PANDAS, went to this
exact Stanford PANS clinic and are doing amazing.
So if anyone from that clinic, Stanford is listening, thank you from the bottom of this lady's heart.
It's really challenging to find doctors
who are looking at different types of treatment for this,
but it's heartening to see
that it's become more widely known and treated.
Now, if you think that your kid is struggling with this,
the National Institute of Mental Health recommends
that you reach out
to the wonderful International OCD Foundation
or the PANDAs Physicians Network
to find a healthcare provider who may be knowledgeable about PANs and PANDAs Physicians Network to find a health care provider who
may be knowledgeable about PANs and PANDAs. We'll link that on our website.
And you know, we talked a little bit about like a childhood situation. I know we're throwing
around a lot of letters. When it comes to complex PTSD, some folks, Jordan Irons, Kayla
Tozier, Will Clark, Alex Miner, Or Lusper, Reese Parini wanted to know, is OCD,
in Reese's words, sometimes trauma-induced?
Do you see that in any patients?
Kayla wanted to know, can childhood trauma lead to OCD?
I've seen some cases over the years
where I thought that there was a direct connection
between a traumatic life event and the OCD,
but it's not all that common in my experience.
I remember one patient I treated who was a combat veteran
and he had an awful job of,
this was in the Vietnam era, of doing body counts.
And it was obviously a very traumatic experience
and he developed OCD after that
and I thought there was definitely a connection.
Well, well, well, look at that.
A 2024 study titled,
Exploring the Interplay between
Complex Post-Traumatic Stress Disorder
and Obsessive-Compulsive Disorder Severity,
Implications for Clinical Practice,
which opens with a banger of a sentence,
Traumatic Events Adversely Affect the Clinical Course
of Obsessive-Compulsive Disorder.
And the paper concludes that the coexistence of CPTSD in OCD
exacerbates obsessive-compulsive symptoms
and increases the burden of anxiety.
So yeah, you're not imagining that.
And here, I just have to shout out
one of my favorite musicians, Alison Pontier, who not only
has the voice of an angel.
You may have heard her EP's Faking My Own Death
and Shaking Hands with
Elvis the last few years or her feature on Lord Huron's song I Lied.
But also last week released an essay on Substack about her OCD titled
Manifesting but Evil, What I Couldn't Tell
Anyone.
And I'll link it on our website, but it opens, around age 11, I discovered that if I made
deals with God, my stomach wouldn't hurt anymore, at least until the next time it happened.
God isn't big on money or favors.
He's mostly interested in meaningless tasks performed in exchange for a few minutes of
relief.
Now on Alison's Instagram post about it, the comments flooded in like, ex-religious OCDiva's rise up and religious OCD plus magical
thinking OCD were rude. And I was really moved by her essay and I found it relatable as,
well, hell.
And Olivia Lester, I want her to know if there's a correlation between OCD and Judaism. I was personally raised
Catholic and if there's ever an obsessive and compulsion, Catholicism is like, you will go to
hell unless you say this rosary the exact number of times. You know what I mean? They extend you
to penance. So do you ever see people with maybe religious backgrounds that are-
Oh, yeah. Yeah. All the time. And definitely a lot of Catholics for sure.
In fact, some of the earliest,
probably some of the earliest descriptions of OCD
that correspond to our current definitions
go back to the Catholic Church.
Wow.
Referring to the scrupulosity.
In fact, I don't know if it's still exists,
but there was a treatment center in the Midwest
for priests who were scrupulous.
They were taking biblical studies too literally. And so one of the things when I, I'm Jewish and I've certainly,
I've had Jewish and Catholic and people from all walks of life, all religions who have had OCD,
and some of them do involve religious ideation. And what I will ask them is have you sought out
your priest, your rabbi, and have they tried to reassure you
that you're overinterpreting these concerns?
And usually that doesn't work.
My experience is that that kind of reassurance
doesn't cure the OCD.
The priest is like, no, yeah, you do have to do this.
That's interesting that Catholic literature
is some of the first, but Keegan Newman and Linda English
wanted to know about hoarding.
Does it ever bother you when you see shows like or hear of shows like Hoarders where they're
like, we're just going to come in and clean up your house and you're going to be fine
when it's so much deeper than that? Is that under the OCD umbrella?
Again, it's separate. Again, it's under the same umbrella of OCD and related disorders.
Sometimes they're connected. Other times hoarding is separate. I'll give you an anecdote, a patient years ago,
got into the point where she collected her cat litter
in bags because she was afraid that the cat
would ingest something valuable.
And she pointed out that she really didn't own
anything valuable, but nevertheless, she was worried
that something would be thrown out in the trash
that was valuable, including in the cat litter.
And you can imagine, you know, collecting bags of cat litter in your basement.
So her husband took advantage of a weekend when she was visiting her sister, brought
in a dumpster, and he and his friends decided to clear out the house.
She came home early and she did a dumpster dive.
So it did not work. That approach doesn't work. Just a dumpster dive. Oh no. So it did not work.
Oh no.
That approach doesn't work.
Just a fun side note,
we have an episode on decluttering called Oikology
and the expert in it is named Jamie Hort.
But simply Marie Kondoing your house
is not gonna do the full trick.
Results on medical trials for hoarding disorder
have been a little, mostly focused on SSRIs disorder have been a little mostly focused on SSRIs
which have been a little effective although SNRIs and glutamate modulators
or ADHD medications may show some promise but a ton more research is needed.
So for now the best treatment for hoarding disorder seems to be cognitive
behavioral therapy and usually a lot of support from caregivers or loved ones.
And hoarding disorder, remember, isn't OCD, although some folks can struggle with both.
Now what if some of this OCD info is hitting a little too close to home, but you also don't
want to diagnose yourself from a one-hour-long podcast episode?
Do you have any advice for someone who suspects that they might have OCD in terms of how to seek help and how to
How to really recognize the impact that it's having
So I want to put a plug in for the International OCD Foundation that I was a co-founder of that organization
Back in the 80s you go to their website. They have a lot of great information
They identify different places where you can seek treatment.
So I think that's a good starting point.
What about for people whose loved ones might have OCD?
Anonymous wanted to know about living with someone with OCD, both in ways to help and
ways to cope.
And Elena Gorilla also wanted to know any tips on coping, how to support but also not
enable too many compulsions.
Yeah, you know, that's a tough struggle for loved ones. You talk about enabling,
you don't want to enable, but also if you have a loved one who's in distress, or you have to make
it to a dinner date together, and they say, well, you got to check, or they're asking for
your reassurance that they did something correctly, or that they have to check the locks again or the stove.
Or in the case of say, moral scrupulosity, OCD involving ruminations worrying that you're
not a good or moral person or that you're always harming people, reassurance seeking
may come in the form of asking loved ones over and over if you've done anything wrong.
Now, with a therapist who doesn't specialize in OCD,
you may just run around in circles treatment wise,
just asking your therapist for reassurance and getting it,
but not getting to the root of the issue or confronting those obsessions and compulsions.
Also, I said enable, but I meant accommodate.
My brain did not do words well.
It's easy just to give into it because that's the most parsimonious thing to do.
So there's no one script. I think if somebody's going for exposure response prevention,
it's really important for the family members to participate so that they're not inadvertently
accommodating the symptoms, but also not looking like they shown feeling no empathy for the person's feelings
It's easy to say from the outside just stop it. Yeah
But it isn't for the patient who has OCD
especially if the stakes are
Typically so high where you're asking someone to or like going to going to hell. Yeah going to hell or
Giving someone an illness that could kill them.
Just this notion that if I don't do this correctly, I could kill someone.
It's not as easy as just not doing it.
Any biggest myths, last question, any biggest myths that you want to stand on a soapbox
and flim flam you want to bust?
Again, this goes back to sometimes, there are family members who are very supportive
and understanding and some who feel that the person just doesn't work hard enough to control
their behaviors.
If somebody with OCD, if it were so easy to just stop it, people would.
They wouldn't need treatment.
So I think one of the myths is
that it's a weakness. The other is I see it really as a brain-based disorder. I mean,
there's just so much evidence that this is the disorder of the brain and it certainly has
manifestations or behavioral, but it's a brain-based illness. And even the behavior therapy is acting to retrain the brain.
Again, exposure and response prevention therapy, huge, huge, huge love.
Hate doing it.
Love that it's helped me so much.
What do you feel is the hardest part about your job?
The patients who don't get better.
Yeah.
I mean, and so I've never told the patient
that I can't think of something else that we can do.
So I've always taken that position.
I never give up on somebody.
What about your favorite?
What's the most rewarding?
Doing the deep brain stimulation
and patients who have had OCD for 20 years
and within a few months, they're back to living a normal
life.
It's just incredible.
Do you ever cry about it?
I'm about to start crying.
No, I don't cry.
You don't?
But in the operating room, it's interesting.
So I'm going to get into detail, but we wake up the patients in the operating room to test
the stimulation.
And sometimes what we look for is that they feel happy when we turn on the stimulation and sometimes, you know, what we look for is that they feel happy.
And when we turn on the stimulation and we had one patient who in the middle of the operating room
says, I feel happy. In fact, we asked her, what does it feel like? It feels like love in my chest
for everyone else. And almost everybody, maybe not me, start to tear up in the operating room. And
she did very well. She went on to do very, very well. And almost everybody, maybe not me, start to tear up in the operating room.
And she did very well.
She went on to do very, very well.
Do you ever lie about crying, for example, right now?
I'll cry sometimes in movies.
I'm not a big crier.
I'm crying about it.
I don't even know this person.
Well, the work you're doing is so important and it's really such a privilege to talk to
you.
Anyone who has knowledge of OCD is like, whoa, Wayne Goodman, that's amazing, including me.
So this is really cool.
You know your stuff too, Allie.
I'm impressed.
Thank you so much for doing this.
It's been my pleasure.
So consult an expert about your curiosities.
When it comes to getting treated, please remember that an evaluation is really important. Some
conditions look like others and they overlap and treatment can be really
different, so find a specialist at the link in the show notes or on our website
at alihwar.com slash ologies slash OCD neurobiology, which we've also linked in
the show notes, so you don't have to write that down right now. Now come back in a few days,
should be up this weekend for a bonus episode
all about lived experience and more research and tips
for loved ones and folks with OCD
as I chat with researcher and OCD have her
and mental health advocate Uma Chatterjee, who's amazing.
And thank you so, so much Dr. Wayne Goodman
for the decades of tireless work
to make this condition better understood and to improve the lives of people who have
it and for founding the International OCD Foundation, the charity of choice this week,
and we'll link them in the show notes as well. We're at Ologies on Blue Sky and Instagram.
I'm at Ali Ward on both. We have weekly kid-friendly episodes called Smology's available wherever
you get podcasts. Just look for Smology's, S-M-O-L-O-G-I-E-S, swear free, shorter versions.
Ology's merch is available at Ology'smerch.com.
To support the show and sending questions for upcoming episodes, you can sign up at
patreon.com slash Ology's.
Erin Talbert is our Ology's podcast Facebook admin.
Big hugs to the whole Campbell clan this week.
A whale of a hug
to Mike. Aveline Malik makes our professional transcripts. Kelly R. Dwyer does the webpage.
Noelle Dilworth is our scheduling producer. Susan Hale managing directs the whole show.
Jake Chafee is one wonderful editor and lead editor up top is Mercedes Maitland of Maitland
Audio. Nick Thorburn wrote the theme music. If you stick around to the end of the episode,
I'll tell you a secret. If you heard the ADHD episodes, for a while, my chronic procrastination looked a
lot like ADHD. And one doctor said, it's possible. But a short trial of ADHD meds with me was
like trying to coax a terrified chihuahua out from under a car by injecting it with
espresso. Did not help me. Further evaluation revealed, hey bitch, thinking nonstop that
everyone might hate you because you made a minor mistake and procrastinating to the point
of panic because you're avoiding something so hard. We have a therapy for
that. It's called exposure and it will suck so hard, but then your brain will
say, okay this is not so bad. It's like a jump from a high dive or a plunge into
an ice bath. It is scary, it's not comfortable,
it's not as bad as you thought,
and then it's much easier to do the next time,
and you'll be like, holy shit, I did that.
So if you're listening to this
because you have a loved one going through it,
or you were like me, diagnosed with OCD
in the last couple years,
I hope you get it a little bit more.
Let me tell you, there are brighter days ahead.
You got this.
Also, the second secret is that sometimes
I have a hard time not scrolling
and I don't get a lot of stuff done.
And my friend Simone told me about this thing called a brick.
It's like 50 bucks.
It's a physical object you use to brick certain apps
on your phone.
You keep it on the fridge or somewhere that's not your hand.
If brick wants to advertise, I love them.
But here I am just giving it to them for free. But yeah, this thing called a Brick has helped me stop
scrolling so much when I'm avoiding things. Okay, I hope this episode helped
in some way. Stay tuned. We're gonna talk to Uma in a couple of days. That's a
great combo too. Thank you for hearing about all of my mental health issues. I
feel like we all have them. I just tell you about them. Well, I hope it helps. Okay, bye bye.
Packadermatology, homology, cryptozoology,
lithology, nanotechnology,
meteorology,
oligopeptology,
nephology,
serology,
selenology.
It's OCD.
It's all flared up.