Psychiatry & Psychotherapy Podcast - Obsessive Compulsive Disorder (OCD)

Episode Date: June 23, 2021

In this episode, I am joined once again by Michael Cummings. M.D. and Melissa Pereau, M.D. along with Chantel Fletcher who will soon be a fourth year medical student going into Psychiatry. We will be doing an in-depth analysis on Obsessive Compulsive Disorder including history, assessments, diagnosis, and so much more.  By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast. Go to Psychiatrypodcast.com. Sign up, sign in, take the test, and the certification is emailed to you in seconds. All right, before we begin, this episode on OCD, I want to have a few words. words, thank you. I have amazing listeners. I love you guys so much. And coming back from a week

of vacation before posting this episode, I had about 70 emails of people leaving gratitude, people who are signing up for the resource library who write little notes. I read those notes. I just replied to all of them today. And I really appreciate the notes you leave, both emails to me and also the 672 five-star review. that we have on iTunes now. I'm deeply grateful for people taking the time to leave a review. And if you have not checked out the resource library, you will want to do that for this episode. In particular, we have a 50-page OCD handout. It covers much more than we're able to cover today. It covers tons of details, much more than I got in residency. I think you will find this

almost book-like, and it's free. So I love to give you guys some free resources. And now on to the episode. Welcome back to the podcast. Today I am joined by Dr. Michael Cummings, Dr. Melissa Pro, and they were the two doctors who did the Borderline for Asiator episode with me. And also, Chantal Fletcher, she is a third-year medical student, soon to be fourth-year medical student, going into psychiatry. So thank you guys for joining.

Well, indeed, I'm happy to be back. Welcome everyone. Yeah, and I, I think it might be good to talk about obsessive compulsive disorder today. I was thinking this would be a good topic to go a deep dive into. And so soon to be Dr. Fletcher worked on an amazing handout integrating a lot of content. And so we will be putting that on the resource library. And I will maybe start off with Dr. Cummings,

maybe start with talking about the history and just a little bit about OCD to get us going. Okay. The concept of obsessive-compulsive disorder has been known for literally centuries. You can look back in classic literature, such as Shakespeare's play Macbeth and Lady Macbeth being obsessed and engaging in excessive hand-washing in the Middle Ages. Some people who exhibited obsessive compulsive disorder wound up being tried for witchcraft. because some of the ritualistic behaviors were interpreted as being demonic or influenced by the devil. You can find examples of the description of that in the Malthias Malphacarum, translated from the Latin as the witch's hammer. Jumping forward in time to more recent eras, OCD was originally classified as an anxiety disorder. However, in DSM-5, it has been reclassified as being its own, in its own category of disorder, paired with things like hoarding disorder and trichotillomania and body dysmorphic disorder, essentially where these disorders overlap in our current syndromic system of diagnosis,

is that they cluster around a preoccupation with a particular area in the case of O.C. D itself, preoccupation with intrusive, obsessional, uncomfortable, egotestonic thoughts that raise anxiety and distress to the point where the person often then engages in either mental or physical ritualized behaviors to try to at least temporarily reduce the degree of distress. ultimately the person, however, often becomes trapped in a cycle of obsession and ritual and obsession and more ritual such that it gradually begins to eat away at their life. The current diagnostic criteria require that it either causes distress or occupies at least an hour a day. Frankly, most of the patients that I've seen with this disorder spend far more than an hour preoccupied with and dealing. with their obsessional thoughts and related either thought responses or behavioral responses.

Yeah, so you basically have an obsession, which is an unwanted thought image, urge, which leads to anxiety and distress, which leads to some compulsive behavior, which leads to some relief, and then the cycle repeats, sometimes for hours and hours and hours a day. I've had patients six, seven hours a day of doing these sort of ritualized behaviors. Yeah, Shantel Fletcher, what would you say, at what point does a person's thoughts and actions go from being considered normal to being considered pathological or indicative of OCD? Yeah, so like you were saying, like, they're normal. I mean, there are loops that happen with their thoughts.

you've noticed that you've had some patients who will spend hours, you know, taking part in their obsessions and compulsions. And that actually hits nail on the head. That's when it becomes pathological, when it starts taking up a lot of time. And when it gets in the way of being able to, you know, attend to other responsibilities, other activities you have. Because, I mean, every day we have thoughts, like that thoughts that lead to behaviors. But then it's like when it becomes problematic in that it gets in the way of you accomplishing things, it causes distress. That's when I would say that it's become pathological. Okay.

Yeah, so Dr. Cummings' obsessions contain doubt and uncertainty. Would you consider that the same or different than anxiety? It appears to be different than anxiety. Anxiety is usually attached to real worries or concerns, although the level of fear or anxiety in response to those worries may be excessive. For example, in simple phobia, a person may be very frightened of spiders or very frightened of heights. Well, there are real dangers there. Or in the case of social phobia, the person may be frightened of being embarrassed in particular situations.

But again, it's attached to something real in the world. one of the characteristics of obsessional thoughts in OCD is that often the thoughts are very magical in nature, unattached to reality. For example, some individuals may

develop the obsessive thought that if they don't order things in a particular way or don't achieve a certain degree of symmetry, that horrible disasters will happen to others, perhaps to loved ones, perhaps in some cases to

large groups of people. Very unrealistic. There's no likely cause-effect relationship present. Okay, Dr. Pro, here's a question for you. In the DSM, it says the obsessions or compulsions are time-consuming, take more than one hour per day and can cause or cause clinically significant distress or impairment in social occupation or other important areas in functioning. I know you work at a program both for trauma and another program for eating disorders. And so I would like to hear maybe some stories about the amount of time that you have seen people working on things like this. Yeah, I completely agree with Dr. Cummings. While the criteria is an hour, the majority of the patients that I've treated, it's much more than that, three or four hours. Last weekend, my husband and I

were leaving the house to take the kid to a birthday party. We got a few hundred feet away from the house and my husband said, I think we left the garage door open. And I'm like, are you sure? He says, I don't know. And we drove back and we closed the garage door. And that was good because the garage door was open. However, we would not then have left the house gone a couple few hundred feet and said, are we sure we closed the garage door or not? And I've treated patients in a partial program where they have to get up an hour and a half early before going to work because they need to check all of the locks, check all of the windows, and plug all of the appliances, and then call the security company and make sure the security system's functioning, leave the house, make it to the

first stop sign, go back home, repeat that process, and sometimes we'll repeat that process two or three times. And then on coming home, have a similar process with plugging everything in, and then going to bed, we'll do that again when it's time to fall asleep. And the patient's, the one that I've got in mind, I mean, lost multiple jobs because some days would get to work an hour, two hours late, in the process of checking these things and securing them was four to five hours easily every day. Even with getting up early, it didn't make a difference. Yeah. With that, is there a theme that it's harder for these people to seek treatment than some other issues? Would you say, Dr. Perra? Yes, definitely. I would say that a lot of the data

looks at is these are people that oftentimes are not going to seek care. And I think that there is a component of shame and guilt that goes along with it, a component of doubt as far as, am I doing something that that is insane? And oftentimes they try to find ways around by building things into the infrastructure to prevent having to have it affect their life and just build the time in for it. But I definitely think this is something that patients aren't necessarily forthright about. It's something that you actually have to go digging for. or even when they present in a psychiatric setting. And for me, if a patient has ticks or if a patient has an eating disorder,

I'm going to ask them about OCD every single time. But if we don't ask, a lot of patients don't tell us. Yeah, it even happens to physicians. I had one physician and an anesthesiologist who would check and recheck event settings multiple times before going home and sometimes spend three to four hours extra at work. I'm changing some variables here just to keep the confidentiality of this person. I had another physician who would check and recheck notes before signing them and would spend probably about 15 extra hours a week working on notes than I would consider normal. So high

functioning people as well, you know, people who are at, you know, what you would, would perceive just if you saw them at a high level of capacity also have this type of issue going on. And I've seen some of these people are a little bit more obsessive. It's like if just the right amount of obsessiveness leads to a high amount of success in the field that they're in, but then maybe in their personal life, not so much. So it's sometimes a dagger on the other side. Dr. Cummings, Is any stories come in your mind? I want to make sure we're capturing your thoughts as well. Yes.

Probably the most extreme OCD patient I had was a woman who was a checker. That is, she had to check things over and over and over again before she could be reasonably able to turn loose of them. Her worst example of that was when she left her home, she had to check multiple times whether the front door was locked. On one occasion, she and her husband left. She checked multiple times. They flew all the way to London, 11-hour flight. During the flight, however, she began to doubt that the door was actually locked. She got on a plane as soon as she could and flew all the way back to Los Angeles

to check the front door one more time. Yeah, that's pretty intense. That's pretty intense. Dr. Cummings, tell me about neuropathways involved in OCD. Okay. OCD is thought to be a pathology that involves, at the very least, a corticostriatal thalamic circuit. Essentially, in all of us, and this is always the case with pathology, that it is related to normal functioning, our anterior cingulate cortex and our dorsal striatum, the caudate nucleus in particular,

often triggers grooming or orienting behaviors in us and in other species. That is to check, to order. But when it functions normally, that in turn sends a signal to the orbital prefrontal cortex that results in the behavior that's disdainting. desired. And then that part of the brain, the orbital frontal cortex, sends a negative feedback signal back to the globus pallidus and then back up to the anterior cichlet and the caudate and essentially turns the system off. So we need to check something, we check it, and then we stop. How much as Dr. Perra was describing with checking to find that the garage door needed to be closed, closing it, and then going on about our business. For the person with OCD, however, that feedback signal is either absent or weak, and consequently, the system does not turn off, and that circuit keeps going around and around the loop over and over again. Interestingly, Dr. Fletcher, when you kind of compiled studies on this, you found that there wasn't that much of a link between the serotonin and the dopamine. in the studies that looked at the brain.

Is that correct? I'm looking at this. Pharmacologic challenge studies have been inconglusive statement. Or Cummings, you want to speak to that? Yes, I can. Indeed, one of the reasons that we focused very early on is something that we'll get to in a bit, I suspect. That is that the first-line pharmacologic treatment

for obsessive-compulsive disorder are drugs that increase available serotonin, the SSRI antidepressants, and chlamypramine. When they've done direct challenge studies, though, directly manipulating dopamine or serotonin, those are inconsistent, and that may reflect that they are, in many ways, secondary modulators rather than part of the primary cause of the disorder. People suspect much more that the more potent neurotransmitter, activating neurotransmitter glutamate may actually play a more central role in the pathology of OCD. And Dr. Cummings, in the studies that you looked at, is there anything looking at as far as developmental pathology with respect to abnormalities and pruning based on the age that this develops, et cetera, like why this is here? it appears well it is a strongly heritable disorder which argues that there is an underlying genetic risk however there are also environmental influences such as childhood abuse childhood adversity

but essentially in most of the studies and I'm rounding the numbers here if you look at mono-zogotic versus dysogotic twins or family history positive versus is family history negative, it's clear that genetics appear to be able to roughly double the risk of developing obsessive-compulsive disorder. I suspect that like many psychiatric disorders, if you have an underlying vulnerability that then meets the right environmental circumstances, it makes it much more likely that the system will go from within the bounds of normal functioning, to pathological functioning. There is also a very clear gender difference.

Boys develop OCD much earlier than girls and also have a very strong association with tick disorders, whereas girls tend to develop OCD and their teens are 20s and do not have an association with tick disorders. Yeah, I found that really interesting how there's actually a higher heritability for the younger onset OCD, the childhood onset OCD compared to the adolescent onset or adult onset OCD. Heritability estimated for child onset OCD was around 45 to 65, whereas adolescent and adult was 27 to 47. And just to give you guys some context for ADHD, it's 71 to 73,

schizophrenia 73, bipolar 60. So it's somewhere between those issues. Fletcher, I'm wondering what challenges may younger OCD suffers face in comparison to older. This relates to developmental changes faced when the OCD starts in childhood or adolescence. What did you find there? Yeah, so when it starts really early on, they can definitely face some developmental difficulties. For example, during that time when you would normally be hanging out with your friends, instead of doing that, you're probably spending a lot of time obsessing, performing your compulsions. And so it really gets in the way of exploring just normal activities during that age group. For example, young adults may struggle to leave home and live independently because, I mean, the currency of all of our actions is time. And if

you're spending all your time performing compulsions, it can be hard to hold down a normal job. It can be hard to study. And they may even have like few significant relationships outside of family. They'll feel like they lack autonomy. And they might actually have more financial dependence on the family of origin because of the aforementioned issues. Yeah. So once again, the younger patients are often male. Dr. Cummys, any thoughts on the kind of the younger group of people who get diagnosed, why it's more often male. Any thoughts on that? It is true that males in general show a slower development of prefrontal inhibitory systems,

and that may be true in people who are genetically prone to OCD as well. A lot of the studies of the neurophysiology of this disorder suggest that the real defect, is in the inability of the orbital prefrontal cortex to turn the dorsal stridum and anterior cingulate off. That is, the negative feedback signal is too weak to do the job that it's supposed to do. It's supposed to be, if you will, a front-down or top-down inhibition of the system once the behavior that's being sought by the system is achieved. And these people, it doesn't turn off.

It again goes round and round and round, a bit like a Mobius loop. And I think the chief defect in that is the orbital prefrontal cortex doesn't seem to be able to override the activation input from the caudate. And that, I think, is why serotonergic drugs play a role in this is one of the effects of serotonin in the prefrontal cortex is to strengthen in general inhibitory signals coming out of the prefrontal cortex. And can you speak to the role of dopamine blocking agents in that circuitry as well? Dopamine blocking agents likely also play a role,

particularly with respect to D3 dopamine receptors. D3. D3 receptors also play a significant role in activating and modulating the excitability of prefrontal cortical neurons so that if you inhibit D3 receptors, you're more likely to get a, if you will, a more robust output signal. Again, though the primary driver of that signal is typically glutamate, serotonin and dopamine are acting as modulating agents rather than as the primary actor, which is, again, why I think that the direct challenge studies are often inconsistent. Yeah, I think about the direct challenge studies as well.

It's like these medications take a while to work, like serenergic meds in my experience, four to six weeks. So it makes sense to me why direct challenge wouldn't show much. Yeah, because direct challenges, those studies are very brief. And in some ways, I'm not surprised that the results are mixed. One of the truisms about treating OCD pharmacologically is that it often takes exposure to higher concentrations of medication than would be true, say, for treating other types of anxiety or a depressive disorder. And often for a longer period of time, I know that the formal definition for time of for an adequate trial in OCD is six weeks. Clinically, though, I've often seen patients not really begin to robustly respond until they've been at a fairly high dose of medication for eight to 12 weeks, you know, much longer, much longer than is characteristic for either anxiety disorders or major depressive disorder.

Yeah. Yeah. I think it's worth mentioning the gold standard for OCD psychometric testing, the Yale Brown obsessive compulsive scale, the Wybock. And the scoring of this, each score is on a four-point scale. So zero, no symptoms, four extreme symptoms. So there's a total range from zero to 40 with separate subtotals for severity obsessions and compulsions. So a score of less than seven is subclinical, eight to 15, mild, 16 to 23 moderate, 24 to 31 severe, and 32 to 40, extreme. dream. I'm curious, Dr. Pro, because I know that you test pretty much, did you say everyone that

comes into your program for eating disorders on the Wybok or often? I screen all that come in and if they have any symptoms at all, then we do a YBOX and we probably do one or two a week. Okay. And what kind of scores are you seeing in people that you would say as like, you know, they're, they're doing their activities multiple hours a day and it's taking away from their life. What kind of scores are you seeing? The last month or two, just off the top of my head, usually moderate to severe, so 23 to 30 on the Y box coming back. And generally, these are in patients that also have comorbid anorexia. Okay.

The other thing I would mention about the Y box is it comes in both a clinician-rated and a self-rated form, patients tend to rate their symptoms as being somewhat worse than clinicians rate them, but for a lot of clinical practices, once the patient is essentially trained to self-rate, it provides a very nice data point for tracking treatment response and things like that. I think this is an important one to know about if you've never seen the Wybok get it, download it, you know, you could do this on your OCU patients and then track their progress. The other thing that I would say is be careful about doing this before you've built a therapeutic alliance. I remember one person that I had early on in residency, I wanted to know their Wibok right

away, and then they wouldn't show up the subsequent visit. So it may be beneficial to develop a therapeutic alliance, you know, a connection before jumping to just checking their score. Yeah, it's important to realize many people with OCD are quite embarrassed and ashamed of both the content of their obsessions as well as many of their rituals. Yeah, and there's a lot of questions here that may be positive that you would not know to ask. and I've been surprised a couple times looking at them, some more of the taboo types of questions. Chantelle Fletcher, do you have any that you can remember more of the taboo questions

or more of the taboo symptoms that you think patients would have a harder time disclosing? Yeah, so I know some would be like, you know, sexual obsessions, like, oh man, I saw that kid and I got this weird feeling. Does that mean I'm a pedophile? Things like that. So I could see how people would be hesitant to do. disclose that, even though they're meeting with a professional, it's still kind of jarring because you're not quite sure how the person is going to react. Yeah, I had a patient I remember vividly because

we were wondering why this person was admitted like the third time in the month, and then it came out that he had obsessions about sexual thoughts towards a relative. And when he had disclosed it to his very conservatively religious Islamic parents, they basically wanted to, you know, to throw him out of the house. He was an adolescent. And so the level of the taboo, but it was also associated with things like washing hands and other obsessions.

So I remember explaining it to his parents and the relief on their face when they found out their son wasn't, you know, a pedophile, basically. Yeah. One of the comment I was going to make is that once you do have a rapport and the person can be introduced to the Y box.

One of the reasons it's very important to track the score over time is that, frankly, it's fairly rare for us to provide treatment and for the person to become entirely non-obsessional, non-compulsive. More often what you see with treatment is a partial improvement. And tracking where you are with that can be very helpful in knowing whether the treatment that you're pursuing, whether it be pharmacology or psychotherapy or a combination of the two is being adequately effective. Yeah, I want to emphasize that, especially if you're a new provider, you may not be able to judge the nuance in changes. And one of the

things I recommend for the people I coach is to have some way of assessing that, whether it's the OQ45 or this type of measure, because it allows you. allows you to see number changes, which if you're a new provider, you may not be able to judge the subtleties, oh, this depression is getting a little bit better, or this person is becoming more functional. Chantelle, I wanted to jump and ask you, what are some of the distinguishing features between OCD and OCPD? I think it might be worthwhile to differentiate here.

Yeah, so I think this one's important because I think because of the name of OCPD to the general public, it can kind of have them think differently about what it actually is. One, OCD, it's ego dysotonic, meaning it doesn't match up with their self-concept, whereas OCPD is egosintonic, meaning it does match up with how they see it themselves. They like it. It's, they have that pervasive pattern of excessive and maladaptive and perfectionistic need for control and order, you know, preoccupied with rules. Whereas OCD, it's not always perfectionistic in nature and the ups and the obstinate.

can vary quite a bit, and their actions are in response to those obsessions, whereas the actions in OCPD are just in response to their internal values. And OCD patients generally know that their obsessions and compulsions are bit rational, going back to what Dr. Cummings said. That's part of what contributes to the embarrassment because, you know, they think it seems weird, something seems off. Whereas those with OCPD think everything's fine. I think it makes sense. and everyone else is a problem, like, you know, along those lines. Yeah, indeed, one of the quips about OCD and OCPD is that people with OCD are driven somewhat mad by their illness.

On the other hand, people with OCPD tend to drive other people a bit mad. Yeah, I actually, I have a couple people in my life with OCPD, and I really enjoy their OCPD. It I gosh, I can't say too much about this or I would disclose who they are, but basically their job and what they do, they do it so well because of their OCPD. And as long as they're on your side and they're working for you, it's actually really delightful. Dr. Pro, you're nodding your head. Yes, I agree. There are many different jobs within a hospital that it would be very nice to have a person with OCPD who pays attention to D.C. tells and takes care of minutia and micromanages.

Sometimes I need that, and I'm very grateful to have people like that that will, you know, keep me in line. Probably not myself, Dr. Probably not myself. Okay. Okay, Michael Cumming, this is a question for you. How often will we see bipolar and OCD at the same time? And how might this combination be uniquely difficult to treat?

Okay. There is a fair degree of overlap between bipolar mood disorder and obsessive-compulsive disorder. In fact, there's a fair amount of core morbidity between OCD and a variety of other psychiatric disorders. The difficulty with OCD and bipolar illness is that the chief treatment for OCD typically are SSRI antidepressants or the tricyclic antidepressant chlomypramine as first line or second line treatment. Unfortunately, antidepressants are problematic or contraindicated in bipolar illness because of the risks of switching the person into mania are causing an increase in mood cycling. So in this case, you have the problem of one medication may be a benefit in one disorder

and quite problematic in the other disorder. Very good, yeah. And you shared a paper, Dr. Cummings, called Management of Obsessive-compulsive disorder, comorbid with bipolar disorder 2016. And I was wondering if you had any insight into what would be the first-line and second-line recommendations for this group? Often first-line treatment in the case of somebody with,

bipolar mood disorder is treatment with lithium. Lithium increases serotonin by desensitizing 5HT1A receptors, auto receptors in the RAFA nuclei. So you get a boost in serotonin, but at the same time, you get, of course, mood stabilization because that's lithium's primary effect. This is also a role in which, in particular, there's some of the second generation antipsychotics may play a role because they often have both mood stabilizing and anti-dopaminergic properties, which also may be helpful in OCD.

Dr. Pro, any thoughts on the combination of OCD and bipolar? How often do you see these maybe inpatient or in your programs that you run? Personally, I would say it's something that you see very rarely. So I would say that I see a lot more OCD and eating disorder, OCD and major depressive disorder. Bipolar disorder and OCD together, I can think of maybe two instances ever. Yeah. I had a long-term patient with that, and the only thing that would help him was a combination of clomipramine and Cyprexia. I know that, coming from what you said, it was counterinticated, but whenever we would try to take him off of it,

he would just completely unravel. So, oh, and he was on lithium. So the combination of all three of those seemed to stabilize him quite a bit. Good. Yeah, that type of patient, though, can be very difficult because indeed you're walking a tightrope. It's, it was like a delicate balance act of managing side effects, of getting the doses right. getting blood levels when symptoms were low and so on and so forth. So, Dr. Pro, back to you. Can you tell me about how OCD shows up in your eating disorders and how much of this is orthorexia?

Yes, so about like 30% of inorexics have OCD and it's something that we see commonly where these are two comorbid conditions. And so some of it may be that they have. anorexia and meet all of those criteria. In addition to that, they've got counting in the microwave needs to be a certain number of seconds and they have to chew in sequences of five, et cetera. And so you'll see things where there's some crossover, but there clearly is two separate entities. Other times you'll see there was, the OCD symptoms were primary where it had to be like cleanliness or brushing their teeth many, many times a day. And then the eating disorder presented and essentially took over some of the machinations involved in the OCD, and you'd see the OCD symptoms come down,

but the eating disorder becoming more prominent. And so I think there is a lot of crossover within anorexia and OCD. And I think that's kind of where orthorexia comes in. And orthorexia is a term that was coined back in the 90s to describe people that have obsessional thoughts about eating healthy. And when it comes to eating disorder, orders. It could be a person that became vegan for animal rights reasons or somebody that started a keto diet to lose weight that they needed to. And then they start to lose weight. They lose more weight. And then they begin restricting more and more and more of what they eat, not because they're trying to be healthy anymore, but either because they're trying to lose weight. And they lose weight and people give them praise and then

they keep doing it to the point where what they're doing becomes unhealthy. Or they're very fixated on what they're eating is the only way to eat or it's better than what other people are doing and they get very, very much tunnel vision and end up again getting malnutrition from that mechanism. And so orthorexia is kind of where anorexia and OCD have a crossroads where they kind of meet in the middle in some ways. And there's a high number of patients I've encountered at least that had OCD and band orthorexia. And it ends up being a condition that is a little bit more difficult. to treat sometimes because there's very strong pervasive beliefs about the value of specific kinds of food in addition to, you know, a drive for thinness.

Okay. Yeah. I can imagine someone listening to this would be like, I wish I was orthorexia, but how can that end in malnutrition? I just don't get that. That doesn't seem like eating just green leafy plants all day would lead to malnutrition. How does that work? I had one patient many years ago that started a paleo diet. And he was a teenager and he wanted to build more muscle and began with doing paleo. And then over the course of time where, and I'd never heard of it before. This was a long time ago. I was like, what's paleo?

And he's like, oh, you know, where you just like are like caveman and you just like, you know, eat meat and a little bit of berries. And that's it. And it's a diet that really doesn't have a lot of carbs. It has a little bit, but not much. M. He became paleo and over time started cutting more and more foods out to the point where I'm like, if you're paleo, you're still allowed to have quinoa. Why are you not eating quinoa? And he said, because it's carbs and it'll make me gain weight. And I'm like, oh, okay, this just moved away from paleo to try to become healthy. And now it's moved into restrictive patterns of eating. The only thing

that he eats is bison from Trader Joe's. And that is the only thing he eats about eight. nine hundred calories a day and he has massive massive uh amounts of lab abnormalities he's got pan cytoppenia he's got the zeal his testosterone level is practically undetectable i mean the body begins to break down because all he's eating is one type of a food group and he's restricted everything else out shantelle you look really worried for that person yeah you know like that does not sound healthy or enjoyable No, and indeed, in some ways, this parallels an experiment that was done, oh, now decades and decades ago, where they took healthy college students and got them to volunteer essentially for a starvation diet. These were not people with any history of anorexia, any history of any psychiatric disorder.

Interestingly, as their weight fell further and further below ideal body weight, they cognitively began. to exhibit a lot of the same preoccupation with food and with weight gain and with body distortion that you see in classic anorexia nervosa. And I remember that toward the end of it, the number of them that ended up with binge eating as a result years after the study and lifelong patterns of abnormal eating. I mean, this is before you had to get an I or B or whatever, I guess, but I just starve a bunch of college students. But, yeah, if I recall, they ended up with many of them with lifelong eating and feeding abnormalities.

Yes. Yeah, indeed, starvation itself appears to produce a number of pathologic changes in the brain. That's my problem. That's my problem. I wrestled in high school and I had to starve myself for months at a time. Oh, man. Okay. Dr. Cummings, any thoughts on how you would treat maybe someone with eating disorder and OCD differently, pharmacologically, or is it pretty much the same?

In many ways, it is parallel. You know, certainly in the eating disorders, the SSRIs have shown some benefit. And, of course, in OCD, they are first-line treatment. particularly those people prone at times to binge eating may benefit from increased serotonin levels. The hallmark, at least an anorexia nervosa, though, of successful treatment is to move the person back toward normal body weight. Because indeed, although many of the people in that study that we just mentioned wound up with lifelong pathologic changes, many of them, their symptoms in terms of eating disorder went away once their body weight was back in the normal range. Dr. Pro is nodding.

Dr. Pro, is that what you see in your partial program? That's very, very important. Getting them back to a normal weight, getting the brain nourished is the most important thing that you can do. In the absence of that, the medication is going to be useless. Yeah. Okay, Dr. Cummings. What about the mix of schizophrenia and OCD?

As you might guess, since schizophrenia involves, if you will, many of the same frontal and temporal lobe circuits that also overlap with OCD. There is also an overlap. There is, indeed, there have been papers published suggesting that there may be essentially a form of schizo obsessive disorder. And indeed, if you look at OCD itself, while we say that, well, one of the differences between psychotic disorder and OCD is that people with OCD typically realize that their obsessions are fantastical or unrealistic, that's true of the majority, but not all. Some people have only partial insight that their obsessions are not rational. And there is a small minority of OCD patients who could be characterized as delusional. That is, they believe that their obsessions are real, that if they don't, for example, tap a surface X number of times, it will somehow magically cause things to explode or the world to end, which parallels what we see in more traditionally psychotic illnesses like schizophrenia.

My guess is there is indeed at the neural circuit level and overlap between the two in some instances. It's certainly not the vast majority of patients with either OCD or schizophrenia, but I like the term of the Dr. Pro used. In cases where you have two different disorders, you can still have an intersection between the two, particularly if they involve. neural circuits in the same area. And Dr. Cummings, you shared a article, Grassy et al-2013, which looked at clozapine and other atypical antipsychotics for OCD and schizophrenia when they're comorbid together.

In the article, it talks about clozapine increasing hypochondriasis and closepine-treated patients had increased OCD symptoms. Yes. One of the reasons for that, at least the hypothesized reason, is that clozapine and frankly many of the second generation antipsychotics are also very potent serotonin antagonists, especially at 5HT2A serotonin receptors. And indeed, it's well recognized that the antipsychotics that are also very good serotonin antagonists, sometimes induce obsessive-compulsive symptoms in people who did not previously show any signs or symptoms of obsessive-compulsive disorder. Fortunately, most of those people will respond to either a change in antipsychotic, or if that's not feasible because they are, for example, treatment-resistant and only respond to chlozapine in terms of their psychosis, they can be treated with the serotonergic aid. to help ameliorate the obsessive-compulsive symptoms that may have been medication-induced.

I think that's really good for us providers to be aware of that Clozapine can actually make the obsessiveness worse. Is that fair to say? Either make it worse or in some cases it may actually create it. Create it, yep. I've seen that one time. Impatient, actually, it created the OCD symptoms when they weren't there before. Yeah, indeed, we had a young woman here at Patton State Hospital who had no history of obsessive-compulsive disorder. She responded to clozepine. Her psychosis got much, much better. However, she began to experience fears of contamination, obsessive thoughts about being contaminated,

and then she began ritualistic hand-washing. Fortunately, that responded to treatment with the SSRI Certraline. Dr. Pro with the antipsychotics, what type of doses help someone with OCD if you needed to use one? Yeah. Most frequently with treating OCD, I'll use a medication like Prozac, fluoxetine, something that's serotonergic, that I can get to good doses that will be tolerated. And in the event that that medication is helping, and usually you're looking at those doses of, you know, 80 milligrams, 100 milligrams, I've gone to 120 and some before, you know, they had resolution. But most of the time, 60 or 80 can show some benefit at least. And in those patients with the SSRI, oftentimes you can see less distress, less anxiety, secondary to the obsessional thoughts. and some of the thoughts even can improve, and yet they may still feel strong drives toward the

compulsion, or they may still feel unable to block the thoughts urging them toward behaviors. And so they say, I'm feeling less anxious about the thoughts, but the thoughts are still there pretty constantly telling me to check things or telling me to count things. And in those patients, clinically at least, I've seen that 0.5 of Risperdal, a milligram of rispetal just at night, maybe enough to bring down some of those repetitive thoughts that are urging the patient toward behaviors that otherwise they're able to, you know, use the SSRI and therapy to diminish, but to take down some of that chatter. I've personally, I've seen that to be helpful.

Chantelle, what can patients reasonably expect to gain from taking medications? Yes, so with medications, you know, You always want to use them to help them make the positive changes in their lives to help them tolerate the distressing feelings that they have. When patients do take SSRI as an inclimapramine, 40 to 60 percent of people, they'll see an improvement. And those who receive a sufficient trial of that will probably experience a 20 to 40 percent reduction in their symptoms. So instead of complete elimination of the symptoms, they'll likely experience amelioration of the symptoms. Okay. And Dr. Cummings, is there one that's better than the other? No, and this is a common misperception that people have based on marketing.

Fluvoxamine or Louvox was marketed as a treatment for OCD rather than depression, but that was because it was the fourth SSRI introduced in the U.S. market. Actually, studies have found that all of the SSRIs are, equally effective given at comparable doses and plasma concentrations. Clomipramine may be slightly more effective than the SSRIs, although that is an issue of debate because the placebo response rates in early studies were different than they are now, which makes it statistically difficult to compare meaningfully. Would you say clomipramine and afrinel is a good option if they're,

resistant to the SSRIs, or how would you think about that? It certainly is. The SSRIs are typically listed as first-line treatment. Climipramine is listed as a second-line treatment, in part that's because like most tricyclic antidepressants, it comes with a much more difficult to tolerate side effect profile, it's anticholinergic, it's antihistaminic and may cause excessive sedation. Probably the biggest caveat, though, is like all of the tricyclic antipsy. The lethal dose, average lethal dose in 50% of the population for chlamopramine is only about six to eight times the therapeutic dose. So a week's worth of chlamopramine would kill about 50% of people, which makes it a dangerous drug in overdose. Unlike the SSRIs, it's very difficult to do yourself in with an SSRI as monotherapy.

Yeah, so if we have suicidal patients, then that would be probably one we might want to skip, especially if they have a history of overdosing. Okay, so Dr. Pro talked about how you can go up to pretty high doses of the antidepressants, higher than you would otherwise expect, like Prozac 120. I don't think you would do that for many other issues other than OCD. That's correct. Often the dose is above the upper end of the range of what you would say. C4 treatment of major depressive or anxiety disorders.

Of course, as is often the case, at higher doses, of course, side effects become more problematic. With the SSRIs, things like hyperhydrosis, sexual dysfunction, all of those can become problematic. Cytalopram and S-cytalopram can prolong the QT interval at higher doses, as can. very, very, very high concentrations of fluoxetine, although those would have to be astronomical. With respect to the sexual side effects, there is some evidence that vortyoxetine and valazodone, because they're also active at 5HT1A receptors,

may mitigate against sexual side effects at higher doses. Shantau, what role would neurofeedback potentially play in treatment of OCD. Yeah, so with neurofeedback, it's not something that's super mainstream for OCD treatment right now, but it does seem like it could help those who are resistant to medications. The benefit with neurofeedback is that it often doesn't cause distress as much as, like, you know, exposure will. They found out there was a 2011 case series that was conducted that showed some good evidence

for the efficacy of neurofeedback. And of course, you know, you want something more than a case series. we have to start somewhere. This particular one had 36 drug-resistant subjects, and they found that 33 out of 36 showed some clinical improvement, and they measured this using the WIPA scale. They also used the Minnesota multi-physic inventory, and they found that there were improvements. And I also looked at a 2018 study that focused on, like, residual benefits from neurofeedback. And typically, you'd probably think that most of the improvements would be shown, like during the actual treatment.

But this one found that the clinical benefits actually were maximal in the weeks following. So it looks like it could not only have some benefits during treatment, but also some benefits that continue even after the treatment has stopped. And so when we think of therapy, we think first maybe of CBT. And I know we looked at some papers talking about intensive CBT. Tell me what that looks like, Chantal. Yeah, so with intensive therapy, it tends to be shorter, but then there are just many more weeks. I mean, excuse me, many more hours.

I'm attending to therapy within one week. For example, it can be like 20 hours in like one week versus, you know, typical like 50-minute session as every other week. I mean, every week. So basically, it's just, yeah, just regular therapy turned way up. Therapy boot camp. Yeah. Yeah. I think about partial and I think about how powerful partial is.

Dr. Pro, with those people with a really high Wybock when they come in, like how much of a YBOC drop do they have usually from the partial level of treatment? I think a lot of it has to do with being able to have partial hospital treatment where they're able to get therapies designed to help with the OCD specifically. I think probably any CBT is going to be helpful, but I think to get your best results, and certainly the best results that we've seen in the eating disorder program, because we've got a lot of CBT and DVT, but in cases where we've had more severe OCD cases in the high 20s, low 30s, we've actually had individual therapists that work alongside with the patient to do exposure and response prevention,

and then we build it into the curriculum that they're doing there. And so it's a specialized as a specialized form of treatment. And so if you have a patient that at lunchtime doesn't want to use the. plate out of the cupboard because the plate is contaminated over the course of time being able to have them take the plate out of the cupboard and put it on their tray and use that plate rather than the one that they bring from home, et cetera. And so what we've seen in doing kind of more of a hybrid treatment in that way, seen why box scores coming down at least from the, you know, high 20s to the, you know, mid to high teens. So, I mean, we're not talking about anything that that's magical, at the same time over the course of, you know, four or five months, which is about how long

patients get treated in eating disorder and having this alongside, you can see a lot of success. And places like UCLA have full OCD partial programs, which is a completely separate thing. And so we've had a number of patients that had severe OCD, and we sent them there to get care. And I think that that probably was the best option because in some ways, patients with really severe OCD, I question how much benefit they're going to get solely from doing the CBT without doing something targeted for OCD. Yeah, and, you know, some of these patients get so severe that there's not a lot of treatment that helps.

And Dr. Cummings, you shared a paper with me, Pepper et al-2015. Do you want to talk about deep brain stimulation and other sort of? Yes, as we alluded to earlier, we have at least some understanding of the circuitry involved in the corticostriidal thalamic circuit. And indeed, there are areas such as the anterior capsule or the thalamic nucleus where electrodes can be implanted deep in the brain. these are actually a small network of electrodes, and then you can turn them off and on individually and figure out which ones may be stimulating the right part of the circuitry

to help ameliorate symptoms, and then you can essentially set those to fire when they need to disrupt this cycle that we've talked about, and that has now begun to be used in very refractory, cases of OCD where the person just fails to respond. That may eventually replace what was previously ablative forms of intervention where essentially the more activating parts of the circuit were essentially intentionally destroyed either by freezing or by other surgical techniques,

capsulotomy or subthalamic tractotomy. this at least has the advantage from not actually destroying neural tissue but attempting to modulate it electronically. People have also looked at things like transcranial magnetic stimulation, mixed results for RTS. These are an area though where clearly in the most severe, most treatment, resistant patients, we are beginning to reach for things that involve direct application of energy to neural circuits or for surgical interventions to alter pathology when we can't get the same result pharmacologically. Do you think that the TMS studies have been positive or hopeful? What are your thoughts on that?

In truth, they have been mixed, and that in part is because of methodology choices within the study, They've been different. There are some studies that have shown positive results, in particular those that tried to stimulate the orbital prefrontal cortex and did so successfully appear to have some benefit in terms of then being more able to inhibit the initiation of obsessions and compulsive behaviors. But if you look at the data set for RTMS as a whole, it is very much a mixed bag because people were using different frequencies, different energy settings, different durations of treatment.

Unfortunately, many of these studies also were relatively short-term and relatively small, which, like the challenge studies, maybe not the greatest research design for this disorder. Okay. Chantelle, from your reading, CBT, what are some of the things that they're doing in CBT to help these patients? Yeah, so one of the things that they always do is psychoeducation, because before you start implementing, you know, certain changes, you want to kind of give an understanding of what you're doing. One of them is to, you know, do hypothesis testing. You want to see, like, is what's your thinking going to happen? Is that actually likely? another one is just making a list of the types of things that trigger you. And so once you do that

in a systematic way, then you can start attacking them. You can start with what's tolerable and slowly move your way up so that you can learn that you can handle the distress and that the distress might actually get better. Yeah. And in the handout that you did, you did an excellent job reviewing what actually goes on in the therapy. And so I think I will refer people to there. and we might need to do sort of a second episode on that but I want to pull this together out of respect for Dr. Cummings' time

and Dr. Proz time and Dr. Cummings, do you have any final pearls, things that we haven't really talked about that you would like to put out there to mental health professionals around the world? I think something that Dr. Perot touched on is very, very important.

People with OCD tend not to come forward When I was a resident, which is now, of course, eons ago, OCD was described as a rare disorder. Current prevalence estimates range from one and a half to around 3% with the American Neurological Society's estimate coming in at a 2.5% lifetime prevalence. So it is not an uncommon disorder. And as a consequence, we need to be looking for it. if we don't ask, many of these patients won't tell us. Yeah, my favorite question, Dr. Cummings, is do you have any thoughts, repetitive thoughts, that start when you wake up in the morning and happen all day?

And that's one of the questions I ask. Do you have a favorite question that you sort of use as a screening question? Yes. I often start with a question that's actually a parallel of one that occurs in the schedule for affective disorders and schizophrenia. And essentially, I'll start by asking the person, do you have any thoughts that repeat that you can't get out of your mind?

Okay. Yeah, I like that. Dr. Peros, any final pearls, any things that you haven't had the time to put out there that you would like to put out there? I apologize for having to, like, fan girl out here, but I get to be in the same space as Dr. Cummings for, like, two seconds.

So I have to ask, like, an awesome question. Dr. Cummings, if you had severe OCD, like some of the patients that you've seen, like fly back from the UK level of OCD, and you took and you had medicines and you'd gone through the treatments and were still not better, personally, would you opt for an anterior capillotomy? I would probably opt for deep brain stimulation before the anterior capsulotomy. Why? it is more flexible and less destructive of tissue and would you how much partial or how much day treatment program would you attempt before you would get to that place dr cummings i would certainly exhaust all of the treatment therapy modalities available to me including cbt and response prevention and I would certainly want to exhaust the pharmacological interventions first.

Just briefly, one of the studies done at UCLA by Lou Baxter at L using a PET scanner found that indeed, when they did response prevention alone, they got about a 25, 30 percent reduction in activation of obsessive-compulsive symptoms as circuit being active. They got a very similar number with SSRI treatment when they can. combined them, they got a more robust response than with either treatment modality alone. So I think that combined pharmacotherapy and psychotherapy is, for many of the more difficult cases, necessary before moving on to more invasive or destructive forms of treatment.

Dr. Pro, any words of wisdom to providers out there, maybe starting out, like what to think about when they first encounter OCD? Yeah, I would definitely say this is something that's important to ask patients about, to screen them for, because again, this is not something that they're going to acknowledge or admit to. And I can say there have been plenty of cases I've had where I forgot or did not ask. And then I found out much later. And I was like, I wish that I would have known that this is what was underneath this because we would have treated this very differently. Okay. Dr. Fletcher, anything or future Dr. Fletcher here, anything that jumps out that was new for you as you were doing this like 60 page review paper that we have on this? I'm really happy to have been a part of this project. I think we were able to address important points, including some misconceptions that even clinicians can have. I really hope our hand-out and podcasts will help a lot of people give even better care to those who need it. I'm excited and encouraged by the direction OCD treatment is heading, and I look forward to seeing all that comes next. Yeah, well, I think this is a good start of knowledge for people out there who might not have that much familiarity with OCD. And if you want to do a deep dive into this material, I will put up this massive article along with the citations.

And it was definitely too much knowledge to get through. but I think what we put out here was really helpful. So I really think, I really thank you guys for taking the time to come out and to talk about this. Okay. Thank you. Thank you very much. Thank you so much for joining us for this episode. And I hope that it inspired you, gave you some new ideas for OCD, gave you some ideas on how to assess it, how to treat it. if you would like to go to the website, go to the resource library. You can download the 50-page

PDF that goes with this episode. And if you leave me a little note, I will read it and I will respond to it. Sometimes I'm able to give you specific episodes that I think that that I think might be a good fit for you. So I hope you are having a great day. I wish you all well.