- Welcome to The Huberman Lab Podcast where we discuss science
and science-based tools for everyday life. [upbeat guitar music] I'm Andrew Huberman and I'm a professor of
neurobiology and ophthalmology at Stanford School of Medicine. Today, we are talking about
obsessive-compulsive disorder or OCD. We are also going to talk about obsessive-compulsive
personality disorder which, as you will soon learn, is distinct from obsessive-compulsive disorder. In fact, many people that
refer to themselves o
r others as obsessive or compulsive
or quote-unquote, having OCD or OCD about
this or OCD about that do not have clinically diagnosable OCD, rather, many people have
obsessive-compulsive personality disorder. However, there are many
people in the world that have actual OCD,
and for those people, there's a tremendous amount of suffering. In fact, OCD turns out to be number seven on the list of most
debilitating illnesses, not just psychiatric
illnesses, but of all illnesses which is remarkable an
d
somewhat frightening. The good news is thanks to
the fields of psychiatry, psychology, and science in general, there are now excellent
treatments for OCD. We're going to talk about
those treatments today. Those treatments range
from behavioral therapies, to drug therapies, and brain stimulation, and even some of the more
holistic or natural therapies. As you'll soon learn, for certain people, they may want to focus more
on the behavioral therapies, whereas for others, more
on the drug-based th
erapies and so on and so forth. One extremely interesting
and important thing I learned from this episode is that the particular
sequence that behavioral and/or drug and/or holistic
therapies are applied is extremely important. In fact, the outcomes of studies often depend on whether not people start on drug treatment and then follow with cognitive behavioral
treatment or vice versa. We're going to go into all those details and how they relate to
different types of OCD, because it turns out ther
e are indeed different types of
obsessions and compulsions, and the age of onset for
OCD, and so on and so forth. What I can assure you is
by the end of this episode, you'll have a much greater understanding of what OCD is and what it isn't and what obsessive-compulsive
personality disorder is and what it is not. And you'll have a rich array
of different therapy options to explore in yourself or in others that are suffering from OCD. And if neither you or others that you know suffer from OCD or
obsessive-compulsive personality disorder,
the information covered in today's episode will
also provide insight into how the brain and nervous system translate thought into action generally. And also, you're going to learn a lot about goal-directed behavior generally. My hope is that by the end of the episode you'll both understand a
lot about this disease state that we call OCD, you will
have access to information that will allow you to
direct treatments to yourself or others in better ways, an
d that you will gain greater insight into how you function and
how human beings function in general. The Huberman Lab Podcast
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livemomentous.com/huberman. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and
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within the USA, Canada, and in the United Kingdom. Again, that's eightsleep.com/huberman to save $150 at checkout. Let's talk about OCD or
obsessive-compulsive disorder. First of all, as the name suggests, OCD includes thoughts or obsessions and compulsions which are actions. The obsessions and the
compulsions are often linked. In fact, most of the time, the obses
sions and the
compulsions are linked such that the compulsion, the behavior, is designed to relieve the obsession. However, one of the hallmark themes of obsessive-compulsive disorder is that the obsessions are intrusive. People don't want to have them. They don't enjoy having them. They just seem to pop into people's minds and they seem to pop into
their mind recurrently. And the compulsions, unlike
other sorts of behaviors, provide brief relief to the obsession, but then very quickly reinforce
or strengthen the obsession. This is a very key theme to realize about obsessive-compulsive disorder so I'm just going to repeat it again. These two features, first,
the fact that the obsessions are intrusive and recurrent, as well as the fact that the
compulsions, the behaviors, provide, if anything, only
brief relief for the obsessions, but in most cases simply serve to make the obsessions stronger
are the hallmark features of obsessive-compulsive disorder. And it turns out to be very importa
nt to keep these in mind as we go forward, not just because they define
obsessive-compulsive disorder, but they also define
the sorts of treatments that will and will not work for obsessive-compulsive disorder. And then once you understand a little bit about the neural circuitry underlying obsessive-compulsive disorder, which we'll talk about in a few moments, then you will clearly understand why being a quote-unquote,
obsessive person or having obsessive-compulsive personality is not the same a
s OCD. In fact, we can leap ahead a little bit and compare and contrast OCD with obsessive-compulsive
personality disorder along one very particular set of features. Again, I'll go into this
in more detail later, but it's fair to say
that OCD is characterized by these recurrent and
intrusive obsessions. And as I mentioned before,
the fact that those obsessions get stronger as a function of people performing certain behaviors. So unlike an itch that you feel, and then you scratch
it and it feels
better, OCD is more like an itch that
you feel, you scratch it, and the itch intensifies. That contour or that pattern of behaviors and thoughts interacting is very different than obsessive-compulsive
personality disorder, which mainly involves a sense
of delayed gratification that people want and somewhat enjoy because it allows them to function better or more in line with how they would like to show up in the world. So again, OCD has mainly
to do with obsessions that are intrusive and recurren
t, whereas obsessive-compulsive
personality disorder does not have that
intrusive feature to it. People do not mind, or in fact, often invite or like the
particular patterns of thought that lead them to be compulsive
along certain dimensions. So leaving aside obsessive-compulsive personality disorder for the moment, let's focus a bit more on OCD and define how it tends to show up in the world. First of all, OCD is extremely common. In fact, current estimates
are that anywhere from 2.5% to as hig
h as 3 or even 4% of people suffer from true OCD, that is an astonishingly high number. Now, the reason the range is so big, 2.5% all the way up to
3, or maybe even 4%, is that a lot of the features of OCD go unnoticed both in
the clinician's office and simply because people don't report it and don't talk about it. In fact, it is possible to have recurrent and intrusive obsessions and not engage in the sorts of behaviors
that would ever allow people to notice that somebody has OCD. That can be b
ecause some
of the intrusive thoughts don't actually lead to overt behaviors like hand washing or checking that other people would notice. It can also be because people learn to disguise or hide their obsessions and their compulsions out of shame or fear of looking strange
or whatever it might be such that they have these obsessive and intrusive thoughts, and
they do little micro-behaviors like they might tap their
fingers on their thigh as a way to avoid, at
least in their own mind, something c
atastrophic happening. That might seem crazy to you, it might seem bizarre, but
this is the sort of thing that operates in a lot of people. And I really want to emphasize this because the clinical
literature that are out there really point to the fact
that many people have OCD, full blown OCD, and never report it because of the kind of shame and hiding associated with it. Another thing to point out is that OCD is extremely debilitating. I mentioned this a few minutes ago, but OCD is currently
li
sted as number seven in terms of the most
debilitating illnesses, not just mental illnesses or disorders, but all types of illnesses including things like asthma
and cancer, et cetera. So you can imagine with that
standing at number seven, that it is both extremely common and extremely debilitating. And as a consequence, it's now realized that many hours, days,
weeks, months, or even years of work performance or showing up at work of relational interactions really suffer as a consequence of peop
le having OCD. So this is a vital problem
that the scientific and psychiatric and psychological
communities understand. And it's one of the reasons
that I'm doing this podcast. And of course, I received
a ton of interest in OCD because of this incredibly
high incidence of OCD and how debilitating it is. We could go really deep into
why it's so debilitating. I don't want to spend
too much time on that because I think most of
that is pretty obvious, but some of it is not. For instance, one of the
things that makes OCD so debilitating is, of course, the shame that we talked about before. But it's also the fact that
when people are focusing on their obsessions and their compulsions, they're not able to focus on other things. That's simply the way
that the brain works. We're not able to focus on
too many things at once. The other thing is that
OCD takes a lot of time out of people's lives. With recurrent intrusive
thoughts happening at very high frequency, or
even at moderate frequency, peo
ple are spending a lot of
time thinking about this stuff and they're thinking about the behaviors they need to engage in, and
then engaging in the behaviors, which as I mentioned before, just serve to strengthen the compulsions and so they're not actually
doing the other things that make us functional human beings like commuting to work or doing homework or doing work or listening
when people are talking or interacting or sports or working out, all the things that make
for a rich quality life ar
e taken over by OCD in many cases. So while that might be obvious to some, I'm not sure that it's
obvious to everybody just how much time OCD can occupy. Another thing you'll
soon learn is that sadly, a lot of the obsessions
and compulsions in OCD often relate to taboo topics. And that's because the
general categories of OCD fall into three different bins, checking obsessions and compulsions, repetition obsessions and compulsions, and order obsessions and compulsions. The checking ones are somew
hat obvious, checking the stove or checking the locks, which I think we all tend to do. I'm somebody typically
I'll head off to the car to commute to work and I'll think, did I lock the front door, and I'll go back once, but I won't go back twice or 50 times. People with OCD will often
go back 20 or 30 times before they'll actually allow
themselves to drive off. And then it's a real challenge for them to continue to drive off
and discard with the idea that they didn't check the stove or they did
n't check the locks or they didn't check
something else critical. Repetition obsessions and compulsions, obviously can dovetail
with the the checking ones, but those tend to be
things like counting off of a certain number of numbers, like one, two, three,
four, five, six, seven, seven, six, five, four, three, two, one. People perform that repeatedly,
repeatedly, repeatedly, or feel that they have to. I remember years ago
watching a documentary about the band, The Ramones, right? Most people hear
d of The Ramones, right? Jeans, T-shirts, aviator glasses, everyone had to change
their last name to Ramone. They weren't actually all related to one another, by the way. You had to change your
last name to Ramone. The Ramones had one band member who was admittedly and known
to others as having OCD. And during that documentary,
which I forget the name, I think it was called, can't remember, anyway, can't remember, hippocampal lapse there, but in this documentary, the band members describe Joey R
amone as leaving hotels, walking down the stairs to the parking lot, but then having to walk up and down them
seven or eight times, and sometimes getting out of the van again and walking up and down
them seven or eight times and it always had to be a
certain number of times, given a certain number of stairs. This appears, quote-unquote, crazy, but of course, we don't want
to think of this as crazy. This is somebody who very
likely had full blown OCD. Now that particular
example, believe it or no
t, is not all that uncommon. It just so happens that that example entailed certain compulsions and behaviors that were overt and that
other people could see. And you can imagine how
that would prevent somebody from moving about their daily life easily. A lot of people, as I mentioned before, have obsessions and
compulsions that they hide and they do these little micro behaviors, or they'll just count off in their head as opposed to generating
some sort of walking up and downstairs or tapping
or
things of that sort. So we have checking, we have repetition, and then there's order. Order oftentimes is thought of as putting cleanliness or making sure everything is aligned and perfect and orderly. And oftentimes that is the case, but there are other forms of order that people with OCD can focus on in a obsessive and compulsive way. Things like incompleteness, the idea that one can't walk away from something or stop doing something
because something's not right or complete in that picture. I
t could be the way the table is set. It could be the way that
something's written on a page. It could be an email. Again, now we're still talking
about OCD, the disorder. We're not talking about
obsessive-compulsive personality disorder. I'm aware of, well, I'll just be direct, several colleagues of mine
and it's just remarkable, the order in their emails. Every email is perfect,
punctuated, perfect, grammar, perfect,
everything's spaced perfect. Do they have OCD? Well, they might, they might no
t. How would I know unless
they disclose that to me. But they might have obsessive-compulsive personality disorder, or
they just might be able to generate a lot of order and they have a lot of discipline around the way they write,
and the way they present any communication with anybody at all. So if somebody has a OCD
that's in the domain of order, it could be incompleteness
and the constant feeling of something not being completed and a need to complete it. It can also be in terms of symmetry,
that everything be aligned
in symmetric in some way. This could be seen perhaps in young kids. This is one example that
I read in the literature of children that need to
arrange their stuffed animals in exact same order every day and in a particular order to the point where if you were to move
the little stuffed frog over next to the stuffed rabbit, that the child would have
an anxiety reaction to that and feel literally
compelled, driven to fix that maybe even multiple times
over and over again
. We'll talk about OCD in children versus adults in a little bit. And then the other aspect of order, which is a little bit less than intuitive, is this notion of disgust, this idea that something is contaminated. So we often think about OCD
and hand washing behavior in response to people feeling that something is contaminated, a space, a towel, et cetera, or even simply somebody else's hand and so they're unwilling
to shake somebody's hand. You can imagine how these
different bins of obsessions
and compulsions, checking
repetition and order be extremely debilitating
depending on how severe they are and how many
different domains of life they show up in. Because oftentimes in movies and even the way I'm describing it now it sounds as if, okay, well
somebody has to check the locks but they don't have to
also check the stove, or somebody has the need to
count to seven back and forth up to seven and down to seven seven times seven times a day or
something of that sort where they need symm
etry in
very specific domains of life. But it turns out that this recurrent and intrusive aspect of obsessions leads people with OCD to have checking repetition and/or order compulsions everywhere. So whether or not somebody
is at work or in school or trying to engage in sport or trying to engage in relationship or just something simple
like walking down the street, the obsessions are so
intrusive that they show up and they compel people to
do things in that domain independent of whether or not
they happen to be in
one location or another. In other words, the thought patterns and the behaviors take
over the environment as opposed to the environment driving the thought
patterns and behaviors. So it therefore becomes impossible to ever find a room that's clean enough, to find a bed that's made well enough, to find anything that's done well enough to remove the obsession. And I know I've said
it multiple times now, but I'm going to say it many
times throughout this episode in a somewhat o
bsessive,
but I believe justified way that every time that one
engages in the compulsion related to the obsession, the obsession simply becomes stronger. So you can imagine what a powerful and debilitating loop that really is. So let's drill a little bit deeper into how the obsessions and compulsions relate to one another. If we were to draw a line
between the obsessions and the compulsions, that
line could be described as anxiety. Now, we need to define what anxiety is and to be quite honest, m
ost of psychology and science can't agree on exactly what anxiety is. Typically the way we think about fear is that it's a heightened
state of autonomic arousal, so increased heart rate,
increased breathing, sweating, et cetera, in
response to an immediate and present threat or perceived threat. Whereas anxiety, generally speaking in the scientific literature, relates to the same
sorts of thought patterns and somatic bodily responses, heart rate, breathing, et cetera, but without a clear and pre
sent danger being in the environment or right there. So that's the way that we're
going to talk about anxiety now. And anxiety is really
what binds the obsessions and compulsions such
that someone will have an intrusive thought. So for instance, someone
will have the thought that if they turn left on any street, that something bad will happen. Okay, that's an obsession. It's actually not all that uncommon. Now, how bad and what the specificity of that bad thing really is will vary. Some people w
ill think, if I turn left, something generally bad will happen, it just makes me feel anxious, So they always insist on going right. Whereas other people will
think if I turn left, so and so will die, or I will die, or something terrible will happen, I'll get a disease or someone
else will get a disease or I'll be cursing myself or somebody else in some very specific way. This is unfortunately quite
common in people with OCD. So they have this feeling and the feeling can be generally or specific
ally related
to a particular outcome. But beneath that is a feeling of anxiety, a quickening of the heartbeat, a quickening of breathing, a narrowing of one's visual focus. I've talked about this
before in another podcast, the Master Stress, another podcast but if you haven't heard those, let me just briefly describe that when we are in a state of increased so-called autonomic arousal, alertness, stress, et cetera, our visual field literally narrows, the aperture of our
visual field gets smaller
and that's because of the relationship between the autonomic nervous system and your visual system, so
you start seeing the world through sort of soda straw view or through binocular-like view, as opposed to seeing the big picture. Why is that important? Well, it literally sharpens
and narrows your focus toward the very thing that the obsessions and the compulsions are focused on. So the person walking
down the street who sees the opportunity to go left or right will only see the bad decision,
their visual field narrows very tightly along that possibility
of taking a left turn. And I know as I describe this
seems totally irrational, but I want to emphasize
that the person with OCD knows it's irrational. They might feel crazy because
they're having these thoughts, but they know it makes no sense whatsoever that left somehow would
be different than right in terms of outcomes in
this particular case, and yet it feels as if it would. In fact, in some cases it
feels as if they went left, t
hey would have a full blown panic attack. So the idea here is that the
obsessions and compulsions are bound by anxiety, but then by taking a right-hand turn, again, in
this one particular example, by taking a right-hand
turn, there's a very brief, I should mention, very
brief relief of that anxiety at the time of the decision
to go right, not left and there's an additional drop in anxiety while one takes the right-hand turn as opposed to the left-hand turn. And then as I alluded to before, there
's a reinforcement of the compulsion. In other words, by going right, it doesn't create a situation in the brain and psychology of the person
that, oh, you know what, I'm not anxious anymore, left
would've probably been okay. It reinforces the idea that
right made me feel better, or turning right made me feel better, and going left would've
been that much worse. Again, it reinforces the
obsession even further. And again, we could swap out
right turns and left turns with something like hand washi
ng, the feeling that something is contaminated and the need to wash one's hands even though one already washed their hands 20, 30, 50 times prior. And we're actually going
to go back to that example a little bit later when we talk about one particular category of therapies that are very effective
in many people for OCD which are the cognitive
behavioral and exposure therapies. I think some of you have heard of cognitive behavioral
and exposure therapies, but the way they're used to treat OCD is
very much different
than the way they're used to treat other sorts of anxiety disorders and other sorts of disorders generally. So it's fair to say that up
to 70% of people with OCD have some sort of anxiety
or elevated anxiety, either directly related to the OCD or indirectly related to the OCD and it's really hard to tease those apart because OCD can create its own anxiety, as I mentioned before, it can
even increase its own anxiety. And there's also an issue of depression. Having OCD can be v
ery depressing, especially if some of these
OCD thoughts and behaviors start to really impede people's ability to function in life. At work, and school, and relationship, they can start feeling
less optimistic about life. And in fact, some people can
become suicidally depressed. That's how bad OCD can be for us. So we have to be careful when saying that 70% of people with
OCD also have anxiety or X number of people with
OCD are also depressed because we don't know whether or not the depression l
ed the OCD
or the other way around or whether or not they're operating, as we say in science, in parallel. Some of the drug treatments
for OCD and depression and anxiety can tease some of that apart and we'll talk about that, but I think it's fair to say that what binds the obsessions
and compulsions is anxiety, that there's a feeling of, or I should say an
urgent feeling of a need to get rid of the obsession. And the person feels as if the only way they can do that is to engage in a particular
compulsive behavior. Some people are probably wondering if there's a genetic component to OCD and indeed there is, although the nature of
it isn't exactly clear. And oftentimes when
people hear that something has a genetic component, they think it's always directly
inherited from a parent, and that's not always the case. There can be genes that
surface in siblings or genes that surface in children that are not readily apparent in terms of what we call a phenotype. So you have a genotype, the gen
e, and then you have a
phenotype, the way it shows up as a body form or like eye color or how it shows up in terms of a behavior or behavioral pattern. Based on twin studies where researchers have examined identical
twins, fraternal twins, even identical twins that
share the same sack in utero, the what we call monochorionic, so sitting in the same
little bag during pregnancy or in different little bags, you can see different levels of what's called genetic concordance. But if we were to just
so
rt of cut a broad swath through all of the genetic data, it's fair to say that about
40 to 50% of OCD cases have some genetic component, some mutation or some
inherited aspect that's genetic and that one could point to if they got their genome mapped. Now, while that's interesting, I don't think it's terribly
useful for most people. First of all, you can't
really control your genes, at least at this point in history, even though there are things
like epigenetic control and people are very
excite
d about technologies like CRISPR for modifying the genome in humans at some point, most people can't control
their genetics, right? You can't pick who your
parents were as they say. So just know that there
is a genetic component in about half of people
with OCD, but not always. Now as is typical for this podcast, I want to focus on some
of the neural mechanisms and chemical systems in the brain and body that generate
obsessive-compulsive disorder. In fact, if you've watched
this podcast before,
listen to this podcast before, this is always how I structure things. First, we introduce a topic and we explore that topic in detail and really define what
it is and what it isn't. And then it's very
important that we focus on what is known and what is not known about the biological
mechanisms that generate whatever that thing happens
to be, in this case, OCD and obsessive-compulsive
personality disorder. Now I want to emphasize
that even if you don't have a background in biology, I will make t
his information
accessible to you. And I also want to emphasize
that for those of you that are interested in treatments and are anxiously awaiting
the description of things that can help with OCD, I encourage you, if you will, to please try and digest some of the material about
the underlying mechanisms because understanding
even just a little bit of those biological
mechanisms can really help shed light on why particular drug and behavioral treatments and other sorts of treatments
work and don'
t work. This is especially
important in the case of OCD where it turns out that the order and type of treatment can really vary according to individual, and that's something really
special and important about OCD that we really can't say
for a number of the other sorts of disorders that we've described on previous podcasts. So let's take a step back and look at the neural circuitry. What's going on in the brain
and body of people with OCD? Why the intrusive recurrent thoughts? Why the compulsion
s? Why is that whole system bound by anxiety? And in some ways in thinking about that, I want you to keep in mind that the brain has two main functions. The brain's main functions are to take care of all
the housekeeping stuff, make sure digestion works, make sure the heart beats, make sure you keep
breathing no matter what, make sure that you can see, you can hear, you can smell, et cetera, the basic stuff, and then
there's an enormous amount of brain real estate that's designed to allow you to
predict
what's going to happen next, either in the immediate future or in the long-term future. And largely that's done based
on your knowledge of the past. So you also have memory systems. And of course you have
systems in the brain and body that are designed to bind what's happening at the housekeeping level,
like your heart rate, to your anticipation of
what's going to happen next. So if you're thinking about
something very fearful, your body will have one type of reaction. If you're thinkin
g about
something very pleasant and relaxing, your body will
have another type of reaction. So whenever I hear about
the brain-body distinction, I have to just remind everybody that there really is no distinction between brain and body
when you think about it through the nervous system. The nervous system is the brain,
the eyes, the spinal cord, but of course all their connections with all the organs of the body and the connections of
all the organs of the body with the brain, the
spinal cord, e
t cetera. So as I describe these neural circuits, I don't want you to think of them as just things happening in the head, they are certainly happening in the head, in fact, the circuits all
described most in detail do exist within the confines
of your cranial vault, that's nerd speak for skull, but those circuits are
driving particular predictions and therefore particular biases towards particular actions in your body. They're creating a state of readiness or a state of desire to
check or desire
to count or desire to avoid et cetera, et cetera. So what are these circuits? Well, there's been a lot
of wonderful research exploring the neural circuit's underlying obsessive-compulsive disorder and that's mainly been accomplished through a couple of methods. Most of those methods
when applied in humans involve getting some look
into which brain areas are active when people
are having obsessions and when people are
engaging in compulsions. Now that might seem simple to do, but of course your
brain is
housed inside the cranial vault. And in order to look inside it, you have to use things like
magnetic resonance imaging, which is just fancy technology
for looking at blood flow, which relates to activation
of neurons, nerve cells, or things lik PET, P-E-T, imaging, which has nothing to do with the verb pet and has nothing to do with your house pet, has everything to do with
positron emission tomography, which is just another way of seeing which brain areas are active and then you can a
lso
use PET to figure out what sorts of neurochemicals are active, like dopamine, et cetera. Many studies, we can fairly say dozens if not hundreds of studies, have now identified a particular circuit or loop of brain areas
that are interconnected and very active in
obsessive-compulsive disorder. That loop includes the cortex, which is kind of the outer
shell of the human brain. The lumpy stuff, as
it's sometimes appears, if the skull is removed. And it involves an area
called the striatum which
is involved in action selection and holding back action. The striatum is involved
in what's commonly called go and no-go types of behaviors. So every type of behavior
like picking up a pen or a mug of coffee involves
a go type function. It involves generating an action. But every time I resist an action, my nervous system is also doing that using this brain structure, the striatum, which includes, among other
things, the basal ganglia. We've talked about that before. I'm not trying to overload
you with terminology here, but I know some people are
interested in terminology. So you have go behaviors
and you have no-go, resisting of behaviors,
not going toward behavior. The cortex and the striatum
are in this intricate back and forth talk. It's really loops of connections. The cortex doesn't tell
the striatum what to do, the striatum doesn't tell
the cortex what to do. They're in a crosstalk. Like any good relationship, there's a lot of back and forth communication. There's a third eleme
nt in
this cortico-striatal loop as it's called, and that's the thalamus. Now, the thalamus is not a structure I've talked a lot about
before on this podcast, but it's one of my favorite
structures to think about and teach about in neuroanatomy, which I teach back at Stanford and I've taught for many years elsewhere because the thalamus is this incredible egg-like structure in
the center of your brain that has different channels through it. Channels for relaying visual information or auditory in
formation
or touch information from your environment up into your cortex, and as a consequence,
making certain things that are happening to you and around you apparent to you, making you aware of them, making you perceive them
and suppressing others. So for instance, right now, if you're hearing me say this, your thalamus has what are
called auditory nuclei, there's collections of neurons that respond to sound waves that are of course coming
in through your ears, and your thalamus is active in a
way that those particular
regions of your thalamus are allowed, literally permitted
to pass the information coming from your ears
through some other steps but then to your thalamus,
your auditory thalamus, then up to your cortex and you can hear what I'm saying right now. At the same time, your
thalamus is surrounded by a kind of a shell, something called the
thalamic reticular nucleus. Again, you don't have
to remember the names, but this thalamic reticular nucleus, also sometimes called the
r
eticular thalamic nucleus, this is, believe it or not, a
subject of debate in science. There are people that
literally hated each other, probably still hate each other, even though one of them
is dead for decades, because they would argue it
was thalamic reticular nucleus, the other was reticular thalamic nucleus. Anyway, these are scientists, they're people, they tend to debate. but the thalamic reticular nucleus, as I'm going to call it, serves as a sort of gate as to which information
is allo
wed to pass through up to your conscious
experience, and which is not. And that gating mechanism
is strongly regulated by the chemical GABA. GABA is a neurotransmitter
that is inhibitory, as we say, it serves to shut down
or suppress the activity of other neurons. So the thalamic reticular
nucleus is really saying, no, touch information
cannot come in right now. You should not be
thinking about the contact of the back of your legs with the chair that you're sitting on, Andrew, you should be thin
king about
what you're trying to say and what you're hearing
and how your voice sounds and what you see in
front of you, et cetera. Whereas if I'm about to get
an injection from a doctor or I'm in pain, or I'm in pleasure, I'm going to think about
my somatic sensation at the level of touch and I'm probably going to think less about smells in the room, although I might also think
about smells in the room or what I'm seeing and what I'm hearing. We can combine all these
different sensory modalitie
s, but the thalamic reticular nucleus really allows us to funnel, to direct particular categories
of sensory experience into our conscious awareness and suppress other categories
of sensory experience. In addition, the thalamic
reticular nucleus plays a critical role in which thoughts are allowed to pass up to
our conscious perception and which ones are not, so much so that some neuroscientists and indeed some neurophilosophers, if you want call them that, have theorized or philosophized that th
e thalamic reticular nucleus is actually involved in our consciousness. Now, consciousness isn't a topic that I really want to
talk about this episode and it's a very kind of mushy-murky, as we say in science, it's a shmooey term because it doesn't really
have clear definitions so arguments about it often get lost in the fact that people are
arguing about different things. But when I say consciousness, what I mean is conscious awareness. So let's zoom out and
take a look at the circuit that we'v
e got and that we now know based on neuroimaging studies is intimately involved in
generating obsessions and compulsions in OCD. We have a cortex or neocortex, which is involved in
perception and understanding of what's happening. We have the striatum and basal ganglia, which are involved in
generating behaviors, go, and suppressing behaviors, no-go. And we have the thalamus which collects all of our sensory experience in parallel, hearing, touch, smell, et cetera, not so much smell through the
thalamus, I should mention, but the other senses that is. And then that thalamus is encased by the thalamic reticular
nucleus, which serves as a kind of a guard
saying you can pass through and you can pass through,
but you, you, you can't pass through up to conscious understanding and perception. So that loop, this
cortico-striatal-thalamic loop, cortico-striatal-thalamic
loop is the circuit thought to underlie OCD, and dysfunction in that circuit is what's thought to underlie OCD. Now, again, t
his circuit
exists in all of us and it can operate in healthy ways, or it can operate in ways
that make us feel unhealthy or even suffer from full blown OCD. How do we know that this
circuit is involved in OCD? Well there, we can look to
some really interesting studies that involve bringing human
subjects into the laboratory and generating their
obsessions and compulsions and then imaging their brain using any variety of techniques
that we talked about before. What would such an experiment look
like? Well, in order to do
that sort of experiment, first of all, you need people who have OCD and of course you need
control subjects that don't, and you need to be able to reliably evoke the obsessions and the compulsions. Now, it turns out this is
most easily, or I should say most simply done, 'cause it can't be easy for the people with OCD, but this is most straightforward, that's the word I was looking for, most straightforward when
looking at the category of obsessions and compulsions that
relate to order and cleanliness. So what they do typically
is bring subjects into the laboratory who have a obsession about germs and contamination and a compulsion to hand wash, and they give these
people, believe it or not, a sweaty towel that contains the sweat and the odor and the liquid, basically, from
somebody else's hands. In fact, they'll sometimes have someone wipe their own sweat off
the back of their neck and put it on the towel
and then they'll put it in front of the person,
which
as you can imagine for someone with OCD is
incredibly anxiety-provoking and almost always evokes
these obsessions about, ugh, this is really, this is really bad. This is really bad, I need to clean, I need to clean. I need to clean. Now they're doing all this while someone is in a brain scanner or while they're being imaged for positron emission tomography. And then they can also look at the patterns of activation in the brain while the person is doing hand washing. Although sometimes the appara
ti associated with these imaging studies make it hard to do a lot of movement, they can do these sorts of studies. They have done these sorts of studies in many subjects using
different variations of what I just described. And low and behold what lights up? And when I say lights up, what sorts of brain regions are more metabolically
active, more blood flow, more neural activity? Well, it's this particular
cortico-striatal-thalamic loop. In addition to that, some of the drug treatments that are e
ffective in some, and I want to emphasize some individuals, at suppressing obsessions
and or compulsions such as the selective
serotonin reuptake inhibitors or SSRIs, which we'll talk
about in a little bit, when people take those drugs, they see not just a suppression of the obsession and compulsion, but also a suppression of these
particular neural circuits. They become less active. Now I want to emphasize
and telegraph a little bit of what's coming later, these drugs like SSRIs do not
work for
everybody with OCD. And as many of you know, they carry other certain
problems and side effects for many but not all individuals. But nonetheless, what we have now is an observation that this circuit, the cortico-striatal-thalamic loop, is active in OCD. We have a manipulation that
when people take a drug that at least in those individuals is effective in suppressing or eliminating the obsessions and compulsions, there's less activity in this loop. And thanks to some very
good animal model stud
ies, that at least at this point in time, you really couldn't do in humans, although soon that may change, we now know in a causal way that the equivalent circuitry
exists in other animals, such as mice, such as
cats, such as monkeys, and that activation of those particular cortico-striatal-thalamic circuits in animal models can indeed evoke OCD in an individual that prior to that did not have OCD. So I'm just going to
briefly describe one study. This is a now classic study published in the jour
nal Science, one of the three apex journals in 2013. The first author on this paper is Susanne Ahmari, A-H-M-A-R-I. I will provide a link to
this in the show notes. It's a truly landmark paper done in Rene Hen's lab at Columbia University. And the title of the paper is repeated cortico-striatal
stimulation generates, that's the key word here, generates persistent OCD-like behavior. What they did is they took mice, mice do mouse things. They move around, they play with toys, they eat, they pee, t
hey mate, they do various things in their cage, but they also groom. Humans groom, animals with fur groom, Well, you hope most people groom, some people over-groom,
some people under-groom, but most people groom. They'll comb their hair,
they'll clean, et cetera. Those are normal behaviors
that humans engage in. I'm not aware that mice comb their hair, but mice adjust their hair. So they'll kind of pet their hair and they'll do this. They'll sometimes even
do it to each other. We used to have mi
ce in the lab, now we only do human studies, but the mice will groom themselves, and typical, what we call wild type mice, not because they're wild, but because they're typical, will groom themselves at
a particular frequency, but not to the point where
their hair is falling out. Not constantly, they are
grooming some of the time and they're doing other mouse
things other mouse times. So in this particular study, what they did is they
used some technology, which it actually was discussed on a pr
evious episode of
The Huberman Lab Podcast, this is technology that was
developed by a psychiatrist and bioengineer by the
name of Karl Deisseroth, one of my colleagues at
Stanford School of Medicine. This is technology that allows researchers to use the presentation of light to control neural activity
in particular brain areas in a very high fidelity way. You control the activity in
the cortex of the striatum or the thalamus when you
want and how you want. It's really a beautiful technology. In
any event, what they
did in this study is, or I should say what Susan Ahmari and colleagues did in this study was to stimulate the
cortico-striatal circuitry in animals that did not
have any OCD-like behavior. And when they did that, those animals started grooming incessantly to the point where their hair
was falling out or they even, they didn't take the experiments
this far, fortunately, but the animals would have a tendency to almost rub themselves raw in the same way that
somebody who has a
compulsion to hand wash would, sadly,
people will hand wash to the point where their hands are actually bleeding and raw. It's really that bad. I know that's tough imagery to imagine, and you can't even imagine
why someone would self harm in that way, but again,
that's that incredible anxiety relationship between the
compulsion, excuse me, the obsession and the compulsion, and the fact that
engaging in the compulsion simply strengthens the obsession and therefore the anxiety. So that collection
of studies, of data, FMRI, PET scanning in humans, the treatment with SSRIs,
and these experiments where researchers have actively triggered these particular circuits in animal models that previously did not have too much activity in these circuits and then they observe OCD emerging really points squarely to the fact that the cortico-striatal-thalamic loop is likely to be the basis of OCD. Now, of course, other circuits
could also be involved, but the cortico-striatal-thalamic circuit seems to
be the main circuit
generating OCD-like behavior. That's a lot of mechanism. Hopefully it was described in a way that you can digest and understand. And some of you might be
thinking, well, so what? Why does that help me? I mean, I can't reach into my brain and turn off my cortex. I can't reach into my brain
and turn off my thalamus. And indeed, on the one hand, that's true. But as you'll next learn when thinking about the
various behavioral treatments and drug treatments and holistic treatments
for OCD, what you'll notice is that each one taps into a different component of this cortico-striatal-thalamic loop. And by understanding
that, you can start to see why certain treatments
might work at one stage of the illness versus others. You will also start to understand why obsessive-compulsive personality disorder does not have the same
sorts of engagements of these neural loops, and yet relies on other
aspects of brain and body and therefore responds best
to other sorts of treatments. Or
in some cases, people
with obsessive-compulsive personality disorder are
not even seeking treatment as I alluded to before. The point here is that by understanding the underlying mechanism why certain drugs and
behavioral treatments work and don't work will become
immediately apparent and in thinking about
that, in knowing that, you'll be able to make excellent choices, I believe, in terms of what
sorts of treatments you pursue, what sorts of treatments you abandon, and most importantly, the or
der, the sequence that you pursue
and apply those treatments. Before we go any further,
I'd like to give people a little bit of a window into what a diagnosis for OCD would look like. Give you a sense of the sorts of questions that a clinician would ask to determine whether or not somebody has OCD or not. Now, I want to be clear,
I'm not going to do this in an exhaustive way. I wouldn't want anyone to self-diagnose. Although I'm hoping that
by sharing some of this, that some of you might get ins
ight into whether or not you do have obsessions and compulsions that
might qualify for OCD, and perhaps even to seek out help. The most commonly used test of OCD, or for OCD, I should say, is called the Yale-Brown
Obsessive Compulsive Scale. And this is, scientists love acronyms as do the military, and it's the Y-BOCS, the Y-B-O-C-S, the Y-BOCS. So typically someone
will go into the clinic either because a family
member encouraged them to or because they feel
that they're suffering from obsessio
ns and compulsions, and before the clinician would proceed with any kind of direct questions, they would very clearly define what obsessions and compulsions are. And here I'm actually
reading from the Y-BOCS. So quote, "obsessions are
unwelcome and distressing ideas, thoughts, images or impulses that repeatedly enter your mind. They may seem to occur against your will. They may be repugnant to you, you may recognize them as senseless and they may not fit your personality." Then there are compuls
ions. Quote, "Compulsions, on the other hand, are behaviors or acts that
you feel driven to perform although you may recognize
them as senseless or excessive. At times, you may try to resist doing them but this may prove difficult. You may experience anxiety
that does not diminish until the behavior is completed." And as I mentioned before in many cases, immediately after the
behavior has completed, the anxiety doesn't just return,
it indeed can strengthen. Now, there are a tremendous
number of
questions on the Y-BOCS. So I'm just going to highlight a few of the general categories. Typically, the person
will fill out a checklist, so they will designate whether or not currently or in the past they have, for instance, aggressive obsessions, fear that one might harm themselves, fear that one might harm others, fear that they'll steal things, fear that they will act
on unwanted impulses, currently or in the past or both, that's one category. The other one are
contamination obsessions. So c
oncern with dirt or germs, bothered by sticky substances or residues, et cetera, et cetera. So there are a bunch
of different categories that include, for instance,
sexual obsessions, what are called saving obsessions, even moral obsessions, excess concern with right
or wrong or morality, concerned with sacrilege and blasphemy, obsession with need for
symmetry and exactness. Again, all of these
questions being answered as either present in the past or not present in the past, present currently o
r
not present currently. And then the test generally transitions over to questions
about target symptoms. They really try and get people to identify if they have obsessions, what
are their exact obsessions? Now, this turns out to be really important because as we talk about some of the therapies that really work, I'll just give away a little bit of why they work best in certain cases and why they don't work
as well in other cases, it turns out that it
becomes very important for the clinician and
the patient to not just identify the obsessions and the compulsions generally in a kind of a generic or top contour way, but to really encourage
or even force the patient to define very precisely what the biggest, most catastrophic fear is, what the obsession really relates to. That turns out to be very important in disrupting this
cortico-striatal-thalamic loop and getting relief from symptoms one way or the other. So the Yale-Brown Obsessive
Compulsive Scale, this Y-BOCS, again, is very exten
sive, it goes on for dozens of pages actually, and has all these different categories, not so much designed to just pinpoint what people obsess about or what they feel compelled to do, but to also try and identify what is the fear that's driving all this. In the way that we've
set this up thus far, we've been talking about
obsessions and compulsions is kind of existing in a vacuum. You're obsessed about germs and you're compelled to wash your hands, obsessed about germs,
compelled to wash your h
ands. Or obsessed about symmetry, compelled to put right
angles on everything. Or obsessed about counting and therefore counting, et cetera. But beneath that is a cognitive component
that is not at all apparent from someone describing their obsession and from someone describing or
displaying their compulsion. The deeper layer to all
that is what is the fear, exactly, if one were to
not perform the compulsion, meaning what is the fear
that's driving the obsession? So that brings us to a
very powe
rful category of treatments that I
should say does not work in everybody with OCD but works in many people with OCD and really speaks to the
underlying neural circuitry that generates OCD and
how to interrupt it. And that is the treatment of cognitive behavioral therapy and in particular, exposure-based cognitive
behavioral therapy. So we're going to talk about
cognitive behavioral therapy and exposure therapy now, but right at the outset, I want to distinguish the kinds of cognitive behavioral
therapy and exposure therapies that are done for obsessive-compulsive disorder, for the sorts of cognitive
behavioral therapies that are done for other types of mental challenges and disorders because cognitive
behavioral therapy for OCD really has everything to do with identifying the utmost fear. In some sense, we can think of fears as kind of along a hierarchy. An the example earlier of somebody being afraid to turn left and therefore feeling compelled to turn right, you would want to take th
at person and really understand
what do they fear most about turning left? Now they might not be aware of it. They might not be conscious
to what that really is, but if you were to probe
them in a clinical setting, you would eventually get to an answer. That answer could be at first, I don't know, just, it's just bad. I don't know why it's
bad, it makes no sense, but it's just bad. I do not want to go left. I don't know why, I don't know why. But if you were to push
that person a little bit in a
respectful and kind and caring way aimed at their treatment, if you were to push 'em and say, well, what do you mean by bad? If you turn left, you
think the world would end? They might say, no, the
world's not going to end, but you know, someone is
going to die suddenly. I know that sounds crazy, but
somebody's going to die suddenly. This almost sounds like superstition, we'll talk about superstitions later, but indeed it is somewhat superstitious. So for instance, you would
say, who's going to
die? And they'd say, I don't know. And you'd say, no, really
who's going to die? If you think about this,
are you going to die? Is so and so going to die? And very often, very often what you find is that people will start to reveal the underlying obsession at a level of detail that
both to the clinician and to them can be somewhat astonishing even though they've been
living with that detail in their mind for a very long time. Now, how could somebody
start to reveal detail about something that's
existed in their mind for a very long time, but
not known about it, right? Not been aware of it. Now, some of you might think, oh, it's repressed or something. That's not at all what's happening. If you think about the
architecture of OCD, typically, people will have an obsession and then they'll engage in the compulsion as quickly as they can to
relieve that obsession. So in many ways, the disease itself prevents people from ever
getting to the bottom of that trough, ever getting to the point
where they really clearly
articulate to themselves exactly what it is that they fear. But it becomes so essential to articulate exactly what it is that they fear for a somewhat counterintuitive reason. You might think, oh,
the moment they realize exactly what they fear, everything lifts, the circuit turns off
and they just feel better because they realized it. I wish I could tell you that's the case, but it turns out it's the opposite. What the clinician is
actually trying to do is get people to
feel
more anxiety, not less. What they're trying to get them to do is to short circuit, no pun intended, to intervene in their own neural circuit, I should say, with that relief of anxiety, however brief, brought on by engaging in the compulsion
related to the obsession. So, whereas typically someone would feel the obsession with, ugh,
I don't want to turn left 'cause something bad's going to happen, someone's going to die,
and then they turn right, they never get the
option or the opportunity
to really explore what would happen were they to turn left or to
not be able to turn right. By forcing them down the path of inquiry, that leads them to the place
where they very clearly identify the fear, the anxiety, it raises the anxiety in them, and that's actually what
the clinician is after. Cognitive behavioral
therapy and exposure therapy in the context of OCD, most often involves trying to get people to tolerate, not relieve their anxiety. This is extremely important. And I realize ther
e's variation to this depending on the style of
cognitive behavioral therapy, the style of exposure therapy,
but almost across the board, The goal, again, is to get
people to feel the anxiety that normally they are able
to at least partially relieve, however briefly, by
engaging in the compulsion. So if we think back to that circuit of cortico-striatal-thalamic,
what's going on here? Where is CBT intervening? What part of the circuit
is getting interrupted? Well, as you recall, the cortex is inv
olved
in conscious perception. The thalamus and that
thalamic reticular nucleus are involved in the
passage of certain types of experience up to our
conscious perception, not others. And the striatum is involved in this go, no-go type behavior. When OCD is really expressing
itself in its fullness, people feel an anxiety
around a particular thought and they either have a go, for instance, wash hands, or a no-go, do not turn
left type reaction. By having people progressively, in a kind of hierarch
ical way, reveal their precise source of anxiety, their utmost fear in this context, what happens is they feel enormous amounts of autonomic arousal. Now in the context of anxiety treatment or other types of treatments, the goal would be to
teach people to dampen, to lessen their anxiety
through breathing techniques or through visualization techniques or through self-talk or
through social support, any of the number of
things that are well-known to help people self
regulate their own anxiety. He
re, it's the opposite. What they're trying to
get the patient to do is to really feel the
anxiety at its maximum, but then do the exact opposite of whatever the normal compulsion is. So if normally the compulsion
is to wash one's hands, then the idea is to suppress hand washing while being in the experience
of the utmost anxiety. Or in the case of not turning left, the person is expected to or would hopefully be able
to actually turn left, and as you can imagine, that
would evoke tremendous anxi
ety and yet to tolerate that anxiety. Now I want to be very clear, this is not the sort of thing
you want to do on your own. This is not the sort of thing
you want to do for a friend. This is done by trained
licensed psychologists and psychiatrists. But nonetheless, it
really points to the fact that as a anxiety-related disorder, OCD is distinct from
other types of anxiety and anxiety-related disorders, things like PTSD and
panic disorder, et cetera, because the goal again
is to bring the person
right up close to the thing
that they fear the most and then to interrupt the circuit. And now you should be able to know, just intuitively, 'cause you
understand the mechanisms, that the circuit you're trying to disrupt is the pattern of information flow from the thinking part of the brain, the perception part of the brain, which is the cortex, to the striatum. The striatum has these
neurons which are active that essentially are, I
know it sounds a little bit like a discussion about free will,
but they're trying to get some, the person to generate a certain behavior, suppress a certain behavior. And as anxiety ramps up, it's sort of a hydraulic
pressure to do that very thing that they've done for so long and they suffer from so much. We talked about hydraulic
pressure in the context of aggression in the aggression episode, this is very similar. There's a kind of a, now when I say hydraulic pressure, it's not actual hydraulic pressure, it's the confluence of a
lot of different systems
. It's neurochemicals, we'll soon learn, it's hormonal, it's electrical, it's a lot of different
things operating in parallel so we can't point to one
chemical or transmitter. What's happening is the
person is feeling compelled to act, act, act to relieve the anxiety and through a progressive
type of exposure, you don't throw people in the deep end in this kind of therapy right off the bat, you gradually ratchet them toward or move them toward the discussion of exactly what they fear the most an
d then eventually move them toward the interruption of the compulsion as they're feeling this
extremely elevated anxiety, of course, within the context of a supportive clinical setting. But in doing that, what
you are teaching people is that the anxiety can
exist without the need to engage in the compulsion. Now some of this might
sound to people like, oh, this is a lot of kind of fancy psychological neuroscience speak around something that's kind of intuitive. But I think for most people,
this
is not intuitive. And for people with OCD, there's no really other way to put it, the impulse, the
compulsion to avoid anxiety is such a powerful driving force that it should now make sense to you as to why being able to tolerate anxiety and really sit with it
and do the exact opposite of what you're normally compelled to do is going to be the path to treatment. And indeed CBT has been shown
to be enormously effective, again for a large number
of people with OCD, but not all of them. And oftenti
mes it requires that it also be used in concert with
certain drug treatments, which we're going to
talk about in a moment. Next, let's talk about some
of the really unique features of cognitive behavioral
therapy and exposure therapy in the context of OCD
that you often don't see in the use of CBT, that is
cognitive behavioral therapy, for other types of psychiatric
challenges and disorders. The first element is one of stair casing. And I already mentioned this before, but this gradual and progr
essive increase in the anxiety that you're
trying to evoke from the patient, from the person suffering from OCD. That's done in the context of
the office or the laboratory, again, by a trained
and licensed clinician. But then the person leaves, right? They leave the office,
they leave the laboratory. And a very vital component of CBT and exposure
therapy for people with OCD is that they have and perform
what's called homework, is literally what they call. This might be seen in
other sorts of tre
atments but for OCD, homework
is extremely important, because within the context of a laboratory experiment or the clinic, patients often feel so much support that they can tolerate
those heightened levels of anxiety and interrupt
their compulsions. Whereas when they get home, oftentimes the familiarity
of the environment brings 'em to a place
where all of a sudden those obsessions and compulsions start interacting the same way and they have a very hard time
suppressing the behaviors. Why would
that be? Well in neuroscience, we have a phrase, it's called conditioned place preference and conditioned place avoidance. There's some other phrases too but basically it all has to do with a simple thing which is, when you feel something
repeatedly in a given environment, or sometimes even once
within a given environment, you tend to feel that same thing again when you return to that
or similar environments. Okay, So conditioned place blank, or conditioned place that
is simply fancy nerd speak
for the fact that when you're in a place and something good happens, you tend to feel good if
you return to that place or a place like it, or
if something bad happens in a given place, you tend to feel bad when you return to that
place or a place like it. I think that most salient
example that leaps to mind is in, unfortunately, the category of bad, but I had some friends years
ago visit San Francisco. There's been a ongoing, it seems like it's been happening forever, but this is really in the l
ast decade of daytime break-ins and
nighttime break-ins into cars to steal anything from computers to what seems to be like a box of tissues. And there are numerous reasons for this, I don't want to get into, it's not the topic of today's podcast, but I will use this as
an opportunity to say if you're visiting
anywhere in the Bay Area, do not leave anything in your car because the window will get broken into, sometimes in broad daylight. Some good friends of mine
were visiting the Bay Area and I
texted them and said, hey, by the way, when you're
headed to dinner, guys, make sure you bring in all
your luggage and computers however inconvenient that might be. They wrote back, too late,
everything got stolen. So some years ago now, I
think five, six years ago this happened, sadly,
everything got stolen. Most of it could be replaced, but some of it was very
sentimental to them. Every time we talk, every time we consider having a meeting in a particular city, this comes up as I don't want t
o be there, I don't like that city anymore, et cetera. And of course, San
Francisco has some wonderful redeeming features, but it
only takes one bad incident in one location to kind of color the whole picture dark, so to speak. The brain works that way. The brain generalizes, it's
not a very specific organ, again, it's a prediction machine in addition to other things. So in the case of CBT therapy, the reason there's homework
is that when people go home, oftentimes that's when they relapse, if y
ou want to call it that, back into their obsessions
and compulsions. And that location, that conditioned place is where it becomes most
important to challenge the anxiety and to deal with the anxiety, to not try and suppress the anxiety through compulsions or other means. And when I say other means, I
want to highlight something, it will come up again a little
bit later in the podcast, that substance abuse is very
common in people with OCD because of the anxiety component and also because of peo
ple's feelings that they just can't
escape from the thoughts or behavioral patterns that
are so characteristic of OCD. So alcohol abuse or cannabis abuse, or other forms of narcotics abuse are very common in OCD. Later, we'll talk about
whether or not cannabis can or cannot help with OCD. But needless to say, suppressing anxiety is
exactly the wrong direction that one should take if
the goal is to ultimately relieve or eliminate the OCD. So we now have two characteristics
of CBT exposure therapy
that are extremely important for OCD and somewhat unique to
the treatment of OCD and that's the staircasing up
towards the really bad fear, the really severe and
specific articulation and understanding and
feeling of how bad things really would be if someone engaged in a particular behavior or
avoided a particular behavior. Then there's the component of homework given by the clinician for
the person to be able to create a broader set of context in which they can deal with the anxiety, not engag
e in the compulsions. And then a very unique
feature of treatment of OCD that you don't see in many
other psychiatric disorders are home visits. And I find this fascinating. I think that the field of
psychiatry and psychology traditionally doesn't allow
for or invite home visits, but this component of
context, location and context being so vital to the
treatment and relief of OCD has inspired many
psychiatrists and psychologists to get permission to do home visits where they actually go
visit th
eir patients in their native setting,
in their home cages, right? They're not mice, but in
their home-home cages, I'm being facetious here, but people, mice live in cages, at
least in the laboratory, and humans generally live
in houses or elsewhere, so they visit them in their home in order to see how they're interacting and the particular locations that evoke the most anxiety and the least anxiety. Some of the, I don't want
to call them crutches, but some of the tools
that people are using to c
onfront and deal with the
obsessions and compulsions and in particular to try and identify some of the tools and tricks that people are using to try and avoid that heightened anxiety,
because, once again, and I know I'm repeating myself, but I think this is just
so vital and so unique about OCD and the treatment of OCD, the critical need for the
patient to be able to tolerate extremely elevated levels
of anxiety is so crucial. So if people are avoiding
certain rooms in the house, or if people ar
e avoiding certain foods or certain locations in the kitchen, the clinician can start to identify that by mere observation. And I should mention here that patients are not always aware of
how they're interacting with their home environment. Some of these patterns are
so deeply ingrained in people that they don't even realize that they're constantly turning to the left, or they don't even realize that they're only washing their
hands on one side of the sink. And so the clinician,
by visiting the
home, can start to interrogate
a bit in a polite way, in a friendly, in a supportive way as to, do you ever think
about why you always flip the faucet to the left or flip the faucet to
the right, et cetera. Now, we all do a lot of
things that are habitual. We all do things that are somewhat regular from day to day. In fact, I would invite
you to ask yourself, do you always put your
toothbrush in the same location? Do you always cap the toothbrush before or after you use it? What sorts of things
do you- You wipe the little threading
on the toothpaste or not? I'm somebody, I confess that I have, well, I have about 3,500 pet peeves, but one of my pet peeves is toothpaste kind of on the
thread of the toothpaste. It really bothers me, I don't know why, almost as much as trying
to wipe it off bothers me, which creates a certain challenge. And if I talk about this any further, then I think I would qualify for obsessive-compulsive
personality disorder. But I have to say, I don't experience a t
on of anxiety about it. It doesn't govern my life. In fact, I realize that right now there are tubes of toothpaste that have toothpaste along the thread everywhere in the world and it doesn't really bother me. I can still sit here and
provide some information about OCD to you. It's not intrusive, at
least not to my awareness. So by the home visit, the therapist can really start to explore through direct questioning
and can allow the patient to explore through direct
questioning of themselves the
things that they might be conscious of and the things that they
might not be conscious of that would qualify for OCD. So I'd like to just briefly
summarize the key elements of cognitive behavioral
therapy and exposure therapy and how they can be combined
with drug treatments that are very effective. Much of what I'm going to talk about next relates to the data
and indeed the practice of an incredible research
scientist and clinician. So this is Helen Blair Simpson, or I should say Dr. Helen Bla
ir Simpson, because she is indeed an MD medical doctor and a PhD research scientist at Columbia University School of Medicine. And one of the world's foremost experts, if not the expert, I would
put her in a category of maybe just one to three people who is most knowledgeable about
the mechanisms of OCD, is actively researching OCD in humans, trying to find new treatments, trying to unveil new mechanisms and expand on our current
understanding and who also treats OCD quite actively in her own cl
inic. Dr. Simpson gave a beautiful presentation which she summarized
some of the core elements of CBT and exposure therapy for the treatment of
obsessive-compulsive disorders. She describes that the key
procedures are exposures, of course, done in person and with the actual thing that evokes the obsessions and compulsions. So this could be the sweaty
towel as described earlier, or could be any number of
different triggers done with the patient in real time, so in vivo, as we say. And it could al
so be
things that are imaginal, sitting somebody down in a chair, in an office and saying, okay, I want you to imagine the thing that triggers the intrusive thought, or let's just focus on the
intrusive thought as it arises, and then to explore and expose the patient to their obsessions and
compulsions that way. So it can be real, or it can be imaginal. And the goal, of course, then is to gradually and progressively increase the level of anxiety, but then to intervene in
so-called ritual prevent
ion to prevent the person from
engaging in the compulsion. The goals, again I'm paraphrasing here, are to, as she states, disconfirm fears and challenge the beliefs
about the obsessions and compulsions, to
intervene in the thoughts and the behaviors, and to break the habit of ritualizing and avoiding. Now, how is this typically done? What are the nuts and
bolts of this procedure? Typically, this is done
through two planning sessions with the patient. So describing to the
patient what will happen
and when it will happen
and how long it will happen so that they're not just thrown into this out of the blue. And then 15 exposure sessions
done twice a week or more. So the one thing to really understand about cognitive behavioral therapy is that it can take some period of time, several or more weeks, as
many as 10 or 12 weeks. However, as you'll soon learn, many of the drug treatments
that are effective in treating OCD either
alone or in combination with behavioral therapies
also can take 8,
10, 12 weeks or longer, and many of
those never work at all. So even though 10 to 12 weeks seems like a long period of time, it's actually a pretty standard. If you'd like to see
more complete description of the protocols for
cognitive behavioral therapy and exposure therapy for OCD, I'll provide links to two papers, Kozak and Foa, F-O-A, which is published in 1997, which might seem like a long time ago, but nonetheless, that the
protocols are still very useful. And then the second paper
is by
that last author, FOA et al in 2012 and we'll provide links to both of those. In addition, Dr. Blair Simpson and others have explored what are the best treatments for patients with OCD by comparing cognitive behavioral
therapy alone, placebo, so essentially no intervention or something that takes an
equivalent amount of time but is not thought to be
effective in treatment. As well as selective
serotonin reuptake inhibitors. So what is an SSRI? An SSRI is a drug that
prevents the re-uptake of ser
otonin at the synapse. What are synapses? They're the little spaces between neurons where neurons communicate with one another by vomiting little bits of
chemical into the space, the synapse, and then those
chemicals either evoke or suppress the electrical activity of the next neuron across the synapse. And in this case, the neurotransmitter, the chemical that we're
referring to is serotonin. SSRI, selective serotonin
reuptake inhibitors prevent the reuptake of
the chemical that's left, in this
case, the serotonin
that's left in the synapse. After that, I call it
vomiting to be dramatic, but it's not actually vomiting, the extrusion of the
chemical into the synapse. And as a consequence,
there's more serotonin around to have more of an effect over time, the net effect being more
serotonergic transmission, more serotonin overall. So not more serotonin being made, more serotonin being available for use, that's what an SSRI does. So they compared cognitive
behavioral therapy, SSRIs, they
also had the placebo group and they had cognitive behavioral therapy plus the selective serotonin
reuptake inhibitor. This was a 12-week study
done as described before, two times a week over
the course of 12 weeks. First of all, the most
important thing, of course, placebo did nothing. It did not relieve the OCD
to any significant degree. How did they know that? They gave them the Y-BOCS test that we talked about
before, the Yale-Brown test with all those questions
of which I read a few. So the
OCD severity that one has to have on the Y-BOCS is measured
in terms of an index that goes from here from
8 all the way up to 28, that shouldn't mean anything. So that number eight is
kind of meaningless here. It's in terms of an index
that's only meaningful for the Y-BOCS, but if
somebody has a threshold of 16 or higher, it means
that they're still having somewhat debilitating symptoms or very debilitating symptoms. Placebo did not reduce the
obsessions or compulsions to any significant degree.
However, and I think quite excitingly, cognitive behavioral
therapy had a dramatic effect in reducing the
obsessions and compulsions such that by four weeks, that
score that, in this case, ranged from 8 to 28, dropped all the way from
25 down to about 11. So it's a huge drop in the
severity of the symptoms. Now, what's really interesting is that when you look
at the effects of SSRIs in the treatment of OCD symptoms, they had a significant effect
in reducing the symptoms of OCD that showed up fi
rst at four weeks, and then continued to eight weeks. In fact, there was a progressive
and further reduction in OCD symptoms from the
four to eight week period. Again, these are the people
just taking the SSRI, and then it sort of
flattened out a little bit, such that by 12 weeks, there was still a significant
reduction in OCD symptoms for people taking SSRIs
as compared to placebo. But the severity of their symptoms was still much greater than those receiving cognitive
behavioral therapy alone.
So at least in this study, and I should tell you which study it is, this is Foa, Liebowitz et al 2005 in the American Journal of Psychiatry, we'll also provide a link to this so you can peruse the data if you like. But at least in this study, cognitive behavioral therapy
was the most effective, selective serotonin reuptake
inhibitors, less effective. So what happens when you combine them? Well, they explored that as well, and the combination of
cognitive behavioral therapy and the SSRIs togethe
r did not lead to any further
decrease in OCD symptoms. This points to the idea that
cognitive behavioral therapy is the most effective treatment. And again, when I say
cognitive behavioral therapy, now I'm still referring
to cognitive behavioral, slash, exposure therapy done in the way that I detailed before, twice a week for 12 weeks or more. So all of the data, at
least in this study, point to the fact that
cognitive behavioral therapy is really effective
and the most effective. Does it allev
iate OCD
symptoms for everybody? No. Is it very time consuming? Yes. Twice a week for two sessions
or more of 15 minutes, sometimes in the office,
plus there's homework, plus, in an ideal case,
there's also home visits from the psychiatrist or psychologist, that's a lot of investment,
a lot of time investment, to say nothing of the
potential financial investment. Now, Dr. Blair Simpson has
given some beautiful talks where she describes these data and also emphasizes the fact that despite the dem
onstrated power of cognitive behavioral therapy
for the treatment of OCD, most people are given drug treatments simply because of the availability
of those drug treatments. Now, when I say most people, I want to emphasize that I'm referring to most people who
actually go seek treatment because a really
important thing to realize is that most people with OCD do not actually go seek
evidence-based treatment. I want to repeat that,
most people with OCD do not seek evidence-based treatment, which is
a tragic thing. One of the motivations for
doing this podcast episode is to try and encourage people who think they may have
persistent obsessions and compulsions to seek treatment, but most people don't
for a variety of reasons we spelled out earlier, shame, et cetera. Of those that do, the first line of attack is typically a prescription,
most often an SSRI, although not always just SSRIs because soon we'll talk
about the somewhat common use of also prescribing a
low dose of a neuroleptic or
an antipsychotic, not always but often. So the important thing to understand here is that excellent
researchers like Dr. Simpson understand that while there are treatments that we could say are best or are ideal based on the data, that
doesn't necessarily mean that's what's being deployed most often in the general public. As a consequence, Dr. Simpson and others have explored in a very practical way whether or not it matters if somebody is getting SSRI treatment and is experiencing that
reductio
n in OCD symptoms that as you may recall, is more than what they would experience
with placebo alone, but not as dramatic a
reduction in OCD symptoms as they would get with
cognitive behavioral therapy. And as I mentioned before,
there was this exploration of combining drug treatment with cognitive behavioral
therapy from the outset, but they also quite impressively explored what happens when people
who are already taking SSRIs initiate cognitive behavioral therapy. This is a really wonderful th
ing that they've done this
because in doing that, first of all, they're acknowledging that there are many people out
there who have sought treatment and are getting some
relief from those SSRIs, but it perhaps is not as much
relief as they could get. And they are actively
acknowledging that many people are getting these drug treatments first. In fact, most often people are getting these drug treatments first. So what happens when you add in cognitive behavioral therapy? Well, the good news is wh
en you add cognitive behavioral therapy to someone who's already taking SSRIs, that further improves their symptoms. Now that's different than the results that I described before from the same laboratory in fact, that if you combine
cognitive behavioral therapy with SSRIs from the outset, there's no additional benefit of SSRI. However, as I just described, if someone is already taking an SSRI and they're experiencing a
reduction in their OCD symptoms, by adding in cognitive behavioral therapy, t
here is a further reduction
in the symptoms of OCD. This is very important. So for those of you that
have sought treatment and you're taking a SSRI, or if you're thinking about treatment and you're prescribed an SSRI, the ideal scenario really would be to combine the drug treatment with cognitive behavioral therapy, or in some cases, maybe cognitive
behavioral therapy alone, although that's a decision
that you really have to make with the close advice and oversight of
a licensed physician, becau
se, of course, these
are prescription drugs. And anytime you're going to add or remove a prescription drug or change dosage, you really want to do that
in close discussion with and on the advice of your physician. I don't just say that to protect me, I say that to protect you 'cause it's just the right thing to do. So again, cognitive behavioral therapy is extremely powerful. Drug treatments seem less powerful though. If you're already on a drug treatment, adding cognitive behavioral
therapy can
really help. So I've been talking about SSRIs and described a little
bit about how they work at a kind of superficial level of keeping more serotonin in the synapse so that more serotonin can be in action as opposed to gobbled
back up by those neurons. I should just mention what some of the selective serotonin
reuptake inhibitors are. So things like clomipramine, which is not entirely selective, I should say that that one generally falls into a category of less selective. So it can impair or ca
n enhance some of
the other neurotransmitter or neuromodulator systems
like epinephrine, et cetera. The selective serotonin
reuptake inhibitors are, at least the classic ones
are, fluoxetine, Prozac, fluvoxamine, Luvox,
paroxetine, sertraline, citalopram, et cetera, et cetera. There are about six or classic SSRIs, some of them like citalopram are used in children and are available in pediatric doses. Some like Prozac may or may
not be used in children. The details of which SSRIs, et cetera, is a
very extensive
literature and discussion. And I think it's safe to say that which drugs to use and which dosage and whether or not to continue, excuse me, the same dosage over time depends a lot on the individual variation
that people express and the responses that they have. All of these drugs, in
fact, I think we can say all drugs have side effects. The question is how detrimental
those side effects are to daily life. The SSRIs are well known to
have effects on appetite. In some cases, they a
bolish appetite. In some cases, they just
reduce it a little bit. In some cases, they increase appetite. Really is highly individual. They can have effects on libido. For instance, they can reduce sex drive, sometimes in a dose dependent way, sometimes in a way that's
more like a step function where people are fine at
say 5 or 10 milligrams, but then they get to 15 milligrams and there's a cliff for their libido. That can happen, it really depends. Please don't take those
dosages as exact values
'cause this is going to depend on what they're being used for,
depression or anxiety or OCD, and it's also going to depend
on the drug, et cetera. I just threw out those numbers as a way to illustrate what a
kind of a step function would look like. It's not gradual, it's
immediate at a given dose is what that means. The other thing is that
some of these drugs will have transient effects. So side effects that show
up and then disappear or sadly people will
sometimes take these drugs for a while
and then side
effects will surface later that weren't there previously depending on life factors,
nutrition factors. So it's a very complicated
landscape overall. And that's why it's really
important to explore any kind of drug treatment,
SSRI or otherwise, really in close communication
with a psychiatrist who really understands
the pharmacokinetics and has a lot of patient history and experience with them. So what I'm about to tell you next is most certainly going
to come as a big surprise, whi
ch is that despite the fact that the selective serotonin
reuptake inhibitors can be effective in reducing
the symptoms of OCD, at least somewhat, and certainly more than placebo, there is very little, if any evidence, that the serotonin system
is disrupted in OCD. And I have to point out that this is a somewhat consistent theme
in the field of psychiatry, that is a given drug can be very effective or even partially effective
in reducing symptoms or in changing the overall landscape of a psychiat
ric disorder or illness, and yet there is very little, if any evidence, that
that particular system is what's causal for OCD, or anxiety, or depression, et cetera. This is just the landscape
that we're living in in terms of our understanding of the brain and psychiatry and the ways
of treating brain disorders. So as a consequence,
there are a huge number of academic reviews that
clinicians and research scientists have generated and read and share. One of the more, I think, thorough ones in recen
t years was published in 2021. I'll provide a link to this. This is by an excellent,
truly excellent researcher from Yale university School of Medicine, I should say not just a researcher but a clinician scientist,
again, an MD-PhD. This is Christopher Pittenger And the title of the review is Pharmacotherapeutic Strategies and New Targets in OCD. And again, we'll provide a link to it. This is a just gorgeous review describing, as I just told you, that
the serotonin system isn't really disrupted
in OCD and yet SSRIs can be very effective. The review goes on to explore
even what sorts of receptors for serotonin might be involved. If it's in fact the case that serotonin is a culprit in the
creation of OCD symptoms. Talk about the serotonin 2A receptor and the serotonin 1A receptor. Why am I mentioning all that detail? If in fact it's not clear, serotonin is involved because I'll just tell you right now, there is currently a lot of interest in whether or not some
of the psychedelics, in pa
rticular psilocybin, can be effective in the treatment of OCD. Psilocybin has been shown
in various clinical trials in particular the clinical trials done at Johns Hopkins School of Medicine by Matthew Johnson and others. Matthew was on The Huberman Lab Podcast. He's been on the Tim Ferris podcast. He's been on the Lex Fridman podcast. He's a world class researcher on the use of psychedelics for depression and other psychiatric challenges. And their psilocybin treatment has been seen, at least i
n those trials, to be very effective in the treatment of certain kinds of major depression. Currently the exploration of psilocybin for the treatment of OCD has not yielded similar results, although the studies are ongoing. Again, has not yielded
similar effectiveness, but the studies are ongoing And the serotonin 2A receptor and the serotonin 1A receptors are primary targets for
the drug psilocybin. So I figured there were
going to be some questions about whether or not
psychedelics help with O
CD, thus far it's inconclusive. If any of you have been
part of clinical trials or have knowledge or intuition
about this relationship or potential relationship, I should say, between psilocybin and other psychedelics in OCD, please put them
in the comment section. We'd love to love to hear from you. One thing I should point out is that even though serotonin has not been directly implicated in OCD, serotonin and the general
systems of serotonin, the circuits in the brain
that carry serotonin and
depend on it have been shown to impact cognitive
flexibility and inflexibility, which are kind of hallmark themes of OCD. So in animals that have
their serotonin depleted or in humans that have very
low levels of serotonin, you can see evidence of
cognitive inflexibility, challenges in tasks, switching challenges and switching the rules by
which one performs a game, challenges in any kind of
cognitive domain switching. And so that does indirectly implicate serotonin in some of the aspects of OC
D. Again, when one starts to explore the different transmitter systems that have been explored in
animal models and in humans, it's a vast, vast landscape, but serotonergic drugs do seem to be the most effective drugs in treating OCD despite the fact, again, despite the fact that there's no direct evidence that serotonin systems
are the problem in OCD. If you recall the
cortico-striatal-thalamic loop that is so central to the etiology, the presence and the
patterns of symptoms in OCD, of course,
serotonin is
impacting that system. Serotonin is impacting just
about every system in the brain, but there's no evidence that tinkering with serotonin levels, specifically in that network, is what's leading to
the improvements in OCD. However, if people go into a FMRI scanner and those people have OCD and they evoke the
obsessions and compulsions, you see activity in that
cortico-striatal-thalamic loop. Treatments like SSRIs that
reduce the symptoms of OCD equate to a situation where
there is l
ess activity in that loop. And I should point out
cognitive behavioral therapy, which we have no reason to believe only taps into the serotonin system, I think it would be extreme stretch, it would be false actually to say that that cognitive
behavioral therapy taps only into the serotonin system, clearly it's going to affect
a huge number of circuits in neurochemical systems. Well, people who do
cognitive behavioral therapy and find some relief for OCD, they also show reductions in those cortic
o-striatal-thalamic loops. So basically we have a situation where we have a behavioral
therapy that works, in many people, not all, and we have a pretty good understanding of about why it works. It increases anxiety tolerance, and interference with pattern execution, getting people to not engage in the same sorts of behaviors that are detrimental to them. And we have drug treatments that work at least to some degree, but we don't know how they work or where they work in the brain. One of the thi
ngs that really unifies the behavioral treatments
and the drug treatments is that they take some period of time. Some relief from symptoms seems to show up around four weeks and
certainly by eight weeks for both cognitive behavioral
therapy and the SSRIs, but it's really at the 10 to 12 week stage when someone's been
doing these twice a week, cognitive behavioral sessions, where they've been taking
a SSRI for 10 to 12 weeks, that the really significant reduction in OCD symptoms starts to really
show up. Now, up until now, I've
been talking about the fact that people are getting
relief from these treatments, but sadly, in the case of OCD, there is a significant population that simply does not respond to CBT or to SSRIs, or to their combination, which is why psychiatrists
also explore the combination of SSRIs and neuroleptics or drugs that tap into the
so-called dopamine system or the glutamate system. These are other neurotransmitters
and neuromodulators that impact different
circuits i
n the brain. And just to really remind you what neurotransmitters
and neuromodulators do, because this is important
to contextualize all this, neurotransmitters are
typically involved in the rapid communication between neurons. And the two most common
neurotransmitters for that are the neurotransmitter glutamate, which we say is excitatory, meaning when it's
released into the synapse, it causes the next neuron to
be more active, or active, and GABA which is a neurotransmitter that is inhibitory,
meaning when it's released into the synapse, typically, not always, but typically, that GABA
is going to encourage the next neuron to be
less electrically active or even silence its activity. The neuromodulators, by contrast, So not neurotransmitters,
but neuromodulators like dopamine, serotonin, epinephrine, and acetylcholine and others operate a little bit differently. They tend to act a
little bit more broadly. They can act within the synapse, but they can also change
the general patterns of
activity in the brain, making certain circuits more likely to be active and other circuits
less likely to be active. So when we say dopamine does X or dopamine does Y, or serotonin does X or serotonin does Y, they don't really do one thing, they change the sort of overall tonality. They make it more likely or less likely that certain circuits will be active. You can think of them as
kind of activating playlists or genres of activity in the brain, rather than being involved
in the specific commu
nication or specific songs, if you will, in this analogy, or discussions
between particular neurons. So when we hear that
SSRIs increase serotonin and reduce the symptoms of OCD, or a neuroleptic reduces
the amount of dopamine and makes people feel calmer for instance, or can remove some stereotype,
repetitive motor behavior, which they can either generate or reduce motor behavior it turns out. So when I say that, what I'm referring to is the fact that these neuromodulators are kind of turning u
p the
volume on certain circuits and turning down the
volume on other circuits. I say that because if
you are going to explore drug treatments again
with a licensed physician, if you're going to explore
drug treatments for OCD, and in particular, if you
are not getting results from SSRIs, or you're not getting results from cognitive behavioral therapy or the side effect profiles of the drugs that you're taking for OCD are causing problems that
you don't want to take them, well, then it's importa
nt to understand that anytime you take one of these drugs, they're not acting specifically on the cortico-striatal-thalamic circuit. That would be wonderful. That's the future of psychiatry, but as now, when you take a drug, it acts systemically. So it's impacting serotonin in your gut. It's also impacting serotonin
in other areas of the brain, hence the effects on things
like digestion or libido or any number of different things that serotonin is involved in. Likewise, if you take a
neuroleptic
like haloperidol or something that reduces
dopamine transmission, well, then it's going to
have some motor effects 'cause dopamine is
involved in the generation of motor sequences and
smooth limb movement. That's why people with Parkinson's who don't have much dopamine
will get a resting tremor, have a hard time
generating smooth movement. And so the side effects
start to make sense, given the huge number of
different neural circuits that these different
neuromodulators are involved in. I don't
say that to be discouraging, I say that to encourage patients and careful systematic exploration of different drug treatments for OCD always again with the careful and close guidance and oversight of a psychiatrist because psychiatrists really understand which side effect profiles make it likely that you can or cannot or will never, or maybe someday will be
able to take a given drug at a given dose. They're the ones that
really have that knowledge. This is not the sort
of thing that you want to
cowboy and go try
and figure out yourself. Now, I also want to acknowledge that there are other
forms of drug treatments. We touched on psilocybin briefly, but there are other
forms of drug treatments that have been explored for OCD. Earlier, we talked a
little bit about cannabis. Why would cannabis be a
place of exploration at all? Well, first of all, a number of people try
and self medicate for OCD. There is some clinical evidence, I'm not talking about recreational use, I'm talking about cli
nical evidence that cannabis can reduce anxiety. Now earlier we were talking about not reducing anxiety, but
learning anxiety tolerance in order to deal with and treat OCD in the context of cognitive
behavioral therapies. That doesn't necessarily rule out cannabis as a candidate for the treatment of OCD. And in fact, this has been explored. A study from Dr. Blair Simpson
herself looked at this. This was a fairly small scale study. So first of all, I'll give you the title. And again, we'll provid
e a link. This is entitled, Acute
effects of cannabinoids on symptoms of
obsessive-compulsive disorder: A human laboratory study. very briefly, this was 14 adults with OCD. They had prior experience with cannabis. This was randomized, placebo-controlled. The cannabis was smoked,
they had different varietals, as they're called. They had a placebo. So this is basically a condition
in which certain subjects consumed a cigarette that had 0% THC, others had 7% THC,
other groups that is, or some had 0
.4% CBD and THC. So they looked at CBD. I know a lot of people out
there are interested in CBD. This is one of the few
studies I could find where they explored different percentages of THC and CBD in these cannabis or marijuana
cigarettes basically. The total amount that they consumed, I believe, was 800 milligrams. These, again, are not suggestions. These are just simply
reporting what's in this study. You can, again, I'll provide a link. They looked at OCD symptoms, ratings. They looked at car
diovascular effects. They had a large number
of different things that they explored. And I should say this
study was done in 2020, and it was the first
placebo-controlled investigation of cannabis in adults with
obsessive-compulsive disorder. Pretty interesting. And I'm just reading from
their conclusions here. The data suggests that smoked cannabis, whether containing primarily THC or CBD, remember they looked at
different concentrations of those, has little acute impact, meaning immediate impa
ct on OCD symptoms and yield smaller reductions in anxiety compared to placebo. So they did not see a, when
I say a positive effect, I mean a ameliorative effect, an effect in reducing symptoms of OCD from cannabis or CBD, which, it's unfortunate. I think it's unfortunate anytime
a treatment doesn't work. But nonetheless, those are the data, I'm sure there are going
to be other studies. I'm sure there are also going to be people in the YouTube comments section saying that cannabis and CBD
helps
their OCD symptoms, at least I anticipate there probably will. Almost everything I say here, somebody will contradict it with something from their experience, which
I encourage, by the way. I want to hear about your
experience with certain things even if it's not from randomized
placebo-controlled studies, I still find it very interesting to know what people are doing
and what they're experiencing. I think that's one of the
better uses of social media comment sections, is to be
able to share som
e of that, not in an advice-giving
way or prescriptive way, but simply as a way to share and encourage different types of exploration. There are other sorts of drug treatments that are gaining popularity for OCD, at least in the research realm. One treatment that is a legal, L-E-G-A-L. Sometimes when I say legal, sometimes people think I say
illegal, but that is legal, at least by prescription in
the United States, is ketamine. The actions of ketamine
are somewhat complex although we know, for i
nstance, that ketamine acts on
the glutamate system, it tends to disrupt the transmission or the relationship, I should say, between glutamate, not glutamine, not the amino acid, but
glutamate, the neurotransmitter, and the so-called NMDA, the
N-methyl-D-aspartate receptor, which is a receptor that's very special in the nervous system
because when glutamate binds to the NMDA receptor, it tends to offer the opportunity for
that particular synapse to get stronger, so-called neuroplasticity and ket
amine is a,
essentially, an antagonist, although it works through
a complicated mechanism, it tends to block that binding of glutamate to the NMDA receptor or the effectiveness of that. Ketamine therapy is now
being used quite extensively for the treatment of
trauma and for depression. It leads to a dissociative state. It's a so-called dissociative analgesic in the variety of ways
in which that happens. We did an episode on depression. We're going to do another entire
episode all about ketamine
describing the networks that
ketamine impacts, et cetera. Ketamine therapies are
being explored for OCD. As of now, the data
look somewhat promising, but there's still a lot more
work that needs to be done. My read of the data are that the more extensive clinical trials have not happened yet. The smaller studies that have happened revealed that some
patients do get some relief from ketamine therapy for OCD, but there was nothing
overwhelmingly pointing to the fact that ketamine is a magic
bullet
for OCD treatment. So cannabis, CBD, at least now, even though it's one smaller study, there's no real evidence that it can alleviate OCD symptoms. If there are new studies published soon, I'll be sure to update you. And if you see those studies, please send them to me. Ketamine therapy, the jury is still out, psilocybin, The jury is still out. These are early days. Another treatment that's
becoming somewhat common, or at least people are
commonly excited about is transcranial magnetic stimulat
ion. So this is the use of a magnetic coil. This is completely noninvasive, placed on one portion of the skull, and one can direct magnetic energy toward particular
areas of the brain to either suppress, or nowadays, you can also activate
particular brain regions. There are some interesting data showing that if TMS is applied to areas of the brain involved in the generation of motor action, so the so-called motor areas, or supplementary motor
areas as they're called, while people think about
or
have intrusive thoughts, we know that the TMS coil can interrupt the motor behaviors, the
compulsive behaviors, and at least in a small cohort of studies and a small number of
patients within those studies, this has been shown to be effective, not just while the coil
is on the head, of course, but after the study has been performed or the treatment's been performed in reducing OCD symptoms
by disrupting the tendency for the compulsive behavior
to be so automatic. One of the key features of
obses
sive-compulsive disorder is that, especially if it's
been around for a while, the person's been dealing
with it for a while, there isn't a pattern in
which the person thinks, oh, I have this contamination fear, or I need symmetry, or
I'm kind of obsessed to count to the number seven. And then they pause and they go, ooh, and then they do it. No, typically there's a very close pairing of the obsession
and the compulsion in time so that somebody's
walking down the street, thinking one, two, three,
four, five, six, seven, one, two, three, four,
five, six seven, seven... and then they're doing this in such rapid succession because the obsessions
are coming up so quickly. Thoughts can be generated very quickly. And then they're
generating the compulsions as a way to beat down or to try and suppress that anxiety and then it comes right back up again at even stronger as I described earlier. So transcranial magnetic stimulation seems to intervene in these
various fast processes. Right now, I d
on't think it's fair to say that TMS is a magic bullet either. I think there's a lot
of excitement about TMS and in particular, I really want to nail this point home, in particular, there's excitement about the combination of TMS
with drug treatments, or the combination of TMS with
cognitive behavioral therapy. And this is a really important point, not just for sake of discussion about obsessive-compulsive disorder, but also depression, ADHD, schizophrenia, any number of different
psychiatric ch
allenges and disorders in most cases
are going to respond best to a combination of behavioral treatment that's ongoing that
occurs in the laboratory and clinical setting, but also in the home setting
where there's homework, maybe even home visits. Drug treatments, often, not always, are a terrific augment to those cognitive behavioral therapies or other behavioral therapies. And then now we are living in the age of brain-machine interface. You have companies like Neuralink that I think it's fair
to say are going to enter the brain machine-interface world first through the treatment
of certain syndromes, movement syndromes or
psychiatric syndromes probably before they
start putting electrodes into the brain to
stimulate enhanced memory or enhanced cognition, who knows, I don't know exactly what they're doing behind the walls of Neuralink. But I have to imagine, in fact, I would wager maybe not both arms, but I'll wager my left arm that the first set of
FDA approved technologies to come
out of companies like Neuralink are going to be those for
the treatment of things like Parkinson's and movement disorders and cognitive disorders, rather than, shall we say, kind of recreational cognitive enhancement
or things of that sort. So transcranial magnetic
stimulation is noninvasive. It doesn't involve going
down below the skull, can have some effect,
but most laboratories that I'm aware of at
Stanford and elsewhere that are exploring TMS for things like OCD and other types of psychiatr
ic challenges are using TMS in combination with drug therapies, are using, in some cases, for instance, a laboratory at Stanford, hope
to get 'em on the podcast, a psychiatrist, Nolan Williams, is exploring TMS in combination with psychedelic therapies, not
necessarily at the same time, but nonetheless combining them or exploring how they
impact brain circuitry. So if you have OCD, should
you run out and get TMS, or should you try ketamine therapy, of course, with a licensed physician? I think i
t's too early to say yes. I think the answer is
we need to wait and see. I think cognitive behavioral
therapy, the SSRIs, and some other drug
treatments like neuroleptics combined with SSRIs and
cognitive behavioral therapy are where the real bulk of the data are. I want to make one additional
point about cannabis CBD as it relates to
obsessive-compulsive disorder. To me, it's not at all surprising that cannabis CBD did not
improve symptoms of OCD. Because in my discussion
with Dr. Paul Conti a
few weeks ago, and I should mention, Dr. Conti is indeed a medical
doctor, a psychiatrist, we were talking about
cannabis and its various uses, because it does have some
clinical applications. And he mentioned that
one of the main effects of cannabis is to tighten focus and to enhance concentration on and thoughts about one particular thing. And in some cases that can
be clinically beneficial, and in other cases that can
be clinically detrimental. If you accept the idea that
cannabis increases f
ocus, and you think about OCD
and the networks involved, and you think about the
anxiety and the relationship between the obsession and compulsion, well, then it shouldn't
come as any surprise that cannabis did not
improve the symptoms of OCD because if anything,
it would increase focus on the obsessions and the compulsions. Now that's not what they observed. They did not see an exacerbation or a worsening of the
symptoms of OCD with cannabis, at least that's not my read of the data, but they di
d not see an improvement in OCD symptoms with cannabis or CBD. And to me, that's not surprising given that cannabis CBD
seems to increase focus. Next, I'd like to talk
about some of the research on and the roles of hormones in OCD, because it turns out to be a very interesting relationship there. But before I do, I want
to point out something that I realize I probably
should have said earlier, which is one of the key
things for someone with OCD to come to understand if
they're going to experienc
e any relief of their symptoms, whether or not they're
doing drug treatments or behavioral treatments or otherwise, is that thoughts are
not as bad as actions. Thoughts are not as bad as actions. One of the kind of rules
that people with OCD seem to adopt for themselves is that thoughts are really, truly the equivalent of actions. So they'll have an intrusive thought and, we haven't spent too
much time on this today, but earlier I touched on the fact that some of the intrusive
thoughts that peop
le have in OCD are really disturbing. They can be really gross, or at least gross to that person. They can evoke imagery that
is toxic or infectious, or is highly sexualized in a way that is disturbing to
them, it can be very taboo. This is not uncommon when you start talking to people with OCD and you start pulling on the thread. Again, this would be a psychiatrist who was trained to ask the right questions and gain the comfort
and trust of a patient. And they start to reveal that these thought
s are really
intrusive and kind of disturbing, which is why they feel so compelled to try and suppress them with behaviors. One of the powerful elements
of treatment for OCD is to really support the patient and make them realize that
thoughts are just thoughts and that everyone has disturbing thoughts. And that oftentimes
those disturbing thoughts arise at the most
inconvenient, and sometimes, what seems like the most
inappropriate circumstances. And this relates to a
whole larger discussion tha
t we could have about what are thoughts and why do they surface, and how come when you stand
at the edge of a bridge, even if you do not want to jump off, you think about jumping off. And this has to do with the fact that your nervous system,
as a prediction machine, is oftentimes testing possibilities. And sometimes that testing
goes way off into the Netherlands of the thought patterns and emotional patterns that
we all have inside of us. The big difference between
a thought and an action is th
at, of course, the nervous system is, in one case, not translating those patterns of thinking
into motor sequences. That nerdy way of saying
thoughts aren't actions, believe it or not, can be helpful for people if they really think about that and
use it as an opportunity to realize that, first of
all, they're not crazy. They're not thinking
and feeling this stuff because they're bad or evil. And of course, sometimes
this can cross over with other elements of life where we place moral judgment on
people for certain behaviors. I think that's part of a
healthy society, of course, that's why we have laws and punishments and rewards for that matter
for certain types of behaviors. But this idea that thoughts
are not as bad as actions and that thoughts can be tolerated and the anxiety around thoughts can be tolerated and
over time can diminish, that's a very powerful hallmark theme of the treatment of OCD so I'd be remiss if I didn't mention it. Thoughts are not actions. Actions can harm us,
they
can harm other people, they can soak up enormous amounts of time. Thoughts can soak up
enormous amounts of time. They can be very troubling. They can be very detrimental. We of course want to be sensitive to that, but when it really comes down to it, the first step in treatment
for OCD is this realization where the approach to the realization that thoughts are not as bad as actions. So what about hormones in OCD? Well, this has been explored, albeit not as extensively
as I would've liked to
find, but when I went into the literature, I found one particularly
interesting study, entitled, Neurosteroid Levels in Patients with Obsessive-Compulsive Disorder. First author, Erbay And as always, we'll
provide a link to the study. The objective of this
study was to explore serum within blood, neurosteroid
levels in people with OCD. Why? Well, because of the relationship between OCD and anxiety and the fact that in
stress-related disorders such as anxiety and depression, the hormones have be
en
extensively explored, but not so much in OCD,
at least until this study. So they compared serum levels of a number of different hormones,
progesterone, pregnenolone, DHEA, cortisol, and testosterone. This was done in 30 patients with OCD and 30 healthy controls. So it's not a huge study,
but it's enough to draw some pretty nice conclusions. These subjects were 18 to 49 years old, and the controls were age and sex matched healthy volunteers. Again, no OCD. What was the basic
takeaway from the
study? The basic takeaway from the
study was that in females with OCD, there was evidence for significantly elevated
cortisol and DHEA. Now that's interesting because cortisol is well known to be associated
with the stress system. Although every day, should mention, we all, male or female,
everybody experiences an increase in cortisol
shortly after awakening. That's a healthy increase in cortisol. Late shift, I mean, late in
the day peaks in cortisol where a shift in that cortisol peak to later
in the day is a known correlate of depression and anxiety disorders. So the fact that cortisol is elevated and DHEA are elevated in female patients with OCD suggests that cortisol is either reflective of or causal for the increase in anxiety. We don't know the
direction of that effect. Now in male patients with OCD, there was evidence for increased cortisol. Again, not surprising given the
role of anxiety in cortisol, or I should say, given the
role of cortisol in anxiety and the increasing anxi
ety seen in OCD, but there are also significant
reductions in testosterone, which should also not surprise us because cortisol and
testosterone more or less compete in some fashion for their own production, both are derived from
the molecule cholesterol. And there are certain biochemical pathways that can either direct
that cholesterol molecule toward cortisol synthesis
or testosterone synthesis, but not both. So they compete. So when cortisol goes up in general, not always, but in general, test
osterone goes down and vice versa. If you want to learn more
about the relationship between cortisol and testosterone, and there are even some tools
to try and optimize those ratios in both males and females, you can find that in our episode on optimizing testosterone and estrogen, that's at hubermanlab.com. Now, I would say the
most interesting aspect of this study is not
that DHEA and cortisol are elevated in females with OCD or that cortisol and testosterone have this opposite effect, cortiso
l up and testosterone
down in males with OCD, but rather the relationship
between all of those, DHEA, cortisol, and testosterone. In terms of GABA, GABA again being this inhibitory neurotransmitter that tends to quiet
certain neuronal pathways, it does different things
at different synapses, but in general, the more
GABA that's present, the more inhibition that's present, and therefore the more
suppression of neural activity. And DHEA is known to
be a potent antagonist of the GABA system. So her
e we have elevated DHEA in females. And I should also
mention that testosterone is also known to tap into the GABA system. Typically, when testosterone is elevated, GABA transmission, at
least is slightly elevated. So here we have a situation
in which the pattern of hormones in females and males with OCD are different from those
in people without OCD such that GABA transmission is altered and the net effect would be
an overall reduction in GABA. Now GABA, as an inhibitory
neurotransmitter, and b
roadly speaking is associated with lower levels of anxiety, and it tends to create balance within various neural circuits. Now, that's a very broad statement, but we know for instance, in epilepsy, that GABA levels are reduced and therefore you get runaway excitation of certain circuits in the brain, and therefore seizures, either petite mal, mini seizures, or grand
mal, massive seizures, or even drop seizures where
people completely collapse to the floor in seizure. You may have seen this befor
e. I certainly have, it's very dramatic and it actually is quite
debilitating for people because obviously they don't
know when these seizures are coming on most often, and then they can fall into a stove
or while driving, et cetera. So the situation with OCD is one in which, for whatever reason, we don't
know the direction of effect. Certain hormones are elevated in females and certain hormones are elevated in males and those hormones differ
between males and females, and yet they both funnel i
nto a system where GABAergic or GABA
transmission in the brain is reduced because of this ability for those particular hormones to be antagonists to GABA, and as a consequence, there's
likely to be overall levels of increased excitation in
certain networks in the brain and that brings us back to this cortico-striatal-thalamic loop, this repetitive loop
that seems to reinforce, we can say reinforces
obsession, leads to anxiety, leads to compulsion, leads to
transient relief of anxiety, but then i
ncrease in anxiety,
increased obsession, anxiety, compulsion, anxiety,
compulsion, anxiety, compulsion, and so on and so forth. So I have not found
studies that have explored adjusting testosterone levels through exogenous administration, cream or injection or otherwise, or that have focused on
reducing DHEA in females. If anyone is aware of such studies, please put them in the
comment section on YouTube or send them to us. We have a contact site on the
website at hubermanlab.com, but the commen
t section
on YouTube would be best. But because we know that
hormones impact neuromodulators and neurotransmitters,
as I just described, and that those neuromodulators
and neurotransmitters play an intimate role in the generation and the treatment of things like OCD, it stands to reason that manipulations of those hormone systems, however subtle or dramatic might, I want to highlight, might prove useful in
adjusting the symptoms of OCD and I hope that this is
an area that researchers are going t
o pursue in
the very near future because many of the
treatments for reducing DHEA or increasing testosterone
or reducing cortisol have already made it through FDA approval. They're out there, they're
readily prescribed. Many of them are already in generic form which means that the
patents have already lapsed on the first versions of those drugs. So when they're available as
generic drugs, very often, they're available at
significantly lower cost. There's a whole discussion we had there about pat
ent laws and prescription drugs. But because these drugs
are largely available in prescription yet generic form, I think there's a great opportunity to explore how hormones,
not just cortisol, testosterone, and DHA, but the huge category of hormones might impact the symptoms of OCD, especially since many
of the symptoms of OCD show up right around the time of puberty. We haven't talked a lot
about childhood OCD, 'cause we're going to do an entire series on childhood psychiatric
disorders and cha
llenges but many children develop OCD early as young as three or four, believe it or not, or even 6 or 7 and 10 and in adolescence, and
certainly around puberty. and in young adulthood. It is rare, although it does happen, that people will develop
OCD very late in life around 40 or older, just
kind of spontaneously. Most often when you look
at their clinical history, you find that either they were hiding it or is being suppressed in some way, or if it does spontaneously
show up late in life like
mid-thirties or in one's forties, typically there's a
traumatic brain injury, could be due to stroke or
physical injury to the head or something of that sort. Nonetheless, there is a interesting correlation between the onset of puberty
in certain forms of OCD. There's certain forms of, or I should say, there's certain aspects of menopause that can relate to OCD. You can find all these
things in the literature. All this to say that hormones
impact neurotransmitters and neuromodulators, which cle
arly impact the kinds of circuits
that are involved in OCD and it makes sense that, and I would hope that there
would be an exploration of how these hormones impact OCD in the not too distant future. Now there is an extensive
literature exploring how testosterone therapy, both in males and
females, can be effective in some cases in the treatment of anxiety-related disorders, but not, at least to my
knowledge, in OCD in particular. So this whole area of the use of testosterone and estrogen therap
ies, DHEA, cortisol suppression, or maybe even enhancement
for the treatment of OCD is essentially a big black box that very soon, I believe, will be lit. I realize that a number of
listeners of this podcast are probably interested in the non-typical or holistic treatments for OCD. Dr. Blair Simpson's lab
has at least one study exploring the role of
mindfulness meditation for the treatment of OCD. There, the data are a
little bit complicated and I should mention that good things are happening, a
t
least in the United States, probably elsewhere as well, but good things are happening in terms of the exploration of things like meditation and other, let's call them non-traditional or holistic forms of treatment
for psychiatric disorders because of the division
of complimentary health that's now been launched by the National Institutes of Health. So, whereas before
people would think about meditation or yoga nidra, or even CBD supplementation
for that matter, as kind of fringe maybe, or kind
of woo or non-traditional at the very least, the National Institutes of
Health in the United States has now devoted an entire division, an entire Institute,
purely for the exploration of things like breathing
practices, meditation, et cetera. So there's a cancer institute, there's a hearing and deafness institute, there's a vision institute, and now there's this
complimentary health Institute, which I think is a wonderful addition to the more traditional
aspects of medicine. I think no possible
useful treatment should be overlooked or
unresearched in my opinion, provided that can be done safely. And as I mentioned,
Dr. Blair Simpson's lab has looked at the role
of mindfulness meditation and the treatment of OCD. Now we should all keep in mind, no pun intended, that most of the data on mindfulness meditation
shows that it increases the ability to focus. Now, this brings us back to a
kind of repeating theme today, which is that increased focus may not be the best thing
for somebody with
OCD because it might increase
focus on the obsession and/or compulsion. Turns out that mindfulness
meditation can be useful in the treatment of OCD, but mainly by way of how it impacts the focus on and the ability to engage in cognitive
behavioral therapies. So it's very unlikely, at
least by my read of the data, to be a direct effect of meditation on relieving the symptoms, rather it seems that
meditation is increasing focus on things like cognitive
behavioral therapy homework and to not focus
on other things and therefore indirectly
improving the symptoms of OCD. Now somewhat surprisingly, at least to me, there have also been a fairly
large number of studies exploring how nutraceuticals,
as they're sometimes called, supplements that are
available over the counter can impact the treatment of
obsessive-compulsive disorder. Now there's such an extensive
number of different compounds and supplements that
fall under the category of nutraceuticals and
that have been explored in the treatm
ent of OCD
that I'd like to point you to a review that is entitled, Nutraceuticals in the treatment of obsessive-compulsive
disorder: a review, excuse me, of mechanistic
and clinical evidence. So it's published in 2011,
so it's over 10-years-old. And so by now, I have to imagine that
there are an enormous number of additional substances
that could be explored, but there are just one or two
here that I want to focus on. Here in this review, they describe effects
of 5-HTP and tryptophan, so things
that are in
the serotonin pathway, which would make sense given what we know about the SSRIs that people would explore
how different supplements that increase serotonergic transmission might impact OCD. What you find is that they
do have significant effects in improving or reducing
the symptoms of OCD in somewhat similar way
to some of the SSRIs. But you of course have to be careful. Anything that's going to tap into a given neurochemical system to the same degree may very likely have the
same
sorts of side effects that a prescription drug would. One compound that I like to focus on in a little more depth, however, because it's exciting
and interesting to me is inositol. Inositol is a compound that
we are going to talk about in several future podcasts, because, well, first of all, it seems that it can
have impressive effects on reducing anxiety. It also can have pretty impressive effects in improving fertility
and particular in women with polycystic ovarian syndrome. And here I'm refe
rring
specifically to myo-inositol because it comes in several forms. And it does appear that
900 milligrams of inositol can improve sleep and can reduce anxiety perhaps when taken at that
dosage or higher dosages. I will just confess, first
of all, I don't have OCD, although I will also confess
that when I was a child, I had a transient tick. I've talked about this on podcast before. It was a grunting tick. So when I was about six or seven, I recall a trip to
Washington DC with my family, where
I was feeling a strong desire or need even as I recall, to grunt in order to clear something in my throat, but I didn't
have anything in my throat. I didn't have a cold
or any postnasal drip, it was really just the feeling
that I needed to do that, to release some sort of tension. And I remember my dad at the time telling me don't do that. Don't do that, it's not good to grunt or something like that. I think he saw that it was a
kind of compulsive behavior. And so I would actually
hide in the b
ack seat of the rental car and do
it, or I'd hide in my room. Fortunately for me, it was transient, I think about six months or
a year later, it disappeared. Although I did notice, actually
an ex-girlfriend of mine point out that when I get very tired and I've been working very long hours, sometimes that grunting
tick will reappear. What does that mean? Do I have Tourette's? I don't know, maybe. I was never diagnosed with Tourette's. Do I have OCD? Maybe. I certainly could be accused of having o
bsessive-compulsive
personality disorder, which we'll talk about
still in a few minutes. But the point here is that many children transiently express ticks
or low level Tourette's or OCD, and again, transiently and it disappears over time. So inositol has been explored in a bunch of different contexts, including for ticks in OCD, et cetera. Going back to inositol
and its current use, or I should say my current use, I've been taking 900
milligrams of inositol as in addition to my
existing toolkit
for sleep, which I've talked about
many times on this podcast and other podcasts, consists of magnesium threonate,
apigenin, and theanine. If you want to know more about that kit, you can go to our newsletter,
Neural Network Newsletter at hubermanlab.com. The toolkit for sleep is there. You don't even have to
sign up for the newsletter but it'll give you a flavor
of the sorts of things that are in the newsletter. In any case, I've been experimenting a bit with taking 900 milligrams of myo-inosi
tol either alone or combination
with that sleep kit. And I must say the sleep I've been getting on inositol is extremely deep and does seem to lead to enhanced levels of focus and alertness during the day. And perhaps you're noticing that 'cause I'm talking more quickly on this podcast than in previous podcast. No, I'm just kidding. I don't think the two things relate in any kind of causal way. The point here is that inositol is known to be pretty effective
in reducing anxiety, but when taken at
very high dosages. Can it do the same at low dosages? We don't know. I would consider 900
milligrams a low dose. Most of this, given the fact that most of the studies of inositol have explored very high dosages, like even 10 or 12 grams per day, which I must say seems exceedingly high and they do report that
some of the subjects in those experiments actually stop taking the inositol because of gastric discomfort or gastric distress as it's called. So I've reported my results with sleep in a kin
d of anecdotal way. They certainly aren't
peer-reviewed studies that I described about my own experience in an anecdotal way. But nonetheless, it's been explored that things like glycine, which is another, which is an amino acid, which also acts as an
inhibitory neurotransmitter in the brain, taken at very high dosages, 60 grams per day, that is a absolutely astonishingly high amount of glycine. I would not recommend
taking that much glycine unless you're part of a study where they tell you to
a
nd you know it's safe. 18 grams, excuse me, of an inositol, these are very, very high
dosages used in these studies. Nonetheless, there's some interesting data about inositol leading to some alleviation of OCD symptoms or partial alleviation of OCD symptoms in as little as two weeks after initiating the supplement protocol. So I think there's a great
future for these nutraceuticals, meaning I think more
systematic exploration in particular of lower dosages in the context of OCD treatment. And as
we saw before for the SSRIs and other prescription drug treatments, I think there really
needs to be an exploration of these nutraceuticals in combination with behavioral therapies. And who knows, maybe with
brain machine interface like cranial magnetic stimulation as well. Now way back at the
beginning of the episode, I alluded to the fact
that OCD is one thing, obsessive-compulsive disorder, and it's truly a disorder
and it's truly debilitating and it's extremely common, and then there's this
other thing called obsessive-compulsive
personality disorder, which is distinct from that does not have the intrusive component so people don't feel overwhelmed or overtaken by these thoughts, rather, they find that the obsessions can sometimes serve them
or they even welcome them. And I think many of us
know people like this, I perhaps even could be
accused or who knows, maybe have been accused of having an obsessive-compulsive
personality at times. Why do I draw this distinction? Well, first
of all, we've come
to a point in human history, I think in large part
because of social media but also in large part because there are a number
of discussions being held about mental health that have
brought terms like trauma, depression, OCD, et cetera, into the common vernacular so that people will
say, ah, you're so OCD, or someone will say I
was traumatized by that, or I was traumatized by this. We should be very careful, right? I'm certainly not the word police, but we should be very carefu
l in the use of certain types of language, especially language that
has real psychiatric and psychological definitions because it can really draw us off course in providing relief for
some of these syndromes. For instance, the word trauma is thrown
around left and right nowadays. I was traumatized by this,
or that caused trauma, you're giving me trauma. Listen, I realize that many people are traumatized by certain events including things that are said to them, I absolutely acknowledge that, henc
e our episodes on
trauma and trauma treatment, several of them, in fact. Dr. Conti, Dr. David Spiegel, and then dedicated solo episodes with just me blabbing about
trauma and trauma treatment. But as Dr. Conti so
appropriately pointed out, trauma is really something that changes our neural circuitry and
therefore our thoughts and our behaviors in a very persistent way that is detrimental to us. Not every bad event is traumatizing, not everything that we
dislike or even that we hate or that feels
terrible
to us is traumatizing. For something to reach
the level of trauma, it really needs to change
our neural circuitry and therefore our
thoughts and our behaviors in a persistent way that
is maladaptive for us. Similarly, just calling
someone obsessive is one thing, saying that someone has
OCD or assuming one has OCD simply because they have a
personality or a phenotype, as we say, where they need
things in perfect order, like I find myself correcting these pens making sure that the caps a
re facing in the same direction
for instance right now, that is not the same as OCD. If, for instance, I
can tolerate these pens being at different orientation or even throw the cap on
the floor or something, it doesn't create a lot of anxiety for me. I confess, I agree it's a
little bit in the moment, but then I can forget
about it and move on. That's one of the key distinctions between obsessive-compulsive
personality disorder and obsessive-compulsive disorder in its strictest form. Now, once
one hears that OCD is different than obsessive-compulsive personality disorder
because of this difference in how intrusive the thoughts are or not, then that's useful, but
it really doesn't tell us anything about what is
happening mechanistically in one situation or another. Fortunately, there are
beautiful data again from Dr. Blair Simpson's lab. And you can tell based
on the number of studies that I've referred to from her laboratory, she's truly one of the
luminaries in this field, that there
really are some
fundamental wiring differences and behavioral differences
and psychological differences between people who have
obsessive-compulsive disorder and those who have obsessive-compulsive personality disorder. So this is a study, first
author, Pinto, P-I-N-T-O entitled, Capacity to
delay reward differentiates obsessive-compulsive disorder and obsessive-compulsive
personality disorder. And the methods in this
study were to take 25 people with OCD and 25 people
with obsessive-compulsive
personality disorder and 25 people who have both, because it
is possible to have both and that's important to point out, and 25 so-called healthy controls, people that don't have
obsessive-compulsive personality disorder or
obsessive-compulsive disorder. They take clinical assessments and then they took a number of tests that probed their ability
to defer gratification, something called, in the laboratory, we call it delayed discounting. So their ability to defer gratification through a task wh
ere they
can either accept reward right away or accept reward later. Some of you may have heard
of the two marshmallow task. This is based on a study
that was performed years ago on young children at
Stanford and elsewhere where they take young
children into a room, they offer them a marshmallow, kids like marshmallows generally, and you say, you can eat
the marshmallow right now or you can wait some period of time, and if you are able to wait
and not eat the marshmallow, you can have two marshm
allows. And in general, children
want two marshmallows more than they want one marshmallow. So really what you're probing is their ability to access
delayed gratification. And they're very entertaining, even truly amusing videos
of this on the internet. So if you just do two
marshmallow task video and you go into YouTube, what you'll find is that
the children will use all sorts of strategies
to delay gratification. Some of the kids will
cover the marshmallow. Others will talk to the
marshmallow
and say, I know you're not that delicious. You look delicious, but
no, you're not delicious. They'll engage with the marshmallow in all sorts of cute ways. They'll turn around and try
to, you know, avoidance, which actually speaks to a
whole category of behaviors that people with OCD also use. I'm not saying these kids had OCD, but avoidance behaviors are
very much a component of OCD. People really trying to avoid the thing that evokes the obsession. Well some kids are able
to delay gratificatio
n, some aren't and it's
debatable as to whether or not the kids that are able
to delay gratification go on to have more
successful lives or not. Initially, that was the
conclusion of those studies. There's still a lot of debate about it, we'll bring an expert on to
give us the final conclusion on this 'cause there is one
and it's very interesting and not intuitive. Nonetheless, adults are also faced with decisions every day, all day as to whether or not they
can delay gratification. And this stu
dy used a, not
a two marshmallow task, but a game that involved rewards where people could delay in order to get greater rewards later. What is the conclusion? Well, first of all, obsessive-compulsive and obsessive-compulsive
personality disorder subjects both showed impairments in
their psychosocial functioning and quality of life. They had compulsive behavior. So these are people that
are suffering in their life because their compulsions
are really strong. So it's not just being really nit-pic
ky or really orderly in one case and having full blown OCD in the other, both sets of subjects
are challenged in life because they're having relationship issues or job-related issues, et cetera, because they are that compulsive. However, the individuals with obsessive-compulsive personality disorder, they discounted the value
of delayed gratification significantly less than those with obsessive-compulsive disorder. What do I mean? They are both impairing disorders that are marked by compulsive b
ehaviors, here I'm paraphrasing, but they can be
differentiated by the presence of obsessions in OCD. So obsessions in OCD. People with OCD are absolutely fixated on certain ideas and
those ideas are intrusive. Again, that's the hallmark theme. And by an excessive
capacity to delay reward in obsessive-compulsive
personality disorder. That is people who have
obsessive-compulsive personality disorder are really good at delaying gratification. So they are able to
concentrate very intensely and perf
orm very intensely in ways that allow them to instill order such that they can delay reward. Now you can see why this
contour of symptoms, meaning that the people with OCD are experiencing intrusive thoughts, whereas the people with
obsessive-compulsive personality disorder
show an enhanced ability to defer gratification. You could see how that would lead to very different outcomes. People with obsessive-compulsive
personality disorder can actually leverage
that personality disorder to perform b
etter in
certain domains of life, not all domains of life, because remember, again, these people are in this study and they're showing up as
experiencing challenges in life because of their obsessive-compulsive
personality disorder. Nonetheless, people with
obsessive-compulsive personality disorder, you could imagine, would be very good at say architecture or anything that involves
instilling a ton of order. Maybe sushi chef, for instance,
maybe a chef in general. I know chefs that just
kind of
throw things around like the chef on the Muppets
and just like throw things everywhere and still produce amazing food. And then there's some people
there incredibly exacting, they're just incredibly precise. I think that movie, what is it? Jiro Dreams of Sushi? That movie is incredible. Certainly not saying he
has obsessive-compulsive personality disorder, but
I think it's fair to say that he is obsessive or
extremely meticulous and orderly about everything from start to finish. You can imagine
a huge array
of different occupations and life endeavors where
this would be beneficial, science being one of them
where data collection and analysis is exceedingly
important that one be precise, or mathematics or physics or engineering, anything where precision has a payoff and gaining precision takes time and delay of immediate gratification, you can imagine that obsessive-compulsive personality disorder would synergize well with those sorts of
activities and professions. Whereas obsessive-com
pulsive
disorder is really intrusive. It's preventing functionality in many different domains of life. So the key takeaway here is that when we use the words
obsessive-compulsive, or we call someone obsessive-compulsive, or we are trying to
evaluate whether or not we are obsessive compulsive, it's very important that we highlight that obsessive compulsive
disorder is very intrusive. It involves intrusive thoughts and it interrupts with
normal functioning in life. Whereas obsessive-compulsive
per
sonality disorder, while it can interrupt
normal functioning in life, it also can be productive. It can enhance functioning
in life, not just in work, but perhaps at home as well. If you are somebody and
you have family members that really place enormous value on having a beautiful and highly organized home, well, then it could lend
itself well to that. it's going to be a matter
of degrees, of course. None of these things is an absolute, it's going to be on a continuum, but I think it is fair to
say that obsessive-compulsive disorder, whether or
not in mild, moderate, or severe form is impairing
normal functioning, whereas obsessive-compulsive
personality disorder, there's a range of expressions of that, some of which can be adaptive, some of which can be maladaptive, and again, it's all going
to depend on context. Before we conclude, I do
want to touch on something that I think a lot of people experience and that's superstitions. Superstitions are fascinating, and there's some fascina
ting
research on superstitions. One particular study that I'm a big fan of is the work of Bence Olveczky at Harvard. He studies motor sequences
and motor learning, and he has beautiful
data on how people learn, for instance, a tennis swing and the patterns that
they engage in early on and then the patterns
of swinging that they, swinging the racket that is, that they engage in later
as they acquire more skill. And basically the takeaway is that the amount of error or
variation from swing to swin
g is dramatically reduced
as they acquire skill. That's all fine and good, and there's some
beautiful mechanistic data that he and others have discovered to support how that comes to be, but they also explore animal models, in particular, rats pressing
sequences of buttons and levers to obtain a reward. Believe it or not, rats are pretty smart. I've seen this with my own eyes. You can teach a rat to press
a lever for a pellet of food. Rats can also learn to press levers in a particular sequence
in order to gain a piece of food. And they can actually learn to press an enormous number of levers
in very particular sequences in order to obtain pellets of food. You can also give them
little buttons to press or even a paddle to, or I
should say a pedal, excuse me, to stomp on with their foot in order to obtain a pellet of food. Basically rats can learn
exactly what they need to do in order to obtain a piece of food, especially if they're made a little bit hungry first. Bence's lab has publis
hed beautiful data showing that as animals and humans come to learn a particular motor sequence, very often they will
introduce motor patterns in that sequence that are
irrelevant to the outcome and yet that persist. If you've ever watched a game of baseball, you've seen this before. Oftentimes the pitcher
up on the mound will bring the ball to their chin. They'll look over their shoulder, they'll look back over the other shoulder, and then they will, of course,
reel back and pitch the ball. But
if you watch closely, oftentimes there are components
in the motor sequence, which are completely
unrelated to the pitch. They're not looking necessarily to see if someone's stealing a base. They're not necessarily looking down at home plate where the batter is. They're also doing things like touching the back of their ear before they bring the ball to their chin or adjusting their hat. And if you watch individual pictures, what you'll find is that
they'll do the same sequence of completely irr
elevant motor patterns before each and every single pitch. Similarly, rats that have
been trained to, for instance, hit two levers and step on a pedal with their left hind foot, and then tap a button up above
that is the red button, will do that to gain a piece of food. But sometimes they'll
also introduce a pattern into that motor sequence where they will shake their tail a little bit, or they'll turn their head a little bit, or they'll move their ears
a little bit, et cetera. Motor patterns th
at have nothing to do with obtaining the
particular outcome in mind. In other words, you could eliminate certain components of the motor sequence and it would not matter, the
rat would still get the pellet, the pitcher would still be able to pitch, and yet that get
introduced because somehow because they were
performed again and again prior to successful trials, the rat or the human baseball pitcher comes to believe in some way that it was involved in
generating the outcome, hence superstition,
right? I confess I have a few superstitions. I occasionally will knock on wood. I'll say something that I want to happen, and I'll say, oh, knock on
wood, and I'll just do it. And occasionally I'll
challenge myself and think, ah, I don't want to knock,
don't knock on wood, Andrew, don't do that. I don't think anyone
wants to be superstitious, I certainly don't. And so every once in a while, I'll just challenge it, and I
won't actually knock on wood. I'm admitting this to you to kind of I guess n
ormalize some of this. Some people have superstitions that border on or even become compulsions. They really come to believe that if they don't knock on wood, that something terrible
is going to happen, maybe something in particular. Or in the case of the baseball pitcher, they come to believe
that if they don't touch their right ear before they
reel back on the pitch, that the pitch won't be any good or that they're going to lose the game. Well, I don't know what
their thought process is. Now,
I also don't know
what the rat is thinking, but the rat is clearly doing something or thinking something is
related to the final outcome. I don't know of any studies
where they've intervened with the particular
superstition-like behaviors of the rat to see whether or not the rat somehow doesn't continue
to do the motor sequence to get the pellet. We don't know the rats, they're rats. I don't speak rat, most people don't, or if you speak to a rat, if it speaks back, it's not in English. Anyway, t
he point is that
superstitions are beliefs that we, on an individual
scale, come to believe are linked to the
probability of an outcome when in fact we know, we actually know in our rational minds, they
have no real relationship to the outcome. Superstitions can become full-blown compulsions and obsessions when we repeat them often enough that they become automatic. And I think this is what
we observe most of the time when we see a pitcher touching their ear, or for instance, in
tennis, you see
this a lot, you'll see someone
they'll slap their shoes. Often, I see this, they'll like slap the undersides of their soles. They may tell themselves
that this is, I don't know, maybe moving out some
of the dust or something in the bottoms of their soles, that gives them more
traction and they want that to be ready for the serve
or something like that. And maybe there's some truth to that, but here, what we're referring to are behaviors that really
have no rational relationship to the outcome, a
nd yet we
perform in a compulsive way. People with OCD, yes, tend
to have more superstitions. People with more superstitions, yes, tend to have a tendency towards OCD and I should mention, obsessive-compulsive personality disorder. If you think way back to the
first part of this episode, when I was just describing
what the brain does, right? What does your brain do? Housekeeping functions to keep you alive and it's a prediction machine. Your neural circuits, you, have an enormous amount
of biolo
gical investment of real estate, literally,
cells and chemicals that are there to try and
make your world predictable and to try and give you control, or at least the sense of
control over that world and that's a normal process. Low-level superstitions,
moderate superstitions represent a kind of a
healthy range, I would say, of behaviors that are aimed
at generating predictability that don't disrupt normal function. Obsessive-compulsive personality disorder, provided is not too severe, would I t
hink represent the next level along that continuum. And then obsessive-compulsive disorder, as I pointed out earlier, is really a case of highly debilitating, highly intrusive, really
overtake of neural circuitry over our thoughts and behaviors that requires very
dedicated, very persistent, and very effective
treatments in order to stop those obsessions and compulsions and the anxiety that links them somewhat counterintuitively
by teaching people to tolerate that level
of increased anxiety and i
nterrupt those patterns. And fortunately, as we described earlier, such treatments exist,
cognitive behavioral therapy, drug treatments like
SSRIs, also drug treatments that tap into the glutamate system and into perhaps also the dopamine system, the so-called neuroleptics. And then, as we described, there's now an extensive
exploration of things like ketamine, psilocybin, cannabis, the initial studies don't
seem to hold much promise for cannabis and CBD and
the treatment of OCD, but who knows,
maybe more
studies will come along that will change that story. And then of course,
brain machine interface like transcranial magnetic stimulation. And then just to remind you
what I already told you before combinations of behavioral
and drug treatments and brain machine interface, I think, is really where the future lies. Fortunately, good treatments exist. We cannot say that any
one individual treatment works for everybody. There are fairly large
percentages of people that won't respond to one
set of treatments or another, and therefore one has
to try different ones. And then there are the
so-called supplementation-based or more holistic therapies. Today, I've tried to cover each and all of these in a fairly
substantial amount of detail. I realize this is a fairly long episode, that is intentional. Much like our episode on ADHD, on attention deficit
hyperactivity disorder, I received an enormous number of requests to talk about OCD, and
my decision to make this a very long and detail
ed episode about OCD really doesn't stem from any desire to subject you to too much information or to avoid the opportunity
to just list things off, but what I've tried to
provide is an opportunity to really drill deep
into the neural circuitry and an understanding of
where OCD comes from, how OCD is different from things like the personality disorders
that I described. And also to give you a
sense of how the individual behavioral and drug treatments work and perhaps don't work so that you can r
eally make
the best informed choices, again, highlighting the fact that OCD is an extremely common, extremely common, and yet extremely debilitating condition and one that I hope
that if any of you have, or that you know people that have it that you'll both gain
sympathy and understanding for what they're dealing with, perhaps as a consequence of some of the information presented today, and maybe help them
direct their treatment, find better treatment, and of course, apply those treatments for s
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Comments
I’ve suffered with OCD for 15 years and it has to be the most misunderstood condition. And because people downplay it we have to carry on as if all is well whereas somebody with a physical disability gets all the support they need. It infuriates me. Shout out to all of us suffering from this horrible condition!
Maybe this can help someone: Looking back I've had OCD for all of my life. But about 2 years ago it peaked. Never been so scared in my life. The scariest obsessions I had were about suicide, harm and existentialism. I was having panic attacks and hefty bouts of depression (further inducing the suicide theme). After a while I got diagnosed with OCD. Suddenly my whole life made sense. I am doing great now. Here'e what helped me the most: - Acceptance and Commitment Therapy - Exposure and Response Prevention Therapy Mindsets: - Learn as much about OCD as you can. Learn the game it plays. - Understanding that embracing uncertainty is a practice. It's sweaty work, but you get better at it. Do it with consistently with attitude. - Remember metaphorically that to get to that 'pot of gold' you have to 'fight the dragon'. Do stuff you care about, even if you're scared sh*tless. You will thank yourself later. Books that helped me tremendously: - You Are Not A Rock (Mark Freeman) - The Happiness Trap (Russ Harris) - Man's Search For Meaning (Victor Frankl) - Help And Hope for Your Nerves (Claire Weekes)
If anyone needs to hear this, I’ve suffered from OCD all my life. Early symptoms started in 2nd grade, and when I turned 13 that’s when I noticed it more. I’ve gone through all the symptoms you can google or research about, but I can tell you that everything will be ok. I am currently 27 and still suffer from it, but you own it. I still have tough days and nights, but remember that YOU own it. You can accomplish anything you want. I finished university, got married, and have accomplished many things. I’ve also missed out on a lot due to OCD, GAD, and panic disorder. This doesn’t make us weak, it only makes us stronger and more empathetic individuals. This is a long journey, be patient, embrace it, and don’t be afraid to get out of the comfort zone, even if it causes GREAT anxiety, because I know it will, I’ve been there. You are definitely not alone, always remember that. Do what makes you happy and stand tall♥️🙏🏻 Don’t give in to your rituals, compulsions, obsessions. I know those thoughts are HORRIBLE and will cause you LOTS of pain and anxiety if you don’t “fix” your thought, but trust me, don’t give in to it. It’s better if you lose sleep than giving into it, it will help you in the long run. Be very very patient and work on yourself. There’s a new thought every day, so this is a long journey, but I can’t stress enough about being patient with yourself and the process. Trust it. I wish you all the very best🙏🏻♥️
OCD is pure hell. I suffered from HOCD, intrusive thoughts I was attracted to my parents/sisters/friends, and intrusive thoughts that made me think I was going crazy. I would ruminate, search online, do mental compulsions, anything to relieve the anxiety and fear it would cause me. The "what ifs" would follow me morning, noon, and night. The only relief I would get was when I would sleep (if I could fall asleep). Even when I woke up at 2am, it would be consuming my mind. It wasn't until I accept all those possibilities and cut compulsions, that it started to get much better. I look back now on how worried I was, and get upset that I wasted so much time on nothing. Luckily, I only suffered for a couple months. I feel for those who have suffered for years.
I have ocd and cbt training helped a lot! I wouldn't leave the house, now I'm living life again!
Thank you for this! There is a large 4th “bucket” which is mental compulsions and is very common! This can look like reassurance seeking, review of past events, emotional checking, etc. These compulsions are virtually undetectable by anyone but the sufferer. It’s also important to note that obsessions can be harm related, religious, sexual, and relationship based. It’s the taboo nature of the obsessions that can keep people from seeking treatment and lead to intense shame and disgust with oneself. It is commonly accepted that OCD often presents in the arenas in which the sufferer values the most, I.e., I care about my relationship to God…I have obsessions about going to hell. Such a complex issue. Thank you for tackling it!!!
This podcast is just amazing. As someone who "had" OCD as a child, and after years of treatment has almost no symproms left, this episode really touched my heart. For anyone in this comment section who never dealt with this, andrew described pretty well in my opinion what it is. I wanted to open a little discussion in regards o childhood ocd, because my mom was the one who "saved" me from OCD, she went to therapy for ocd in order to help me, she studied tactis and things she should say to help, she even developed her own way of "treating " ocd by the end, and honestly she ended up being better than any CBT out there. She saved me, and i think this is an aspect of treatment for children with OCD that i see very little talks about
Dr.Huberman, I just wanted take a moment out and thank you for the amazing work you provide all your viewers. You’ve had an enormous positive impact on my life, and I’m sure the same goes for many of your other viewers. Your contribution to society through the work you’re doing here is remarkable. Thank you!
THANK YOU for this TREMENDOUSLY HELPFUL episode Andrew! As someone who has suffered from OCD since childhood- ultimately manifesting into an intense ED- I found your clarity in discussing OCD vs. OCPD to be particularly valuable. I also appreciate your discussion of the newer therapies that are starting to be studied and used for OCD treatment. While I've has lots of therapy (including CBT) during my struggles, ultimately what helped me recover the most was developing a profound joy and passion for strength training, and also realizing that I didn't want anything (like obsessions and rituals) to own me and control my life. Thank you again for your time and effort in educating us on here, I always look forward to spending time with you while watching and learning🙏💜🤗
From someone who had severe OCD once, thank you Andrew, for shedding light on this condition. My life’s been saved due to CBT therapy, SSRI’s, exercise, nutraceuticals, lifestyle changes and Sauna therapy.
I’ve had OCD chronically since I was eight. I’m 59 now and listening to this podcast, I honestly now understand my own brain much more than l have ever done. Mine includes mostly intrusive thoughts, harm OCD and scrupulosity. My thirties and fourties’ were lost to it. Right down to sleeping in my cupboard and getting up at dawn to measure the angles of the rising sun’s light coming in the window so I knew we’d be safe from something catching fire. It was my universe, and your explanation of how our view narrows with this anxiety is spot on. I also have severe agoraphobia, DPDR, complicated grief, and chronic pain from diabetic neuropathy, so it can get a little tricky trying to work on recovery. I have been suicidal several times, but not now and I know how to deal with that nowadays. CBTis hardest for me because I always believe I’ll never sleep unless I settle the compulsive thought. And my mind will jolt me awake if I try to resist and sleep. But now, listening to you, I’ve realised I try to jump in to far too soon. I’ve had help on and off, at the moment I can’t really afford it. But I’m going to hang in there and keep trying. I’m on Sertraline, which has helped, but now I’m going to commit to the CBT as well, but not try to do it all at once. My late mum literally saved me so many times with her understanding of OCD and her understanding of me, now she’s passed I want to keep working on recovery for her, so she’s at peace, as well as for myself. Thank you so much for uploading this, it will help more people than you can ever know.
Have been asking for this for a while, can't believe it's here! Thank you so much for everything Andrew. You are changing lives everyday. <3
My son was diagnosed with OCD at 13. He was tested with an IQ of 131 in 5th grade and has always had difficulty in school. Musically gifted and philosophical minded. I wish you could work with him and study his brain! He’s an amazing kid who suffers in ways most don’t understand.
I realized my daughter had OCD just a few years ago, as I thought she just had ADHD. She's 24 now, but starting in elementary school she had to organize things in specific ways. While doing homework she kept writing, erasing, and rewriting everything and it took forever for her to to complete any assignment. As she got older, if someone touched any of her personal items she would throw a fit. I had been listening to various podcast on mental health issues and realized I had similar issues while growing up and now I was seeing it in her. I thought I just had anxiety starting oat a young age and didn't realize that my own behaviors were indicative of OCD. I found her a great therapist that uses Exposure and Response Prevention therapy. It has been amazing for her.
I could remember several years ago, I was diagnosed with OCD. Also suffered severe depression and mental disorder. Not until my wife recommended me to psilocybin mushrooms treatment. Psilocybin treatment saved my life honestly. 8 years totally clean. Never thought I would be saying this about mushrooms.
Thank you. Our 32 year old son has OCD. We are learning a lot these days and you have been very helpful.
Thank you so much for starting out this podcast shedding light on how OCD is completely misunderstood by the general public. This is such a great service to everyone suffering with this chronic condition- thank you so much for this podcast!
This podcast is a beacon of hope for me....I have been struggling with severe "Harm OCD" for the past two and a half years. Sometimes it just takes that one person to tell you you're not crazy or evil. I don't want ANY of these thoughts of hurting people, but now I believe once again that I will get through this. Thank you Andrew. 🙏
I can't remember a time where I maintained this much undivided attention to a podcast as much as listening to this one. Can't believe I've just discovered your podcasts! Very thorough and informative.
Great episode as always, but very important to point out that obsessions are, more often than not actually, non-behavioral, involving mental compulsions, such as rumination and mental checking. It's a very common misconception that compulsions must mirror those more classically described examples, like hand washing and counting, but this is not at all the case and contributes to misdiagnosis.