back to indexThe Science & Treatment of Obsessive Compulsive Disorder (OCD) | Huberman Lab Podcast #78
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Welcome to the Huberman Lab Podcast,
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where we discuss science and science-based tools
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for everyday life.
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I'm Andrew Huberman,
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and I'm a professor of neurobiology and ophthalmology
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at Stanford School of Medicine.
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Today, we are talking about obsessive-compulsive disorder,
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We are also going to talk about
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obsessive-compulsive personality disorder,
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which, as you will soon learn,
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is distinct from obsessive-compulsive disorder.
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In fact, many people that refer to themselves
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or others as obsessive or compulsive,
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or quote-unquote having OCD,
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or OCD about this or OCD about that,
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do not have clinically diagnosable OCD.
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Rather, many people have obsessive-compulsive
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personality disorder.
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However, there are many people in the world
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that have actual OCD.
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And for those people,
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there's a tremendous amount of suffering.
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In fact, OCD turns out to be number seven
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on the list of most debilitating illnesses,
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not just psychiatric illnesses, but of all illnesses,
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which is remarkable and somewhat frightening.
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thanks to the fields of psychiatry,
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psychology, and science in general,
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there are now excellent treatments for OCD.
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We're going to talk about those treatments today.
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Those treatments range from behavioral therapies
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to drug therapies and brain stimulation,
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and even some of the more holistic or natural therapies.
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As you'll soon learn,
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for certain people, they may want to focus more
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on the behavioral therapies,
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whereas for others, more on the drug-based therapies,
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and so on and so forth.
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One extremely interesting and important thing
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I learned from this episode
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is that the particular sequence
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that behavioral and or drug and or holistic therapies
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are applied is extremely important.
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In fact, the outcomes of studies
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often depend on whether or not people
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start on drug treatment and then follow
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with cognitive behavioral treatment or vice versa.
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We're going to go into all those details
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and how they relate to different types of OCD,
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because it turns out there are indeed different types
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of obsessions and compulsions,
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and the age of onset for OCD, and so on and so forth.
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What I can assure you is by the end of this episode,
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you'll have a much greater understanding
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of what OCD is and what it isn't,
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and what obsessive compulsive personality disorder is
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and what it is not,
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and you'll have a rich array of different therapy options
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to explore in yourself or in others
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that are suffering from OCD.
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And if neither you or others that you know suffer from OCD
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or obsessive compulsive personality disorder,
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the information covered in today's episode
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will also provide insight into how the brain
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and nervous system translate thought into action generally.
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And also you're going to learn a lot
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about goal-directed behavior generally.
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My hope is that by the end of the episode,
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you will both understand a lot about this disease state
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You will have access to information
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that will allow you to direct treatments
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to yourself or others in better ways,
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and that you will gain greater insight into how you function
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and how human beings function in general.
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The Huberman Lab Podcast is proud to announce
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that we partnered with Momentous Supplements.
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We've done that for several reasons.
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First of all, the quality of their supplements
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is exceedingly high.
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Second of all, we wanted to have a location
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You can now find that place at livemomentous.com
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So that's terrific whether or not you live in the US
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Before we begin, I'd like to emphasize
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that this podcast is separate
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from my teaching and research roles at Stanford.
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It is however, part of my desire and effort
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to bring zero cost to consumer information about science
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and science related tools to the general public.
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In keeping with that theme,
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I'd like to thank the sponsors of today's podcast.
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The reason I started taking Athletic Greens
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Let's talk about OCD or obsessive compulsive disorder.
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First of all, as the name suggests,
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OCD includes thoughts or obsessions
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and compulsions, which are actions.
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The obsessions and the compulsions are often linked.
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In fact, most of the time,
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the obsessions and the compulsions are linked
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such that the compulsion, the behavior,
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is designed to relieve the obsession.
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However, one of the hallmark themes
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of obsessive compulsive disorder
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is that the obsessions are intrusive.
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People don't want to have them.
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They don't enjoy having them.
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They just seem to pop into people's minds
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and they seem to pop into their mind recurrently.
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And the compulsions, unlike other sorts of behaviors,
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provide brief relief to the obsession,
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but then very quickly reinforce or strengthen the obsession.
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This is a very key theme to realize
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about obsessive compulsive disorder.
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So I'm just going to repeat it again.
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These two features,
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first, the fact that the obsessions are intrusive
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and recurrent, as well as the fact that the compulsions,
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the behaviors, provide, if anything,
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only brief relief for the obsessions,
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but in most cases,
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simply serve to make the obsession stronger,
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are the hallmark features of obsessive compulsive disorder.
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And it turns out to be very important to keep these in mind
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not just because they define obsessive compulsive disorder,
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but they also define the sorts of treatments
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that will and will not work
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for obsessive compulsive disorder.
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And then once you understand a little bit
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about the neural circuitry
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underlying obsessive compulsive disorder,
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which we'll talk about in a few moments,
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then you will clearly understand
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why being a quote unquote obsessive person
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or having obsessive compulsive personality
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is not the same as OCD.
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In fact, we can leap ahead a little bit
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and compare and contrast OCD
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with obsessive compulsive personality disorder
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along one very particular set of features.
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Again, I'll go into this in more detail later,
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but it's fair to say that OCD is characterized
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by these recurrent and intrusive obsessions.
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And as I mentioned before,
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the fact that those obsessions get stronger
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as a function of people performing certain behaviors.
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So unlike an itch that you feel
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and then you scratch it and it feels better,
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OCD is more like an itch that you feel,
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you scratch it and the itch intensifies.
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That contour or that pattern of behaviors
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and thoughts interacting is very different
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than obsessive compulsive personality disorder,
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which mainly involves a sense of delayed gratification
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that people want and somewhat enjoy
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because it allows them to function better
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or more in line with how they would like
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to show up in the world.
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So again, OCD has mainly to do with obsessions
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that are intrusive and recurrent,
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whereas obsessive compulsive personality disorder
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does not have that intrusive feature to it.
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People do not mind or in fact often invite
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or like the particular patterns of thought
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that lead them to be compulsive along certain dimensions.
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So leaving aside obsessive compulsive personality disorder
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for the moment, let's focus a bit more on OCD
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and define how it tends to show up in the world.
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First of all, OCD is extremely common.
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In fact, current estimates are that anywhere
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from 2.5% to as high as three or even 4%
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of people suffer from true OCD.
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That is an astonishingly high number.
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Now, the reason the range is so big,
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2.5% all the way up to three or maybe even 4%,
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is that a lot of the features of OCD go unnoticed,
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both in the clinician's office
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and simply because people don't report it
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and don't talk about it.
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In fact, it is possible to have recurrent
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and intrusive obsessions and not engage
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in the sorts of behaviors that would ever allow people
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to notice that somebody has OCD.
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That can be because some of the intrusive thoughts
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don't actually lead to overt behaviors like hand-washing
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or checking that other people would notice.
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It can also be because people learn to disguise
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or hide their obsessions and their compulsions out of shame
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or fear of looking strange or whatever it might be,
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such that they have these obsessive and intrusive thoughts
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and they do little micro-behaviors,
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like they might tap their fingers on their fly
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as a way to avoid, at least in their own mind,
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something catastrophic happening.
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That might seem crazy to you, it might seem bizarre,
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but this is the sort of thing
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that operates in a lot of people.
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And I really want to emphasize this
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because the clinical literature that are out there
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really point to the fact that many people have OCD,
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full-blown OCD, and never report it
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because of the kind of shame and hiding associated with it.
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Another thing to point out is that OCD
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is extremely debilitating.
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I mentioned this a few minutes ago,
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but OCD is currently listed as at number seven
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in terms of the most debilitating illnesses,
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not just mental illnesses or disorders,
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but all types of illnesses,
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including things like asthma and cancer, et cetera.
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So you can imagine with that standing at number seven,
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that it is both extremely common
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and extremely debilitating.
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And as a consequence, it's now realized that many hours,
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days, weeks, months, or even years of work performance
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or showing up at work, of relational interactions,
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really suffer as a consequence of people having OCD.
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So this is a vital problem that the scientific
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and psychiatric and psychological communities understand.
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And it's one of the reasons that I'm doing this podcast.
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And of course, I received a ton of interest in OCD
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because of this incredibly high incidence of OCD
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and how debilitating it is.
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We could go really deep into why it's so debilitating.
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I don't want to spend too much time on that
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because I think most of that is pretty obvious,
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but some of it is not.
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For instance, one of the things that makes OCD
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so debilitating is of course the shame
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that we talked about before,
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but it's also the fact that when people are focusing
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on their obsessions and their compulsions,
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they're not able to focus on other things.
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That's simply the way that the brain works.
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We're not able to focus on too many things at once.
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The other thing is that OCD takes a lot of time
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out of people's lives.
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With recurrent intrusive thoughts happening
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at very high frequency or even at moderate frequency,
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people are spending a lot of time thinking about this stuff
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and they're thinking about the behaviors
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they need to engage in and then engaging in the behaviors,
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which as I mentioned before,
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just serve to strengthen the compulsions.
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And so they're not actually doing the other things
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that make us functional human beings,
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like commuting to work or doing homework or doing work
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or listening when people are talking or interacting
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or sports or working out.
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All the things that make for a rich quality life
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are taken over by OCD in many cases.
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So while that might be obvious to some,
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I'm not sure that it's obvious to everybody
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just how much time OCD can occupy.
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Another thing you'll soon learn is that sadly,
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a lot of the obsessions and compulsions in OCD
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often relate to taboo topics.
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And that's because the general categories of OCD
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fall into three different bins,
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checking obsessions and compulsions,
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repetition obsessions and compulsions
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and order obsessions and compulsions.
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The checking ones are somewhat obvious,
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checking the stove or checking the locks,
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which I think we all tend to do.
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I'm somebody typically I'll head off to the car
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to commute to work.
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And I'll think I locked the front door
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and I'll go back once.
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But I won't go back twice or 50 times.
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People with OCD will often go back 20 or 30 times
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before they'll actually allow themselves to drive off.
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And then it's a real challenge for them
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to continue to drive off and discard with the idea
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that they didn't check the stove
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or they didn't check the locks
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or they didn't check something else critical.
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Repetition obsessions and compulsions
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obviously can dovetail with the checking ones,
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but those tend to be things like counting off
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of a certain number of numbers,
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like one, two, three, four, five, six, seven,
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seven, six, five, four, three, two, one.
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People will perform that repeatedly, repeatedly, repeatedly
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or feel that they have to.
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I remember years ago watching a documentary
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about the band, the Ramones.
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Most people heard of the Ramones, right?
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Jeans, t-shirts, aviator glasses.
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Everyone had to change their last name to Ramone.
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They weren't actually all related to one another,
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by the way, you had to change your last name to Ramone.
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The Ramones had one band member who was admittedly
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and known to others as having OCD.
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And during that documentary, which I forget the name,
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I think it was called, can't remember.
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Anyway, can't remember, hippocampal lapse there.
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But in this documentary,
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the band members describe Joey Ramone as leaving hotels,
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walking down the stairs to the parking lot,
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but then having to walk up and down them seven or eight
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times and sometimes getting out of the van again
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and walking up and down them seven or eight times.
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And it always had to be a certain number of times
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given a certain number of stairs.
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This appears quote unquote crazy,
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but of course we don't want to think of this as crazy.
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This is somebody who very likely had full-blown OCD.
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Now that particular example, believe it or not,
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is not all that uncommon.
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It just so happens that that example entailed
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certain compulsions and behaviors that were overt
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and that other people could see.
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And you can imagine how that would prevent somebody
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from moving about their daily life easily.
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A lot of people, as I mentioned before,
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have obsessions and compulsions that they hide
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and they do these little micro-behaviors
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or they'll just count off in their head
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as opposed to generating some sort of walking up
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and down stairs or tapping or things of that sort.
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So we have checking, we have repetition,
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and then there's order.
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Order oftentimes is thought of as putting cleanliness
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or making sure everything is aligned
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and perfect and orderly.
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And oftentimes that is the case,
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but there are other forms of order that people with OCD
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can focus on in a obsessive and compulsive way.
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Things like incompleteness,
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the idea that one can't walk away from something
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or stop doing something because something's not right
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or complete in that picture.
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It could be the way the table is set.
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It could be the way that something's written on a page.
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It could be an email.
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Again, now we're still talking about OCD, the disorder.
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We're not talking about
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obsessive compulsive personality disorder.
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I'm aware of, well, I'll just be direct,
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several colleagues of mine, and it's just remarkable,
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the order in their emails.
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Every email is perfect, punctuated perfect,
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grammar perfect, everything's spaced perfect.
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Well, they might, they might not.
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How would I know unless they disclose that to me?
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But they might have obsessive compulsive personality disorder
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or they just might be able to generate a lot of order
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and they have a lot of discipline
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around the way they write and the way they present
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any communication with anybody at all.
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So if somebody has a OCD that's in the domain of order,
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it could be incompleteness and the constant feeling
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of something not being completed and a need to complete it.
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It can also be in terms of symmetry,
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that everything be aligned and symmetric in some way.
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This could be seen perhaps in young kids.
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This is one example that I read in the literature
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of children that need to arrange their stuffed animals
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in exact same order every day and in a particular order
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to the point where if you were to move
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the little stuffed frog over next to the stuffed rabbit,
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that the child would have an anxiety reaction to that
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and feel literally compelled, driven to fix that,
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maybe even multiple times over and over again.
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We'll talk about OCD in children
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versus adults in a little bit.
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And then the other aspect of order,
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which is a little bit less than intuitive
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is this notion of disgust.
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This idea that something is contaminated.
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So we often think about OCD and hand-washing behavior
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in response to people feeling that something is contaminated,
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a space, a towel, et cetera,
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or even simply somebody else's hand.
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And so they're unwilling to shake somebody's hand.
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You can imagine how these different bins of obsessions
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and compulsions, checking repetition and order
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could be extremely debilitating
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depending on how severe they are
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and how many different domains of life they show up in.
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Because oftentimes in movies,
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and even the way I'm describing it now,
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it sounds as if, okay, well, somebody has to check the locks
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but they don't have to also check the stove.
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Or somebody has the need to count to seven back and forth
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up to seven and down to seven,
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seven times a day or something of that sort.
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Where they need symmetry in very specific domains of life.
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But it turns out that this recurrent
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and intrusive aspect of obsessions leads people with OCD
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to have checking repetition
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and or order compulsions everywhere.
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So whether or not somebody is at work or in school
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or trying to engage in sport
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or trying to engage in relationship
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or just something simple like walking down the street,
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the obsessions are so intrusive that they show up
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and they compel people to do things in that domain
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independent of whether or not
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they happen to be in one location or another.
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In other words, the thought patterns and the behaviors
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take over the environment as opposed to the environment
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driving the thought patterns and behaviors.
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So it therefore becomes impossible
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to ever find a room that's clean enough
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to find a bed that's made well enough
link |
to find anything that's done well enough
link |
to remove the obsession.
link |
And I know I've said it multiple times now,
link |
but I'm going to say it many times throughout this episode
link |
in a somewhat obsessive, but I believe justified way
link |
that every time that one engages in the compulsion
link |
related to the obsession,
link |
the obsession simply becomes stronger.
link |
So you can imagine what a powerful
link |
and debilitating loop that really is.
link |
So let's drill a little bit deeper
link |
into how the obsessions and compulsions
link |
relate to one another.
link |
If we were to draw a line
link |
between the obsessions and the compulsions,
link |
that line could be described as anxiety.
link |
Now we need to define what anxiety is.
link |
And to be quite honest,
link |
most of psychology and science
link |
can't agree on exactly what anxiety is.
link |
Typically the way we think about fear
link |
is that it's a heightened state of autonomic arousal.
link |
So increased heart rate, increased breathing,
link |
sweating, et cetera,
link |
in response to an immediate and present threat
link |
or perceived threat.
link |
Whereas anxiety, generally speaking
link |
in the scientific literature,
link |
relates to the same sorts of thought patterns
link |
and somatic bodily responses,
link |
heart rate, breathing, et cetera,
link |
but without a clear and present danger
link |
being in the environment or right there.
link |
that we're going to talk about anxiety now.
link |
And anxiety is really what binds the obsessions
link |
and compulsions such that
link |
someone will have an intrusive thought.
link |
So for instance, someone will have the thought that
link |
if they turn left on any street,
link |
that something bad will happen, okay?
link |
That's an obsession.
link |
It's actually not all that uncommon.
link |
Now, how bad and what the specificity
link |
of that bad thing really is will vary.
link |
Some people will think if I turn left,
link |
something generally bad will happen.
link |
It just makes me feel anxious.
link |
So they always insist on going right.
link |
Whereas other people will think if I turn left,
link |
so-and-so will die or I will die
link |
or something terrible will happen.
link |
I'll get a disease or someone else will get a disease
link |
or I'll be cursing myself or somebody else
link |
in some very specific way.
link |
This is unfortunately quite common in people with OCD.
link |
So they have this feeling and the feeling can be generally
link |
or specifically related to a particular outcome.
link |
But beneath that is a feeling of anxiety,
link |
a quickening of the heartbeat,
link |
a quickening of breathing,
link |
a narrowing of one's visual focus.
link |
I've talked about this before on other podcasts,
link |
the master stress and other podcasts.
link |
But if you haven't heard those,
link |
let me just briefly describe that
link |
when we are in a state of increased
link |
so-called autonomic arousal, alertness, stress, et cetera,
link |
our visual field literally narrows.
link |
The aperture of our visual field gets smaller
link |
and that's because of the relationship
link |
between the autonomic nervous system and your visual system.
link |
So you start seeing the world through sort of
link |
soda straw view or through binocular like view
link |
as opposed to seeing the big picture.
link |
Why is that important?
link |
Well, it literally sharpens and narrows your focus
link |
toward the very thing that the obsessions
link |
and the compulsions are focused on.
link |
So the person walking down the street
link |
who sees the opportunity to go left or right
link |
will only see the bad decision.
link |
Their visual field narrows very tightly
link |
along that possibility of taking a left turn.
link |
And I know as I described, this seems totally irrational,
link |
but I want to emphasize that the person with OCD
link |
knows it's irrational.
link |
They might feel crazy because they're having these thoughts,
link |
but they know it makes no sense whatsoever
link |
that left somehow would be different than right
link |
in terms of outcomes in this particular case.
link |
And yet it feels as if it would.
link |
In fact, in some cases, it feels as if they went left,
link |
they would have a full-blown panic attack.
link |
So the idea here is that the obsessions and compulsions
link |
are bound by anxiety, but then by taking a right-hand turn,
link |
again, in this one particular example,
link |
by taking a right-hand turn, there's a very brief,
link |
I should mention very brief relief of that anxiety
link |
at the time of the decision to go right, not left.
link |
And there's an additional drop in anxiety
link |
while one takes the right-hand turn
link |
as opposed to the left-hand turn.
link |
And then as I alluded to before,
link |
there's a reinforcement of the compulsion.
link |
In other words, by going right,
link |
it doesn't create a situation in the brain
link |
and psychology of the person that,
link |
oh, you know what, I'm not anxious anymore,
link |
left would have probably been okay.
link |
It reinforces the idea that right made me feel better
link |
or turning right made me feel better
link |
and going left would have been that much worse.
link |
Again, it reinforces the obsession even further.
link |
And again, we could swap out right turns and left turns
link |
with something like hand-washing,
link |
the feeling that something is contaminated
link |
and the need to wash one's hands,
link |
even though one already washed their hands
link |
20, 30, 50 times prior.
link |
And we're actually going to go back to that example
link |
a little bit later when we talk about
link |
one particular category of therapies
link |
that are very effective in many people for OCD,
link |
which are the cognitive behavioral and exposure therapies.
link |
So I think some of you have heard
link |
of cognitive behavioral and exposure therapies,
link |
but the way they are used to treat OCD
link |
is very much different than the way they're used to treat
link |
other sorts of anxiety disorders
link |
and other sorts of disorders generally.
link |
So it's fair to say that up to 70% of people with OCD
link |
have some sort of anxiety or elevated anxiety,
link |
either directly related to the OCD
link |
or indirectly related to the OCD.
link |
And it's really hard to tease those apart
link |
because OCD can create its own anxiety.
link |
As I mentioned before, it can even increase its own anxiety.
link |
And there's also an issue of depression.
link |
Having OCD can be very depressing, right?
link |
Especially if some of these OCD thoughts and behaviors
link |
start to really impede people's ability to function in life
link |
at work and school and relationship,
link |
they can start feeling less optimistic about life.
link |
And in fact, some people can become suicidally depressed.
link |
That's how bad OCD can be for us.
link |
So we have to be careful when saying
link |
that 70% of people with OCD also have anxiety
link |
or X number of people with OCD are also depressed
link |
because we don't know whether or not
link |
the depression led the OCD or the other way around,
link |
or whether or not they're operating,
link |
as we say in science, in parallel.
link |
Some of the drug treatments for OCD and depression
link |
and anxiety can tease some of that apart.
link |
And we'll talk about that.
link |
But I think it's fair to say that what binds the obsessions
link |
and compulsions is anxiety,
link |
that there's a feeling of it,
link |
or I should say an urgent feeling of a need
link |
to get rid of the obsession.
link |
And the person feels as if the only way they can do that
link |
is to engage in a particular compulsive behavior.
link |
Some people are probably wondering
link |
if there's a genetic component to OCD.
link |
And indeed there is,
link |
although the nature of it isn't exactly clear.
link |
And oftentimes when people hear
link |
that something has a genetic component,
link |
they think it's always directly inherited from a parent.
link |
And that's not always the case.
link |
There can be genes that surface in siblings
link |
or genes that surface in children
link |
that are not readily apparent
link |
in terms of what we call a phenotype.
link |
So you have a genotype, the gene,
link |
and then you have a phenotype,
link |
the way it shows up as a body form or like eye color,
link |
or how it shows up in terms of a behavior
link |
or behavioral pattern.
link |
Based on twin studies where researchers
link |
have examined identical twins, fraternal twins,
link |
even identical twins that share the same sac in utero,
link |
what we call monochorionic.
link |
So sitting in the same little bag during pregnancy
link |
or in different little bags,
link |
you can see different levels
link |
of what's called genetic concordance.
link |
But if we were to just sort of cut a broad swath
link |
through all of the genetic data,
link |
it's fair to say that about 40 to 50% of OCD cases
link |
have some genetic component,
link |
some mutation or some inherited aspect that's genetic
link |
and that one could point to if they got their genome mapped.
link |
Now, while that's interesting,
link |
I don't think it's terribly useful for most people.
link |
First of all, you can't really control your genes,
link |
at least at this point in history,
link |
even though there are things like epigenetic control
link |
and people are very excited about technologies like CRISPR
link |
for modifying the genome.
link |
In humans at some point,
link |
most people can't control their genetics, right?
link |
You can't pick who your parents were, as they say.
link |
So just know that there is a genetic component
link |
in about half of people with OCD, but not always.
link |
Now, as is typical for this podcast,
link |
I want to focus on some of the neural mechanisms
link |
and chemical systems in the brain and body
link |
that generate obsessive compulsive disorder.
link |
In fact, if you've watched this podcast before,
link |
listened to this podcast before,
link |
this is always how I structure things.
link |
First, we introduce a topic and we explore that topic
link |
in detail and really define what it is and what it isn't.
link |
And then it's very important that we focus on what is known
link |
and what is not known about the biological mechanisms
link |
that generate whatever that thing happens to be,
link |
or obsessive compulsive personality disorder.
link |
Now, I want to emphasize that even if you don't have
link |
a background in biology,
link |
I will make this information accessible to you.
link |
And I also want to emphasize that for those of you
link |
that are interested in treatments
link |
and are anxiously awaiting the description of things
link |
that can help with OCD, I encourage you, if you will,
link |
to please try and digest some of the material
link |
about the underlying mechanisms,
link |
because understanding even just a little bit
link |
of those biological mechanisms can really help shed light
link |
on why particular drug and behavioral treatments
link |
and other sorts of treatments work and don't work.
link |
This is especially important in the case of OCD,
link |
where it turns out that the order and type of treatment
link |
can really vary according to individual.
link |
And that's something really special and important about OCD
link |
that we really can't say for a number of the other
link |
sorts of disorders that we've described
link |
on previous podcasts.
link |
So let's take a step back and look at the neural circuitry.
link |
What's going on in the brain and body of people with OCD?
link |
Why the intrusive recurrent thoughts?
link |
Why the compulsions?
link |
Why is that whole system bound by anxiety?
link |
And in some ways in thinking about that,
link |
I want you to keep in mind that the brain
link |
has two main functions.
link |
The brain's main functions are to take care
link |
of all the housekeeping stuff, make sure digestion works,
link |
make sure the heart beats,
link |
make sure you keep breathing no matter what,
link |
make sure that you can see, you can hear,
link |
you can smell, et cetera, the basic stuff.
link |
And then there's an enormous amount of brain real estate
link |
that's designed to allow you to predict
link |
what's going to happen next,
link |
either in the immediate future or in the long-term future.
link |
And largely that's done based on your knowledge of the past.
link |
So you also have memory systems.
link |
And of course, you have systems in the brain and body
link |
that are designed to bind what's happening
link |
at the housekeeping level, like your heart rate,
link |
to your anticipation of what's going to happen next.
link |
So if you're thinking about something very fearful,
link |
your body will have one type of reaction.
link |
If you're thinking about something very pleasant
link |
and relaxing, your body will have another type of reaction.
link |
So whenever I hear about the brain-body distinction,
link |
I have to just remind everybody
link |
that there really is no distinction between brain and body
link |
when you think about it through the nervous system.
link |
The nervous system is the brain, the eyes, the spinal cord,
link |
but of course, all their connections
link |
with all the organs of the body
link |
and the connections of all the organs of the body
link |
with the brain, the spinal cord, et cetera.
link |
So as I describe these neural circuits,
link |
I don't want you to think of them
link |
as just things happening in the head.
link |
They are certainly happening in the head.
link |
In fact, the circuits I'll describe most in detail
link |
do exist within the confines of your cranial vault,
link |
that's nerd speak for skull,
link |
but those circuits are driving particular predictions
link |
and therefore particular biases
link |
towards particular actions in your body.
link |
They're creating a state of readiness
link |
or a state of desire to check or desire to count
link |
or desire to avoid, et cetera, et cetera.
link |
So what are these circuits?
link |
Well, there's been a lot of wonderful research
link |
exploring the neural circuits
link |
underlying obsessive compulsive disorder,
link |
and that's mainly been accomplished
link |
through a couple of methods.
link |
Most of those methods when applied in humans
link |
involve getting some look
link |
into which brain areas are active
link |
when people are having obsessions
link |
and when people are engaging in compulsions.
link |
Now, that might seem simple to do,
link |
but of course, your brain is housed inside the cranial vault
link |
and in order to look inside it,
link |
you have to use things like magnetic resonance imaging,
link |
which is just fancy technology for looking at blood flow,
link |
which relates to activation of neurons, nerve cells,
link |
or things like PET, P-E-T imaging,
link |
which has nothing to do with the verb pet
link |
and has nothing to do with your house pet,
link |
has everything to do with positron emission tomography,
link |
which is just another way of seeing
link |
which brain areas are active,
link |
and then you can also use PET
link |
to figure out what sorts of neurochemicals are active,
link |
like dopamine, et cetera.
link |
Many studies, we can fairly say dozens,
link |
if not hundreds of studies have now identified
link |
a particular circuit or loop of brain areas
link |
that are interconnected and very active
link |
in obsessive compulsive disorder.
link |
That loop includes the cortex,
link |
which is kind of the outer shell of the human brain,
link |
the lumpy stuff, as it sometimes appears
link |
if the skull is removed,
link |
and it involves an area called the striatum,
link |
which is involved in action selection
link |
and holding back action.
link |
The striatum is involved in what's commonly called
link |
go and no-go types of behaviors.
link |
So every type of behavior,
link |
like picking up a pen or a mug of coffee,
link |
involves a go type function.
link |
It involves generating an action.
link |
But every time I resist an action,
link |
my nervous system is also doing that
link |
using this brain structure, the striatum,
link |
which includes, among other things, the basal ganglia.
link |
Talked about that before.
link |
I'm not trying to overload you with terminology here,
link |
but I know some people are interested in terminology.
link |
So you have go behaviors and you have no-go,
link |
resisting of behaviors, not going toward behavior.
link |
The cortex and the striatum
link |
are in this intricate back-and-forth talk.
link |
It's really loops of connections.
link |
The cortex doesn't tell the striatum what to do.
link |
The striatum doesn't tell the cortex what to do.
link |
They're in a crosstalk.
link |
Like any good relationship,
link |
there's a lot of back-and-forth communication.
link |
There's a third element in this corticostriatal loop,
link |
as it's called, and that's the thalamus.
link |
Now, the thalamus is not a structure
link |
I've talked a lot about before on this podcast,
link |
but it's one of my favorite structures to think about
link |
and teach about in neuroanatomy,
link |
which I teach back at Stanford
link |
and have taught for many years elsewhere,
link |
because the thalamus is this incredible egg-like structure
link |
in the center of your brain
link |
that has different channels through it,
link |
channels for relaying visual information
link |
or auditory information or touch information
link |
from your environment up into your cortex,
link |
and as a consequence,
link |
making certain things that are happening to you,
link |
and around you, apparent to you,
link |
making you aware of them,
link |
making you perceive them, and suppressing others.
link |
So for instance, right now, if you're hearing me say this,
link |
your thalamus has what are called auditory nuclei.
link |
Those are just collections of neurons
link |
that respond to sound waves
link |
that are, of course, coming in through your ears,
link |
and your thalamus is active in a way
link |
that those particular regions of your thalamus
link |
are allowed, literally permitted,
link |
to pass the information coming from your ears
link |
through some other steps,
link |
but then to your thalamus, your auditory thalamus,
link |
then up to your cortex,
link |
and you can hear what I'm saying right now.
link |
At the same time, your thalamus is surrounded
link |
by a kind of a shell,
link |
something called the thalamic reticular nucleus.
link |
Again, you don't have to remember the names,
link |
but this thalamic reticular nucleus
link |
also sometimes called the reticular thalamic nucleus.
link |
This is, believe it or not, a subject of debate in science.
link |
There are people that literally hated each other,
link |
probably still hate each other,
link |
even though one of them's dead,
link |
for decades because they would argue
link |
it was the thalamic reticular nucleus,
link |
the other was reticular thalamic nucleus.
link |
Anyway, these are scientists, they're people.
link |
They tend to debate.
link |
But the thalamic reticular nucleus, as I'm going to call it,
link |
serves as a sort of gate
link |
as to which information is allowed to pass through
link |
up to your conscious experience and which is not.
link |
And that gating mechanism is strongly regulated
link |
by the chemical GABA.
link |
GABA is a neurotransmitter that is inhibitory, as we say.
link |
It serves to shut down
link |
or suppress the activity of other neurons.
link |
So the thalamic reticular nucleus is really saying no.
link |
Touch information cannot come in right now.
link |
You should not be thinking about the contact
link |
of the back of your legs
link |
with the chair that you're sitting on, Andrew.
link |
You should be thinking about what you're trying to say
link |
and what you're hearing and how your voice sounds
link |
and what you see in front of you, et cetera.
link |
Whereas if I'm about to get an injection from a doctor
link |
or I'm in pain or I'm in pleasure,
link |
I'm going to think about my somatic sensation
link |
at the level of touch.
link |
And I'm probably going to think less about
link |
smells in the room,
link |
although I might also think about smells in the room
link |
or what I'm seeing and what I'm hearing.
link |
We can combine all these different sensory modalities,
link |
but the thalamic reticular nucleus
link |
really allows us to funnel,
link |
to direct particular categories of sensory experience
link |
into our conscious awareness
link |
and suppress other categories of sensory experience.
link |
In addition, the thalamic reticular nucleus
link |
plays a critical role in which thoughts are allowed
link |
to pass up to our conscious perception
link |
and which ones are not.
link |
So much so that some neuroscientists
link |
and indeed some neurophilosophers,
link |
if you want to call them that,
link |
have theorized or philosophized
link |
that the thalamic reticular nucleus
link |
is actually involved in our consciousness.
link |
Now, consciousness is in a topic
link |
that I really want to talk about this episode
link |
and it's a very kind of mushy, murky,
link |
as we say in science, it's a schmooey term
link |
because it doesn't really have clear definitions
link |
so arguments about it often get lost in the fact
link |
that people are arguing about different things.
link |
But when I say consciousness,
link |
what I mean is conscious awareness.
link |
So let's zoom out and take a look at the circuit
link |
that we've got and that we now know
link |
based on neuroimaging studies is intimately involved
link |
in generating obsessions and compulsions in OCD.
link |
We have a cortex or neocortex,
link |
which is involved in perception
link |
and understanding of what's happening.
link |
We have the striatum and basal ganglia,
link |
which are involved in generating behaviors, GO,
link |
and suppressing behaviors, NO-GO.
link |
And we have the thalamus,
link |
which collects all of our sensory experience in parallel,
link |
hearing, touch, smell, et cetera,
link |
not so much smell through the thalamus I should mention,
link |
but the other senses that is.
link |
And then that thalamus is encased
link |
by the thalamic reticular nucleus,
link |
which serves as a kind of a guard
link |
saying you can pass through and you can pass through,
link |
but you, you, you can't pass through
link |
up to conscious understanding and perception.
link |
So that loop, this corticostriatal thalamic loop,
link |
corticostriatal thalamic loop
link |
is the circuit thought to underlie OCD
link |
and dysfunction in that circuit
link |
is what's thought to underlie OCD.
link |
Now, again, the circuit exists in all of us
link |
and it can operate in healthy ways
link |
or it can operate in ways that make us feel unhealthy
link |
or even suffer from full blown OCD.
link |
How do we know that this circuit is involved in OCD?
link |
Well, there we can look to some really interesting studies
link |
that involve bringing human subjects into the laboratory
link |
and generating their obsessions and compulsions
link |
and then imaging their brain using any variety of techniques
link |
that we talked about before.
link |
What would such an experiment look like?
link |
Well, in order to do that sort of experiment,
link |
first of all, you need people who have OCD
link |
and of course you need control subjects that don't
link |
and you need to be able to reliably evoke the obsessions
link |
and the compulsions.
link |
Now it turns out this is most easily,
link |
or I should say most simply done
link |
because it can't be easy for the people with OCD,
link |
but this is most straightforward.
link |
That's the word I was looking for.
link |
Most straightforward when looking at the category
link |
of obsessions and compulsions
link |
that relate to order and cleanliness.
link |
So what they do typically is bring subjects
link |
into the laboratory who have a obsession
link |
about germs and contamination
link |
and a compulsion to hand wash.
link |
And they give these people, believe it or not,
link |
a sweaty towel that contains the sweat
link |
and the odor and the liquid basically
link |
from somebody else's hands.
link |
In fact, they'll sometimes have someone wipe
link |
their own sweat off the back of their neck
link |
and put it on the towel
link |
and then they'll put it in front of the person,
link |
which as you can imagine for someone with OCD
link |
is incredibly anxiety provoking
link |
and almost always evokes these obsessions about,
link |
oh, this is really bad, this is really bad,
link |
I need to clean, I need to clean, I need to clean.
link |
Now they're doing all this while someone
link |
is in a brain scanner or while they're being imaged
link |
for positron emission tomography.
link |
And then they can also look at the patterns of activation
link |
in the brain while the person is doing hand washing.
link |
Although sometimes the apparatus associated
link |
with these imaging studies make it hard
link |
to do a lot of movement,
link |
they can do these sorts of studies.
link |
They have done these sorts of studies in many subjects
link |
using different variations of what I just described.
link |
And lo and behold, what lights up, when I say lights up,
link |
what sorts of brain regions are more metabolically active,
link |
more blood flow, more neural activity?
link |
Well, it's this particular corticostriatal thalamic loop.
link |
In addition to that, some of the drug treatments
link |
that are effective in some,
link |
and I want to emphasize some individuals
link |
at suppressing obsessions and or compulsions
link |
such as the selective serotonin reuptake inhibitors
link |
or SSRIs, which we'll talk about in a little bit.
link |
When people take those drugs,
link |
they see not just a suppression
link |
of the obsession and compulsion,
link |
but also a suppression of these particular neural circuits.
link |
They become less active.
link |
Now I want to emphasize and telegraph
link |
a little bit of what's coming later.
link |
These drugs like SSRIs do not work for everybody with OCD.
link |
And as many of you know,
link |
they carry other certain problems and side effects
link |
for many, but not all individuals.
link |
But nonetheless, what we have now is an observation
link |
that this circuit, the corticostriatal thalamic loop,
link |
We have a manipulation that when people take a drug
link |
that at least in those individuals is effective
link |
in suppressing or eliminating the obsessions and compulsions
link |
there's less activity in this loop.
link |
And thanks to some very good animal model studies
link |
that at least at this point in time
link |
you really couldn't do in humans,
link |
although soon that may change,
link |
we now know in a causal way that the equivalent circuitry,
link |
A, exists in other animals,
link |
such as mice, such as cats, such as monkeys.
link |
And that activation of those particular
link |
corticostriatal thalamic circuits in animal models
link |
can indeed evoke OCD in an individual
link |
that prior to that did not have OCD.
link |
So I'm just going to briefly describe one study.
link |
This is a now classic study published in the journal Science,
link |
one of the three apex journals in 2013.
link |
The first author on this paper is Suzanne Amari,
link |
I will provide a link to this in the show notes.
link |
It's a truly landmark paper
link |
done in Renee Hen's lab at Columbia University.
link |
And the title of the paper is
link |
Repeated Corticostriatal Stimulation Generates,
link |
that's the key word here,
link |
Generates Persistent OCD-Like Behavior.
link |
What they did is they took mice,
link |
mice do mouse things, they move around,
link |
they play with toys, they eat, they pee, they mate,
link |
they do various things in their cage, but they also groom.
link |
Humans groom, animals with fur groom.
link |
Well, you hope most people groom, some people overgroom,
link |
some people undergroom, but most people groom.
link |
They'll comb their hair, they'll clean, et cetera.
link |
Those are normal behaviors that humans engage in.
link |
I'm not aware that mice comb their hair,
link |
but mice adjust their hair.
link |
So they'll kind of pet their hair and they'll do this.
link |
They'll sometimes even do it to each other.
link |
We used to have mice in the lab.
link |
Now we only do human studies,
link |
but the mice will groom themselves.
link |
And typical, what we call wild type mice,
link |
not because they're wild, but because they're typical,
link |
will groom themselves at a particular frequency,
link |
but not to the point where their hair is falling out,
link |
They are grooming some of the time
link |
and they're doing other mouse things, other mouse times.
link |
So in this particular study,
link |
what they did is they used some technology,
link |
which actually was discussed on a previous episode
link |
of the Huberman Lab Podcast.
link |
This is technology that was developed by a psychiatrist
link |
and bioengineer by the name of Karl Deisseroth,
link |
one of my colleagues at Stanford School of Medicine.
link |
This is technology that allows researchers
link |
to use the presentation of light to control neural activity
link |
in particular brain areas in a very high fidelity way.
link |
You control the activity in the cortex or the striatum
link |
or the thalamus when you want and how you want.
link |
It's really a beautiful technology.
link |
In any event, what they did in this study is,
link |
or I should say what Susan Amari and colleagues did
link |
in the study, was to stimulate the corticostriatal circuitry
link |
in animals that did not have any OCD-like behavior.
link |
And when they did that,
link |
those animals started grooming incessantly
link |
to the point where their hair was falling out
link |
or they even, you know,
link |
they didn't take the experiments this far, fortunately,
link |
but the animals would have a tendency
link |
to almost rub themselves raw.
link |
In the same way that somebody who has a compulsion
link |
to hand wash would, sadly, people will hand wash
link |
to the point where their hands are actually bleeding and raw.
link |
It's really that bad.
link |
I know that's tough imagery to imagine.
link |
And you can't even imagine why someone would self-harm
link |
But again, that's that incredible anxiety relationship
link |
between the compulsion, excuse me,
link |
the obsession and the compulsion,
link |
and the fact that engaging in the compulsion
link |
simply strengthens the obsession and therefore the anxiety.
link |
So that collection of studies, of data,
link |
fMRI, PET scanning in humans, the treatment with SSRIs,
link |
and these experiments where researchers
link |
have actively triggered these particular circuits
link |
in animal models that previously did not have
link |
too much activity in these circuits,
link |
and then they observe OCD emerging really points squarely
link |
to the fact that the corticosteroidal thalamic loop
link |
is likely to be the basis of OCD.
link |
Now, of course, other circuits could also be involved,
link |
but the corticosteroidal thalamic circuit
link |
seems to be the main circuit generating OCD-like behavior.
link |
That's a lot of mechanism.
link |
Hopefully, it was described in a way
link |
that you can digest and understand.
link |
And some of you might be thinking, well, so what?
link |
Why does that help me?
link |
I can't reach into my brain and turn off my cortex.
link |
I can't reach into my brain and turn off my thalamus.
link |
And indeed, on the one hand, that's true.
link |
But as you'll next learn,
link |
when thinking about the various behavioral treatments
link |
and drug treatments and holistic treatments for OCD,
link |
what you'll notice is that each one taps
link |
into a different component
link |
of this corticosteroidal thalamic loop.
link |
And by understanding that,
link |
you can start to see why certain treatments might work
link |
at one stage of the illness versus others.
link |
You will also start to understand why obsessive-compulsive
link |
personality disorder does not have the same sorts
link |
of engagements of these neural loops,
link |
and yet relies on other aspects of brain and body,
link |
and therefore, responds best to other sorts of treatments.
link |
people with obsessive-compulsive personality disorder
link |
are not even seeking treatment, as I alluded to before.
link |
The point here is that by understanding
link |
the underlying mechanism,
link |
why certain drugs and behavioral treatments work
link |
and don't work will become immediately apparent.
link |
And in thinking about that,
link |
in knowing that, you'll be able to make excellent choices,
link |
I believe, in terms of what sorts of treatments you pursue,
link |
what sorts of treatments you abandon,
link |
and most importantly, the order,
link |
the sequence that you pursue and apply those treatments.
link |
Before we go any further,
link |
I'd like to give people a little bit of a window
link |
into what a diagnosis for OCD would look like.
link |
Give you a sense of the sorts of questions
link |
that a clinician would ask
link |
to determine whether or not somebody has OCD or not.
link |
Now, I want to be clear,
link |
I'm not going to do this in an exhaustive way.
link |
I wouldn't want anyone to self-diagnose,
link |
although I'm hoping that by sharing some of this,
link |
that some of you might get insight
link |
into whether or not you do have obsessions and compulsions
link |
that might qualify for OCD
link |
and perhaps even to seek out help.
link |
The most commonly used test of OCD,
link |
or for OCD, I should say,
link |
is called the Yale-Brown Obsessive-Compulsive Scale.
link |
And this is, you know, scientists love acronyms,
link |
as do the military, and it's the Y box,
link |
the Y-B-O-C-S, the Y box.
link |
So typically, someone will go into the clinic,
link |
either because a family member encouraged them to
link |
or because they feel that they're suffering
link |
from obsessions and compulsions.
link |
And before the clinician would proceed
link |
with any kind of direct questions,
link |
they would very clearly define
link |
what obsessions and compulsions are.
link |
And here I'm actually reading from the Y box.
link |
obsessions are unwelcome in distressing ideas,
link |
thoughts, images, or impulses
link |
that repeatedly enter your mind.
link |
They may seem to occur against your will.
link |
They may be repugnant to you.
link |
You may recognize them as senseless,
link |
and they may not fit your personality.
link |
Then there are compulsions.
link |
Quote, compulsions, on the other hand,
link |
are behaviors or acts that you feel driven to perform,
link |
although you may recognize them as senseless or excessive.
link |
At times, you may try to resist doing them,
link |
but this may prove difficult.
link |
You may experience anxiety that does not diminish
link |
until the behavior is completed.
link |
And as I mentioned before,
link |
in many cases, immediately after the behavior is completed,
link |
the anxiety doesn't just return, it indeed can strengthen.
link |
Now, there are a tremendous number of questions
link |
So, I'm just going to highlight
link |
a few of the general categories.
link |
Typically, the person will fill out a checklist.
link |
So, they will designate whether or not currently
link |
or in the past, they have, for instance,
link |
aggressive obsessions,
link |
fear that one might harm themselves,
link |
fear that one might harm others,
link |
fear that they'll steal things,
link |
fear that they will act on unwanted impulses,
link |
currently or in the past or both.
link |
That's one category.
link |
The other one are contamination obsessions.
link |
So, concern with dirt or germs,
link |
bothered by sticky substances or residues,
link |
et cetera, et cetera.
link |
So, a bunch of different categories that include,
link |
for instance, sexual obsessions,
link |
what are called saving obsessions,
link |
even moral obsessions, right?
link |
Excess concern with right or wrong or morality,
link |
concerned with sacrilege and blasphemy,
link |
obsession with need for symmetry and exactness.
link |
Again, all of these questions being answered
link |
as either present in the past or not present in the past,
link |
present currently or not present currently.
link |
And then the test generally transitions over
link |
to questions about target symptoms.
link |
They're really trying to get people to identify
link |
if they have obsessions, what are their exact obsessions?
link |
Now, this turns out to be really important
link |
because as we talk about some of the therapies
link |
I'll just give away a little bit of why they work best
link |
in certain cases and why they don't work as well
link |
it turns out that it becomes very important
link |
for the clinician and the patient
link |
to not just identify the obsessions
link |
and the compulsions generally
link |
in a kind of a generic or top contour way,
link |
but to really encourage or even force the patient
link |
to define very precisely
link |
what the biggest, most catastrophic fear is,
link |
what the obsession really relates to.
link |
That turns out to be very important
link |
in disrupting this corticostriatal thalamic loop
link |
and getting relief from symptoms one way or the other.
link |
So the Yale Brown Obsessive Compulsive Scale,
link |
this Y box, again, is very extensive.
link |
It goes on for dozens of pages actually
link |
and has all these different categories,
link |
not so much designed to just pinpoint
link |
what people obsess about or what they feel compelled to do,
link |
but to also try and identify
link |
what is the fear that's driving all this, right?
link |
In the way that we've set this up thus far,
link |
we've been talking about obsessions and compulsions
link |
as kind of existing in a vacuum.
link |
You're obsessed about germs and you're compelled
link |
to wash your hands,
link |
obsessed about germs, compelled to wash your hands,
link |
or obsessed about symmetry,
link |
compelled to put right angles on everything,
link |
or obsessed about counting and therefore counting, et cetera.
link |
But beneath that is a cognitive component
link |
that is not at all apparent
link |
from someone describing their obsession
link |
and from someone describing or displaying their compulsion.
link |
The deeper layer to all that is what is the fear exactly
link |
if one were to not perform the compulsion,
link |
meaning what is the fear that's driving the obsession?
link |
So that brings us to a very powerful category of treatments
link |
that I should say does not work in everybody with OCD,
link |
but works in many people with OCD
link |
and really speaks to the underlying neural circuitry
link |
that generates OCD and how to interrupt it.
link |
And that is the treatment of cognitive behavioral therapy
link |
and in particular exposure based cognitive
link |
behavioral therapy.
link |
So we're going to talk about cognitive behavioral therapy
link |
and exposure therapy now, but right at the outset,
link |
I want to distinguish the kinds of cognitive behavioral
link |
therapy and exposure therapies that are done
link |
for obsessive compulsive disorder,
link |
the sorts of cognitive behavioral therapies that are done
link |
for other types of mental challenges and disorders.
link |
Because cognitive behavioral therapy for OCD
link |
really has everything to do with identifying
link |
In some sense, we can think of fears
link |
as kind of along a hierarchy, right?
link |
In the example earlier of somebody being afraid
link |
to turn left and therefore feeling compelled to turn right,
link |
you would want to take that person and really understand
link |
what do they fear most about turning left?
link |
Now they might not be aware of it.
link |
They might not be conscious to what that really is,
link |
but if you were to probe them in a clinical setting,
link |
you would eventually get to an answer.
link |
That answer could be at first, I don't know,
link |
I don't know why it's bad, it makes no sense,
link |
but it's just bad, I do not want to go left.
link |
I don't know why, I don't know why.
link |
But if you were to push that person a little bit
link |
in a respectful and kind and caring way aimed
link |
at their treatment, if you were to push them and say,
link |
well, what do you mean by bad?
link |
If you turn left, do you think the world would end?
link |
They might say, no, the world's not going to end,
link |
but someone is going to die suddenly.
link |
I know that sounds crazy, but somebody's going to die
link |
suddenly, this almost sounds like superstition.
link |
We'll talk about superstitions later,
link |
but indeed it is somewhat superstitious.
link |
So for instance, you would say, who's going to die?
link |
And they'd say, I don't know.
link |
And you'd say, no, really, who's going to die?
link |
If you think about this, are you going to die?
link |
Is so-and-so going to die?
link |
And very often, very often, what you find is that
link |
people will start to reveal the underlying obsession
link |
at a level of detail that both to the clinician
link |
and to them can be somewhat astonishing,
link |
even though they've been living with that detail
link |
in their mind for a very long time.
link |
Now, how could somebody start to reveal detail
link |
about something that's existed in their mind
link |
for a very long time, but not known about it, right?
link |
Not been aware of it.
link |
Now, some of you might think,
link |
oh, it's repressed or something.
link |
That's not at all what's happening.
link |
If you think about the architecture of OCD,
link |
typically people will have an obsession
link |
and then they'll engage in the compulsion
link |
as quickly as they can to relieve that obsession.
link |
So in many ways, the disease itself prevents people
link |
from ever getting to the bottom of that trough,
link |
ever getting to the point
link |
where they really clearly articulate to themselves
link |
exactly what it is that they fear.
link |
But it becomes so essential to articulate
link |
exactly what it is that they fear
link |
for a somewhat counterintuitive reason.
link |
You might think, oh, the moment they realize
link |
exactly what they fear, everything lifts.
link |
The circuit turns off and they just feel better
link |
because they realized it.
link |
I wish I could tell you that's the case,
link |
but it turns out it's the opposite.
link |
What the clinician is actually trying to do
link |
is get people to feel more anxiety, not less.
link |
What they're trying to get them to do
link |
is to short circuit, no pun intended,
link |
to intervene in their own neural circuit, I should say,
link |
with that relief of anxiety, however brief,
link |
brought on by engaging in the compulsion
link |
related to the obsession.
link |
So whereas typically someone would feel the obsession
link |
with, oh, I don't want to turn left
link |
because something bad's going to happen,
link |
someone's going to die, and then they turn right,
link |
they never get the option or the opportunity
link |
to really explore what would happen were they to turn left
link |
or to not be able to turn right.
link |
By forcing them down the path of inquiry,
link |
that leads them to the place
link |
where they very clearly identify the fear, the anxiety.
link |
It raises the anxiety in them,
link |
and that's actually what the clinician is after.
link |
Cognitive behavioral therapy and exposure therapy
link |
in the context of OCD most often involves
link |
trying to get people to tolerate, not relieve their anxiety.
link |
This is extremely important,
link |
and I realize there's variation to this
link |
depending on the style of cognitive behavioral therapy,
link |
the style of exposure therapy, but almost across the board,
link |
the goal, again, is to get people to feel the anxiety
link |
that normally they are able to at least partially relieve,
link |
however briefly, by engaging in the compulsion.
link |
So if we think back to that circuit
link |
of corticostriatal thalamic, what's going on here?
link |
Where is CBT intervening?
link |
What part of the circuit is getting interrupted?
link |
Well, as you recall,
link |
the cortex is involved in conscious perception,
link |
the thalamus and that thalamic reticular nucleus
link |
are involved in the passage of certain types of experience
link |
up to our conscious perception, not others,
link |
and the striatum is involved
link |
in this go, no-go type behavior.
link |
When OCD is really expressing itself in its fullness,
link |
people feel an anxiety around a particular thought,
link |
and they either have a go, for instance, wash hands,
link |
or a no-go, do not turn left type reaction.
link |
By having people progressively in a kind of hierarchical way
link |
reveal their precise source of anxiety,
link |
their utmost fear in this context,
link |
what happens is they feel enormous amounts
link |
of autonomic arousal.
link |
Now, in the context of anxiety treatment
link |
or other types of treatments,
link |
the goal would be to teach people to dampen,
link |
to lessen their anxiety through breathing techniques
link |
or through visualization techniques
link |
or through self-talk or through social support,
link |
any of the number of things that are well known
link |
to help people self-regulate their own anxiety.
link |
Here, it's the opposite.
link |
What they're trying to get the patient to do
link |
is to really feel the anxiety at its maximum,
link |
but then do the exact opposite
link |
of whatever the normal compulsion is.
link |
So if normally the compulsion is to wash one's hands,
link |
then the idea is to suppress hand washing
link |
while being in the experience of the utmost anxiety.
link |
Or in the case of not turning left,
link |
the person is expected to,
link |
or would hopefully be able to actually turn left.
link |
And as you can imagine, that would evoke tremendous anxiety
link |
and yet to tolerate that anxiety.
link |
Now, I want to be very clear.
link |
This is not the sort of thing you want to do on your own.
link |
This is not the sort of thing you want to do for a friend.
link |
This is done by trained licensed psychologists
link |
and psychiatrists.
link |
But nonetheless, it really points to the fact
link |
that as a anxiety-related disorder,
link |
OCD is distinct from other types of anxiety
link |
and anxiety-related disorders,
link |
things like PTSD and panic disorder, et cetera,
link |
because the goal again is to bring the person
link |
right up close to the thing that they fear the most
link |
and then to interrupt the circuit.
link |
And now you should be able to know just intuitively,
link |
because you understand the mechanisms,
link |
that the circuit you're trying to disrupt
link |
is the pattern of information flow
link |
from the thinking part of the brain,
link |
the perception part of the brain,
link |
which is the cortex, to the striatum, right?
link |
The striatum has these neurons which are active
link |
that essentially are,
link |
I know it sounds a little bit
link |
like a discussion about free will,
link |
but they're trying to get the person
link |
to generate a certain behavior
link |
or suppress a certain behavior.
link |
And as anxiety ramps up,
link |
it's sort of a hydraulic pressure to do that very thing
link |
that they've done for so long
link |
and they suffer from so much.
link |
We talked about hydraulic pressure
link |
in the context of aggression in the aggression episode.
link |
This is very similar, right?
link |
There's a kind of a, now when I say hydraulic pressure,
link |
it's not actual hydraulic pressure.
link |
It's the confluence of a lot of different systems.
link |
It's neurochemical, as we'll soon learn.
link |
It's hormonal, it's electrical.
link |
It's a lot of different things operating in parallel.
link |
So we can't point to one chemical or transmitter.
link |
What's happening is the person is feeling compelled
link |
to act, act, act to relieve the anxiety.
link |
And through a progressive type of exposure, right?
link |
You don't throw people in the deep end
link |
in this kind of therapy right off the bat.
link |
You gradually ratchet them toward
link |
or move them toward the discussion
link |
of exactly what they fear the most.
link |
And then eventually move them toward
link |
the interruption of the compulsion
link |
as they're feeling this extremely elevated anxiety.
link |
Of course, within the context
link |
of a supportive clinical setting.
link |
But in doing that, what you are teaching people
link |
is that the anxiety can exist without the need
link |
to engage in the compulsion.
link |
Now, some of this might sound to people like,
link |
oh, this is a lot of the kind of fancy
link |
psychological neuroscience speak
link |
around something that's kind of intuitive.
link |
But I think for most people, this is not intuitive.
link |
And for people with OCD, there's no really other way
link |
to put it, the impulse, the compulsion to avoid anxiety
link |
is such a powerful driving force
link |
that it should now make sense to you
link |
as to why being able to tolerate anxiety
link |
and really sit with it and do the exact opposite
link |
of what you're normally compelled to do
link |
is going to be the path to treatment.
link |
And indeed CBT has been shown to be enormously effective,
link |
again, for a large number of people with OCD,
link |
but not all of them.
link |
And oftentimes it requires that it also be used
link |
in concert with certain drug treatments,
link |
which we're going to talk about in a moment.
link |
Next, let's talk about some of the really unique features
link |
of cognitive behavioral therapy and exposure therapy
link |
in the context of OCD that you often don't see
link |
in the use of CBT, that is cognitive behavioral therapy,
link |
for other types of psychiatric challenges and disorders.
link |
The first element is one of staircasing.
link |
And I already mentioned this before,
link |
but this gradual and progressive increase in the anxiety
link |
that you're trying to evoke from the patient,
link |
from the person suffering from OCD.
link |
That's done in the context of the office or the laboratory,
link |
again, by a trained and licensed clinician.
link |
But then the person leaves, right?
link |
They leave the office, they leave the laboratory.
link |
And a very vital component of CBT and exposure therapy
link |
for people with OCD is that they have and perform
link |
what's called homework, is literally what they call.
link |
This might be seen in other sorts of treatments,
link |
but for OCD, homework is extremely important
link |
because within the context of a laboratory experiment
link |
or the clinic, patients often feel so much support
link |
that they can tolerate those heightened levels of anxiety
link |
and interrupt their compulsions.
link |
Whereas when they get home, oftentimes the familiarity
link |
of the environment brings them to a place
link |
where all of a sudden those obsessions and compulsions
link |
start interacting the same way
link |
and they have a very hard time suppressing the behaviors.
link |
Why would that be?
link |
Well, in neuroscience, we have a phrase,
link |
it's called condition place preference
link |
and condition place avoidance.
link |
There's some other phrases too,
link |
but basically it all has to do with a simple thing,
link |
which is when you feel something repeatedly
link |
in a given environment,
link |
or sometimes even once within a given environment,
link |
you tend to feel that same thing again
link |
when you return to that or similar environments, okay?
link |
So condition place blank or condition place that
link |
is simply fancy nerd speak for the fact that
link |
when you're in a place and something good happens,
link |
you tend to feel good if you return to that place
link |
or a place like it,
link |
or if something bad happens in a given place,
link |
you tend to feel bad when you return to that place
link |
or a place like it.
link |
I think the most salient example that leaps to mind
link |
is in unfortunately the category of bad,
link |
but I had some friends years ago visit San Francisco.
link |
There's been a ongoing,
link |
it seems like it's been happening forever,
link |
but this is really in the last decade of daytime break-ins
link |
and nighttime break-ins into cars to steal anything
link |
from computers to what seems to be like a box of tissues.
link |
And there are numerous reasons for this.
link |
I don't want to get into,
link |
it's not the topic of today's podcast,
link |
but I will use this as an opportunity to say,
link |
if you're visiting anywhere in the Bay Area,
link |
do not leave anything in your car
link |
because the window will get broken into
link |
sometimes in broad daylight.
link |
Some good friends of mine were visiting the Bay Area
link |
and I texted them and said,
link |
hey, by the way, when you're headed to dinner, guys,
link |
make sure you bring in all your luggage and computers,
link |
however inconvenient that might be.
link |
They wrote back, too late, everything got stolen.
link |
So some years ago now,
link |
I think five, six years ago, this happened.
link |
Sadly, everything got stolen.
link |
Most of it could be replaced,
link |
but some of it was very sentimental to them.
link |
Every time we talk,
link |
every time we consider having a meeting
link |
in a particular city,
link |
this comes up as I don't want to be there,
link |
I don't like that city anymore, et cetera.
link |
And of course, San Francisco has some wonderful
link |
redeeming features,
link |
but it only takes one bad incident in one location
link |
to kind of color the whole picture dark, so to speak.
link |
The brain works that way.
link |
The brain generalizes.
link |
It's not a very specific organ.
link |
Again, it's a prediction machine in addition to other things.
link |
So in the case of CBT therapy,
link |
the reason there's homework is that when people go home,
link |
oftentimes that's when they relapse,
link |
if you want to call it that,
link |
back into their obsessions and compulsions.
link |
And that location, that conditioned place
link |
is where it becomes most important
link |
to challenge the anxiety and to deal with the anxiety,
link |
to not try and suppress the anxiety
link |
through compulsions or other means.
link |
And when I say other means, I want to highlight something.
link |
We'll come up again a little bit later in the podcast
link |
that substance abuse is very common in people with OCD
link |
because of the anxiety component
link |
and also because of people's feelings
link |
that they just can't escape from the thoughts
link |
or behavioral patterns that are so characteristic of OCD.
link |
So alcohol abuse or cannabis abuse
link |
or other forms of narcotics abuse are very common in OCD.
link |
Later, we'll talk about whether or not cannabis can
link |
or cannot help with OCD, but needless to say,
link |
suppressing anxiety is exactly the wrong direction
link |
that one should take if the goal is to ultimately relieve
link |
or eliminate the OCD.
link |
So we now have two characteristics of CBT exposure therapy
link |
that are extremely important for OCD
link |
and somewhat unique to the treatment of OCD.
link |
And that's the staircasing up towards the really bad fear,
link |
the really severe and specific articulation
link |
and understanding and feeling of how bad things really
link |
would be if someone engaged in a particular behavior
link |
or avoided a particular behavior.
link |
Then there's the component of homework
link |
given by the clinician for the person to be able
link |
to create a broader set of contexts
link |
in which they can deal with the anxiety,
link |
not engage in the compulsions.
link |
And then a very unique feature of treatment of OCD
link |
that you don't see in many other psychiatric disorders
link |
I find this fascinating.
link |
I think that the field of psychiatry and psychology
link |
traditionally doesn't allow for or invite home visits,
link |
but this component of context, location and context
link |
being so vital to the treatment and relief of OCD
link |
has inspired many psychiatrists and psychologists
link |
to get permission to do home visits
link |
where they actually go visit their patients
link |
in their native setting, in their home cages, right?
link |
They're not mice, but in their home home cages, right?
link |
I'm being facetious here, but people,
link |
mice live in cages, at least in the laboratory
link |
and humans generally live in houses or elsewhere.
link |
So they visit them in their home
link |
in order to see how they're interacting
link |
and the particular locations that evoke the most anxiety
link |
and the least anxiety.
link |
Some of the, I don't want to call them crutches,
link |
but some of the tools that people are using
link |
to confront and deal with the obsessions and compulsions
link |
and in particular, to try and identify
link |
some of the tools and tricks that people are using
link |
to try and avoid that heightened anxiety.
link |
Because once again, and I know I'm repeating myself,
link |
but I think this is just so vital and so unique
link |
about OCD and the treatment of OCD,
link |
the critical need for the patient
link |
to be able to tolerate extremely elevated levels of anxiety
link |
So if people are avoiding certain rooms in the house,
link |
or if people are avoiding certain foods
link |
or certain locations in the kitchen,
link |
the clinician can start to identify that
link |
by mere observation.
link |
And I should mention here that patients
link |
are not always aware of how they are interacting
link |
with their home environment.
link |
Some of these patterns are so deeply ingrained in people
link |
that they don't even realize
link |
that they're constantly turning to the left
link |
or they don't even realize
link |
that they're only washing their hands
link |
on one side of the sink.
link |
And so the clinician by visiting the home
link |
can start to interrogate a bit in a polite way,
link |
in a friendly, in a supportive way
link |
as to do you ever think about why you always
link |
flip the faucet to the left
link |
or flip the faucet to the right, et cetera.
link |
Now, we all do a lot of things that are habitual.
link |
We all do things that are somewhat regular from day to day.
link |
In fact, I would invite you to ask yourself,
link |
do you always put your toothbrush in the same location?
link |
Do you always cap the toothbrush before or after you use it?
link |
What sorts of things do you wipe the little threading
link |
on the toothpaste or not?
link |
I'm somebody, I confess that I have,
link |
well, I have about 3,500 pet peeves,
link |
but one of my pet peeves is toothpaste
link |
kind of on the thread of the toothpaste.
link |
It really bothers me.
link |
Almost as much as trying to wipe it off bothers me,
link |
which creates a certain challenge.
link |
And if I talk about this any further,
link |
then I think I would qualify
link |
for obsessive compulsive personality disorder.
link |
But I have to say,
link |
I don't experience a ton of anxiety about it.
link |
It doesn't govern my life.
link |
In fact, I realized that right now
link |
there are tubes of toothpaste
link |
that have toothpaste along the thread
link |
everywhere in the world, and it doesn't really bother me.
link |
I can still sit here
link |
and provide some information about OCD to you.
link |
It's not intrusive, at least not to my awareness.
link |
So by the home visit,
link |
the therapist can really start to explore
link |
through direct questioning
link |
and can allow the patient to explore
link |
through direct questioning of themselves
link |
the things that it might be conscious of
link |
and the things that they might not be conscious of
link |
that would qualify for OCD.
link |
So I'd like to just briefly summarize the key elements
link |
of cognitive behavioral therapy and exposure therapy
link |
and how they can be combined with drug treatments
link |
that are very effective.
link |
Much of what I'm going to talk about next
link |
relates to the data and indeed the practice
link |
of an incredible research scientist and clinician.
link |
So this is Helen Blair Simpson,
link |
or I should say Dr. Helen Blair Simpson
link |
because she is indeed an MD, medical doctor,
link |
and a PhD research scientist
link |
at Columbia University School of Medicine.
link |
And one of the world's foremost experts, if not the expert,
link |
I would put her in a category
link |
of maybe just one to three people
link |
who is most knowledgeable about the mechanisms of OCD,
link |
is actively researching OCD in humans,
link |
trying to find new treatments,
link |
trying to unveil new mechanisms
link |
and expand on our current understanding
link |
and who also treats OCD quite actively in her own clinic.
link |
Dr. Simpson gave a beautiful presentation
link |
in which she summarized some of the core elements of CBT
link |
and exposure therapy
link |
for the treatment of obsessive compulsive disorders.
link |
She describes that the key procedures are exposures,
link |
of course, done in person and with the actual thing
link |
that evokes the obsessions and compulsions.
link |
So this could be the sweaty towel as described earlier,
link |
or could be any number of different triggers
link |
done with the patient in real time.
link |
So in vivo, as we say.
link |
And it could also be things that are imaginal,
link |
sitting somebody down in a chair in an office and saying,
link |
okay, I want you to imagine the thing
link |
that triggers the intrusive thought,
link |
or let's just focus on the intrusive thought as it arises
link |
and then to explore and expose the patient
link |
to their obsessions and compulsions that way.
link |
So it can be real or it can be imaginal.
link |
And the goal of course then is to gradually
link |
and progressively increase the level of anxiety,
link |
but then to intervene in so-called ritual prevention
link |
to prevent the person from engaging in the compulsion.
link |
The goals, again, I'm paraphrasing here,
link |
are to, as she states,
link |
disconfirm fears and challenge the beliefs
link |
about the obsessions and compulsions,
link |
to intervene in the thoughts and the behaviors,
link |
and to break the habit of ritualizing and avoiding.
link |
Now, how is this typically done?
link |
What are the nuts and bolts of this procedure?
link |
Typically, this is done through two planning sessions
link |
So describing to the patient what will happen
link |
and when it will happen and how long it will happen
link |
so they're not just thrown into this out of the blue.
link |
And then 15 exposure sessions done twice a week or more.
link |
So the one thing to really understand
link |
about cognitive behavioral therapy
link |
is that it can take some period of time,
link |
several or more weeks, as many as 10 or 12 weeks.
link |
However, as you'll soon learn,
link |
many of the drug treatments that are effective
link |
in treating OCD either alone
link |
or in combination with behavioral therapies
link |
also can take eight, 10, 12 weeks or longer,
link |
and many of those never work at all.
link |
So even though 10 to 12 weeks
link |
seems like a long period of time,
link |
it's actually pretty standard.
link |
If you'd like to see more complete description
link |
of the protocols for cognitive behavioral therapy
link |
and exposure therapy for OCD,
link |
I'll provide links to two papers,
link |
COSAC and FOA, F-O-A, which is published in 1997,
link |
which might seem like a long time ago,
link |
but nonetheless, the protocols are still very useful.
link |
And then the second paper is by that last author,
link |
Faux et al. in 2012,
link |
and we'll provide links to both of those.
link |
In addition, Dr. Blair Simpson and others have explored
link |
what are the best treatments for patients with OCD
link |
by comparing cognitive behavioral therapy alone, placebo,
link |
so essentially no intervention,
link |
or something that takes an equivalent amount of time
link |
but is not thought to be effective in treatment,
link |
as well as selective serotonin reuptake inhibitors.
link |
So what is an SSRI?
link |
An SSRI is a drug that prevents the reuptake
link |
of serotonin at the synapse.
link |
What are synapses?
link |
They're the little spaces between neurons
link |
where neurons communicate with one another
link |
by vomiting little bits of chemical into the space,
link |
the synapse, and then those chemicals
link |
either evoke or suppress the electrical activity
link |
of the next neuron across the synapse.
link |
And in this case, the neurotransmitter,
link |
the chemical that we're referring to is serotonin.
link |
SSRI, selective serotonin reuptake inhibitors,
link |
prevent the reuptake of the chemical that's left,
link |
in this case, the serotonin that's left in the synapse
link |
after that, I called it vomiting to be dramatic,
link |
but it's not actually a vomiting,
link |
the extrusion of the chemical into the synapse.
link |
And as a consequence, there's more serotonin around
link |
to have more of an effect over time,
link |
the net effect being more serotonergic transmission,
link |
more serotonin overall.
link |
So not more serotonin being made,
link |
more serotonin being available for use.
link |
That's what an SSRI does.
link |
So they compared cognitive behavioral therapy, SSRIs,
link |
they also had the placebo group
link |
and they had cognitive behavioral therapy
link |
plus the selective serotonin reuptake inhibitor.
link |
This was a 12-week study done as described before,
link |
two times a week over the course of 12 weeks.
link |
First of all, the most important thing, of course,
link |
placebo did nothing.
link |
It did not relieve the OCD to any significant degree, right?
link |
How did they know that?
link |
They gave them the Y-box test that we talked about before,
link |
the Yale-Brown test with all those questions
link |
of which I read a few.
link |
So the OCD severity that one has to have on the Y-box
link |
is measured in terms of an index that goes from any here
link |
from eight all the way up to 28,
link |
that shouldn't mean anything.
link |
So the number eight is kind of meaningless here.
link |
It's in terms of an index that's only meaningful
link |
But if somebody has a threshold of 16 or higher,
link |
it means that they're still having
link |
somewhat debilitating symptoms
link |
or very debilitating symptoms.
link |
Placebo did not reduce the obsessions or compulsions
link |
to any significant degree.
link |
However, and I think quite excitingly,
link |
cognitive behavioral therapy had a dramatic effect
link |
in reducing the obsessions and compulsions
link |
such that by four weeks, that score,
link |
that in this case range from eight to 28,
link |
dropped all the way from 25 down to about 11.
link |
So it's a huge drop in the severity of the symptoms.
link |
Now, what's really interesting
link |
is that when you look at the effects of SSRIs
link |
in the treatment of OCD symptoms,
link |
they had a significant effect
link |
in reducing the symptoms of OCD
link |
that showed up first at four weeks
link |
and then continued to eight weeks.
link |
In fact, there was a progressive and further reduction
link |
in OCD symptoms from the four to eight week period.
link |
Again, these are the people just taking the SSRI.
link |
And then it sort of flattened out a little bit
link |
such that by 12 weeks,
link |
there was still a significant reduction in OCD symptoms
link |
for people taking SSRIs as compared to placebo.
link |
But the severity of their symptoms
link |
was still much greater
link |
than those receiving cognitive behavioral therapy alone.
link |
So at least in this study,
link |
and I should tell you which study it is.
link |
This is Faux Leibowitz et al. 2005
link |
in the American Journal of Psychiatry.
link |
We'll also provide a link to this
link |
so you can peruse the data if you like.
link |
But at least in this study,
link |
cognitive behavioral therapy was the most effective.
link |
Selective serotonin reuptake inhibitors, less effective.
link |
So what happens when you combine them?
link |
Well, they explored that as well.
link |
And the combination of cognitive behavioral therapy
link |
and the SSRIs together
link |
did not lead to any further decrease in OCD symptoms.
link |
This points to the idea that cognitive behavioral therapy
link |
is the most effective treatment.
link |
And again, when I say cognitive behavioral therapy,
link |
now I'm still referring to cognitive behavioral
link |
slash exposure therapy
link |
done in the way that I detailed before.
link |
Twice a week for 12 weeks or more.
link |
So all of the data, at least in this study,
link |
point to the fact that cognitive behavioral therapy
link |
is really effective and the most effective.
link |
Does it alleviate OCD symptoms for everybody?
link |
No. Is it very time consuming?
link |
Yes. Twice a week for two sessions or more of 15 minutes,
link |
sometimes in the office, plus there's homework,
link |
plus in an ideal case, there's also home visits
link |
from the psychiatrist or psychologist.
link |
That's a lot of investment, a lot of time investment
link |
to say nothing of the potential financial investment.
link |
Now, Dr. Blair Simpson has given some beautiful talks
link |
where she describes these data
link |
and also emphasizes the fact that
link |
despite the demonstrated power of cognitive behavioral
link |
therapy for the treatment of OCD,
link |
most people are given drug treatments
link |
simply because of the availability of those drug treatments.
link |
Now, when I say most people,
link |
I want to emphasize that I'm referring to
link |
most people who actually go seek treatment
link |
because a really important thing to realize
link |
is that most people with OCD
link |
do not actually go seek evidence-based treatment.
link |
I want to repeat that.
link |
Most people with OCD do not seek evidence-based treatment,
link |
which is a tragic thing.
link |
One of the motivations for doing this podcast episode
link |
is to try and encourage people
link |
who think they may have persistent obsessions
link |
and compulsions to seek treatment,
link |
but most people don't for a variety of reasons
link |
we spelled out earlier, shame, et cetera.
link |
Of those that do, the first line of attack
link |
is typically a prescription, most often an SSRI,
link |
although not always just SSRIs
link |
because soon we'll talk about the somewhat common use
link |
of also prescribing a low dose of a neuroleptic
link |
or an antipsychotic, not always, but often.
link |
So the important thing to understand here
link |
is that excellent researchers like Dr. Simpson
link |
understand that while there are treatments
link |
that we could say are best or are ideal based on the data,
link |
that doesn't necessarily mean that's what's being deployed
link |
most often in the general public.
link |
As a consequence, Dr. Simpson and others
link |
have explored in a very practical way
link |
whether or not it matters
link |
if somebody is getting SSRI treatment
link |
and is experiencing that reduction in OCD symptoms
link |
that as you may recall
link |
is more than what they would experience with placebo alone,
link |
but not as dramatic a reduction in OCD symptoms
link |
as they would get with cognitive behavioral therapy.
link |
And as I mentioned before,
link |
there was this exploration of combining drug treatment
link |
with cognitive behavioral therapy from the outset,
link |
but they also quite impressively explored
link |
what happens when people who are already taking SSRIs
link |
initiate cognitive behavioral therapy.
link |
This is a really wonderful thing that they've done this
link |
because in doing that, first of all,
link |
they're acknowledging that there are many people out there
link |
who have sought treatment
link |
and are getting some relief from those SSRIs,
link |
but it perhaps is not as much relief as they could get.
link |
And they are actively acknowledging
link |
that many people are getting these drug treatments first.
link |
In fact, most often people
link |
are getting these drug treatments first.
link |
So what happens when you add in cognitive behavioral therapy?
link |
Well, the good news is
link |
when you add cognitive behavioral therapy
link |
to someone who's already taking SSRIs,
link |
that further improves their symptoms.
link |
Now that's different than the results
link |
that I described before from the same laboratory in fact,
link |
that if you combine cognitive behavioral therapy
link |
with SSRIs from the outset,
link |
there's no additional benefit of SSRI.
link |
However, as I just described,
link |
if someone is already taking an SSRI
link |
and they're experiencing a reduction in their OCD symptoms,
link |
by adding in cognitive behavioral therapy,
link |
there's a further reduction in the symptoms of OCD.
link |
So it's very important.
link |
So for those of you that have sought treatment
link |
and you're taking a SSRI,
link |
or if you're thinking about treatment
link |
and you're prescribed an SSRI,
link |
the ideal scenario really would be
link |
to combine the drug treatment
link |
with cognitive behavioral therapy,
link |
or in some cases, maybe cognitive behavioral therapy alone,
link |
although that's a decision that you really have to make
link |
with the close advice and oversight of a licensed physician,
link |
because of course these are prescription drugs.
link |
And anytime you're going to add or remove a prescription drug
link |
or change dosage, you really want to do that
link |
in close discussion with and on the advice of your physician.
link |
I don't just say that to protect me,
link |
I say that to protect you
link |
and because it's just the right thing to do.
link |
So again, cognitive behavioral therapy is extremely powerful.
link |
Drug treatments seem less powerful,
link |
though if you're already on a drug treatment,
link |
adding cognitive behavioral therapy can really help.
link |
So I've been talking about SSRIs
link |
and described a little bit about how they work
link |
at a kind of superficial level
link |
of keeping more serotonin in the synapse
link |
so that more serotonin can be in action
link |
as opposed to gobbled back up by those neurons.
link |
I should just mention
link |
what some of the selective serotonin reuptake inhibitors are.
link |
So things like clomipramine,
link |
which is not entirely selective,
link |
I should say that that one generally falls
link |
into a category of less selective.
link |
So it can impair or can enhance
link |
some of the other neurotransmitter
link |
or neuromodulator systems like epinephrine, et cetera.
link |
The selective serotonin reuptake inhibitors are,
link |
at least the classic ones are fluoxetine, Prozac,
link |
fluvoxamine, fluvox, peroxetine, sertraline, citalopram,
link |
et cetera, et cetera.
link |
There are about six classic SSRIs.
link |
Some of them like citalopram are used in children
link |
and are available in pediatric doses.
link |
Some like Prozac may or may not be used in children.
link |
The details of which SSRIs, et cetera,
link |
is a very extensive literature and discussion.
link |
And I think it's safe to say that which drugs to use
link |
and at which dosage and whether or not to continue,
link |
excuse me, the same dosage over time
link |
depends a lot on the individual variation
link |
that people express and the responses that they have.
link |
All of these drugs, in fact,
link |
I think we can say all drugs have side effects.
link |
The question is how detrimental
link |
those side effects are to daily life.
link |
The SSRIs are well known to have effects on appetite.
link |
In some cases, they abolish appetite.
link |
In some cases, they just reduce it a little bit.
link |
In some cases, they increase appetite,
link |
really is highly individual.
link |
They can have effects on libido.
link |
For instance, they can reduce sex drive,
link |
sometimes in a dose dependent way,
link |
sometimes in a way that's more like a step function
link |
where people are fine at say five or 10 milligrams,
link |
but then they get to 15 milligrams
link |
and there's a cliff for their libido.
link |
That can happen, it really depends.
link |
Please don't take those dosages as exact values
link |
because this is going to depend on what they're being used
link |
for, depression or anxiety or OCD.
link |
And it's also going to depend on the drug, et cetera.
link |
I just threw out those numbers as a way to illustrate
link |
what a kind of a step function would look like.
link |
It's not gradual, it's immediate at a given dose
link |
is what that means.
link |
The other thing is that some of these drugs
link |
will have transient effects.
link |
So side effects that show up and then disappear,
link |
or sadly people will sometimes take these drugs for a while
link |
and then side effects will surface later
link |
that weren't there previously,
link |
depending on life factors, nutrition factors.
link |
So it's a very complicated landscape overall.
link |
And that's why it's really important to explore
link |
any kind of drug treatment, SSRI or otherwise,
link |
really in close communication with a psychiatrist
link |
who really understands the pharmacokinetics
link |
and has a lot of patient history and experience with them.
link |
So what I'm about to tell you next
link |
is most certainly going to come as a big surprise.
link |
Which is that despite the fact
link |
that the selective serotonin reuptake inhibitors
link |
can be effective in reducing the symptoms of OCD,
link |
at least somewhat, and certainly more than placebo,
link |
there is very little, if any evidence
link |
that the serotonin system is disrupted in OCD.
link |
And I have to point out that this is a somewhat
link |
consistent theme in the field of psychiatry.
link |
That is a given drug can be very effective
link |
or even partially effective in reducing symptoms
link |
or in changing the overall landscape
link |
of a psychiatric disorder or illness.
link |
And yet there is very little, if any, evidence
link |
that that particular system is what's causal for OCD
link |
or anxiety or depression, et cetera.
link |
This is just the landscape that we're living in
link |
in terms of our understanding of the brain and psychiatry
link |
and the ways of treating brain disorders.
link |
So as a consequence, there are a huge number
link |
of academic reviews that clinicians
link |
and research scientists have generated
link |
and read and share one of the more,
link |
I think, thorough ones in recent years
link |
was published in 2021.
link |
I'll provide a link to this.
link |
This is by an excellent, truly excellent researcher
link |
from Yale University School of Medicine.
link |
I should say not just a researcher,
link |
but a clinician scientist, again, an MD, PhD.
link |
This is Christopher Pittenger.
link |
And the title of the review is
link |
pharmacotherapeutic strategies and new targets in OCD.
link |
And again, we'll provide a link to it.
link |
This is a just gorgeous review describing,
link |
as I just told you,
link |
that the serotonin system isn't really disrupted in OCD
link |
and yet SSRIs can be very effective.
link |
The review goes on to explore even what sorts of receptors
link |
for serotonin might be involved,
link |
if it's in fact the case that serotonin is a culprit
link |
in the creation of OCD symptoms.
link |
Talk about the serotonin 2A receptor
link |
and the serotonin 1A receptor.
link |
Why am I mentioning all that detail
link |
if in fact it's not clear serotonin is involved?
link |
Because I'll just tell you right now,
link |
there is currently a lot of interest
link |
in whether or not some of the psychedelics,
link |
in particular psilocybin,
link |
can be effective in the treatment of OCD.
link |
Psilocybin has been shown in various clinical trials,
link |
in particular the clinical trials done
link |
at Johns Hopkins School of Medicine
link |
by Matthew Johnson and others.
link |
Matthew is on the Huberman Lab Podcast.
link |
He's been on the Tim Ferriss Podcast.
link |
He's been on the Lex Friedman Podcast.
link |
He's a world-class researcher
link |
on the use of psychedelics for depression
link |
and other psychiatric challenges.
link |
And there, psilocybin treatment has been seen,
link |
at least in those trials, to be very effective
link |
in the treatment of certain kinds of major depression.
link |
Currently, the exploration of psilocybin
link |
for the treatment of OCD has not yielded similar results,
link |
although the studies are ongoing.
link |
Again, has not yielded similar effectiveness,
link |
but the studies are ongoing.
link |
And the serotonin 2A receptor
link |
and the serotonin 1A receptors are primary targets
link |
for the drug psilocybin.
link |
So I figured there were going to be some questions
link |
about whether or not psychedelics help with OCD.
link |
Thus far, it's inconclusive.
link |
If any of you have been part of clinical trials
link |
or have knowledge or intuition about this relationship
link |
or potential relationship, I should say,
link |
between psilocybin or other psychedelics and OCD,
link |
please put them in the comment section.
link |
We'd love to hear from you.
link |
One thing I should point out is that even though serotonin
link |
has not been directly implicated in OCD,
link |
serotonin and the general systems of serotonin,
link |
the circuits in the brain that carry serotonin
link |
and depend on it, have been shown
link |
to impact cognitive flexibility and inflexibility,
link |
which are kind of hallmark themes of OCD.
link |
So in animals that have their serotonin depleted
link |
or in humans that have very low levels of serotonin,
link |
you can see evidence of cognitive inflexibility,
link |
challenges in task switching,
link |
challenges in switching the rules
link |
by which one performs a game,
link |
challenges in any kind of cognitive domain switching.
link |
And so that does indirectly implicate serotonin
link |
in some of the aspects of OCD.
link |
Again, when one starts to explore
link |
the different transmitter systems that have been explored
link |
in animal models and in humans, it's a vast, vast landscape,
link |
but serotonergic drugs do seem to be
link |
the most effective drugs in treating OCD, despite the fact,
link |
again, despite the fact that there's no direct evidence
link |
that serotonin systems are the problem in OCD.
link |
If you recall the corticostriatal thalamic loop
link |
that is so central to the etiology,
link |
the presence and the patterns of symptoms in OCD,
link |
of course, serotonin is impacting that system.
link |
Serotonin is impacting just about every system in the brain,
link |
but there's no evidence that tinkering with serotonin levels
link |
specifically in that network
link |
is what's leading to the improvements in OCD.
link |
However, if people go into a fMRI scanner
link |
and those people have OCD
link |
and they evoke the obsessions and compulsions,
link |
you see activity in that corticostriatal thalamic loop.
link |
Treatments like SSRIs that reduce the symptoms of OCD
link |
equate to a situation where there is less activity
link |
And I should point out cognitive behavioral therapy,
link |
which we have no reason to believe
link |
only taps into the serotonin system.
link |
I think it would be,
link |
the extreme stretch would be false actually
link |
to say that cognitive behavioral therapy taps
link |
only into the serotonin system.
link |
Clearly it's going to affect a huge number of circuits
link |
in neurochemical systems.
link |
Well, people who do cognitive behavioral therapy
link |
and find some relief for OCD,
link |
they also show reductions
link |
in those corticostriatal thalamic loops.
link |
So basically we have a situation
link |
where we have a behavioral therapy that works
link |
in many people, not all,
link |
and we have a pretty good understanding of about why it works.
link |
It increases anxiety tolerance
link |
and interference with pattern execution,
link |
getting people to not engage in the same sorts of behaviors
link |
that are detrimental to them.
link |
And we have drug treatments that work,
link |
at least to some degree,
link |
but we don't know how they work
link |
or where they work in the brain.
link |
One of the things that really unifies
link |
the behavioral treatments and the drug treatments
link |
is that they take some period of time.
link |
Some relief from symptoms seems to show up around four weeks
link |
and certainly by eight weeks
link |
for both cognitive behavioral therapy and the SSRIs,
link |
but it's really at the 10 to 12 week stage
link |
when someone's been doing these twice a week
link |
cognitive behavioral sessions,
link |
where they've been taking a SSRI for 10 to 12 weeks,
link |
that the really significant reduction
link |
in OCD symptoms starts to really show up.
link |
Now, up until now, I've been talking about the fact
link |
that people are getting relief from these treatments,
link |
but sadly, in the case of OCD,
link |
there is a significant population
link |
that simply does not respond to CBT
link |
or to SSRIs or to their combination,
link |
which is why psychiatrists also explore
link |
the combination of SSRIs and neuroleptics
link |
or drugs that tap into the so-called dopamine system
link |
or the glutamate system.
link |
These are other neurotransmitters and neuromodulators
link |
that impact different circuits in the brain.
link |
And just to really remind you
link |
what neurotransmitters and neuromodulators do,
link |
because this is important to contextualize all this,
link |
neurotransmitters are typically involved
link |
in the rapid communication between neurons.
link |
And the two most common neurotransmitters for that
link |
are the neurotransmitter glutamate,
link |
which we say is excitatory,
link |
meaning when it's released into the synapse,
link |
it causes the next neuron to be more active or active,
link |
and GABA, which is a neurotransmitter that is inhibitory,
link |
meaning when it's released into the synapse,
link |
typically, not always,
link |
but typically that GABA is going to encourage
link |
the next neuron to be less electrically active
link |
or even silence its activity.
link |
The neuromodulators, by contrast,
link |
so not neurotransmitters, but neuromodulators,
link |
like dopamine, serotonin, epinephrine, and acetylcholine,
link |
and others, operate a little bit differently.
link |
They intend to act a little bit more broadly.
link |
They can act within the synapse,
link |
but they can also change the general patterns
link |
of activity in the brain,
link |
making certain circuits more likely to be active
link |
and other circuits less likely to be active.
link |
So when we say dopamine does X or dopamine does Y
link |
or serotonin does X or serotonin does Y,
link |
they don't really do one thing.
link |
They change the sort of overall tonality.
link |
They make it more likely or less likely
link |
that certain circuits will be active.
link |
You can think of them as kind of activating playlists
link |
or genres of activity in the brain
link |
rather than being involved in the specific communication
link |
or specific songs, if you will, in this analogy,
link |
or discussions between particular neurons.
link |
So when we hear that SSRIs increase serotonin
link |
and reduce the symptoms of OCD,
link |
or a neuroleptic reduces the amount of dopamine
link |
and makes people feel calmer, for instance,
link |
or can remove some stereotyped repetitive motor behavior,
link |
which they can either generate
link |
or reduce motor behavior, it turns out.
link |
So when I say that, what I'm referring to is the fact
link |
that these neuromodulators are turning up the volume
link |
on certain circuits
link |
and turning down the volume on other circuits.
link |
I say that because if you are going
link |
to explore drug treatments, again, with a licensed physician,
link |
if you're going to explore drug treatments for OCD,
link |
and in particular, if you are not getting results
link |
from SSRIs or you're not getting results
link |
from cognitive behavioral therapy
link |
or the side effect profiles of the drugs
link |
that you're taking for OCD are causing problems
link |
that you don't want to take them,
link |
well, then it's important to understand
link |
that anytime you take one of these drugs,
link |
they're not acting specifically
link |
on the corticostriatal thalamic circuit.
link |
That would be wonderful.
link |
That's the future of psychiatry.
link |
But as now, when you take a drug, it acts systemically.
link |
So it's impacting serotonin in your gut.
link |
It's also impacting serotonin in other areas of the brain,
link |
hence the effects on things like digestion or libido
link |
or any number of different things
link |
that serotonin is involved in.
link |
Likewise, if you take a neuroleptic like haloperidol
link |
or something that reduces dopamine transmission,
link |
well, then it's going to have some motor effects
link |
because dopamine is involved in the generation
link |
of motor sequences and smooth limb movement.
link |
That's why people with Parkinson's
link |
who don't have much dopamine will get a resting tremor,
link |
have a hard time generating smooth movement.
link |
And so the side effects start to make sense
link |
given the huge number of different neural circuits
link |
that these different neuromodulators are involved in.
link |
I don't say that to be discouraging.
link |
I say that to encourage patients
link |
and careful systematic exploration
link |
of different drug treatments for OCD,
link |
always, again, with the careful and close guidance
link |
and oversight of a psychiatrist
link |
because psychiatrists really understand
link |
which side effect profiles make it likely
link |
that you can or cannot or will never
link |
or maybe someday we'll be able to take a given drug
link |
They are the ones that really have that knowledge.
link |
This is not the sort of thing that you want a cowboy
link |
and go try and figure out yourself.
link |
Now, I also want to acknowledge
link |
that there are other forms of drug treatments.
link |
We touched on psilocybin briefly,
link |
but there are other forms of drug treatments
link |
that have been explored for OCD.
link |
Earlier, we talked a little bit about cannabis.
link |
Why would cannabis be a place of exploration at all?
link |
Well, first of all,
link |
a number of people try and self-medicate for OCD.
link |
There is some clinical evidence,
link |
I'm not talking about recreational use,
link |
I'm talking about clinical evidence
link |
that cannabis can reduce anxiety.
link |
Now, earlier, we were talking about not reducing anxiety,
link |
but learning anxiety tolerance
link |
in order to deal with and treat OCD
link |
in the context of cognitive behavioral therapies.
link |
That doesn't necessarily rule out cannabis
link |
as a candidate for the treatment of OCD.
link |
And in fact, this has been explored.
link |
A study from Dr. Blair Simpson herself looked at this.
link |
This was a fairly small scale study.
link |
So first of all, I'll give you the title,
link |
and again, we'll provide a link.
link |
This is entitled Acute Effects of Cannabinoids
link |
on Symptoms of Obsessive Compulsive Disorder,
link |
Human Laboratory Study.
link |
Very briefly, this was 14 adults
link |
with OCD, they had prior experience with cannabis.
link |
This was randomized, placebo-controlled.
link |
The cannabis was smoked.
link |
They had different varietals, as they're called.
link |
They had a placebo.
link |
So this is basically a condition
link |
in which certain subjects consumed a cigarette
link |
that had 0% THC, others had 7% THC,
link |
other groups, that is,
link |
or some had 0.4% CBD and THC,
link |
so they looked at CBD.
link |
I know a lot of people out there are interested in CBD.
link |
There's one of the few studies I could find
link |
where they explored different percentages of THC and CBD
link |
in these cannabis or marijuana cigarettes, basically.
link |
The total amount that they consumed,
link |
I believe, was 800 milligrams.
link |
These, again, are not suggestions.
link |
This was just simply reporting what's in this study.
link |
You can, again, I'll provide a link.
link |
They looked at OCD symptoms ratings.
link |
They looked at cardiovascular effects.
link |
They had a large number of different things
link |
that they explored.
link |
And I should say, this study was done in 2020,
link |
and it was the first placebo-controlled investigation
link |
of cannabis in adults with obsessive compulsive disorder.
link |
Pretty interesting.
link |
And I'm just reading from their conclusions here.
link |
The data suggests that smoked cannabis,
link |
whether containing primarily THC or CBD,
link |
remember, they looked at different concentrations of those,
link |
has little acute impact,
link |
meaning immediate impact on OCD symptoms,
link |
and yields smaller reductions in anxiety
link |
compared to placebo.
link |
So they did not see a, when I say a positive effect,
link |
I mean a ameliorative effect,
link |
an effect in reducing symptoms of OCD from cannabis or CBD,
link |
which, you know, it's unfortunate.
link |
I think it's unfortunate anytime a treatment doesn't work,
link |
but nonetheless, those are the data.
link |
I'm sure there are going to be other studies.
link |
I'm sure there are also going to be people
link |
in the YouTube comments section saying that cannabis
link |
and CBD helps their OCD symptoms.
link |
At least I anticipate there probably will.
link |
Almost everything I say here,
link |
somebody will contradict it with something
link |
from their experience, which I encourage, by the way.
link |
I want to hear about your experience with certain things,
link |
even if it's not from randomized placebo-controlled studies.
link |
I still find it very interesting to know
link |
what people are doing and what they're experiencing.
link |
I think that's one of the better uses
link |
of social media comment sections
link |
is to be able to share some of that,
link |
not in an advice-giving way or prescriptive way,
link |
but simply as a way to share and encourage
link |
different types of exploration.
link |
There are other sorts of drug treatments
link |
that are gaining popularity for OCD,
link |
at least in the research realm.
link |
One treatment that is a legal, L-E-G-A-L, right?
link |
Sometimes when I say legal,
link |
sometimes people think I say illegal,
link |
but that is legal, at least by prescription
link |
in the United States, is ketamine.
link |
The actions of ketamine are somewhat complex.
link |
Although we know, for instance,
link |
that ketamine acts on the glutamate system,
link |
it tends to disrupt the transmission
link |
or the relationship, I should say, between glutamate,
link |
right, not glutamine, not the amino acid,
link |
but glutamate, the neurotransmitter,
link |
and the so-called NMDA, the N-methyl-D-aspartate receptor,
link |
which is a receptor that's very special
link |
in the nervous system,
link |
because when glutamate binds to the NMDA receptor,
link |
it tends to offer the opportunity
link |
for that particular synapse to get stronger,
link |
so-called neuroplasticity,
link |
and ketamine is essentially an antagonist,
link |
although it works through a complicated mechanism,
link |
it tends to block that binding of glutamate
link |
to the NMDA receptor or the effectiveness of that.
link |
Ketamine therapy is now being used quite extensively
link |
for the treatment of trauma and for depression.
link |
It leads to a dissociative state.
link |
It's a so-called dissociative analgesic,
link |
and there are a variety of ways in which that happens.
link |
We did an episode on depression.
link |
We're going to do another entire episode all about ketamine,
link |
describing the networks that ketamine impacts, et cetera.
link |
Ketamine therapies are being explored for OCD.
link |
As of now, the data look somewhat promising,
link |
but there's still a lot more work that needs to be done.
link |
My read of the data are that the more extensive
link |
clinical trials have not happened yet.
link |
The smaller studies that have happened
link |
reveal that some patients do get some relief
link |
from ketamine therapy for OCD,
link |
but there was nothing overwhelmingly pointing to the fact
link |
that ketamine is a magic bullet for OCD treatment.
link |
So cannabis CBD, at least now,
link |
even though it's one smaller study,
link |
there's no real evidence that it can alleviate OCD symptoms.
link |
If there are new studies published soon,
link |
I'll be sure to update you.
link |
And if you see those studies, please send them to me.
link |
Ketamine therapy, the jury is still out.
link |
Psilocybin, the jury is still out.
link |
These are early days.
link |
Another treatment that's becoming somewhat common,
link |
or at least people are commonly excited about,
link |
is transcranial magnetic stimulation.
link |
So this is the use of a magnetic coil.
link |
This is completely noninvasive,
link |
placed on one portion of the skull,
link |
and one can direct magnetic energy
link |
toward particular areas of the brain
link |
to either suppress or nowadays,
link |
you can also activate particular brain regions.
link |
There are some interesting data
link |
showing that if TMS is applied
link |
to areas of the brain involved
link |
in the generation of motor action,
link |
so the so-called motor areas
link |
or supplementary motor areas, as they're called,
link |
while people think about or have intrusive thoughts,
link |
we know that the TMS coil can interrupt the motor behaviors,
link |
the compulsive behaviors,
link |
and at least in a small cohort of studies,
link |
in a small number of patients within those studies,
link |
this has been shown to be effective,
link |
not just while the coil is on the head, of course,
link |
but after the study has been performed
link |
or the treatment's been performed in reducing OCD symptoms
link |
by disrupting the tendency for the compulsive behavior
link |
to be so automatic.
link |
One of the key features of obsessive compulsive disorder
link |
is that, especially if it's been around for a while,
link |
the person's been dealing with it for a while,
link |
there isn't a pattern in which the person thinks,
link |
oh, I have this contamination fear, or I need symmetry,
link |
or I'm kind of obsessed to count to the number seven,
link |
and then they pause and they go, ooh, and then they do it.
link |
No, typically there's a very close pairing
link |
of the obsession and the compulsion in time
link |
so that somebody is walking down the street
link |
thinking 1, 2, 3, 4, 5, 6, 7, 1, 2, 3, 4, 5, 6, 7, 7,
link |
7, 7, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20,
link |
and then they're doing this in such rapid succession
link |
because the obsessions are coming up so quickly, right?
link |
Thoughts can be generated very quickly,
link |
and then they're generating the compulsions
link |
as a way to beat down or to try and suppress that anxiety,
link |
and then it comes right back up again at even stronger,
link |
as I described earlier.
link |
So transcranial magnetic stimulation seems to intervene
link |
in these various fast processes.
link |
Right now, I don't think it's fair to say
link |
that TMS is a magic bullet either.
link |
I think there's a lot of excitement about TMS,
link |
and in particular, I really want to nail this point home.
link |
In particular, there's excitement about the combination
link |
of TMS with drug treatments,
link |
or the combination of TMS with cognitive behavioral therapy,
link |
and this is a really important point,
link |
not just for sake of discussion
link |
about obsessive-compulsive disorder,
link |
but also depression, ADHD, schizophrenia,
link |
any number of different psychiatric challenges
link |
and disorders in most cases are going to respond best
link |
to a combination of behavioral treatment that's ongoing
link |
that occurs in the laboratory and clinical setting,
link |
but also in the home setting where there's homework,
link |
maybe even home visits.
link |
Drug treatments often, not always,
link |
are a terrific augment to those cognitive behavioral
link |
therapies or other behavioral therapies,
link |
and then now we are living in the age
link |
of brain-machine interface.
link |
You have companies like Neural Length
link |
that I think it's fair to say are going to enter
link |
the brain-machine interface world first
link |
through the treatment of certain syndromes, right?
link |
Movement syndromes or psychiatric syndromes,
link |
probably before they start putting electrodes
link |
into the brain to stimulate enhanced memory
link |
or enhanced cognition, who knows?
link |
I don't know exactly what they're doing
link |
behind the walls of Neural Link, but I have to imagine,
link |
in fact, I would wager, maybe not both arms,
link |
but I'll wager my left arm,
link |
that the first set of FDA-approved technologies
link |
to come out of companies like Neural Link
link |
are going to be those for the treatment
link |
of things like Parkinson's and movement disorders
link |
and cognitive disorders, rather than, shall we say,
link |
kind of recreational cognitive enhancement
link |
or things of that sort.
link |
So transcranial magnetic stimulation is noninvasive.
link |
It doesn't involve going down below the skull,
link |
can have some effect, but most laboratories
link |
that I'm aware of at Stanford and elsewhere
link |
that are exploring TMS for things like OCD
link |
and other types of psychiatric challenges
link |
are using TMS in combination with drug therapies,
link |
are using, in some cases, for instance,
link |
a laboratory at Stanford, hope to get them on the podcast,
link |
psychiatrist Nolan Williams is exploring TMS
link |
in combination with psychedelic therapies,
link |
not necessarily at the same time,
link |
but nonetheless combining them
link |
or exploring how they impact brain circuitry.
link |
So if you have OCD, should you run out and get TMS
link |
or should you try ketamine therapy, of course,
link |
with a licensed physician?
link |
I think it's too early to say yes.
link |
I think the answer is we need to wait and see.
link |
I think cognitive behavioral therapy, the SSRIs
link |
and some other drug treatments like neuroleptics
link |
combined with SSRIs and cognitive behavioral therapy
link |
are where the real bulk of the data are.
link |
I want to make one additional point about cannabis CBD
link |
as it relates to obsessive compulsive disorder.
link |
To me, it's not at all surprising that cannabis CBD
link |
did not improve symptoms of OCD
link |
because in my discussion with Dr. Paul Conte a few weeks ago
link |
and as you mentioned, Dr. Conte is indeed a medical doctor,
link |
a psychiatrist, we were talking about cannabis
link |
and its various uses
link |
because it does have some clinical applications.
link |
And he mentioned that one of the main effects of cannabis
link |
is to tighten focus and to enhance concentration on
link |
and thoughts about one particular thing.
link |
And in some cases that can be clinically beneficial
link |
and in other cases that can be clinically detrimental.
link |
If you accept the idea that cannabis increases focus
link |
and you think about OCD and the networks involved
link |
and you think about the anxiety and the relationship
link |
between the obsession and compulsion,
link |
well then it shouldn't come as any surprise
link |
that cannabis did not improve the symptoms of OCD
link |
because if anything, it would increase focus
link |
on the obsessions and the compulsions.
link |
Now that's not what they observed.
link |
They did not see an exacerbation or a worsening
link |
of the symptoms of OCD with cannabis.
link |
At least that's not my read of the data
link |
but they did not see an improvement
link |
in OCD symptoms with cannabis or CBD.
link |
And to me, that's not surprising
link |
given that cannabis CBD seems to increase focus.
link |
Next, I'd like to talk about some of the research on
link |
and the roles of hormones in OCD
link |
because it turns out to be
link |
a very interesting relationship there.
link |
But before I do, I want to point out something that
link |
I realize I probably should have said earlier
link |
which is one of the key things for someone with OCD
link |
to come to understand if they're going to experience
link |
any relief of their symptoms,
link |
whether or not they're doing drug treatments
link |
or behavioral treatments or otherwise,
link |
is that thoughts are not as bad as actions, right?
link |
Thoughts are not as bad as actions.
link |
One of the kind of rules that people with OCD
link |
seem to adopt for themselves is that
link |
thoughts are really truly the equivalent of actions.
link |
So they'll have an intrusive thought
link |
and we haven't spent too much time on this today,
link |
but earlier I touched on the fact that
link |
some of the intrusive thoughts that people have in OCD
link |
are really disturbing.
link |
They can be really gross or at least gross to that person.
link |
They can evoke imagery that is toxic or infectious
link |
or is highly sexualized in a way that is disturbing to them,
link |
can be very taboo.
link |
This is not uncommon when you start talking to people
link |
with OCD and you start pulling on the thread.
link |
Again, this would be a psychiatrist
link |
who is trained to ask the right questions
link |
and gain the comfort and trust of a patient.
link |
They start to reveal that these thoughts
link |
are really intrusive and kind of disturbing,
link |
which is why they feel so compelled
link |
to try and suppress them with behaviors.
link |
One of the powerful elements of treatment for OCD
link |
is to really support the patient
link |
and make them realize that thoughts are just thoughts
link |
and that everyone has disturbing thoughts.
link |
And that oftentimes those disturbing thoughts
link |
arise at the most inconvenient
link |
and sometimes what seems like
link |
the most inappropriate circumstances.
link |
And this relates to a whole larger discussion
link |
that we could have about what are thoughts
link |
and why do they surface
link |
and how come when you stand at the edge of a bridge,
link |
even if you do not want to jump off,
link |
you think about jumping off.
link |
And this has to do with the fact that your nervous system
link |
as a prediction machine is oftentimes testing possibilities.
link |
And sometimes that testing goes way off
link |
into the Netherlands of the thought patterns
link |
and emotional patterns that we all have inside of us.
link |
The big difference between a thought and an action
link |
is that, of course, the nervous system is in one case
link |
not translating those patterns of thinking
link |
into motor sequences.
link |
That nerdy way of saying thoughts aren't actions,
link |
believe it or not, can be helpful for people
link |
if they really think about that
link |
and use it as an opportunity to realize that,
link |
first of all, they're not crazy.
link |
They're not thinking and feeling this stuff
link |
because they're bad or evil.
link |
And of course, sometimes this can cross over
link |
with other elements of life where we place moral judgment
link |
on people for certain behaviors.
link |
I think that's part of a healthy society, of course.
link |
That's where we have laws and punishments
link |
and rewards for that matter for certain types of behaviors.
link |
But this idea that thoughts are not as bad as actions
link |
and that thoughts can be tolerated
link |
and the anxiety around thoughts can be tolerated
link |
and over time can diminish,
link |
that's a very powerful hallmark theme
link |
of the treatment of OCD.
link |
So I'd be remiss if I didn't mention it.
link |
Thoughts are not actions.
link |
Actions can harm us.
link |
They can harm other people.
link |
They can soak up enormous amounts of time.
link |
Thoughts can soak up enormous amounts of time.
link |
They can be very troubling.
link |
They can be very detrimental.
link |
We, of course, want to be sensitive to that.
link |
But when it really comes down to it,
link |
the first step in treatment for OCD is this realization
link |
or the approach to the realization
link |
that thoughts are not as bad as actions.
link |
So what about hormones in OCD?
link |
Well, this has been explored,
link |
albeit not as extensively as I would have liked to find.
link |
But when I went into the literature,
link |
I found one particularly interesting study
link |
entitled Neurosteroid Levels in Patients
link |
with Obsessive Compulsive Disorder for Sathur Erbe.
link |
And as always, we'll provide a link to the study.
link |
The objective of this study was to explore serum
link |
within blood, neurosteroid levels in people with OCD.
link |
Well, because of the relationship between OCD and anxiety
link |
and the fact that in stress-related disorders,
link |
such as anxiety and depression,
link |
the hormones have been extensively explored,
link |
but not so much in OCD, at least until this study.
link |
So they compared serum levels
link |
of a number of different hormones, progesterone,
link |
pregnenolone, DHEA, cortisol, and testosterone.
link |
This was done in 30 patients with OCD
link |
and 30 healthy controls.
link |
So it's not a huge study,
link |
but it's enough to draw some pretty nice conclusions.
link |
These subjects were 18 to 49 years old,
link |
and the controls were age and sex matched,
link |
healthy volunteers, again, no OCD.
link |
What was the basic takeaway from the study?
link |
The basic takeaway from the study was that
link |
in females with OCD, there was evidence
link |
for significantly elevated cortisol and DHEA.
link |
Now that's interesting because cortisol is well-known
link |
to be associated with the stress system,
link |
although every day, I should mention,
link |
we all, male or female,
link |
everybody experiences an increase in cortisol
link |
shortly after awakening.
link |
That's a healthy increase in cortisol.
link |
Late shifted, I mean, late in the day peaks in cortisol,
link |
where a shift in that cortisol peak to later in the day
link |
is a known correlate of depression and anxiety disorders.
link |
So the fact that cortisol is elevated in DHEA,
link |
are elevated in female patients with OCD,
link |
suggests that cortisol is either reflective of
link |
or causal for the increase in anxiety.
link |
We don't know the direction of that effect.
link |
Now, in the male patients with OCD,
link |
there was evidence for increased cortisol,
link |
again, not surprising given the role of anxiety in cortisol,
link |
or I should say, given the role of cortisol in anxiety
link |
and the increasing anxiety seen in OCD,
link |
but there were also significant reductions in testosterone,
link |
which should also not surprise us
link |
because cortisol and testosterone more or less compete
link |
in some fashion for their own production.
link |
Both are derived from the molecule cholesterol,
link |
and there are certain biochemical pathways
link |
that can either direct that cholesterol molecule
link |
toward cortisol synthesis or testosterone synthesis,
link |
So when cortisol goes up in general, not always,
link |
but in general, testosterone goes down and vice versa.
link |
If you want to learn more about the relationship
link |
between cortisol and testosterone,
link |
and there are even some tools to try and optimize those
link |
ratios in both males and females,
link |
you can find that in our episode on optimizing testosterone
link |
and estrogen, that's at Hubermanlab.com.
link |
Now, I would say the most interesting aspect of this study
link |
is not that DHEA and cortisol are elevated in females
link |
with OCD or that cortisol and testosterone
link |
have this opposite effect,
link |
cortisol up and testosterone down in males with OCD,
link |
but rather the relationship between all of those,
link |
DHEA, cortisol, and testosterone in terms of GABA.
link |
GABA, again, being this inhibitory neurotransmitter
link |
that tends to quiet certain neuronal pathways.
link |
It does different things at different synapses,
link |
but in general, the more GABA that's present,
link |
the more inhibition that's present,
link |
and therefore the more suppression of neural activity.
link |
And DHEA is known to be a potent antagonist
link |
of the GABA system, okay?
link |
So here we have elevated DHEA in females,
link |
and I should also mention that testosterone
link |
is also known to tap into the GABA system.
link |
Typically when testosterone is elevated,
link |
GABA transmission at least is slightly elevated.
link |
So here we have a situation in which the pattern of hormones
link |
in females and males with OCD are different
link |
from those in people without OCD,
link |
such that GABA transmission is altered,
link |
and the net effect would be an overall reduction in GABA.
link |
Now, GABA as an inhibitory neurotransmitter,
link |
and broadly speaking,
link |
is associated with lower levels of anxiety,
link |
and it tends to create balance
link |
within various neural circuits.
link |
Now that's a very broad statement,
link |
but we know for instance in epilepsy
link |
that GABA levels are reduced,
link |
and therefore you get runaway excitation
link |
of certain circuits in the brain,
link |
and therefore seizures,
link |
either petit mal, mini seizures,
link |
or grand mal, massive seizures,
link |
or even drop seizures,
link |
where people completely collapse to the floor in seizure.
link |
You may have seen this before.
link |
It's very dramatic,
link |
and it actually is quite debilitating for people
link |
because obviously they don't know
link |
when these seizures are coming on most often,
link |
and then they can fall into a stove
link |
or while driving, et cetera.
link |
So the situation with OCD is one in which,
link |
for whatever reason,
link |
we don't know the direction of effect.
link |
Certain hormones are elevated in females,
link |
and certain hormones are elevated in males,
link |
and those hormones differ between males and females,
link |
and yet they both funnel into a system
link |
where GABAergic or GABA transmission in the brain
link |
is reduced because of this ability
link |
for those particular hormones to be antagonists to GABA,
link |
and as a consequence,
link |
there's likely to be overall levels of increased excitation
link |
in certain networks in the brain,
link |
and that brings us back
link |
to this corticostriatal thalamic loop,
link |
this repetitive loop that seems to reinforce,
link |
we can say reinforces obsession,
link |
leads to anxiety, leads to compulsion,
link |
leads to transient relief of anxiety,
link |
but then increase in anxiety, increased obsession,
link |
anxiety, compulsion, anxiety, compulsion,
link |
anxiety, compulsion, and so on and so forth.
link |
So I have not found studies
link |
that have explored adjusting testosterone levels
link |
through exogenous administration,
link |
cream or injection or otherwise,
link |
or that have focused on reducing DHEA in females.
link |
If anyone is aware of such studies,
link |
please put them in the comment section on YouTube
link |
or send them to us.
link |
We have a contact site on the website at HubermanLab.com,
link |
but the comment section on YouTube would be best,
link |
but because we know that hormones impact neuromodulators
link |
and neurotransmitters, as I just described,
link |
and that those neuromodulators and neurotransmitters
link |
play an intimate role in the generation
link |
and the treatment of things like OCD,
link |
it stands to reason that manipulations
link |
of those hormone systems, however subtle or dramatic,
link |
might, I want to highlight, might prove useful
link |
in adjusting the symptoms of OCD,
link |
and I hope that this is an area
link |
that researchers are going to pursue in the very near future
link |
because many of the treatments for reducing DHEA
link |
or increasing testosterone or reducing cortisol
link |
have already made it through FDA approval.
link |
They're out there.
link |
They're readily prescribed.
link |
Many of them are already in generic form,
link |
which means that the patents have already lapsed
link |
on the first versions of those drugs,
link |
so when they're available as generic drugs,
link |
very often they're available at significantly lower cost.
link |
There's a whole discussion to be had there
link |
about patent laws and prescription drugs,
link |
but because these drugs are largely available
link |
in prescription yet generic form,
link |
I think there's a great opportunity
link |
to explore how hormones, not just cortisol,
link |
testosterone, and DHEA, but the huge category of hormones
link |
might impact the symptoms of OCD,
link |
especially since many of the symptoms of OCD
link |
show up right around the time of puberty.
link |
We haven't talked a lot about childhood OCD
link |
because we're going to do an entire series
link |
on childhood psychiatric disorders and challenges,
link |
but many children develop OCD early,
link |
as young as three or four, believe it or not,
link |
or even six or seven and 10,
link |
and in adolescence and certainly around puberty
link |
and in young adulthood, it is rare,
link |
although it does happen,
link |
that people will develop OCD very late in life,
link |
around 40 or older, just kind of spontaneously.
link |
Most often, when you look at their clinical history,
link |
you find that either they were hiding it
link |
or it was being suppressed in some way,
link |
or if it does spontaneously show up late in life,
link |
like mid-30s or in one's 40s,
link |
typically there's a traumatic brain injury,
link |
could be due to stroke or physical injury to the head
link |
or something of that sort.
link |
Nonetheless, there is a interesting correlation
link |
between the onset of puberty in certain forms of OCD.
link |
There's certain forms of, or I should say,
link |
there's certain aspects of menopause that can relate to OCD.
link |
You can find all these things in the literature,
link |
all this to say that hormones impact neurotransmitters
link |
and neuromodulators, which clearly impact
link |
the kinds of circuits that are involved in OCD,
link |
and it makes sense that,
link |
and I would hope that there would be an exploration
link |
of how these hormones impact OCD
link |
in the not too distant future.
link |
Now, there is an extensive literature
link |
exploring how testosterone therapy,
link |
both in males and females,
link |
can be effective in some cases
link |
in the treatment of anxiety-related disorders,
link |
but not, at least to my knowledge, in OCD in particular.
link |
So this whole area of the use of testosterone
link |
and estrogen therapy is DHEA, cortisol suppression,
link |
or maybe even enhancement for the treatment of OCD
link |
is essentially a big black box that very soon, I believe,
link |
I realize that a number of listeners of this podcast
link |
are probably interested in the non-typical
link |
or holistic treatments for OCD.
link |
Dr. Blair Simpson's lab has at least one study
link |
exploring the role of mindfulness meditation
link |
for the treatment of OCD.
link |
There, the data are a little bit complicated,
link |
and I should mention that good things are happening,
link |
at least in the United States, probably elsewhere as well,
link |
but good things are happening
link |
in terms of the exploration of things like meditation
link |
and other, let's call them non-traditional
link |
or holistic forms of treatment for psychiatric disorders
link |
because of the division of complementary health
link |
that's now been launched
link |
by the National Institutes of Health.
link |
So whereas before people would think about meditation
link |
or yoga nidra or even CBD supplementation for that matter
link |
as kind of fringe maybe, or kind of woo,
link |
or non-traditional at the very least,
link |
the National Institutes of Health in the United States
link |
has now devoted an entire division,
link |
an entire institute purely for the exploration
link |
of things like breathing practices, meditation, et cetera.
link |
So there's a cancer institute,
link |
there's a hearing and deafness institute,
link |
there's a vision institute,
link |
and now there's this complementary health institute,
link |
which I think is a wonderful addition
link |
to the more traditional aspects of medicine.
link |
I think no possible useful treatment should be overlooked
link |
or unresearched in my opinion,
link |
provided that can be done safely.
link |
And as I mentioned, Dr. Blair Simpson's lab
link |
has looked at the role of mindfulness meditation
link |
in the treatment of OCD.
link |
Now we should all keep in mind, no pun intended,
link |
that most of the data on mindfulness meditation
link |
shows that it increases the ability to focus.
link |
Now this brings us back to a kind of repeating theme today,
link |
which is that increased focus may not be the best thing
link |
for somebody with OCD because it might increase focus
link |
on the obsession and or compulsion.
link |
Turns out that mindfulness meditation can be useful
link |
in the treatment of OCD,
link |
but mainly by way of how it impacts the focus on
link |
and the ability to engage in cognitive behavioral therapies.
link |
So it's very unlikely, at least by my read of the data,
link |
to be a direct effect of meditation
link |
on relieving the symptoms.
link |
Rather, it seems that meditation is increasing focus
link |
on things like cognitive behavioral therapy homework
link |
and to not focus on other things
link |
and therefore indirectly improving the symptoms of OCD.
link |
Now, somewhat surprisingly, at least to me,
link |
there have also been a fairly large number of studies
link |
exploring how nutraceuticals,
link |
as they're sometimes called,
link |
supplements that are available over the counter
link |
can impact the treatment of obsessive compulsive disorder.
link |
Now there's such an extensive number of different compounds
link |
and supplements that fall under the category
link |
of nutraceuticals and that have been explored
link |
in the treatment of OCD that I'd like to point you
link |
to a review that is entitled
link |
Nutraceuticals and the Treatment
link |
of Obsessive Compulsive Disorder,
link |
a Review, excuse me, of Mechanistic and Clinical Evidence.
link |
This was published in 2011, so it's over 10 years old.
link |
And so by now, I have to imagine that there are
link |
an enormous number of additional substances
link |
that could be explored.
link |
But there are just one or two here that I want to focus on.
link |
Here in this review, they describe effects of 5-HTP
link |
and tryptophan, so things that are in the serotonin pathway,
link |
which would make sense given what we know about the SSRIs
link |
that people would explore how different supplements
link |
that increase serotonergic transmission might impact OCD.
link |
What you find is that they do have significant effects
link |
in improving or reducing the symptoms of OCD
link |
in somewhat similar way to some of the SSRIs.
link |
But you of course have to be careful.
link |
So anything that's going to tap into
link |
a given neurochemical system to the same degree
link |
may very likely have the same sorts of side effects
link |
that a prescription drug would.
link |
One compound that I'd like to focus on
link |
in a little more depth, however,
link |
because it's exciting and interesting to me is inositol.
link |
Inositol is a compound that we are going to talk about
link |
in several future podcasts because, well, first of all,
link |
it seems that it can have pretty impressive effects
link |
on reducing anxiety.
link |
It also can have pretty impressive effects
link |
in improving fertility in particular in women
link |
with polycystic ovarian syndrome.
link |
And here I'm referring specifically to myoinositol
link |
because it comes in several forms.
link |
And it does appear that 900 milligrams of inositol
link |
can improve sleep and can reduce anxiety
link |
perhaps when taken at that dosage or higher dosages.
link |
I will just confess, first of all, I don't have OCD,
link |
although I will also confess that when I was a child,
link |
I had a transient tic.
link |
I've talked about this on podcasts before.
link |
It was a grunting tic.
link |
So when I was about six or seven,
link |
I recall a trip to Washington, D.C. with my family
link |
where I was feeling a strong desire or need even,
link |
as I recall, to grunt in order to clear something
link |
in my throat, but I didn't have anything in my throat.
link |
I didn't have a cold or any post-nasal drip.
link |
It was really just the feeling that I needed to do that
link |
to release some sort of tension.
link |
And I remember my dad at the time telling me,
link |
don't do that, don't do that.
link |
It's not good to grunt or something like that.
link |
I think he saw that it was kind of compulsive behavior.
link |
And so I would actually hide in the backseat
link |
of the rental car and do it, or I'd hide in my room.
link |
Fortunately for me, it was transient.
link |
I think about six months or a year later, it disappeared.
link |
Although I did notice, actually an ex-girlfriend of mine
link |
pointed out that when I get very tired
link |
and I've been working very long hours,
link |
sometimes that grunting tic will reappear.
link |
What does that mean?
link |
Do I have Tourette's?
link |
I don't know, maybe.
link |
I was never diagnosed with Tourette's.
link |
I certainly could be accused of having
link |
obsessive compulsive personality disorder,
link |
which we'll talk about still in a few minutes.
link |
But the point here is that many children
link |
transiently express tics or low-level Tourette's or OCD,
link |
and again, transiently and it disappears over time.
link |
So inositol has been explored
link |
in a bunch of different contexts,
link |
including for tics and OCD, et cetera.
link |
Going back to inositol and its current use,
link |
or I should say my current use,
link |
I've been taking 900 milligrams of inositol
link |
as an addition to my existing toolkit for sleep,
link |
which I've talked about many times on this podcast
link |
and other podcasts,
link |
consists of magnesium threonate, apigenin, and theanine.
link |
If you want to know more about that kit,
link |
you can go to our newsletter,
link |
neural network newsletter at hubermanlab.com.
link |
The toolkit for sleep is there.
link |
You don't even have to sign up for the newsletter,
link |
but it'll give you a flavor of the sorts of things
link |
that are in the newsletter.
link |
In any case, I've been experimenting a bit
link |
with taking 900 milligrams of myoinositol,
link |
either alone or in combination with that sleep kit.
link |
And I must say the sleep I've been getting on inositol
link |
is extremely deep and does seem to lead
link |
to enhanced levels of focus and alertness during the day.
link |
And perhaps you're noticing that
link |
because I'm talking more quickly on this podcast
link |
than in previous podcasts.
link |
No, I'm just kidding.
link |
I don't think the two things relate
link |
in any kind of causal way.
link |
The point here is that inositol
link |
is known to be pretty effective in reducing anxiety,
link |
but when taken at very high dosages.
link |
Can it do the same at low dosages?
link |
I would consider 900 milligrams a low dose.
link |
Most of this, given the fact
link |
that most of the studies of inositol
link |
have explored very high dosages,
link |
like even 10 or 12 grams per day,
link |
which I must say seems exceedingly high.
link |
And they do report that some of the subjects
link |
in those experiments actually stopped taking the inositol
link |
because of gastric discomfort
link |
or gastric distress as it's called.
link |
So I've reported my results with sleep
link |
in a kind of anecdotal way.
link |
They certainly aren't peer-reviewed studies
link |
that I described about my own experience
link |
in an anecdotal way.
link |
But nonetheless, it's been explored
link |
that things like glycine, which is another,
link |
which is an amino acid,
link |
which also acts as an inhibitory neurotransmitter
link |
in the brain, taken at very high dose,
link |
just 60 grams per day.
link |
That is a absolutely astonishingly high amount of glycine.
link |
I would not recommend taking that much glycine
link |
unless you're part of a study where they tell you to
link |
and you know it's safe.
link |
18 grams, excuse me, of inositol.
link |
These are very, very high dosages used in these studies.
link |
Nonetheless, there's some interesting data about inositol
link |
leading to some alleviation of OCD symptoms
link |
or partial alleviation of OCD symptoms
link |
in as little as two weeks
link |
after initiating the supplement protocol.
link |
So I think there's a great future for these nutraceuticals,
link |
meaning I think more systematic exploration
link |
in particular of lower dosages
link |
in the context of OCD treatment.
link |
And as we saw before for the SSRIs
link |
and other prescription drug treatments,
link |
I think there really needs to be an exploration
link |
of these nutraceuticals in combination
link |
with behavioral therapies and who knows,
link |
maybe with brain-machine interface
link |
like cranial magnetic stimulation as well.
link |
Now, way back at the beginning of the episode,
link |
I alluded to the fact that OCD is one thing,
link |
obsessive compulsive disorder, and it's truly a disorder,
link |
and it's truly debilitating, and it's extremely common.
link |
And then there's this other thing
link |
called obsessive compulsive personality disorder,
link |
which is distinct from that,
link |
does not have the intrusive component.
link |
So people don't feel overwhelmed
link |
or overtaken by these thoughts.
link |
Rather, they find that the obsessions
link |
can sometimes serve them or they even welcome them.
link |
And I think many of us know people like this.
link |
I perhaps even could be accused or who knows,
link |
maybe have been accused of having
link |
an obsessive compulsive personality at times.
link |
Why do I draw this distinction?
link |
Well, first of all, we've come to a point in human history,
link |
I think in large part because of social media,
link |
but also in large part because there are a number
link |
of discussions being held about mental health
link |
that have brought terms like trauma, depression, OCD, et cetera
link |
into the common vernacular so that people will say,
link |
oh, you're so OCD, or someone will say,
link |
I was traumatized by that, or I was traumatized by this.
link |
We should be very careful, right?
link |
I'm certainly not the word police,
link |
but we should be very careful in the use
link |
of certain types of language,
link |
especially language that has real psychiatric
link |
and psychological definitions because it can really draw us
link |
off course in providing relief for some of these syndromes.
link |
For instance, the word trauma is thrown around left
link |
and right nowadays, I was traumatized by this,
link |
or that caused trauma, or you're giving me trauma.
link |
Listen, I realize that many people are traumatized
link |
by certain events, including things that are said to them.
link |
I absolutely acknowledge that,
link |
hence our episodes on trauma and trauma treatment,
link |
several of them in fact, Dr. Conti, Dr. David Spiegel,
link |
and then dedicated solo episodes with just me blabbing
link |
about trauma and trauma treatment.
link |
But as Dr. Conti so appropriately pointed out,
link |
trauma is really something that changes our neural circuitry
link |
and therefore our thoughts and our behaviors
link |
in a very persistent way that is detrimental to us.
link |
Not every bad event is traumatizing,
link |
not everything that we dislike or even that we hate
link |
or that feels terrible to us is traumatizing.
link |
For something to reach the level of trauma,
link |
it really needs to change our neural circuitry
link |
and therefore our thoughts and our behaviors
link |
in a persistent way that is maladaptive for us.
link |
Similarly, just calling someone obsessive is one thing,
link |
saying that someone has OCD or assuming one has OCD
link |
simply because they have a personality or a phenotype,
link |
as we say, where they need things in perfect order.
link |
Like I find myself correcting these pens,
link |
making sure that the caps are facing in the same direction,
link |
for instance, right now.
link |
That is not the same as OCD.
link |
If, for instance, I can tolerate these pens
link |
being at different orientation
link |
or even throw the cap on the floor or something,
link |
it doesn't create a lot of anxiety for me.
link |
I confess I agree it's a little bit in the moment,
link |
then I can forget about it and move on.
link |
That's one of the key distinctions
link |
between obsessive compulsive personality disorder
link |
and obsessive compulsive disorder in its strictest form.
link |
Now, once one hears that OCD
link |
is different than obsessive compulsive personality disorder
link |
because of this difference
link |
in how intrusive the thoughts are or not,
link |
then that's useful,
link |
but it really doesn't tell us anything
link |
about what is happening mechanistically
link |
in one situation or another.
link |
Fortunately, there are beautiful data,
link |
again, from Dr. Blair Simpson's lab,
link |
and you can tell based on the number of studies
link |
that I've referred to from her laboratory,
link |
that she's truly one of the luminaries in this field,
link |
that there really are some fundamental wiring differences
link |
and behavioral differences and psychological differences
link |
between people who have obsessive compulsive disorder
link |
and those who have obsessive compulsive
link |
personality disorder.
link |
So this is a study first authored by Pinto, P-I-N-T-O,
link |
entitled Capacity to Delay Reward
link |
Differentiates Obsessive Compulsive Disorder
link |
and Obsessive Compulsive Personality Disorder.
link |
And the methods in this study
link |
were to take 25 people with OCD
link |
and 25 people with obsessive compulsive personality disorder
link |
and 25 people who have both
link |
because it is possible to have both,
link |
and that's important to point out,
link |
and 25 so-called healthy controls,
link |
people that don't have
link |
obsessive compulsive personality disorder
link |
or obsessive compulsive disorder.
link |
They take clinical assessments,
link |
and then they took a number of tests
link |
that probed their ability to defer gratification,
link |
something called, in the laboratory,
link |
we call it delayed discounting,
link |
so their ability to defer gratification
link |
through a task where they can either accept reward
link |
right away or accept reward later.
link |
Some of you may have heard of the two-marshmallow task.
link |
This is based on a study that was performed years ago
link |
on young children at Stanford and elsewhere,
link |
where they take young children into a room,
link |
they offer them a marshmallow,
link |
kids like marshmallows generally,
link |
and you say, you can eat the marshmallow right now,
link |
or you can wait some period of time,
link |
and if you are able to wait and not eat the marshmallow,
link |
you can have two marshmallows.
link |
And in general, children want two marshmallows
link |
more than they want one marshmallow.
link |
So really what you're probing is
link |
their ability to access delayed gratification,
link |
and they're very entertaining,
link |
even truly amusing videos of this on the internet.
link |
So if you just do two marshmallow task video,
link |
and you go into YouTube,
link |
what you'll find is that the children will use
link |
all sorts of strategies to delay gratification.
link |
Some of the kids will cover the marshmallow,
link |
others will talk to the marshmallow and say,
link |
I know you're not that delicious,
link |
you look delicious, but no, you're not delicious.
link |
They'll engage with the marshmallow
link |
in all sorts of cute ways.
link |
They'll turn around and try and, you know, avoidance,
link |
which actually speaks to a whole category of behaviors
link |
that people with OCD also use.
link |
I'm not saying these kids had OCD,
link |
but avoidance behaviors are very much a component of OCD.
link |
People really trying to avoid the thing
link |
that evokes the obsession.
link |
Well, some kids are able to delay gratification, some aren't.
link |
And it's debatable as to whether or not
link |
the kids that are able to delay gratification
link |
go on to have more successful lives or not.
link |
Initially, that was the conclusion of those studies.
link |
There's still a lot of debate about it.
link |
We'll bring an expert on to give us
link |
the final conclusion on this,
link |
because there is one and it's very interesting
link |
and not intuitive.
link |
Nonetheless, adults are also faced
link |
with decisions every day, all day,
link |
as to whether or not they can delay gratification.
link |
And this study used a, not a two-marshmallow task,
link |
but a game that involved rewards where people could delay
link |
in order to get greater rewards later.
link |
What is the conclusion?
link |
Well, first of all, obsessive compulsive
link |
and obsessive compulsive personality disorder subjects
link |
both showed impairments in their psychosocial functioning
link |
and quality of life.
link |
They had compulsive behavior.
link |
So these are people that are suffering in their life
link |
because their compulsions are really strong.
link |
So it's not just being really nitpicky
link |
or really orderly in one case
link |
and having full-blown OCD in the other,
link |
both sets of subjects are challenged in life
link |
because they're having relationship issues
link |
or job-related issues, et cetera,
link |
because they are that compulsive.
link |
However, the individuals
link |
with obsessive compulsive personality disorder,
link |
they discounted the value of delayed gratification
link |
significantly less than those
link |
with obsessive compulsive disorder.
link |
They are both impairing disorders
link |
that are marked by compulsive behaviors.
link |
Here I'm paraphrasing,
link |
but they can be differentiated
link |
by the presence of obsessions in OCD.
link |
So obsessions in OCD.
link |
People with OCD are absolutely fixated on certain ideas
link |
and those ideas are intrusive.
link |
Again, that's the hallmark theme.
link |
And by an excessive capacity to delay reward
link |
in obsessive compulsive personality disorder,
link |
that is people who have obsessive compulsive
link |
personality disorder are really good
link |
at delaying gratification.
link |
So they are able to concentrate very intensely
link |
and perform very intensely in ways
link |
that allow them to instill order
link |
such that they can delay reward.
link |
Now you can see why this contour of symptoms,
link |
meaning that the people with OCD
link |
are experiencing intrusive thoughts,
link |
whereas the people
link |
with obsessive compulsive personality disorder
link |
show an enhanced ability to defer gratification.
link |
You could see how that would lead
link |
to very different outcomes.
link |
People with obsessive compulsive personality disorder
link |
can actually leverage that personality disorder
link |
to perform better in certain domains of life,
link |
not all domains of life,
link |
because remember, again, these people are in this study
link |
and they're showing up as experiencing challenges in life
link |
because of their obsessive compulsive personality disorder.
link |
Nonetheless, people with obsessive compulsive
link |
personality disorder, you can imagine,
link |
would be very good at, say, architecture
link |
or anything that involves instilling a ton of order,
link |
maybe a sushi chef, for instance, maybe a chef in general.
link |
I know chefs that just kind of throw things around
link |
like the chef on the Muppets
link |
and just throw things everywhere
link |
and still produce amazing food.
link |
And then there's some people
link |
where they're incredibly exacting.
link |
They're just incredibly precise.
link |
I think that movie, what is it, Hero Dreams of Sushi,
link |
that movie is incredible.
link |
Certainly not saying he has obsessive
link |
compulsive personality disorder,
link |
but I think it's fair to say that he is obsessive
link |
or extremely meticulous and orderly
link |
about everything from start to finish.
link |
You can imagine a huge array of different occupations
link |
and life endeavors where this would be beneficial,
link |
science being one of them,
link |
where data collection and analysis
link |
is exceedingly important that one be precise,
link |
or mathematics or physics or engineering,
link |
anything where precision has a payoff
link |
and gaining precision takes time
link |
and delay of immediate gratification,
link |
you can imagine that obsessive compulsive
link |
personality disorder would synergize well
link |
with those sorts of activities and professions.
link |
Whereas obsessive compulsive disorder is really intrusive.
link |
It's preventing functionality
link |
in many different domains of life.
link |
So the key takeaway here is that
link |
when we use the words obsessive compulsive,
link |
or we call someone obsessive compulsive,
link |
or we are trying to evaluate whether or not
link |
we are obsessive compulsive,
link |
it's very important that we highlight
link |
that obsessive compulsive disorder is very intrusive.
link |
It involves intrusive thoughts
link |
and it interrupts with normal functioning in life.
link |
Whereas obsessive compulsive personality disorder,
link |
while it can interrupt normal functioning in life,
link |
it also can be productive.
link |
It can enhance functioning in life,
link |
not just in work, but perhaps at home as well.
link |
If you are somebody and you have family members
link |
that really place enormous value
link |
on having a beautiful and highly organized home,
link |
well, then it could lend itself well to that.
link |
It's going to be a matter of degrees, of course.
link |
None of these things is an absolute,
link |
it's going to be on a continuum.
link |
But I think it is fair to say
link |
that obsessive compulsive disorder,
link |
whether or not in mild, moderate or severe form,
link |
is impairing normal functioning.
link |
Whereas obsessive compulsive personality disorder,
link |
there's a range of expressions of that,
link |
some of which can be adaptive,
link |
some of which can be maladaptive.
link |
And again, it's all going to depend on context.
link |
Before we conclude, I do want to touch on something
link |
that I think a lot of people experience,
link |
and that's superstitions.
link |
Superstitions are fascinating
link |
and there's some fascinating research on superstitions.
link |
One particular study that I'm a big fan of
link |
is the work of Ben Solevsky at Harvard.
link |
He studies motor sequences and motor learning.
link |
And he has beautiful data on how people learn,
link |
for instance, a tennis swing
link |
and the patterns that they engage in early on.
link |
And then the patterns of swinging,
link |
that they, swinging the racket, that is,
link |
that they engage in later as they acquire more skill.
link |
And basically the takeaway is that the amount of error
link |
or variation from swing to swing is dramatically reduced
link |
as they acquire skill.
link |
That's all fine and good.
link |
And there's some beautiful mechanistic data
link |
that he and others have discovered
link |
to support how that comes to be.
link |
But they also explore animal models,
link |
in particular, rats pressing sequences of buttons
link |
and levers to obtain a reward.
link |
Believe it or not, rats are pretty smart.
link |
I've seen this with my own eyes.
link |
You can teach a rat to press a lever for a pellet of food.
link |
Rats can also learn to press levers in a particular sequence
link |
in order to gain a piece of food.
link |
And they can actually learn to press an enormous number
link |
of levers in very particular sequences
link |
in order to obtain pellets of food.
link |
You can also give them little buttons to press
link |
or even a paddle to, or I should say a pedal, excuse me,
link |
to stomp on with their foot
link |
in order to obtain a pedal of food.
link |
Basically, rats can learn exactly what they need to do
link |
in order to obtain a piece of food,
link |
especially if they're made a little bit hungry first.
link |
Benson's lab has published beautiful data showing
link |
that as animals and humans
link |
come to learn a particular motor sequence,
link |
very often they will introduce motor patterns
link |
in that sequence that are irrelevant to the outcome
link |
and yet that persist.
link |
If you've ever watched a game of baseball,
link |
you've seen this before.
link |
Oftentimes the pitcher up on the mound
link |
will bring the ball to their chin,
link |
they'll look over their shoulder,
link |
they'll look back over the other shoulder,
link |
and then they will, of course,
link |
reel back and pitch the ball.
link |
But if you watch closely,
link |
oftentimes there are components in the motor sequence
link |
which are completely unrelated to the pitch.
link |
They're not looking necessarily
link |
to see if someone's stealing a base.
link |
They're not necessarily looking down at home plate
link |
where the batter is.
link |
They're also doing things like touching the back of their ear
link |
before they bring the ball to their chin
link |
or adjusting their hat.
link |
And if you watch individual pitchers,
link |
what you'll find is that they'll do the same sequence
link |
of completely irrelevant motor patterns
link |
before each and every single pitch.
link |
Similarly, rats that have been trained to, for instance,
link |
hit two levers and step on a pedal
link |
with their left hind foot,
link |
and then tap a button up above that is the red button,
link |
will do that to gain a piece of food.
link |
But sometimes they'll also introduce a pattern
link |
into that motor sequence
link |
where they will shake their tail a little bit,
link |
or they'll turn their head a little bit,
link |
or they'll move their ears a little bit, et cetera.
link |
Motor patterns that have nothing to do with obtaining
link |
the particular outcome in mind.
link |
In other words, you could eliminate certain components
link |
of the motor sequence and it would not matter.
link |
The rat would still get the pellet.
link |
The pitcher would still be able to pitch.
link |
And yet that can introduce because somehow,
link |
because they were performed again and again,
link |
prior to successful trials,
link |
the rat or the human baseball pitcher
link |
comes to believe in some way
link |
that it was involved in generating the outcome,
link |
hence superstition, right?
link |
I confess I have a few superstitions.
link |
I occasionally will knock on wood.
link |
I'll say something that I want to happen
link |
and I'll say, oh, knock on wood, and I'll just do it.
link |
And occasionally I'll challenge myself and think,
link |
ah, I don't want to knock,
link |
don't knock on wood, Andrew, don't do that.
link |
I don't think anyone wants to be superstitious.
link |
I certainly don't.
link |
And so every once in a while, I'll just challenge it
link |
and I won't actually knock on wood.
link |
I'm admitting this to you to kind of normalize some of this.
link |
Some people have superstitions that border on
link |
or even become compulsions.
link |
They really come to believe that if they don't knock on wood
link |
that something terrible is going to happen,
link |
maybe something in particular,
link |
or in the case of the baseball pitcher,
link |
they come to believe that if they don't touch
link |
their right ear before they reel back on the pitch,
link |
that the pitch won't be any good
link |
or that they're going to lose the game.
link |
I don't know what their thought process is.
link |
Now, I also don't know what the rat is thinking,
link |
but the rat is clearly doing something
link |
or thinking something is related to the final outcome.
link |
I don't know of any studies where they've intervened
link |
with the particular superstition-like behaviors of the rat
link |
to see whether or not the rat somehow doesn't continue
link |
to do the motor sequence to get the pellet.
link |
The rats, I don't speak rat.
link |
Most people don't.
link |
Or if you speak to a rat, if it speaks back,
link |
it's not in English.
link |
Anyway, the point is that superstitions are beliefs
link |
that we on an individual scale come to believe
link |
are linked to the probability of an outcome
link |
when in fact we know,
link |
we actually know in our rational minds,
link |
they have no real relationship to the outcome.
link |
Superstitions can become full-blown compulsions
link |
and obsessions when we repeat them often enough
link |
that they become automatic.
link |
And I think this is what we observe most of the time
link |
when we see a pitcher touching their ear,
link |
or for instance, in tennis, you see this a lot.
link |
You'll see someone, they'll slap their shoes often.
link |
They'll slap the undersides of their soles.
link |
They may tell themselves that this is, I don't know,
link |
maybe moving out some of the dust or something
link |
in the bottoms of their soles that gives them more traction
link |
and they want that to be ready for the serve
link |
or something like that.
link |
And maybe there's some truth to that.
link |
But here, what we're referring to are behaviors
link |
that really have no rational relationship to the outcome.
link |
And yet we perform in a compulsive way.
link |
People with OCD, yes, tend to have more superstitions.
link |
People with more superstitions, yes,
link |
tend to have a tendency towards OCD.
link |
And I should mention obsessive compulsive
link |
personality disorder.
link |
If you think way back to the first part of this episode,
link |
when I was just describing what the brain does, right?
link |
What does your brain do?
link |
Housekeeping functions to keep you alive.
link |
And it's a prediction machine.
link |
Your neural circuits, you have an enormous amount
link |
of biological investment of real estate,
link |
literally cells and chemicals that are there
link |
to try and make your world predictable
link |
and to try and give you control
link |
or at least the sense of control over that world.
link |
And that's a normal process.
link |
Low-level superstitions, moderate superstitions
link |
represent a kind of a healthy range, I would say,
link |
of behaviors that are aimed at generating predictability
link |
that don't disrupt normal function.
link |
Obsessive compulsive personality disorder,
link |
provided it's not too severe,
link |
would, I think, represent the next level
link |
along that continuum.
link |
And then obsessive compulsive disorder,
link |
as I pointed out earlier,
link |
is really a case of highly debilitating,
link |
highly intrusive, really overtake of neural circuitry
link |
over our thoughts and behaviors
link |
that requires very dedicated, very persistent.
link |
And very effective treatments
link |
in order to stop those obsessions and compulsions
link |
and the anxiety that links them somewhat counterintuitively
link |
by teaching people to tolerate
link |
that level of increased anxiety
link |
and interrupt those patterns.
link |
Unfortunately, as we described earlier,
link |
such treatments exist.
link |
Cognitive behavioral therapy, drug treatments like SSRIs,
link |
though also drug treatments
link |
that tap into the glutamate system
link |
and into perhaps also the dopamine system,
link |
the so-called neuroleptics.
link |
And then, as we described,
link |
there's now an extensive exploration
link |
of things like ketamine, psilocybin, cannabis.
link |
The initial studies don't seem to hold much promise
link |
for cannabis and CBD in the treatment of OCD,
link |
but who knows, maybe more studies will come along
link |
that will change that story.
link |
And then, of course, brain-machine interface
link |
like transcranial magnetic stimulation.
link |
And then just to remind you
link |
what I already told you before,
link |
combinations of behavioral and drug treatments
link |
and brain-machine interface,
link |
I think is really where the future lies.
link |
Fortunately, good treatments exist.
link |
We cannot say that any one individual treatment
link |
works for everybody.
link |
There are fairly large percentages of people
link |
that won't respond to one set of treatments or another,
link |
and therefore one has to try different ones.
link |
And then there are the so-called supplementation-based
link |
or more holistic therapies.
link |
Today, I've tried to cover each and all of these
link |
in a fairly substantial amount of detail.
link |
I realize this is a fairly long episode.
link |
That is intentional.
link |
Much like our episode on ADHD,
link |
on attention deficit hyperactivity disorder,
link |
I received an enormous number of requests to talk about OCD.
link |
And my decision to make this a very long
link |
and detailed episode about OCD
link |
really doesn't stem from any desire
link |
to subject you to too much information
link |
or to avoid the opportunity to just list things off.
link |
But what I've tried to provide is an opportunity
link |
to really drill deep into the neural circuitry
link |
and an understanding of where OCD comes from,
link |
how OCD is different from things like
link |
the personality disorders that I described,
link |
and also to give you a sense of
link |
how the individual behavioral and drug treatments work
link |
and perhaps don't work
link |
so that you can really make the best informed choices.
link |
Again, highlighting the fact that OCD
link |
is an extremely common, extremely common,
link |
and yet extremely debilitating condition,
link |
and one that I hope that if any of you have
link |
or that you know people that have it,
link |
that you'll both gain sympathy and understanding
link |
for what they're dealing with,
link |
perhaps as a consequence of some of the information
link |
presented today, and maybe help them direct their treatment,
link |
find better treatment,
link |
and of course apply those treatments for some relief.
link |
If you're learning from and or enjoying this podcast,
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please subscribe to our YouTube channel.
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That's a terrific zero-cost way to support us.
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In addition, please subscribe to the podcast
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And on both Spotify and Apple,
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During today's podcast and on many previous episodes
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of the Huberman Lab Podcast, we talk about supplements.
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While supplements aren't necessary for everybody,
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many people derive tremendous benefit from them
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for things like sleep and focus and anxiety and so on.
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The Huberman Lab Podcast is now partnered
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They ship everywhere in the world, not just in the US.
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If you go to livemomentous.com slash Huberman,
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The catalog of supplements available there
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But right now already there are a number
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Again, that's livemomentous.com slash Huberman.
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In closing, I'd like to thank you
link |
for this in-depth discussion about the mechanisms
link |
and various treatments for obsessive compulsive disorder
link |
and some of the related disorders.
link |
And as always, thank you for your interest in science.
link |
And as always, thank you for your interest in medicine.