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The 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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or OCD.
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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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The good news is,
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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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that we call OCD.
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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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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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as we go forward,
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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,
link |
00:12:41.900
but this is the sort of thing
link |
00:12:43.060
that operates in a lot of people.
link |
00:12:45.420
And I really want to emphasize this
link |
00:12:46.940
because the clinical literature that are out there
link |
00:12:50.060
really point to the fact that many people have OCD,
link |
00:12:54.020
full-blown OCD, and never report it
link |
00:12:56.100
because of the kind of shame and hiding associated with it.
link |
00:12:59.500
Another thing to point out is that OCD
link |
00:13:02.260
is extremely debilitating.
link |
00:13:04.720
I mentioned this a few minutes ago,
link |
00:13:06.100
but OCD is currently listed as at number seven
link |
00:13:08.980
in terms of the most debilitating illnesses,
link |
00:13:11.580
not just mental illnesses or disorders,
link |
00:13:14.980
but all types of illnesses,
link |
00:13:16.680
including things like asthma and cancer, et cetera.
link |
00:13:19.500
So you can imagine with that standing at number seven,
link |
00:13:23.300
that it is both extremely common
link |
00:13:25.620
and extremely debilitating.
link |
00:13:27.060
And as a consequence, it's now realized that many hours,
link |
00:13:31.440
days, weeks, months, or even years of work performance
link |
00:13:35.540
or showing up at work, of relational interactions,
link |
00:13:38.920
really suffer as a consequence of people having OCD.
link |
00:13:41.460
So this is a vital problem that the scientific
link |
00:13:43.760
and psychiatric and psychological communities understand.
link |
00:13:46.420
And it's one of the reasons that I'm doing this podcast.
link |
00:13:49.520
And of course, I received a ton of interest in OCD
link |
00:13:52.380
because of this incredibly high incidence of OCD
link |
00:13:55.140
and how debilitating it is.
link |
00:13:56.940
We could go really deep into why it's so debilitating.
link |
00:14:00.160
I don't want to spend too much time on that
link |
00:14:01.380
because I think most of that is pretty obvious,
link |
00:14:03.100
but some of it is not.
link |
00:14:04.500
For instance, one of the things that makes OCD
link |
00:14:06.660
so debilitating is of course the shame
link |
00:14:08.780
that we talked about before,
link |
00:14:10.180
but it's also the fact that when people are focusing
link |
00:14:12.980
on their obsessions and their compulsions,
link |
00:14:14.600
they're not able to focus on other things.
link |
00:14:16.560
That's simply the way that the brain works.
link |
00:14:17.960
We're not able to focus on too many things at once.
link |
00:14:20.380
The other thing is that OCD takes a lot of time
link |
00:14:23.580
out of people's lives.
link |
00:14:25.320
With recurrent intrusive thoughts happening
link |
00:14:27.700
at very high frequency or even at moderate frequency,
link |
00:14:30.020
people are spending a lot of time thinking about this stuff
link |
00:14:32.820
and they're thinking about the behaviors
link |
00:14:34.740
they need to engage in and then engaging in the behaviors,
link |
00:14:36.820
which as I mentioned before,
link |
00:14:37.840
just serve to strengthen the compulsions.
link |
00:14:39.440
And so they're not actually doing the other things
link |
00:14:41.540
that make us functional human beings,
link |
00:14:43.300
like commuting to work or doing homework or doing work
link |
00:14:46.300
or listening when people are talking or interacting
link |
00:14:48.780
or sports or working out.
link |
00:14:49.680
All the things that make for a rich quality life
link |
00:14:52.720
are taken over by OCD in many cases.
link |
00:14:56.020
So while that might be obvious to some,
link |
00:14:57.820
I'm not sure that it's obvious to everybody
link |
00:14:59.520
just how much time OCD can occupy.
link |
00:15:02.500
Another thing you'll soon learn is that sadly,
link |
00:15:05.220
a lot of the obsessions and compulsions in OCD
link |
00:15:07.860
often relate to taboo topics.
link |
00:15:09.680
And that's because the general categories of OCD
link |
00:15:12.720
fall into three different bins,
link |
00:15:15.440
checking obsessions and compulsions,
link |
00:15:17.820
repetition obsessions and compulsions
link |
00:15:20.220
and order obsessions and compulsions.
link |
00:15:22.380
The checking ones are somewhat obvious,
link |
00:15:23.980
checking the stove or checking the locks,
link |
00:15:26.300
which I think we all tend to do.
link |
00:15:27.720
I'm somebody typically I'll head off to the car
link |
00:15:30.480
to commute to work.
link |
00:15:31.700
And I'll think I locked the front door
link |
00:15:33.160
and I'll go back once.
link |
00:15:34.580
But I won't go back twice or 50 times.
link |
00:15:36.840
People with OCD will often go back 20 or 30 times
link |
00:15:40.320
before they'll actually allow themselves to drive off.
link |
00:15:42.500
And then it's a real challenge for them
link |
00:15:44.780
to continue to drive off and discard with the idea
link |
00:15:47.340
that they didn't check the stove
link |
00:15:48.580
or they didn't check the locks
link |
00:15:49.660
or they didn't check something else critical.
link |
00:15:52.340
Repetition obsessions and compulsions
link |
00:15:54.660
obviously can dovetail with the checking ones,
link |
00:15:57.840
but those tend to be things like counting off
link |
00:16:00.000
of a certain number of numbers,
link |
00:16:02.200
like one, two, three, four, five, six, seven,
link |
00:16:04.100
seven, six, five, four, three, two, one.
link |
00:16:05.500
People will perform that repeatedly, repeatedly, repeatedly
link |
00:16:08.380
or feel that they have to.
link |
00:16:09.980
I remember years ago watching a documentary
link |
00:16:12.100
about the band, the Ramones.
link |
00:16:14.940
Most people heard of the Ramones, right?
link |
00:16:16.360
Jeans, t-shirts, aviator glasses.
link |
00:16:18.140
Everyone had to change their last name to Ramone.
link |
00:16:19.700
They weren't actually all related to one another,
link |
00:16:21.460
by the way, you had to change your last name to Ramone.
link |
00:16:23.500
The Ramones had one band member who was admittedly
link |
00:16:27.360
and known to others as having OCD.
link |
00:16:29.420
And during that documentary, which I forget the name,
link |
00:16:32.040
I think it was called, can't remember.
link |
00:16:33.900
Anyway, can't remember, hippocampal lapse there.
link |
00:16:37.100
But in this documentary,
link |
00:16:38.540
the band members describe Joey Ramone as leaving hotels,
link |
00:16:43.860
walking down the stairs to the parking lot,
link |
00:16:45.640
but then having to walk up and down them seven or eight
link |
00:16:47.540
times and sometimes getting out of the van again
link |
00:16:49.500
and walking up and down them seven or eight times.
link |
00:16:51.620
And it always had to be a certain number of times
link |
00:16:53.580
given a certain number of stairs.
link |
00:16:55.060
This appears quote unquote crazy,
link |
00:16:56.660
but of course we don't want to think of this as crazy.
link |
00:16:58.980
This is somebody who very likely had full-blown OCD.
link |
00:17:03.220
Now that particular example, believe it or not,
link |
00:17:05.160
is not all that uncommon.
link |
00:17:07.820
It just so happens that that example entailed
link |
00:17:10.340
certain compulsions and behaviors that were overt
link |
00:17:12.740
and that other people could see.
link |
00:17:14.780
And you can imagine how that would prevent somebody
link |
00:17:16.860
from moving about their daily life easily.
link |
00:17:18.540
A lot of people, as I mentioned before,
link |
00:17:20.320
have obsessions and compulsions that they hide
link |
00:17:22.740
and they do these little micro-behaviors
link |
00:17:24.260
or they'll just count off in their head
link |
00:17:26.380
as opposed to generating some sort of walking up
link |
00:17:28.600
and down stairs or tapping or things of that sort.
link |
00:17:31.420
So we have checking, we have repetition,
link |
00:17:32.960
and then there's order.
link |
00:17:34.580
Order oftentimes is thought of as putting cleanliness
link |
00:17:39.420
or making sure everything is aligned
link |
00:17:41.460
and perfect and orderly.
link |
00:17:43.720
And oftentimes that is the case,
link |
00:17:45.360
but there are other forms of order that people with OCD
link |
00:17:48.100
can focus on in a obsessive and compulsive way.
link |
00:17:51.680
Things like incompleteness,
link |
00:17:53.260
the idea that one can't walk away from something
link |
00:17:56.320
or stop doing something because something's not right
link |
00:17:58.600
or complete in that picture.
link |
00:18:00.540
It could be the way the table is set.
link |
00:18:02.940
It could be the way that something's written on a page.
link |
00:18:05.060
It could be an email.
link |
00:18:06.700
Again, now we're still talking about OCD, the disorder.
link |
00:18:09.660
We're not talking about
link |
00:18:10.700
obsessive compulsive personality disorder.
link |
00:18:13.820
I'm aware of, well, I'll just be direct,
link |
00:18:16.160
several colleagues of mine, and it's just remarkable,
link |
00:18:18.480
the order in their emails.
link |
00:18:20.260
Every email is perfect, punctuated perfect,
link |
00:18:23.260
grammar perfect, everything's spaced perfect.
link |
00:18:25.860
Do they have OCD?
link |
00:18:26.780
Well, they might, they might not.
link |
00:18:27.940
How would I know unless they disclose that to me?
link |
00:18:31.320
But they might have obsessive compulsive personality disorder
link |
00:18:34.540
or they just might be able to generate a lot of order
link |
00:18:37.880
and they have a lot of discipline
link |
00:18:39.160
around the way they write and the way they present
link |
00:18:40.920
any communication with anybody at all.
link |
00:18:43.620
So if somebody has a OCD that's in the domain of order,
link |
00:18:47.840
it could be incompleteness and the constant feeling
link |
00:18:50.980
of something not being completed and a need to complete it.
link |
00:18:54.220
It can also be in terms of symmetry,
link |
00:18:56.140
that everything be aligned and symmetric in some way.
link |
00:18:58.680
This could be seen perhaps in young kids.
link |
00:19:01.900
This is one example that I read in the literature
link |
00:19:04.020
of children that need to arrange their stuffed animals
link |
00:19:06.540
in exact same order every day and in a particular order
link |
00:19:11.540
to the point where if you were to move
link |
00:19:13.600
the little stuffed frog over next to the stuffed rabbit,
link |
00:19:15.900
that the child would have an anxiety reaction to that
link |
00:19:19.520
and feel literally compelled, driven to fix that,
link |
00:19:23.500
maybe even multiple times over and over again.
link |
00:19:26.360
We'll talk about OCD in children
link |
00:19:27.920
versus adults in a little bit.
link |
00:19:29.400
And then the other aspect of order,
link |
00:19:31.620
which is a little bit less than intuitive
link |
00:19:33.880
is this notion of disgust.
link |
00:19:35.580
This idea that something is contaminated.
link |
00:19:37.440
So we often think about OCD and hand-washing behavior
link |
00:19:41.240
in response to people feeling that something is contaminated,
link |
00:19:44.200
a space, a towel, et cetera,
link |
00:19:46.260
or even simply somebody else's hand.
link |
00:19:48.440
And so they're unwilling to shake somebody's hand.
link |
00:19:50.780
You can imagine how these different bins of obsessions
link |
00:19:53.480
and compulsions, checking repetition and order
link |
00:19:56.760
could be extremely debilitating
link |
00:19:58.040
depending on how severe they are
link |
00:19:59.440
and how many different domains of life they show up in.
link |
00:20:02.760
Because oftentimes in movies,
link |
00:20:04.640
and even the way I'm describing it now,
link |
00:20:06.640
it sounds as if, okay, well, somebody has to check the locks
link |
00:20:09.360
but they don't have to also check the stove.
link |
00:20:11.180
Or somebody has the need to count to seven back and forth
link |
00:20:14.880
up to seven and down to seven,
link |
00:20:16.040
seven times a day or something of that sort.
link |
00:20:20.320
Where they need symmetry in very specific domains of life.
link |
00:20:23.180
But it turns out that this recurrent
link |
00:20:24.820
and intrusive aspect of obsessions leads people with OCD
link |
00:20:29.200
to have checking repetition
link |
00:20:31.880
and or order compulsions everywhere.
link |
00:20:35.420
So whether or not somebody is at work or in school
link |
00:20:38.100
or trying to engage in sport
link |
00:20:39.480
or trying to engage in relationship
link |
00:20:40.920
or just something simple like walking down the street,
link |
00:20:43.580
the obsessions are so intrusive that they show up
link |
00:20:45.880
and they compel people to do things in that domain
link |
00:20:48.700
independent of whether or not
link |
00:20:51.120
they happen to be in one location or another.
link |
00:20:53.040
In other words, the thought patterns and the behaviors
link |
00:20:56.640
take over the environment as opposed to the environment
link |
00:20:59.220
driving the thought patterns and behaviors.
link |
00:21:01.460
So it therefore becomes impossible
link |
00:21:03.100
to ever find a room that's clean enough
link |
00:21:05.200
to find a bed that's made well enough
link |
00:21:07.760
to find anything that's done well enough
link |
00:21:10.720
to remove the obsession.
link |
00:21:13.180
And I know I've said it multiple times now,
link |
00:21:15.080
but I'm going to say it many times throughout this episode
link |
00:21:18.020
in a somewhat obsessive, but I believe justified way
link |
00:21:21.940
that every time that one engages in the compulsion
link |
00:21:25.580
related to the obsession,
link |
00:21:26.780
the obsession simply becomes stronger.
link |
00:21:28.920
So you can imagine what a powerful
link |
00:21:31.320
and debilitating loop that really is.
link |
00:21:33.340
So let's drill a little bit deeper
link |
00:21:34.740
into how the obsessions and compulsions
link |
00:21:36.460
relate to one another.
link |
00:21:37.860
If we were to draw a line
link |
00:21:39.100
between the obsessions and the compulsions,
link |
00:21:41.420
that line could be described as anxiety.
link |
00:21:45.660
Now we need to define what anxiety is.
link |
00:21:47.840
And to be quite honest,
link |
00:21:49.900
most of psychology and science
link |
00:21:51.820
can't agree on exactly what anxiety is.
link |
00:21:53.980
Typically the way we think about fear
link |
00:21:56.220
is that it's a heightened state of autonomic arousal.
link |
00:21:59.020
So increased heart rate, increased breathing,
link |
00:22:00.940
sweating, et cetera,
link |
00:22:02.240
in response to an immediate and present threat
link |
00:22:04.940
or perceived threat.
link |
00:22:06.320
Whereas anxiety, generally speaking
link |
00:22:08.540
in the scientific literature,
link |
00:22:09.960
relates to the same sorts of thought patterns
link |
00:22:13.700
and somatic bodily responses,
link |
00:22:15.820
heart rate, breathing, et cetera,
link |
00:22:17.540
but without a clear and present danger
link |
00:22:20.700
being in the environment or right there.
link |
00:22:22.980
So that's the way
link |
00:22:23.820
that we're going to talk about anxiety now.
link |
00:22:25.820
And anxiety is really what binds the obsessions
link |
00:22:28.580
and compulsions such that
link |
00:22:29.820
someone will have an intrusive thought.
link |
00:22:31.660
So for instance, someone will have the thought that
link |
00:22:34.140
if they turn left on any street,
link |
00:22:36.900
that something bad will happen, okay?
link |
00:22:38.780
That's an obsession.
link |
00:22:39.620
It's actually not all that uncommon.
link |
00:22:41.380
Now, how bad and what the specificity
link |
00:22:43.580
of that bad thing really is will vary.
link |
00:22:45.380
Some people will think if I turn left,
link |
00:22:47.380
something generally bad will happen.
link |
00:22:48.820
It just makes me feel anxious.
link |
00:22:50.140
So they always insist on going right.
link |
00:22:52.080
Whereas other people will think if I turn left,
link |
00:22:55.180
so-and-so will die or I will die
link |
00:22:58.180
or something terrible will happen.
link |
00:23:00.420
I'll get a disease or someone else will get a disease
link |
00:23:02.620
or I'll be cursing myself or somebody else
link |
00:23:04.600
in some very specific way.
link |
00:23:06.580
This is unfortunately quite common in people with OCD.
link |
00:23:10.820
So they have this feeling and the feeling can be generally
link |
00:23:14.940
or specifically related to a particular outcome.
link |
00:23:17.200
But beneath that is a feeling of anxiety,
link |
00:23:20.060
a quickening of the heartbeat,
link |
00:23:22.060
a quickening of breathing,
link |
00:23:23.540
a narrowing of one's visual focus.
link |
00:23:26.260
I've talked about this before on other podcasts,
link |
00:23:28.080
the master stress and other podcasts.
link |
00:23:29.700
But if you haven't heard those,
link |
00:23:31.380
let me just briefly describe that
link |
00:23:32.740
when we are in a state of increased
link |
00:23:34.580
so-called autonomic arousal, alertness, stress, et cetera,
link |
00:23:38.180
our visual field literally narrows.
link |
00:23:40.400
The aperture of our visual field gets smaller
link |
00:23:42.940
and that's because of the relationship
link |
00:23:44.160
between the autonomic nervous system and your visual system.
link |
00:23:46.980
So you start seeing the world through sort of
link |
00:23:49.700
soda straw view or through binocular like view
link |
00:23:52.060
as opposed to seeing the big picture.
link |
00:23:53.580
Why is that important?
link |
00:23:54.580
Well, it literally sharpens and narrows your focus
link |
00:23:58.780
toward the very thing that the obsessions
link |
00:24:00.780
and the compulsions are focused on.
link |
00:24:02.040
So the person walking down the street
link |
00:24:03.380
who sees the opportunity to go left or right
link |
00:24:06.200
will only see the bad decision.
link |
00:24:09.640
Their visual field narrows very tightly
link |
00:24:12.500
along that possibility of taking a left turn.
link |
00:24:15.180
And I know as I described, this seems totally irrational,
link |
00:24:17.620
but I want to emphasize that the person with OCD
link |
00:24:20.420
knows it's irrational.
link |
00:24:22.420
They might feel crazy because they're having these thoughts,
link |
00:24:25.860
but they know it makes no sense whatsoever
link |
00:24:27.980
that left somehow would be different than right
link |
00:24:30.820
in terms of outcomes in this particular case.
link |
00:24:33.500
And yet it feels as if it would.
link |
00:24:36.060
In fact, in some cases, it feels as if they went left,
link |
00:24:38.460
they would have a full-blown panic attack.
link |
00:24:40.820
So the idea here is that the obsessions and compulsions
link |
00:24:43.980
are bound by anxiety, but then by taking a right-hand turn,
link |
00:24:48.260
again, in this one particular example,
link |
00:24:50.400
by taking a right-hand turn, there's a very brief,
link |
00:24:53.880
I should mention very brief relief of that anxiety
link |
00:24:57.660
at the time of the decision to go right, not left.
link |
00:25:01.700
And there's an additional drop in anxiety
link |
00:25:05.060
while one takes the right-hand turn
link |
00:25:07.360
as opposed to the left-hand turn.
link |
00:25:09.580
And then as I alluded to before,
link |
00:25:11.660
there's a reinforcement of the compulsion.
link |
00:25:14.300
In other words, by going right,
link |
00:25:16.100
it doesn't create a situation in the brain
link |
00:25:18.900
and psychology of the person that,
link |
00:25:21.040
oh, you know what, I'm not anxious anymore,
link |
00:25:23.320
left would have probably been okay.
link |
00:25:25.100
It reinforces the idea that right made me feel better
link |
00:25:28.420
or turning right made me feel better
link |
00:25:30.220
and going left would have been that much worse.
link |
00:25:32.660
Again, it reinforces the obsession even further.
link |
00:25:35.660
And again, we could swap out right turns and left turns
link |
00:25:40.200
with something like hand-washing,
link |
00:25:41.860
the feeling that something is contaminated
link |
00:25:44.180
and the need to wash one's hands,
link |
00:25:45.740
even though one already washed their hands
link |
00:25:47.820
20, 30, 50 times prior.
link |
00:25:49.980
And we're actually going to go back to that example
link |
00:25:51.600
a little bit later when we talk about
link |
00:25:53.620
one particular category of therapies
link |
00:25:55.460
that are very effective in many people for OCD,
link |
00:25:58.620
which are the cognitive behavioral and exposure therapies.
link |
00:26:01.420
So I think some of you have heard
link |
00:26:02.840
of cognitive behavioral and exposure therapies,
link |
00:26:04.900
but the way they are used to treat OCD
link |
00:26:07.060
is very much different than the way they're used to treat
link |
00:26:09.980
other sorts of anxiety disorders
link |
00:26:12.360
and other sorts of disorders generally.
link |
00:26:14.680
So it's fair to say that up to 70% of people with OCD
link |
00:26:19.180
have some sort of anxiety or elevated anxiety,
link |
00:26:22.860
either directly related to the OCD
link |
00:26:25.120
or indirectly related to the OCD.
link |
00:26:26.820
And it's really hard to tease those apart
link |
00:26:28.460
because OCD can create its own anxiety.
link |
00:26:31.640
As I mentioned before, it can even increase its own anxiety.
link |
00:26:34.700
And there's also an issue of depression.
link |
00:26:37.660
Having OCD can be very depressing, right?
link |
00:26:40.460
Especially if some of these OCD thoughts and behaviors
link |
00:26:43.560
start to really impede people's ability to function in life
link |
00:26:46.180
at work and school and relationship,
link |
00:26:47.700
they can start feeling less optimistic about life.
link |
00:26:49.780
And in fact, some people can become suicidally depressed.
link |
00:26:52.540
That's how bad OCD can be for us.
link |
00:26:55.340
So we have to be careful when saying
link |
00:26:57.620
that 70% of people with OCD also have anxiety
link |
00:27:00.540
or X number of people with OCD are also depressed
link |
00:27:02.800
because we don't know whether or not
link |
00:27:04.140
the depression led the OCD or the other way around,
link |
00:27:06.700
or whether or not they're operating,
link |
00:27:07.840
as we say in science, in parallel.
link |
00:27:09.800
Some of the drug treatments for OCD and depression
link |
00:27:11.820
and anxiety can tease some of that apart.
link |
00:27:14.420
And we'll talk about that.
link |
00:27:15.600
But I think it's fair to say that what binds the obsessions
link |
00:27:19.040
and compulsions is anxiety,
link |
00:27:20.940
that there's a feeling of it,
link |
00:27:22.860
or I should say an urgent feeling of a need
link |
00:27:25.060
to get rid of the obsession.
link |
00:27:27.060
And the person feels as if the only way they can do that
link |
00:27:29.700
is to engage in a particular compulsive behavior.
link |
00:27:32.380
Some people are probably wondering
link |
00:27:33.680
if there's a genetic component to OCD.
link |
00:27:36.260
And indeed there is,
link |
00:27:37.940
although the nature of it isn't exactly clear.
link |
00:27:40.500
And oftentimes when people hear
link |
00:27:42.620
that something has a genetic component,
link |
00:27:44.580
they think it's always directly inherited from a parent.
link |
00:27:48.180
And that's not always the case.
link |
00:27:49.620
There can be genes that surface in siblings
link |
00:27:52.720
or genes that surface in children
link |
00:27:54.480
that are not readily apparent
link |
00:27:56.540
in terms of what we call a phenotype.
link |
00:27:58.020
So you have a genotype, the gene,
link |
00:27:59.300
and then you have a phenotype,
link |
00:28:00.420
the way it shows up as a body form or like eye color,
link |
00:28:04.220
or how it shows up in terms of a behavior
link |
00:28:06.860
or behavioral pattern.
link |
00:28:08.840
Based on twin studies where researchers
link |
00:28:11.780
have examined identical twins, fraternal twins,
link |
00:28:14.380
even identical twins that share the same sac in utero,
link |
00:28:18.300
what we call monochorionic.
link |
00:28:19.660
So sitting in the same little bag during pregnancy
link |
00:28:22.220
or in different little bags,
link |
00:28:23.700
you can see different levels
link |
00:28:24.800
of what's called genetic concordance.
link |
00:28:26.720
But if we were to just sort of cut a broad swath
link |
00:28:29.380
through all of the genetic data,
link |
00:28:31.100
it's fair to say that about 40 to 50% of OCD cases
link |
00:28:35.320
have some genetic component,
link |
00:28:36.740
some mutation or some inherited aspect that's genetic
link |
00:28:40.180
and that one could point to if they got their genome mapped.
link |
00:28:43.140
Now, while that's interesting,
link |
00:28:44.260
I don't think it's terribly useful for most people.
link |
00:28:46.560
First of all, you can't really control your genes,
link |
00:28:48.940
at least at this point in history,
link |
00:28:50.740
even though there are things like epigenetic control
link |
00:28:53.180
and people are very excited about technologies like CRISPR
link |
00:28:55.740
for modifying the genome.
link |
00:28:58.100
In humans at some point,
link |
00:29:00.460
most people can't control their genetics, right?
link |
00:29:02.580
You can't pick who your parents were, as they say.
link |
00:29:04.740
So just know that there is a genetic component
link |
00:29:07.140
in about half of people with OCD, but not always.
link |
00:29:10.780
Now, as is typical for this podcast,
link |
00:29:13.260
I want to focus on some of the neural mechanisms
link |
00:29:15.940
and chemical systems in the brain and body
link |
00:29:18.100
that generate obsessive compulsive disorder.
link |
00:29:20.720
In fact, if you've watched this podcast before,
link |
00:29:23.020
listened to this podcast before,
link |
00:29:24.580
this is always how I structure things.
link |
00:29:26.300
First, we introduce a topic and we explore that topic
link |
00:29:30.020
in detail and really define what it is and what it isn't.
link |
00:29:32.580
And then it's very important that we focus on what is known
link |
00:29:36.020
and what is not known about the biological mechanisms
link |
00:29:39.280
that generate whatever that thing happens to be,
link |
00:29:41.300
in this case, OCD
link |
00:29:42.140
or obsessive compulsive personality disorder.
link |
00:29:44.500
Now, I want to emphasize that even if you don't have
link |
00:29:46.940
a background in biology,
link |
00:29:48.740
I will make this information accessible to you.
link |
00:29:50.700
And I also want to emphasize that for those of you
link |
00:29:52.820
that are interested in treatments
link |
00:29:54.380
and are anxiously awaiting the description of things
link |
00:29:58.300
that can help with OCD, I encourage you, if you will,
link |
00:30:02.860
to please try and digest some of the material
link |
00:30:05.340
about the underlying mechanisms,
link |
00:30:06.620
because understanding even just a little bit
link |
00:30:08.700
of those biological mechanisms can really help shed light
link |
00:30:11.760
on why particular drug and behavioral treatments
link |
00:30:15.060
and other sorts of treatments work and don't work.
link |
00:30:18.100
This is especially important in the case of OCD,
link |
00:30:20.940
where it turns out that the order and type of treatment
link |
00:30:23.560
can really vary according to individual.
link |
00:30:26.020
And that's something really special and important about OCD
link |
00:30:28.940
that we really can't say for a number of the other
link |
00:30:31.160
sorts of disorders that we've described
link |
00:30:32.700
on previous podcasts.
link |
00:30:34.300
So let's take a step back and look at the neural circuitry.
link |
00:30:37.660
What's going on in the brain and body of people with OCD?
link |
00:30:40.780
Why the intrusive recurrent thoughts?
link |
00:30:43.340
Why the compulsions?
link |
00:30:44.380
Why is that whole system bound by anxiety?
link |
00:30:48.340
And in some ways in thinking about that,
link |
00:30:50.420
I want you to keep in mind that the brain
link |
00:30:53.840
has two main functions.
link |
00:30:56.420
The brain's main functions are to take care
link |
00:30:59.540
of all the housekeeping stuff, make sure digestion works,
link |
00:31:01.980
make sure the heart beats,
link |
00:31:03.020
make sure you keep breathing no matter what,
link |
00:31:05.180
make sure that you can see, you can hear,
link |
00:31:08.180
you can smell, et cetera, the basic stuff.
link |
00:31:10.540
And then there's an enormous amount of brain real estate
link |
00:31:13.340
that's designed to allow you to predict
link |
00:31:15.700
what's going to happen next,
link |
00:31:16.920
either in the immediate future or in the long-term future.
link |
00:31:20.060
And largely that's done based on your knowledge of the past.
link |
00:31:23.140
So you also have memory systems.
link |
00:31:24.440
And of course, you have systems in the brain and body
link |
00:31:26.980
that are designed to bind what's happening
link |
00:31:29.740
at the housekeeping level, like your heart rate,
link |
00:31:31.820
to your anticipation of what's going to happen next.
link |
00:31:34.300
So if you're thinking about something very fearful,
link |
00:31:36.060
your body will have one type of reaction.
link |
00:31:37.620
If you're thinking about something very pleasant
link |
00:31:39.260
and relaxing, your body will have another type of reaction.
link |
00:31:41.900
So whenever I hear about the brain-body distinction,
link |
00:31:44.900
I have to just remind everybody
link |
00:31:46.980
that there really is no distinction between brain and body
link |
00:31:49.700
when you think about it through the nervous system.
link |
00:31:51.420
The nervous system is the brain, the eyes, the spinal cord,
link |
00:31:53.980
but of course, all their connections
link |
00:31:55.380
with all the organs of the body
link |
00:31:56.500
and the connections of all the organs of the body
link |
00:31:58.240
with the brain, the spinal cord, et cetera.
link |
00:32:00.280
So as I describe these neural circuits,
link |
00:32:02.860
I don't want you to think of them
link |
00:32:03.820
as just things happening in the head.
link |
00:32:05.700
They are certainly happening in the head.
link |
00:32:07.720
In fact, the circuits I'll describe most in detail
link |
00:32:10.660
do exist within the confines of your cranial vault,
link |
00:32:13.260
that's nerd speak for skull,
link |
00:32:14.980
but those circuits are driving particular predictions
link |
00:32:19.160
and therefore particular biases
link |
00:32:21.380
towards particular actions in your body.
link |
00:32:23.440
They're creating a state of readiness
link |
00:32:24.980
or a state of desire to check or desire to count
link |
00:32:28.660
or desire to avoid, et cetera, et cetera.
link |
00:32:32.060
So what are these circuits?
link |
00:32:33.420
Well, there's been a lot of wonderful research
link |
00:32:36.440
exploring the neural circuits
link |
00:32:38.120
underlying obsessive compulsive disorder,
link |
00:32:40.760
and that's mainly been accomplished
link |
00:32:41.900
through a couple of methods.
link |
00:32:43.460
Most of those methods when applied in humans
link |
00:32:45.940
involve getting some look
link |
00:32:48.740
into which brain areas are active
link |
00:32:51.560
when people are having obsessions
link |
00:32:53.040
and when people are engaging in compulsions.
link |
00:32:55.740
Now, that might seem simple to do,
link |
00:32:57.380
but of course, your brain is housed inside the cranial vault
link |
00:33:00.480
and in order to look inside it,
link |
00:33:01.740
you have to use things like magnetic resonance imaging,
link |
00:33:04.060
which is just fancy technology for looking at blood flow,
link |
00:33:07.500
which relates to activation of neurons, nerve cells,
link |
00:33:10.980
or things like PET, P-E-T imaging,
link |
00:33:13.980
which has nothing to do with the verb pet
link |
00:33:15.660
and has nothing to do with your house pet,
link |
00:33:17.580
has everything to do with positron emission tomography,
link |
00:33:20.420
which is just another way of seeing
link |
00:33:22.120
which brain areas are active,
link |
00:33:23.480
and then you can also use PET
link |
00:33:24.740
to figure out what sorts of neurochemicals are active,
link |
00:33:27.140
like dopamine, et cetera.
link |
00:33:29.180
Many studies, we can fairly say dozens,
link |
00:33:32.620
if not hundreds of studies have now identified
link |
00:33:35.360
a particular circuit or loop of brain areas
link |
00:33:38.440
that are interconnected and very active
link |
00:33:40.920
in obsessive compulsive disorder.
link |
00:33:44.500
That loop includes the cortex,
link |
00:33:47.340
which is kind of the outer shell of the human brain,
link |
00:33:50.880
the lumpy stuff, as it sometimes appears
link |
00:33:53.680
if the skull is removed,
link |
00:33:55.180
and it involves an area called the striatum,
link |
00:33:57.460
which is involved in action selection
link |
00:33:59.180
and holding back action.
link |
00:34:00.860
The striatum is involved in what's commonly called
link |
00:34:03.140
go and no-go types of behaviors.
link |
00:34:05.420
So every type of behavior,
link |
00:34:06.360
like picking up a pen or a mug of coffee,
link |
00:34:08.940
involves a go type function.
link |
00:34:11.380
It involves generating an action.
link |
00:34:13.500
But every time I resist an action,
link |
00:34:16.080
my nervous system is also doing that
link |
00:34:17.680
using this brain structure, the striatum,
link |
00:34:20.820
which includes, among other things, the basal ganglia.
link |
00:34:24.060
Talked about that before.
link |
00:34:25.140
I'm not trying to overload you with terminology here,
link |
00:34:27.140
but I know some people are interested in terminology.
link |
00:34:29.480
So you have go behaviors and you have no-go,
link |
00:34:31.440
resisting of behaviors, not going toward behavior.
link |
00:34:35.700
The cortex and the striatum
link |
00:34:37.540
are in this intricate back-and-forth talk.
link |
00:34:39.980
It's really loops of connections.
link |
00:34:41.320
The cortex doesn't tell the striatum what to do.
link |
00:34:43.060
The striatum doesn't tell the cortex what to do.
link |
00:34:45.060
They're in a crosstalk.
link |
00:34:45.940
Like any good relationship,
link |
00:34:47.020
there's a lot of back-and-forth communication.
link |
00:34:49.860
There's a third element in this corticostriatal loop,
link |
00:34:53.660
as it's called, and that's the thalamus.
link |
00:34:56.060
Now, the thalamus is not a structure
link |
00:34:57.420
I've talked a lot about before on this podcast,
link |
00:34:59.580
but it's one of my favorite structures to think about
link |
00:35:01.980
and teach about in neuroanatomy,
link |
00:35:03.580
which I teach back at Stanford
link |
00:35:05.500
and have taught for many years elsewhere,
link |
00:35:07.440
because the thalamus is this incredible egg-like structure
link |
00:35:10.580
in the center of your brain
link |
00:35:12.340
that has different channels through it,
link |
00:35:14.480
channels for relaying visual information
link |
00:35:17.380
or auditory information or touch information
link |
00:35:20.520
from your environment up into your cortex,
link |
00:35:23.920
and as a consequence,
link |
00:35:24.760
making certain things that are happening to you,
link |
00:35:27.320
and around you, apparent to you,
link |
00:35:29.500
making you aware of them,
link |
00:35:30.560
making you perceive them, and suppressing others.
link |
00:35:34.420
So for instance, right now, if you're hearing me say this,
link |
00:35:37.120
your thalamus has what are called auditory nuclei.
link |
00:35:40.420
Those are just collections of neurons
link |
00:35:41.820
that respond to sound waves
link |
00:35:44.940
that are, of course, coming in through your ears,
link |
00:35:46.940
and your thalamus is active in a way
link |
00:35:49.860
that those particular regions of your thalamus
link |
00:35:52.260
are allowed, literally permitted,
link |
00:35:54.860
to pass the information coming from your ears
link |
00:35:57.100
through some other steps,
link |
00:35:58.600
but then to your thalamus, your auditory thalamus,
link |
00:36:00.580
then up to your cortex,
link |
00:36:01.580
and you can hear what I'm saying right now.
link |
00:36:03.860
At the same time, your thalamus is surrounded
link |
00:36:06.820
by a kind of a shell,
link |
00:36:07.880
something called the thalamic reticular nucleus.
link |
00:36:09.940
Again, you don't have to remember the names,
link |
00:36:11.400
but this thalamic reticular nucleus
link |
00:36:13.180
also sometimes called the reticular thalamic nucleus.
link |
00:36:15.700
This is, believe it or not, a subject of debate in science.
link |
00:36:18.220
There are people that literally hated each other,
link |
00:36:19.880
probably still hate each other,
link |
00:36:20.820
even though one of them's dead,
link |
00:36:22.220
for decades because they would argue
link |
00:36:23.580
it was the thalamic reticular nucleus,
link |
00:36:24.900
the other was reticular thalamic nucleus.
link |
00:36:27.180
Anyway, these are scientists, they're people.
link |
00:36:29.580
They tend to debate.
link |
00:36:31.000
But the thalamic reticular nucleus, as I'm going to call it,
link |
00:36:34.340
serves as a sort of gate
link |
00:36:36.260
as to which information is allowed to pass through
link |
00:36:38.760
up to your conscious experience and which is not.
link |
00:36:41.800
And that gating mechanism is strongly regulated
link |
00:36:44.160
by the chemical GABA.
link |
00:36:45.900
GABA is a neurotransmitter that is inhibitory, as we say.
link |
00:36:50.420
It serves to shut down
link |
00:36:52.420
or suppress the activity of other neurons.
link |
00:36:54.980
So the thalamic reticular nucleus is really saying no.
link |
00:36:59.920
Touch information cannot come in right now.
link |
00:37:02.160
You should not be thinking about the contact
link |
00:37:04.820
of the back of your legs
link |
00:37:05.780
with the chair that you're sitting on, Andrew.
link |
00:37:07.860
You should be thinking about what you're trying to say
link |
00:37:09.500
and what you're hearing and how your voice sounds
link |
00:37:11.200
and what you see in front of you, et cetera.
link |
00:37:13.900
Whereas if I'm about to get an injection from a doctor
link |
00:37:17.280
or I'm in pain or I'm in pleasure,
link |
00:37:19.540
I'm going to think about my somatic sensation
link |
00:37:22.220
at the level of touch.
link |
00:37:23.460
And I'm probably going to think less about
link |
00:37:25.700
smells in the room,
link |
00:37:26.740
although I might also think about smells in the room
link |
00:37:28.540
or what I'm seeing and what I'm hearing.
link |
00:37:30.300
We can combine all these different sensory modalities,
link |
00:37:33.300
but the thalamic reticular nucleus
link |
00:37:34.940
really allows us to funnel,
link |
00:37:36.980
to direct particular categories of sensory experience
link |
00:37:40.040
into our conscious awareness
link |
00:37:41.400
and suppress other categories of sensory experience.
link |
00:37:45.600
In addition, the thalamic reticular nucleus
link |
00:37:48.300
plays a critical role in which thoughts are allowed
link |
00:37:52.540
to pass up to our conscious perception
link |
00:37:54.820
and which ones are not.
link |
00:37:56.700
So much so that some neuroscientists
link |
00:37:59.360
and indeed some neurophilosophers,
link |
00:38:01.500
if you want to call them that,
link |
00:38:02.640
have theorized or philosophized
link |
00:38:04.380
that the thalamic reticular nucleus
link |
00:38:07.140
is actually involved in our consciousness.
link |
00:38:09.300
Now, consciousness is in a topic
link |
00:38:10.700
that I really want to talk about this episode
link |
00:38:12.300
and it's a very kind of mushy, murky,
link |
00:38:14.620
as we say in science, it's a schmooey term
link |
00:38:17.120
because it doesn't really have clear definitions
link |
00:38:18.900
so arguments about it often get lost in the fact
link |
00:38:21.020
that people are arguing about different things.
link |
00:38:22.960
But when I say consciousness,
link |
00:38:24.400
what I mean is conscious awareness.
link |
00:38:26.260
So let's zoom out and take a look at the circuit
link |
00:38:28.760
that we've got and that we now know
link |
00:38:30.420
based on neuroimaging studies is intimately involved
link |
00:38:33.860
in generating obsessions and compulsions in OCD.
link |
00:38:36.720
We have a cortex or neocortex,
link |
00:38:39.220
which is involved in perception
link |
00:38:40.720
and understanding of what's happening.
link |
00:38:42.520
We have the striatum and basal ganglia,
link |
00:38:44.700
which are involved in generating behaviors, GO,
link |
00:38:47.420
and suppressing behaviors, NO-GO.
link |
00:38:49.460
And we have the thalamus,
link |
00:38:51.100
which collects all of our sensory experience in parallel,
link |
00:38:54.360
hearing, touch, smell, et cetera,
link |
00:38:56.540
not so much smell through the thalamus I should mention,
link |
00:38:58.360
but the other senses that is.
link |
00:39:00.820
And then that thalamus is encased
link |
00:39:04.300
by the thalamic reticular nucleus,
link |
00:39:06.300
which serves as a kind of a guard
link |
00:39:08.260
saying you can pass through and you can pass through,
link |
00:39:09.820
but you, you, you can't pass through
link |
00:39:12.020
up to conscious understanding and perception.
link |
00:39:15.220
So that loop, this corticostriatal thalamic loop,
link |
00:39:18.540
corticostriatal thalamic loop
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00:39:20.580
is the circuit thought to underlie OCD
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00:39:24.540
and dysfunction in that circuit
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00:39:26.380
is what's thought to underlie OCD.
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00:39:28.260
Now, again, the circuit exists in all of us
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00:39:29.900
and it can operate in healthy ways
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00:39:31.220
or it can operate in ways that make us feel unhealthy
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00:39:33.420
or even suffer from full blown OCD.
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00:39:36.460
How do we know that this circuit is involved in OCD?
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00:39:39.640
Well, there we can look to some really interesting studies
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00:39:42.780
that involve bringing human subjects into the laboratory
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00:39:46.660
and generating their obsessions and compulsions
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00:39:48.980
and then imaging their brain using any variety of techniques
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00:39:51.620
that we talked about before.
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00:39:53.660
What would such an experiment look like?
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00:39:55.180
Well, in order to do that sort of experiment,
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00:39:57.580
first of all, you need people who have OCD
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00:40:00.700
and of course you need control subjects that don't
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00:40:02.880
and you need to be able to reliably evoke the obsessions
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00:40:05.800
and the compulsions.
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00:40:06.740
Now it turns out this is most easily,
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00:40:08.620
or I should say most simply done
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00:40:10.980
because it can't be easy for the people with OCD,
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00:40:12.860
but this is most straightforward.
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00:40:15.180
That's the word I was looking for.
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00:40:16.260
Most straightforward when looking at the category
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00:40:19.640
of obsessions and compulsions
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00:40:21.340
that relate to order and cleanliness.
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00:40:25.060
So what they do typically is bring subjects
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00:40:27.500
into the laboratory who have a obsession
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00:40:30.380
about germs and contamination
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00:40:32.660
and a compulsion to hand wash.
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00:40:34.900
And they give these people, believe it or not,
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00:40:37.660
a sweaty towel that contains the sweat
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00:40:40.980
and the odor and the liquid basically
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00:40:45.000
from somebody else's hands.
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00:40:46.460
In fact, they'll sometimes have someone wipe
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00:40:48.740
their own sweat off the back of their neck
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00:40:50.820
and put it on the towel
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00:40:51.660
and then they'll put it in front of the person,
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00:40:53.720
which as you can imagine for someone with OCD
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00:40:55.580
is incredibly anxiety provoking
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00:40:57.980
and almost always evokes these obsessions about,
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00:41:01.300
oh, this is really bad, this is really bad,
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00:41:05.000
I need to clean, I need to clean, I need to clean.
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00:41:07.360
Now they're doing all this while someone
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00:41:08.620
is in a brain scanner or while they're being imaged
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00:41:11.360
for positron emission tomography.
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00:41:13.180
And then they can also look at the patterns of activation
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00:41:15.780
in the brain while the person is doing hand washing.
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00:41:18.980
Although sometimes the apparatus associated
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00:41:20.980
with these imaging studies make it hard
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00:41:22.300
to do a lot of movement,
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00:41:23.300
they can do these sorts of studies.
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00:41:25.320
They have done these sorts of studies in many subjects
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00:41:28.580
using different variations of what I just described.
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00:41:31.620
And lo and behold, what lights up, when I say lights up,
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00:41:34.700
what sorts of brain regions are more metabolically active,
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00:41:39.020
more blood flow, more neural activity?
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00:41:40.500
Well, it's this particular corticostriatal thalamic loop.
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00:41:44.820
In addition to that, some of the drug treatments
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00:41:47.700
that are effective in some,
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00:41:49.220
and I want to emphasize some individuals
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00:41:51.440
at suppressing obsessions and or compulsions
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00:41:54.300
such as the selective serotonin reuptake inhibitors
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00:41:57.420
or SSRIs, which we'll talk about in a little bit.
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00:42:01.180
When people take those drugs,
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00:42:02.920
they see not just a suppression
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00:42:04.980
of the obsession and compulsion,
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00:42:08.420
but also a suppression of these particular neural circuits.
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00:42:12.300
They become less active.
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00:42:13.580
Now I want to emphasize and telegraph
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00:42:15.740
a little bit of what's coming later.
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00:42:18.380
These drugs like SSRIs do not work for everybody with OCD.
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00:42:22.020
And as many of you know,
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00:42:23.040
they carry other certain problems and side effects
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00:42:25.480
for many, but not all individuals.
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00:42:28.060
But nonetheless, what we have now is an observation
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00:42:31.260
that this circuit, the corticostriatal thalamic loop,
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00:42:33.680
is active in OCD.
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00:42:35.020
We have a manipulation that when people take a drug
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00:42:38.100
that at least in those individuals is effective
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00:42:40.100
in suppressing or eliminating the obsessions and compulsions
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00:42:42.780
there's less activity in this loop.
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00:42:44.860
And thanks to some very good animal model studies
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00:42:47.580
that at least at this point in time
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00:42:49.140
you really couldn't do in humans,
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00:42:51.060
although soon that may change,
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00:42:53.060
we now know in a causal way that the equivalent circuitry,
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00:42:57.320
A, exists in other animals,
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00:42:59.820
such as mice, such as cats, such as monkeys.
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00:43:02.180
And that activation of those particular
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00:43:05.820
corticostriatal thalamic circuits in animal models
link |
00:43:09.640
can indeed evoke OCD in an individual
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00:43:13.220
that prior to that did not have OCD.
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00:43:16.220
So I'm just going to briefly describe one study.
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00:43:18.220
This is a now classic study published in the journal Science,
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00:43:21.640
one of the three apex journals in 2013.
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00:43:24.780
The first author on this paper is Suzanne Amari,
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00:43:28.380
A-H-M-A-R-I.
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00:43:30.340
I will provide a link to this in the show notes.
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00:43:32.200
It's a truly landmark paper
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00:43:34.060
done in Renee Hen's lab at Columbia University.
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00:43:37.400
And the title of the paper is
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00:43:38.500
Repeated Corticostriatal Stimulation Generates,
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00:43:41.380
that's the key word here,
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00:43:42.220
Generates Persistent OCD-Like Behavior.
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00:43:45.280
What they did is they took mice,
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00:43:47.020
mice do mouse things, they move around,
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00:43:49.780
they play with toys, they eat, they pee, they mate,
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00:43:52.560
they do various things in their cage, but they also groom.
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00:43:55.820
Humans groom, animals with fur groom.
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00:43:59.420
Well, you hope most people groom, some people overgroom,
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00:44:02.140
some people undergroom, but most people groom.
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00:44:04.040
They'll comb their hair, they'll clean, et cetera.
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00:44:05.900
Those are normal behaviors that humans engage in.
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00:44:08.760
I'm not aware that mice comb their hair,
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00:44:09.860
but mice adjust their hair.
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00:44:11.080
So they'll kind of pet their hair and they'll do this.
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00:44:12.880
They'll sometimes even do it to each other.
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00:44:14.620
We used to have mice in the lab.
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00:44:15.660
Now we only do human studies,
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00:44:16.940
but the mice will groom themselves.
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00:44:19.820
And typical, what we call wild type mice,
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00:44:22.340
not because they're wild, but because they're typical,
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00:44:24.580
will groom themselves at a particular frequency,
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00:44:27.640
but not to the point where their hair is falling out,
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00:44:30.020
not constantly.
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00:44:31.020
They are grooming some of the time
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00:44:33.100
and they're doing other mouse things, other mouse times.
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00:44:36.660
So in this particular study,
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00:44:38.060
what they did is they used some technology,
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00:44:41.020
which actually was discussed on a previous episode
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00:44:43.580
of the Huberman Lab Podcast.
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00:44:44.980
This is technology that was developed by a psychiatrist
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00:44:47.380
and bioengineer by the name of Karl Deisseroth,
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00:44:49.300
one of my colleagues at Stanford School of Medicine.
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00:44:52.280
This is technology that allows researchers
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00:44:54.220
to use the presentation of light to control neural activity
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00:44:58.740
in particular brain areas in a very high fidelity way.
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00:45:03.180
You control the activity in the cortex or the striatum
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00:45:05.620
or the thalamus when you want and how you want.
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00:45:07.780
It's really a beautiful technology.
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00:45:09.620
In any event, what they did in this study is,
link |
00:45:11.980
or I should say what Susan Amari and colleagues did
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00:45:14.300
in the study, was to stimulate the corticostriatal circuitry
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00:45:20.260
in animals that did not have any OCD-like behavior.
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00:45:22.900
And when they did that,
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00:45:24.140
those animals started grooming incessantly
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00:45:26.420
to the point where their hair was falling out
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00:45:28.300
or they even, you know,
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00:45:29.400
they didn't take the experiments this far, fortunately,
link |
00:45:31.300
but the animals would have a tendency
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00:45:32.840
to almost rub themselves raw.
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00:45:34.540
In the same way that somebody who has a compulsion
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00:45:37.020
to hand wash would, sadly, people will hand wash
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00:45:40.220
to the point where their hands are actually bleeding and raw.
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00:45:42.460
It's really that bad.
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00:45:43.580
I know that's tough imagery to imagine.
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00:45:45.580
And you can't even imagine why someone would self-harm
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00:45:47.440
in that way.
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00:45:48.280
But again, that's that incredible anxiety relationship
link |
00:45:51.580
between the compulsion, excuse me,
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00:45:53.020
the obsession and the compulsion,
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00:45:54.900
and the fact that engaging in the compulsion
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00:45:57.580
simply strengthens the obsession and therefore the anxiety.
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00:46:00.580
So that collection of studies, of data,
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00:46:04.580
fMRI, PET scanning in humans, the treatment with SSRIs,
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00:46:08.340
and these experiments where researchers
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00:46:11.980
have actively triggered these particular circuits
link |
00:46:15.740
in animal models that previously did not have
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00:46:18.740
too much activity in these circuits,
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00:46:20.020
and then they observe OCD emerging really points squarely
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00:46:24.620
to the fact that the corticosteroidal thalamic loop
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00:46:27.460
is likely to be the basis of OCD.
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00:46:30.320
Now, of course, other circuits could also be involved,
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00:46:32.900
but the corticosteroidal thalamic circuit
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00:46:35.460
seems to be the main circuit generating OCD-like behavior.
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00:46:39.340
That's a lot of mechanism.
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00:46:40.660
Hopefully, it was described in a way
link |
00:46:42.560
that you can digest and understand.
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00:46:44.380
And some of you might be thinking, well, so what?
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00:46:46.540
Why does that help me?
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00:46:47.380
I can't reach into my brain and turn off my cortex.
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00:46:50.060
I can't reach into my brain and turn off my thalamus.
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00:46:52.620
And indeed, on the one hand, that's true.
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00:46:55.460
But as you'll next learn,
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00:46:57.420
when thinking about the various behavioral treatments
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00:46:59.740
and drug treatments and holistic treatments for OCD,
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00:47:03.540
what you'll notice is that each one taps
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00:47:05.460
into a different component
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00:47:06.820
of this corticosteroidal thalamic loop.
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00:47:09.740
And by understanding that,
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00:47:11.660
you can start to see why certain treatments might work
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00:47:14.540
at one stage of the illness versus others.
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00:47:17.280
You will also start to understand why obsessive-compulsive
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00:47:20.340
personality disorder does not have the same sorts
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00:47:23.980
of engagements of these neural loops,
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00:47:25.940
and yet relies on other aspects of brain and body,
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00:47:30.260
and therefore, responds best to other sorts of treatments.
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00:47:33.700
Or in some cases,
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00:47:35.380
people with obsessive-compulsive personality disorder
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00:47:37.820
are not even seeking treatment, as I alluded to before.
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00:47:40.300
The point here is that by understanding
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00:47:41.760
the underlying mechanism,
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00:47:43.180
why certain drugs and behavioral treatments work
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00:47:45.940
and don't work will become immediately apparent.
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00:47:48.120
And in thinking about that,
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00:47:50.220
in knowing that, you'll be able to make excellent choices,
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00:47:53.420
I believe, in terms of what sorts of treatments you pursue,
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00:47:56.180
what sorts of treatments you abandon,
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00:47:57.880
and most importantly, the order,
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00:48:00.720
the sequence that you pursue and apply those treatments.
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00:48:04.000
Before we go any further,
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00:48:05.060
I'd like to give people a little bit of a window
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00:48:07.140
into what a diagnosis for OCD would look like.
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00:48:10.840
Give you a sense of the sorts of questions
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00:48:13.060
that a clinician would ask
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00:48:15.020
to determine whether or not somebody has OCD or not.
link |
00:48:18.100
Now, I want to be clear,
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00:48:18.920
I'm not going to do this in an exhaustive way.
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00:48:20.620
I wouldn't want anyone to self-diagnose,
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00:48:22.580
although I'm hoping that by sharing some of this,
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00:48:24.660
that some of you might get insight
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00:48:26.000
into whether or not you do have obsessions and compulsions
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00:48:28.660
that might qualify for OCD
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00:48:30.820
and perhaps even to seek out help.
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00:48:33.260
The most commonly used test of OCD,
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00:48:37.540
or for OCD, I should say,
link |
00:48:38.880
is called the Yale-Brown Obsessive-Compulsive Scale.
link |
00:48:41.940
And this is, you know, scientists love acronyms,
link |
00:48:44.580
as do the military, and it's the Y box,
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00:48:46.900
the Y-B-O-C-S, the Y box.
link |
00:48:51.340
So typically, someone will go into the clinic,
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00:48:53.680
either because a family member encouraged them to
link |
00:48:55.740
or because they feel that they're suffering
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00:48:57.620
from obsessions and compulsions.
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00:48:59.460
And before the clinician would proceed
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00:49:02.420
with any kind of direct questions,
link |
00:49:03.980
they would very clearly define
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00:49:05.520
what obsessions and compulsions are.
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00:49:06.900
And here I'm actually reading from the Y box.
link |
00:49:09.160
So, quote,
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00:49:10.000
obsessions are unwelcome in distressing ideas,
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00:49:11.660
thoughts, images, or impulses
link |
00:49:13.060
that repeatedly enter your mind.
link |
00:49:14.440
They may seem to occur against your will.
link |
00:49:16.540
They may be repugnant to you.
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00:49:17.820
You may recognize them as senseless,
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00:49:19.500
and they may not fit your personality.
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00:49:22.320
Then there are compulsions.
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00:49:23.740
Quote, compulsions, on the other hand,
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00:49:25.540
are behaviors or acts that you feel driven to perform,
link |
00:49:27.660
although you may recognize them as senseless or excessive.
link |
00:49:30.900
At times, you may try to resist doing them,
link |
00:49:32.880
but this may prove difficult.
link |
00:49:34.220
You may experience anxiety that does not diminish
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00:49:36.700
until the behavior is completed.
link |
00:49:38.380
And as I mentioned before,
link |
00:49:39.300
in many cases, immediately after the behavior is completed,
link |
00:49:42.280
the anxiety doesn't just return, it indeed can strengthen.
link |
00:49:45.580
Now, there are a tremendous number of questions
link |
00:49:46.860
on the Y box.
link |
00:49:47.700
So, I'm just going to highlight
link |
00:49:49.640
a few of the general categories.
link |
00:49:52.140
Typically, the person will fill out a checklist.
link |
00:49:54.740
So, they will designate whether or not currently
link |
00:49:58.080
or in the past, they have, for instance,
link |
00:50:00.860
aggressive obsessions,
link |
00:50:02.180
fear that one might harm themselves,
link |
00:50:04.180
fear that one might harm others,
link |
00:50:05.860
fear that they'll steal things,
link |
00:50:07.060
fear that they will act on unwanted impulses,
link |
00:50:09.880
currently or in the past or both.
link |
00:50:12.020
That's one category.
link |
00:50:13.100
The other one are contamination obsessions.
link |
00:50:14.820
So, concern with dirt or germs,
link |
00:50:16.500
bothered by sticky substances or residues,
link |
00:50:18.500
et cetera, et cetera.
link |
00:50:19.560
So, a bunch of different categories that include,
link |
00:50:22.060
for instance, sexual obsessions,
link |
00:50:24.280
what are called saving obsessions,
link |
00:50:26.460
even moral obsessions, right?
link |
00:50:28.420
Excess concern with right or wrong or morality,
link |
00:50:30.860
concerned with sacrilege and blasphemy,
link |
00:50:33.900
obsession with need for symmetry and exactness.
link |
00:50:35.780
Again, all of these questions being answered
link |
00:50:37.720
as either present in the past or not present in the past,
link |
00:50:40.980
present currently or not present currently.
link |
00:50:43.340
And then the test generally transitions over
link |
00:50:47.580
to questions about target symptoms.
link |
00:50:49.820
They're really trying to get people to identify
link |
00:50:52.040
if they have obsessions, what are their exact obsessions?
link |
00:50:54.620
Now, this turns out to be really important
link |
00:50:56.160
because as we talk about some of the therapies
link |
00:50:58.140
that really work,
link |
00:50:59.860
I'll just give away a little bit of why they work best
link |
00:51:03.140
in certain cases and why they don't work as well
link |
00:51:05.460
in other cases,
link |
00:51:06.760
it turns out that it becomes very important
link |
00:51:09.360
for the clinician and the patient
link |
00:51:11.300
to not just identify the obsessions
link |
00:51:13.840
and the compulsions generally
link |
00:51:15.460
in a kind of a generic or top contour way,
link |
00:51:17.980
but to really encourage or even force the patient
link |
00:51:21.180
to define very precisely
link |
00:51:23.900
what the biggest, most catastrophic fear is,
link |
00:51:27.480
what the obsession really relates to.
link |
00:51:29.720
That turns out to be very important
link |
00:51:31.380
in disrupting this corticostriatal thalamic loop
link |
00:51:34.440
and getting relief from symptoms one way or the other.
link |
00:51:37.620
So the Yale Brown Obsessive Compulsive Scale,
link |
00:51:39.940
this Y box, again, is very extensive.
link |
00:51:42.380
It goes on for dozens of pages actually
link |
00:51:45.660
and has all these different categories,
link |
00:51:47.960
not so much designed to just pinpoint
link |
00:51:50.760
what people obsess about or what they feel compelled to do,
link |
00:51:54.740
but to also try and identify
link |
00:51:56.860
what is the fear that's driving all this, right?
link |
00:51:59.940
In the way that we've set this up thus far,
link |
00:52:02.140
we've been talking about obsessions and compulsions
link |
00:52:03.980
as kind of existing in a vacuum.
link |
00:52:05.900
You're obsessed about germs and you're compelled
link |
00:52:08.260
to wash your hands,
link |
00:52:09.100
obsessed about germs, compelled to wash your hands,
link |
00:52:10.800
or obsessed about symmetry,
link |
00:52:12.160
compelled to put right angles on everything,
link |
00:52:14.200
or obsessed about counting and therefore counting, et cetera.
link |
00:52:17.360
But beneath that is a cognitive component
link |
00:52:21.380
that is not at all apparent
link |
00:52:23.220
from someone describing their obsession
link |
00:52:26.260
and from someone describing or displaying their compulsion.
link |
00:52:29.520
The deeper layer to all that is what is the fear exactly
link |
00:52:34.260
if one were to not perform the compulsion,
link |
00:52:37.780
meaning what is the fear that's driving the obsession?
link |
00:52:41.060
So that brings us to a very powerful category of treatments
link |
00:52:45.340
that I should say does not work in everybody with OCD,
link |
00:52:49.420
but works in many people with OCD
link |
00:52:51.980
and really speaks to the underlying neural circuitry
link |
00:52:56.260
that generates OCD and how to interrupt it.
link |
00:52:58.660
And that is the treatment of cognitive behavioral therapy
link |
00:53:02.180
and in particular exposure based cognitive
link |
00:53:04.860
behavioral therapy.
link |
00:53:06.620
So we're going to talk about cognitive behavioral therapy
link |
00:53:08.420
and exposure therapy now, but right at the outset,
link |
00:53:11.820
I want to distinguish the kinds of cognitive behavioral
link |
00:53:14.020
therapy and exposure therapies that are done
link |
00:53:15.760
for obsessive compulsive disorder,
link |
00:53:17.380
the sorts of cognitive behavioral therapies that are done
link |
00:53:19.580
for other types of mental challenges and disorders.
link |
00:53:24.260
Because cognitive behavioral therapy for OCD
link |
00:53:27.480
really has everything to do with identifying
link |
00:53:30.160
the utmost fear.
link |
00:53:32.820
In some sense, we can think of fears
link |
00:53:34.060
as kind of along a hierarchy, right?
link |
00:53:35.820
In the example earlier of somebody being afraid
link |
00:53:38.420
to turn left and therefore feeling compelled to turn right,
link |
00:53:41.820
you would want to take that person and really understand
link |
00:53:44.600
what do they fear most about turning left?
link |
00:53:47.420
Now they might not be aware of it.
link |
00:53:48.980
They might not be conscious to what that really is,
link |
00:53:51.340
but if you were to probe them in a clinical setting,
link |
00:53:53.660
you would eventually get to an answer.
link |
00:53:55.060
That answer could be at first, I don't know,
link |
00:53:58.420
it's just bad.
link |
00:53:59.280
I don't know why it's bad, it makes no sense,
link |
00:54:01.220
but it's just bad, I do not want to go left.
link |
00:54:03.380
I don't know why, I don't know why.
link |
00:54:04.800
But if you were to push that person a little bit
link |
00:54:07.040
in a respectful and kind and caring way aimed
link |
00:54:10.500
at their treatment, if you were to push them and say,
link |
00:54:11.900
well, what do you mean by bad?
link |
00:54:13.620
If you turn left, do you think the world would end?
link |
00:54:16.180
They might say, no, the world's not going to end,
link |
00:54:17.800
but someone is going to die suddenly.
link |
00:54:20.940
I know that sounds crazy, but somebody's going to die
link |
00:54:22.820
suddenly, this almost sounds like superstition.
link |
00:54:25.700
We'll talk about superstitions later,
link |
00:54:26.980
but indeed it is somewhat superstitious.
link |
00:54:29.340
So for instance, you would say, who's going to die?
link |
00:54:32.020
And they'd say, I don't know.
link |
00:54:33.620
And you'd say, no, really, who's going to die?
link |
00:54:35.820
If you think about this, are you going to die?
link |
00:54:37.420
Is so-and-so going to die?
link |
00:54:38.420
And very often, very often, what you find is that
link |
00:54:43.020
people will start to reveal the underlying obsession
link |
00:54:48.580
at a level of detail that both to the clinician
link |
00:54:51.580
and to them can be somewhat astonishing,
link |
00:54:53.340
even though they've been living with that detail
link |
00:54:55.140
in their mind for a very long time.
link |
00:54:57.220
Now, how could somebody start to reveal detail
link |
00:54:59.140
about something that's existed in their mind
link |
00:55:00.780
for a very long time, but not known about it, right?
link |
00:55:04.180
Not been aware of it.
link |
00:55:05.420
Now, some of you might think,
link |
00:55:06.300
oh, it's repressed or something.
link |
00:55:07.980
That's not at all what's happening.
link |
00:55:10.300
If you think about the architecture of OCD,
link |
00:55:12.580
typically people will have an obsession
link |
00:55:14.460
and then they'll engage in the compulsion
link |
00:55:16.100
as quickly as they can to relieve that obsession.
link |
00:55:18.620
So in many ways, the disease itself prevents people
link |
00:55:21.540
from ever getting to the bottom of that trough,
link |
00:55:24.500
ever getting to the point
link |
00:55:25.460
where they really clearly articulate to themselves
link |
00:55:27.960
exactly what it is that they fear.
link |
00:55:30.540
But it becomes so essential to articulate
link |
00:55:33.420
exactly what it is that they fear
link |
00:55:35.900
for a somewhat counterintuitive reason.
link |
00:55:37.800
You might think, oh, the moment they realize
link |
00:55:40.020
exactly what they fear, everything lifts.
link |
00:55:42.480
The circuit turns off and they just feel better
link |
00:55:44.340
because they realized it.
link |
00:55:45.820
I wish I could tell you that's the case,
link |
00:55:47.040
but it turns out it's the opposite.
link |
00:55:48.820
What the clinician is actually trying to do
link |
00:55:51.140
is get people to feel more anxiety, not less.
link |
00:55:55.180
What they're trying to get them to do
link |
00:55:56.300
is to short circuit, no pun intended,
link |
00:55:59.360
to intervene in their own neural circuit, I should say,
link |
00:56:02.860
with that relief of anxiety, however brief,
link |
00:56:06.740
brought on by engaging in the compulsion
link |
00:56:09.340
related to the obsession.
link |
00:56:10.700
So whereas typically someone would feel the obsession
link |
00:56:14.380
with, oh, I don't want to turn left
link |
00:56:16.220
because something bad's going to happen,
link |
00:56:17.300
someone's going to die, and then they turn right,
link |
00:56:19.700
they never get the option or the opportunity
link |
00:56:22.620
to really explore what would happen were they to turn left
link |
00:56:26.600
or to not be able to turn right.
link |
00:56:28.500
By forcing them down the path of inquiry,
link |
00:56:30.980
that leads them to the place
link |
00:56:32.220
where they very clearly identify the fear, the anxiety.
link |
00:56:37.180
It raises the anxiety in them,
link |
00:56:39.500
and that's actually what the clinician is after.
link |
00:56:43.660
Cognitive behavioral therapy and exposure therapy
link |
00:56:47.060
in the context of OCD most often involves
link |
00:56:50.060
trying to get people to tolerate, not relieve their anxiety.
link |
00:56:54.880
This is extremely important,
link |
00:56:56.300
and I realize there's variation to this
link |
00:56:58.580
depending on the style of cognitive behavioral therapy,
link |
00:57:01.580
the style of exposure therapy, but almost across the board,
link |
00:57:05.460
the goal, again, is to get people to feel the anxiety
link |
00:57:09.500
that normally they are able to at least partially relieve,
link |
00:57:12.820
however briefly, by engaging in the compulsion.
link |
00:57:15.820
So if we think back to that circuit
link |
00:57:18.140
of corticostriatal thalamic, what's going on here?
link |
00:57:21.100
Where is CBT intervening?
link |
00:57:23.420
What part of the circuit is getting interrupted?
link |
00:57:26.340
Well, as you recall,
link |
00:57:27.180
the cortex is involved in conscious perception,
link |
00:57:29.340
the thalamus and that thalamic reticular nucleus
link |
00:57:31.580
are involved in the passage of certain types of experience
link |
00:57:36.100
up to our conscious perception, not others,
link |
00:57:38.060
and the striatum is involved
link |
00:57:39.180
in this go, no-go type behavior.
link |
00:57:42.420
When OCD is really expressing itself in its fullness,
link |
00:57:47.220
people feel an anxiety around a particular thought,
link |
00:57:50.120
and they either have a go, for instance, wash hands,
link |
00:57:54.620
or a no-go, do not turn left type reaction.
link |
00:57:59.740
By having people progressively in a kind of hierarchical way
link |
00:58:03.560
reveal their precise source of anxiety,
link |
00:58:06.580
their utmost fear in this context,
link |
00:58:09.580
what happens is they feel enormous amounts
link |
00:58:12.040
of autonomic arousal.
link |
00:58:13.800
Now, in the context of anxiety treatment
link |
00:58:16.360
or other types of treatments,
link |
00:58:17.620
the goal would be to teach people to dampen,
link |
00:58:19.740
to lessen their anxiety through breathing techniques
link |
00:58:22.320
or through visualization techniques
link |
00:58:24.740
or through self-talk or through social support,
link |
00:58:27.200
any of the number of things that are well known
link |
00:58:28.920
to help people self-regulate their own anxiety.
link |
00:58:31.340
Here, it's the opposite.
link |
00:58:32.820
What they're trying to get the patient to do
link |
00:58:35.060
is to really feel the anxiety at its maximum,
link |
00:58:38.280
but then do the exact opposite
link |
00:58:40.100
of whatever the normal compulsion is.
link |
00:58:41.780
So if normally the compulsion is to wash one's hands,
link |
00:58:44.260
then the idea is to suppress hand washing
link |
00:58:46.640
while being in the experience of the utmost anxiety.
link |
00:58:49.800
Or in the case of not turning left,
link |
00:58:52.700
the person is expected to,
link |
00:58:55.300
or would hopefully be able to actually turn left.
link |
00:59:00.580
And as you can imagine, that would evoke tremendous anxiety
link |
00:59:04.020
and yet to tolerate that anxiety.
link |
00:59:06.080
Now, I want to be very clear.
link |
00:59:06.960
This is not the sort of thing you want to do on your own.
link |
00:59:08.920
This is not the sort of thing you want to do for a friend.
link |
00:59:10.820
This is done by trained licensed psychologists
link |
00:59:14.420
and psychiatrists.
link |
00:59:15.940
But nonetheless, it really points to the fact
link |
00:59:19.180
that as a anxiety-related disorder,
link |
00:59:22.500
OCD is distinct from other types of anxiety
link |
00:59:25.620
and anxiety-related disorders,
link |
00:59:27.600
things like PTSD and panic disorder, et cetera,
link |
00:59:30.380
because the goal again is to bring the person
link |
00:59:32.920
right up close to the thing that they fear the most
link |
00:59:36.380
and then to interrupt the circuit.
link |
00:59:38.620
And now you should be able to know just intuitively,
link |
00:59:42.620
because you understand the mechanisms,
link |
00:59:44.540
that the circuit you're trying to disrupt
link |
00:59:46.220
is the pattern of information flow
link |
00:59:49.300
from the thinking part of the brain,
link |
00:59:50.960
the perception part of the brain,
link |
00:59:51.980
which is the cortex, to the striatum, right?
link |
00:59:55.200
The striatum has these neurons which are active
link |
00:59:58.520
that essentially are,
link |
00:59:59.980
I know it sounds a little bit
link |
01:00:00.800
like a discussion about free will,
link |
01:00:02.040
but they're trying to get the person
link |
01:00:03.620
to generate a certain behavior
link |
01:00:04.860
or suppress a certain behavior.
link |
01:00:06.780
And as anxiety ramps up,
link |
01:00:08.260
it's sort of a hydraulic pressure to do that very thing
link |
01:00:11.700
that they've done for so long
link |
01:00:12.780
and they suffer from so much.
link |
01:00:14.600
We talked about hydraulic pressure
link |
01:00:16.020
in the context of aggression in the aggression episode.
link |
01:00:18.760
This is very similar, right?
link |
01:00:20.760
There's a kind of a, now when I say hydraulic pressure,
link |
01:00:23.460
it's not actual hydraulic pressure.
link |
01:00:24.860
It's the confluence of a lot of different systems.
link |
01:00:26.900
It's neurochemical, as we'll soon learn.
link |
01:00:28.580
It's hormonal, it's electrical.
link |
01:00:30.460
It's a lot of different things operating in parallel.
link |
01:00:32.820
So we can't point to one chemical or transmitter.
link |
01:00:35.420
What's happening is the person is feeling compelled
link |
01:00:37.400
to act, act, act to relieve the anxiety.
link |
01:00:39.640
And through a progressive type of exposure, right?
link |
01:00:43.400
You don't throw people in the deep end
link |
01:00:45.020
in this kind of therapy right off the bat.
link |
01:00:47.480
You gradually ratchet them toward
link |
01:00:49.180
or move them toward the discussion
link |
01:00:50.880
of exactly what they fear the most.
link |
01:00:52.380
And then eventually move them toward
link |
01:00:54.060
the interruption of the compulsion
link |
01:00:56.240
as they're feeling this extremely elevated anxiety.
link |
01:00:58.740
Of course, within the context
link |
01:00:59.880
of a supportive clinical setting.
link |
01:01:02.560
But in doing that, what you are teaching people
link |
01:01:05.260
is that the anxiety can exist without the need
link |
01:01:08.500
to engage in the compulsion.
link |
01:01:10.100
Now, some of this might sound to people like,
link |
01:01:12.860
oh, this is a lot of the kind of fancy
link |
01:01:14.260
psychological neuroscience speak
link |
01:01:15.860
around something that's kind of intuitive.
link |
01:01:17.360
But I think for most people, this is not intuitive.
link |
01:01:20.820
And for people with OCD, there's no really other way
link |
01:01:25.220
to put it, the impulse, the compulsion to avoid anxiety
link |
01:01:29.460
is such a powerful driving force
link |
01:01:31.740
that it should now make sense to you
link |
01:01:33.020
as to why being able to tolerate anxiety
link |
01:01:35.740
and really sit with it and do the exact opposite
link |
01:01:38.100
of what you're normally compelled to do
link |
01:01:39.680
is going to be the path to treatment.
link |
01:01:41.460
And indeed CBT has been shown to be enormously effective,
link |
01:01:44.980
again, for a large number of people with OCD,
link |
01:01:47.820
but not all of them.
link |
01:01:48.940
And oftentimes it requires that it also be used
link |
01:01:52.340
in concert with certain drug treatments,
link |
01:01:54.180
which we're going to talk about in a moment.
link |
01:01:56.220
Next, let's talk about some of the really unique features
link |
01:01:58.580
of cognitive behavioral therapy and exposure therapy
link |
01:02:00.740
in the context of OCD that you often don't see
link |
01:02:04.300
in the use of CBT, that is cognitive behavioral therapy,
link |
01:02:08.260
for other types of psychiatric challenges and disorders.
link |
01:02:12.020
The first element is one of staircasing.
link |
01:02:15.360
And I already mentioned this before,
link |
01:02:17.020
but this gradual and progressive increase in the anxiety
link |
01:02:22.160
that you're trying to evoke from the patient,
link |
01:02:24.500
from the person suffering from OCD.
link |
01:02:26.960
That's done in the context of the office or the laboratory,
link |
01:02:31.060
again, by a trained and licensed clinician.
link |
01:02:34.700
But then the person leaves, right?
link |
01:02:36.760
They leave the office, they leave the laboratory.
link |
01:02:40.180
And a very vital component of CBT and exposure therapy
link |
01:02:43.860
for people with OCD is that they have and perform
link |
01:02:47.140
what's called homework, is literally what they call.
link |
01:02:50.120
This might be seen in other sorts of treatments,
link |
01:02:51.960
but for OCD, homework is extremely important
link |
01:02:55.280
because within the context of a laboratory experiment
link |
01:02:57.780
or the clinic, patients often feel so much support
link |
01:03:00.780
that they can tolerate those heightened levels of anxiety
link |
01:03:02.900
and interrupt their compulsions.
link |
01:03:04.740
Whereas when they get home, oftentimes the familiarity
link |
01:03:07.220
of the environment brings them to a place
link |
01:03:09.160
where all of a sudden those obsessions and compulsions
link |
01:03:11.580
start interacting the same way
link |
01:03:13.160
and they have a very hard time suppressing the behaviors.
link |
01:03:16.620
Why would that be?
link |
01:03:17.700
Well, in neuroscience, we have a phrase,
link |
01:03:20.300
it's called condition place preference
link |
01:03:21.980
and condition place avoidance.
link |
01:03:23.660
There's some other phrases too,
link |
01:03:24.680
but basically it all has to do with a simple thing,
link |
01:03:27.700
which is when you feel something repeatedly
link |
01:03:30.740
in a given environment,
link |
01:03:31.700
or sometimes even once within a given environment,
link |
01:03:33.920
you tend to feel that same thing again
link |
01:03:36.340
when you return to that or similar environments, okay?
link |
01:03:38.880
So condition place blank or condition place that
link |
01:03:41.280
is simply fancy nerd speak for the fact that
link |
01:03:44.340
when you're in a place and something good happens,
link |
01:03:46.340
you tend to feel good if you return to that place
link |
01:03:48.040
or a place like it,
link |
01:03:48.980
or if something bad happens in a given place,
link |
01:03:51.300
you tend to feel bad when you return to that place
link |
01:03:53.560
or a place like it.
link |
01:03:54.860
I think the most salient example that leaps to mind
link |
01:03:57.260
is in unfortunately the category of bad,
link |
01:03:58.940
but I had some friends years ago visit San Francisco.
link |
01:04:02.420
There's been a ongoing,
link |
01:04:03.680
it seems like it's been happening forever,
link |
01:04:05.460
but this is really in the last decade of daytime break-ins
link |
01:04:08.140
and nighttime break-ins into cars to steal anything
link |
01:04:12.220
from computers to what seems to be like a box of tissues.
link |
01:04:14.600
And there are numerous reasons for this.
link |
01:04:16.440
I don't want to get into,
link |
01:04:17.280
it's not the topic of today's podcast,
link |
01:04:18.720
but I will use this as an opportunity to say,
link |
01:04:20.120
if you're visiting anywhere in the Bay Area,
link |
01:04:21.960
do not leave anything in your car
link |
01:04:23.100
because the window will get broken into
link |
01:04:24.900
sometimes in broad daylight.
link |
01:04:26.380
Some good friends of mine were visiting the Bay Area
link |
01:04:28.460
and I texted them and said,
link |
01:04:30.840
hey, by the way, when you're headed to dinner, guys,
link |
01:04:32.900
make sure you bring in all your luggage and computers,
link |
01:04:36.300
however inconvenient that might be.
link |
01:04:38.340
They wrote back, too late, everything got stolen.
link |
01:04:41.260
So some years ago now,
link |
01:04:42.300
I think five, six years ago, this happened.
link |
01:04:44.620
Sadly, everything got stolen.
link |
01:04:46.580
Most of it could be replaced,
link |
01:04:47.540
but some of it was very sentimental to them.
link |
01:04:49.620
Every time we talk,
link |
01:04:51.860
every time we consider having a meeting
link |
01:04:53.300
in a particular city,
link |
01:04:54.420
this comes up as I don't want to be there,
link |
01:04:56.640
I don't like that city anymore, et cetera.
link |
01:04:58.260
And of course, San Francisco has some wonderful
link |
01:04:59.800
redeeming features,
link |
01:05:00.640
but it only takes one bad incident in one location
link |
01:05:03.560
to kind of color the whole picture dark, so to speak.
link |
01:05:07.820
The brain works that way.
link |
01:05:09.060
The brain generalizes.
link |
01:05:10.620
It's not a very specific organ.
link |
01:05:12.300
Again, it's a prediction machine in addition to other things.
link |
01:05:15.020
So in the case of CBT therapy,
link |
01:05:17.780
the reason there's homework is that when people go home,
link |
01:05:20.820
oftentimes that's when they relapse,
link |
01:05:23.420
if you want to call it that,
link |
01:05:24.420
back into their obsessions and compulsions.
link |
01:05:26.260
And that location, that conditioned place
link |
01:05:30.380
is where it becomes most important
link |
01:05:31.940
to challenge the anxiety and to deal with the anxiety,
link |
01:05:34.860
to not try and suppress the anxiety
link |
01:05:36.400
through compulsions or other means.
link |
01:05:38.860
And when I say other means, I want to highlight something.
link |
01:05:41.700
We'll come up again a little bit later in the podcast
link |
01:05:43.780
that substance abuse is very common in people with OCD
link |
01:05:47.280
because of the anxiety component
link |
01:05:48.920
and also because of people's feelings
link |
01:05:50.760
that they just can't escape from the thoughts
link |
01:05:52.660
or behavioral patterns that are so characteristic of OCD.
link |
01:05:57.000
So alcohol abuse or cannabis abuse
link |
01:05:59.340
or other forms of narcotics abuse are very common in OCD.
link |
01:06:05.380
Later, we'll talk about whether or not cannabis can
link |
01:06:07.180
or cannot help with OCD, but needless to say,
link |
01:06:11.840
suppressing anxiety is exactly the wrong direction
link |
01:06:15.340
that one should take if the goal is to ultimately relieve
link |
01:06:19.400
or eliminate the OCD.
link |
01:06:21.480
So we now have two characteristics of CBT exposure therapy
link |
01:06:25.240
that are extremely important for OCD
link |
01:06:27.000
and somewhat unique to the treatment of OCD.
link |
01:06:29.060
And that's the staircasing up towards the really bad fear,
link |
01:06:31.660
the really severe and specific articulation
link |
01:06:34.900
and understanding and feeling of how bad things really
link |
01:06:37.700
would be if someone engaged in a particular behavior
link |
01:06:40.540
or avoided a particular behavior.
link |
01:06:42.000
Then there's the component of homework
link |
01:06:43.920
given by the clinician for the person to be able
link |
01:06:46.420
to create a broader set of contexts
link |
01:06:49.540
in which they can deal with the anxiety,
link |
01:06:52.680
not engage in the compulsions.
link |
01:06:54.420
And then a very unique feature of treatment of OCD
link |
01:06:57.660
that you don't see in many other psychiatric disorders
link |
01:07:00.800
are home visits.
link |
01:07:02.140
I find this fascinating.
link |
01:07:03.620
I think that the field of psychiatry and psychology
link |
01:07:06.500
traditionally doesn't allow for or invite home visits,
link |
01:07:10.700
but this component of context, location and context
link |
01:07:15.020
being so vital to the treatment and relief of OCD
link |
01:07:19.860
has inspired many psychiatrists and psychologists
link |
01:07:23.620
to get permission to do home visits
link |
01:07:26.080
where they actually go visit their patients
link |
01:07:27.700
in their native setting, in their home cages, right?
link |
01:07:30.180
They're not mice, but in their home home cages, right?
link |
01:07:32.760
I'm being facetious here, but people,
link |
01:07:34.340
mice live in cages, at least in the laboratory
link |
01:07:36.100
and humans generally live in houses or elsewhere.
link |
01:07:39.500
So they visit them in their home
link |
01:07:42.420
in order to see how they're interacting
link |
01:07:44.580
and the particular locations that evoke the most anxiety
link |
01:07:47.700
and the least anxiety.
link |
01:07:48.620
Some of the, I don't want to call them crutches,
link |
01:07:50.540
but some of the tools that people are using
link |
01:07:53.140
to confront and deal with the obsessions and compulsions
link |
01:07:56.900
and in particular, to try and identify
link |
01:07:59.140
some of the tools and tricks that people are using
link |
01:08:03.200
to try and avoid that heightened anxiety.
link |
01:08:05.320
Because once again, and I know I'm repeating myself,
link |
01:08:07.740
but I think this is just so vital and so unique
link |
01:08:10.140
about OCD and the treatment of OCD,
link |
01:08:12.460
the critical need for the patient
link |
01:08:14.140
to be able to tolerate extremely elevated levels of anxiety
link |
01:08:18.180
is so crucial.
link |
01:08:20.140
So if people are avoiding certain rooms in the house,
link |
01:08:23.140
or if people are avoiding certain foods
link |
01:08:25.940
or certain locations in the kitchen,
link |
01:08:27.640
the clinician can start to identify that
link |
01:08:29.500
by mere observation.
link |
01:08:31.200
And I should mention here that patients
link |
01:08:33.420
are not always aware of how they are interacting
link |
01:08:36.680
with their home environment.
link |
01:08:37.780
Some of these patterns are so deeply ingrained in people
link |
01:08:41.060
that they don't even realize
link |
01:08:42.200
that they're constantly turning to the left
link |
01:08:44.100
or they don't even realize
link |
01:08:45.180
that they're only washing their hands
link |
01:08:46.700
on one side of the sink.
link |
01:08:47.760
And so the clinician by visiting the home
link |
01:08:49.980
can start to interrogate a bit in a polite way,
link |
01:08:52.680
in a friendly, in a supportive way
link |
01:08:54.300
as to do you ever think about why you always
link |
01:08:57.560
flip the faucet to the left
link |
01:08:59.140
or flip the faucet to the right, et cetera.
link |
01:09:01.480
Now, we all do a lot of things that are habitual.
link |
01:09:05.740
We all do things that are somewhat regular from day to day.
link |
01:09:10.080
In fact, I would invite you to ask yourself,
link |
01:09:13.080
do you always put your toothbrush in the same location?
link |
01:09:16.480
Do you always cap the toothbrush before or after you use it?
link |
01:09:19.360
What sorts of things do you wipe the little threading
link |
01:09:22.620
on the toothpaste or not?
link |
01:09:23.540
I'm somebody, I confess that I have,
link |
01:09:26.400
well, I have about 3,500 pet peeves,
link |
01:09:28.720
but one of my pet peeves is toothpaste
link |
01:09:30.440
kind of on the thread of the toothpaste.
link |
01:09:32.520
It really bothers me.
link |
01:09:33.360
I don't know why.
link |
01:09:34.200
Almost as much as trying to wipe it off bothers me,
link |
01:09:36.840
which creates a certain challenge.
link |
01:09:38.160
And if I talk about this any further,
link |
01:09:39.700
then I think I would qualify
link |
01:09:40.740
for obsessive compulsive personality disorder.
link |
01:09:43.420
But I have to say,
link |
01:09:44.260
I don't experience a ton of anxiety about it.
link |
01:09:45.860
It doesn't govern my life.
link |
01:09:47.000
In fact, I realized that right now
link |
01:09:48.680
there are tubes of toothpaste
link |
01:09:50.640
that have toothpaste along the thread
link |
01:09:52.160
everywhere in the world, and it doesn't really bother me.
link |
01:09:54.400
I can still sit here
link |
01:09:55.800
and provide some information about OCD to you.
link |
01:09:58.560
It's not intrusive, at least not to my awareness.
link |
01:10:02.200
So by the home visit,
link |
01:10:03.920
the therapist can really start to explore
link |
01:10:06.060
through direct questioning
link |
01:10:08.040
and can allow the patient to explore
link |
01:10:09.780
through direct questioning of themselves
link |
01:10:11.440
the things that it might be conscious of
link |
01:10:12.760
and the things that they might not be conscious of
link |
01:10:15.220
that would qualify for OCD.
link |
01:10:17.600
So I'd like to just briefly summarize the key elements
link |
01:10:20.200
of cognitive behavioral therapy and exposure therapy
link |
01:10:23.340
and how they can be combined with drug treatments
link |
01:10:26.160
that are very effective.
link |
01:10:28.240
Much of what I'm going to talk about next
link |
01:10:29.880
relates to the data and indeed the practice
link |
01:10:33.520
of an incredible research scientist and clinician.
link |
01:10:38.200
So this is Helen Blair Simpson,
link |
01:10:40.080
or I should say Dr. Helen Blair Simpson
link |
01:10:42.080
because she is indeed an MD, medical doctor,
link |
01:10:44.400
and a PhD research scientist
link |
01:10:46.000
at Columbia University School of Medicine.
link |
01:10:49.180
And one of the world's foremost experts, if not the expert,
link |
01:10:53.500
I would put her in a category
link |
01:10:54.720
of maybe just one to three people
link |
01:10:56.680
who is most knowledgeable about the mechanisms of OCD,
link |
01:11:01.440
is actively researching OCD in humans,
link |
01:11:04.720
trying to find new treatments,
link |
01:11:06.120
trying to unveil new mechanisms
link |
01:11:08.720
and expand on our current understanding
link |
01:11:10.720
and who also treats OCD quite actively in her own clinic.
link |
01:11:16.160
Dr. Simpson gave a beautiful presentation
link |
01:11:19.280
in which she summarized some of the core elements of CBT
link |
01:11:22.560
and exposure therapy
link |
01:11:23.720
for the treatment of obsessive compulsive disorders.
link |
01:11:26.160
She describes that the key procedures are exposures,
link |
01:11:29.280
of course, done in person and with the actual thing
link |
01:11:33.520
that evokes the obsessions and compulsions.
link |
01:11:36.400
So this could be the sweaty towel as described earlier,
link |
01:11:39.600
or could be any number of different triggers
link |
01:11:42.960
done with the patient in real time.
link |
01:11:45.040
So in vivo, as we say.
link |
01:11:47.040
And it could also be things that are imaginal,
link |
01:11:50.240
sitting somebody down in a chair in an office and saying,
link |
01:11:53.320
okay, I want you to imagine the thing
link |
01:11:55.940
that triggers the intrusive thought,
link |
01:11:57.320
or let's just focus on the intrusive thought as it arises
link |
01:12:01.000
and then to explore and expose the patient
link |
01:12:03.140
to their obsessions and compulsions that way.
link |
01:12:04.760
So it can be real or it can be imaginal.
link |
01:12:06.880
And the goal of course then is to gradually
link |
01:12:10.240
and progressively increase the level of anxiety,
link |
01:12:12.420
but then to intervene in so-called ritual prevention
link |
01:12:15.360
to prevent the person from engaging in the compulsion.
link |
01:12:18.280
The goals, again, I'm paraphrasing here,
link |
01:12:20.900
are to, as she states,
link |
01:12:22.640
disconfirm fears and challenge the beliefs
link |
01:12:26.840
about the obsessions and compulsions,
link |
01:12:29.720
to intervene in the thoughts and the behaviors,
link |
01:12:31.580
and to break the habit of ritualizing and avoiding.
link |
01:12:34.080
Now, how is this typically done?
link |
01:12:35.420
What are the nuts and bolts of this procedure?
link |
01:12:38.440
Typically, this is done through two planning sessions
link |
01:12:42.280
with the patient.
link |
01:12:43.120
So describing to the patient what will happen
link |
01:12:45.420
and when it will happen and how long it will happen
link |
01:12:47.760
so they're not just thrown into this out of the blue.
link |
01:12:51.080
And then 15 exposure sessions done twice a week or more.
link |
01:12:55.680
So the one thing to really understand
link |
01:12:57.080
about cognitive behavioral therapy
link |
01:12:58.480
is that it can take some period of time,
link |
01:13:00.200
several or more weeks, as many as 10 or 12 weeks.
link |
01:13:03.440
However, as you'll soon learn,
link |
01:13:05.120
many of the drug treatments that are effective
link |
01:13:06.880
in treating OCD either alone
link |
01:13:08.760
or in combination with behavioral therapies
link |
01:13:10.860
also can take eight, 10, 12 weeks or longer,
link |
01:13:13.920
and many of those never work at all.
link |
01:13:16.040
So even though 10 to 12 weeks
link |
01:13:17.720
seems like a long period of time,
link |
01:13:19.120
it's actually pretty standard.
link |
01:13:20.360
If you'd like to see more complete description
link |
01:13:22.520
of the protocols for cognitive behavioral therapy
link |
01:13:24.580
and exposure therapy for OCD,
link |
01:13:26.680
I'll provide links to two papers,
link |
01:13:28.260
COSAC and FOA, F-O-A, which is published in 1997,
link |
01:13:32.280
which might seem like a long time ago,
link |
01:13:33.540
but nonetheless, the protocols are still very useful.
link |
01:13:36.480
And then the second paper is by that last author,
link |
01:13:38.640
Faux et al. in 2012,
link |
01:13:40.720
and we'll provide links to both of those.
link |
01:13:42.900
In addition, Dr. Blair Simpson and others have explored
link |
01:13:46.960
what are the best treatments for patients with OCD
link |
01:13:50.360
by comparing cognitive behavioral therapy alone, placebo,
link |
01:13:54.240
so essentially no intervention,
link |
01:13:57.020
or something that takes an equivalent amount of time
link |
01:13:59.080
but is not thought to be effective in treatment,
link |
01:14:03.040
as well as selective serotonin reuptake inhibitors.
link |
01:14:07.340
So what is an SSRI?
link |
01:14:09.400
An SSRI is a drug that prevents the reuptake
link |
01:14:13.040
of serotonin at the synapse.
link |
01:14:14.780
What are synapses?
link |
01:14:15.620
They're the little spaces between neurons
link |
01:14:17.520
where neurons communicate with one another
link |
01:14:19.520
by vomiting little bits of chemical into the space,
link |
01:14:22.660
the synapse, and then those chemicals
link |
01:14:25.200
either evoke or suppress the electrical activity
link |
01:14:27.840
of the next neuron across the synapse.
link |
01:14:30.680
And in this case, the neurotransmitter,
link |
01:14:32.560
the chemical that we're referring to is serotonin.
link |
01:14:34.960
SSRI, selective serotonin reuptake inhibitors,
link |
01:14:38.640
prevent the reuptake of the chemical that's left,
link |
01:14:42.960
in this case, the serotonin that's left in the synapse
link |
01:14:45.360
after that, I called it vomiting to be dramatic,
link |
01:14:48.080
but it's not actually a vomiting,
link |
01:14:49.120
the extrusion of the chemical into the synapse.
link |
01:14:52.640
And as a consequence, there's more serotonin around
link |
01:14:55.760
to have more of an effect over time,
link |
01:14:57.680
the net effect being more serotonergic transmission,
link |
01:15:00.640
more serotonin overall.
link |
01:15:02.640
So not more serotonin being made,
link |
01:15:04.420
more serotonin being available for use.
link |
01:15:06.840
That's what an SSRI does.
link |
01:15:08.640
So they compared cognitive behavioral therapy, SSRIs,
link |
01:15:13.400
they also had the placebo group
link |
01:15:14.640
and they had cognitive behavioral therapy
link |
01:15:16.160
plus the selective serotonin reuptake inhibitor.
link |
01:15:19.920
This was a 12-week study done as described before,
link |
01:15:22.640
two times a week over the course of 12 weeks.
link |
01:15:25.360
First of all, the most important thing, of course,
link |
01:15:28.360
placebo did nothing.
link |
01:15:29.500
It did not relieve the OCD to any significant degree, right?
link |
01:15:34.800
How did they know that?
link |
01:15:35.640
They gave them the Y-box test that we talked about before,
link |
01:15:38.160
the Yale-Brown test with all those questions
link |
01:15:41.500
of which I read a few.
link |
01:15:42.920
So the OCD severity that one has to have on the Y-box
link |
01:15:47.480
is measured in terms of an index that goes from any here
link |
01:15:51.160
from eight all the way up to 28,
link |
01:15:52.840
that shouldn't mean anything.
link |
01:15:53.840
So the number eight is kind of meaningless here.
link |
01:15:55.860
It's in terms of an index that's only meaningful
link |
01:15:58.240
for the Y-box.
link |
01:15:59.420
But if somebody has a threshold of 16 or higher,
link |
01:16:02.720
it means that they're still having
link |
01:16:04.080
somewhat debilitating symptoms
link |
01:16:05.400
or very debilitating symptoms.
link |
01:16:07.120
Placebo did not reduce the obsessions or compulsions
link |
01:16:10.400
to any significant degree.
link |
01:16:12.240
However, and I think quite excitingly,
link |
01:16:14.440
cognitive behavioral therapy had a dramatic effect
link |
01:16:19.000
in reducing the obsessions and compulsions
link |
01:16:22.280
such that by four weeks, that score,
link |
01:16:25.120
that in this case range from eight to 28,
link |
01:16:27.240
dropped all the way from 25 down to about 11.
link |
01:16:31.360
So it's a huge drop in the severity of the symptoms.
link |
01:16:35.160
Now, what's really interesting
link |
01:16:36.560
is that when you look at the effects of SSRIs
link |
01:16:39.440
in the treatment of OCD symptoms,
link |
01:16:42.860
they had a significant effect
link |
01:16:44.780
in reducing the symptoms of OCD
link |
01:16:47.000
that showed up first at four weeks
link |
01:16:48.740
and then continued to eight weeks.
link |
01:16:51.260
In fact, there was a progressive and further reduction
link |
01:16:54.400
in OCD symptoms from the four to eight week period.
link |
01:16:57.080
Again, these are the people just taking the SSRI.
link |
01:16:59.920
And then it sort of flattened out a little bit
link |
01:17:01.600
such that by 12 weeks,
link |
01:17:03.060
there was still a significant reduction in OCD symptoms
link |
01:17:05.720
for people taking SSRIs as compared to placebo.
link |
01:17:08.980
But the severity of their symptoms
link |
01:17:11.360
was still much greater
link |
01:17:13.220
than those receiving cognitive behavioral therapy alone.
link |
01:17:16.560
So at least in this study,
link |
01:17:18.120
and I should tell you which study it is.
link |
01:17:19.620
This is Faux Leibowitz et al. 2005
link |
01:17:21.960
in the American Journal of Psychiatry.
link |
01:17:23.360
We'll also provide a link to this
link |
01:17:24.760
so you can peruse the data if you like.
link |
01:17:27.020
But at least in this study,
link |
01:17:28.400
cognitive behavioral therapy was the most effective.
link |
01:17:31.320
Selective serotonin reuptake inhibitors, less effective.
link |
01:17:35.100
So what happens when you combine them?
link |
01:17:36.680
Well, they explored that as well.
link |
01:17:38.120
And the combination of cognitive behavioral therapy
link |
01:17:40.600
and the SSRIs together
link |
01:17:42.760
did not lead to any further decrease in OCD symptoms.
link |
01:17:48.280
This points to the idea that cognitive behavioral therapy
link |
01:17:51.440
is the most effective treatment.
link |
01:17:52.800
And again, when I say cognitive behavioral therapy,
link |
01:17:54.520
now I'm still referring to cognitive behavioral
link |
01:17:56.480
slash exposure therapy
link |
01:17:58.220
done in the way that I detailed before.
link |
01:17:59.580
Twice a week for 12 weeks or more.
link |
01:18:01.900
So all of the data, at least in this study,
link |
01:18:03.660
point to the fact that cognitive behavioral therapy
link |
01:18:05.840
is really effective and the most effective.
link |
01:18:08.400
Does it alleviate OCD symptoms for everybody?
link |
01:18:11.880
No. Is it very time consuming?
link |
01:18:13.440
Yes. Twice a week for two sessions or more of 15 minutes,
link |
01:18:17.700
sometimes in the office, plus there's homework,
link |
01:18:19.740
plus in an ideal case, there's also home visits
link |
01:18:22.240
from the psychiatrist or psychologist.
link |
01:18:24.200
That's a lot of investment, a lot of time investment
link |
01:18:28.500
to say nothing of the potential financial investment.
link |
01:18:31.560
Now, Dr. Blair Simpson has given some beautiful talks
link |
01:18:34.320
where she describes these data
link |
01:18:37.240
and also emphasizes the fact that
link |
01:18:39.720
despite the demonstrated power of cognitive behavioral
link |
01:18:43.120
therapy for the treatment of OCD,
link |
01:18:45.120
most people are given drug treatments
link |
01:18:46.560
simply because of the availability of those drug treatments.
link |
01:18:49.020
Now, when I say most people,
link |
01:18:50.200
I want to emphasize that I'm referring to
link |
01:18:52.220
most people who actually go seek treatment
link |
01:18:54.720
because a really important thing to realize
link |
01:18:56.780
is that most people with OCD
link |
01:18:58.680
do not actually go seek evidence-based treatment.
link |
01:19:01.880
I want to repeat that.
link |
01:19:02.700
Most people with OCD do not seek evidence-based treatment,
link |
01:19:05.540
which is a tragic thing.
link |
01:19:06.800
One of the motivations for doing this podcast episode
link |
01:19:09.540
is to try and encourage people
link |
01:19:11.120
who think they may have persistent obsessions
link |
01:19:13.160
and compulsions to seek treatment,
link |
01:19:16.080
but most people don't for a variety of reasons
link |
01:19:19.720
we spelled out earlier, shame, et cetera.
link |
01:19:22.640
Of those that do, the first line of attack
link |
01:19:25.320
is typically a prescription, most often an SSRI,
link |
01:19:29.360
although not always just SSRIs
link |
01:19:31.320
because soon we'll talk about the somewhat common use
link |
01:19:35.440
of also prescribing a low dose of a neuroleptic
link |
01:19:39.240
or an antipsychotic, not always, but often.
link |
01:19:42.560
So the important thing to understand here
link |
01:19:44.760
is that excellent researchers like Dr. Simpson
link |
01:19:47.520
understand that while there are treatments
link |
01:19:49.880
that we could say are best or are ideal based on the data,
link |
01:19:53.720
that doesn't necessarily mean that's what's being deployed
link |
01:19:56.680
most often in the general public.
link |
01:19:58.640
As a consequence, Dr. Simpson and others
link |
01:20:01.440
have explored in a very practical way
link |
01:20:04.480
whether or not it matters
link |
01:20:05.800
if somebody is getting SSRI treatment
link |
01:20:09.800
and is experiencing that reduction in OCD symptoms
link |
01:20:14.240
that as you may recall
link |
01:20:15.880
is more than what they would experience with placebo alone,
link |
01:20:19.900
but not as dramatic a reduction in OCD symptoms
link |
01:20:22.420
as they would get with cognitive behavioral therapy.
link |
01:20:25.040
And as I mentioned before,
link |
01:20:26.020
there was this exploration of combining drug treatment
link |
01:20:29.160
with cognitive behavioral therapy from the outset,
link |
01:20:31.440
but they also quite impressively explored
link |
01:20:34.120
what happens when people who are already taking SSRIs
link |
01:20:37.240
initiate cognitive behavioral therapy.
link |
01:20:39.480
This is a really wonderful thing that they've done this
link |
01:20:41.720
because in doing that, first of all,
link |
01:20:44.080
they're acknowledging that there are many people out there
link |
01:20:46.280
who have sought treatment
link |
01:20:47.200
and are getting some relief from those SSRIs,
link |
01:20:49.780
but it perhaps is not as much relief as they could get.
link |
01:20:52.560
And they are actively acknowledging
link |
01:20:55.300
that many people are getting these drug treatments first.
link |
01:20:58.240
In fact, most often people
link |
01:20:59.340
are getting these drug treatments first.
link |
01:21:01.200
So what happens when you add in cognitive behavioral therapy?
link |
01:21:04.580
Well, the good news is
link |
01:21:05.420
when you add cognitive behavioral therapy
link |
01:21:07.960
to someone who's already taking SSRIs,
link |
01:21:10.800
that further improves their symptoms.
link |
01:21:13.200
Now that's different than the results
link |
01:21:16.280
that I described before from the same laboratory in fact,
link |
01:21:20.460
that if you combine cognitive behavioral therapy
link |
01:21:23.480
with SSRIs from the outset,
link |
01:21:25.600
there's no additional benefit of SSRI.
link |
01:21:29.320
However, as I just described,
link |
01:21:30.800
if someone is already taking an SSRI
link |
01:21:33.000
and they're experiencing a reduction in their OCD symptoms,
link |
01:21:37.340
by adding in cognitive behavioral therapy,
link |
01:21:40.060
there's a further reduction in the symptoms of OCD.
link |
01:21:44.260
So it's very important.
link |
01:21:45.100
So for those of you that have sought treatment
link |
01:21:46.740
and you're taking a SSRI,
link |
01:21:49.060
or if you're thinking about treatment
link |
01:21:50.420
and you're prescribed an SSRI,
link |
01:21:52.060
the ideal scenario really would be
link |
01:21:53.480
to combine the drug treatment
link |
01:21:55.000
with cognitive behavioral therapy,
link |
01:21:56.420
or in some cases, maybe cognitive behavioral therapy alone,
link |
01:21:58.780
although that's a decision that you really have to make
link |
01:22:00.920
with the close advice and oversight of a licensed physician,
link |
01:22:06.640
because of course these are prescription drugs.
link |
01:22:08.680
And anytime you're going to add or remove a prescription drug
link |
01:22:11.380
or change dosage, you really want to do that
link |
01:22:13.320
in close discussion with and on the advice of your physician.
link |
01:22:16.580
I don't just say that to protect me,
link |
01:22:17.680
I say that to protect you
link |
01:22:18.560
and because it's just the right thing to do.
link |
01:22:20.640
So again, cognitive behavioral therapy is extremely powerful.
link |
01:22:23.860
Drug treatments seem less powerful,
link |
01:22:25.880
though if you're already on a drug treatment,
link |
01:22:27.320
adding cognitive behavioral therapy can really help.
link |
01:22:29.620
So I've been talking about SSRIs
link |
01:22:30.980
and described a little bit about how they work
link |
01:22:32.520
at a kind of superficial level
link |
01:22:33.780
of keeping more serotonin in the synapse
link |
01:22:36.560
so that more serotonin can be in action
link |
01:22:39.540
as opposed to gobbled back up by those neurons.
link |
01:22:42.520
I should just mention
link |
01:22:43.360
what some of the selective serotonin reuptake inhibitors are.
link |
01:22:46.180
So things like clomipramine,
link |
01:22:49.480
which is not entirely selective,
link |
01:22:52.700
I should say that that one generally falls
link |
01:22:54.820
into a category of less selective.
link |
01:22:56.580
So it can impair or can enhance
link |
01:23:01.260
some of the other neurotransmitter
link |
01:23:02.740
or neuromodulator systems like epinephrine, et cetera.
link |
01:23:05.820
The selective serotonin reuptake inhibitors are,
link |
01:23:09.380
at least the classic ones are fluoxetine, Prozac,
link |
01:23:11.900
fluvoxamine, fluvox, peroxetine, sertraline, citalopram,
link |
01:23:16.540
et cetera, et cetera.
link |
01:23:19.060
There are about six classic SSRIs.
link |
01:23:21.860
Some of them like citalopram are used in children
link |
01:23:25.260
and are available in pediatric doses.
link |
01:23:27.840
Some like Prozac may or may not be used in children.
link |
01:23:30.620
The details of which SSRIs, et cetera,
link |
01:23:33.700
is a very extensive literature and discussion.
link |
01:23:36.140
And I think it's safe to say that which drugs to use
link |
01:23:40.260
and at which dosage and whether or not to continue,
link |
01:23:43.700
excuse me, the same dosage over time
link |
01:23:45.080
depends a lot on the individual variation
link |
01:23:47.920
that people express and the responses that they have.
link |
01:23:50.460
All of these drugs, in fact,
link |
01:23:51.980
I think we can say all drugs have side effects.
link |
01:23:54.900
The question is how detrimental
link |
01:23:57.780
those side effects are to daily life.
link |
01:23:59.220
The SSRIs are well known to have effects on appetite.
link |
01:24:02.380
In some cases, they abolish appetite.
link |
01:24:04.860
In some cases, they just reduce it a little bit.
link |
01:24:06.900
In some cases, they increase appetite,
link |
01:24:09.120
really is highly individual.
link |
01:24:10.740
They can have effects on libido.
link |
01:24:12.340
For instance, they can reduce sex drive,
link |
01:24:15.700
sometimes in a dose dependent way,
link |
01:24:17.140
sometimes in a way that's more like a step function
link |
01:24:19.340
where people are fine at say five or 10 milligrams,
link |
01:24:22.060
but then they get to 15 milligrams
link |
01:24:24.980
and there's a cliff for their libido.
link |
01:24:28.820
That can happen, it really depends.
link |
01:24:30.520
Please don't take those dosages as exact values
link |
01:24:32.660
because this is going to depend on what they're being used
link |
01:24:35.500
for, depression or anxiety or OCD.
link |
01:24:37.580
And it's also going to depend on the drug, et cetera.
link |
01:24:39.460
I just threw out those numbers as a way to illustrate
link |
01:24:41.980
what a kind of a step function would look like.
link |
01:24:43.860
It's not gradual, it's immediate at a given dose
link |
01:24:46.180
is what that means.
link |
01:24:47.660
The other thing is that some of these drugs
link |
01:24:50.860
will have transient effects.
link |
01:24:52.860
So side effects that show up and then disappear,
link |
01:24:54.700
or sadly people will sometimes take these drugs for a while
link |
01:24:57.620
and then side effects will surface later
link |
01:24:59.080
that weren't there previously,
link |
01:25:00.860
depending on life factors, nutrition factors.
link |
01:25:03.040
So it's a very complicated landscape overall.
link |
01:25:05.820
And that's why it's really important to explore
link |
01:25:07.480
any kind of drug treatment, SSRI or otherwise,
link |
01:25:09.980
really in close communication with a psychiatrist
link |
01:25:12.280
who really understands the pharmacokinetics
link |
01:25:14.140
and has a lot of patient history and experience with them.
link |
01:25:17.100
So what I'm about to tell you next
link |
01:25:18.340
is most certainly going to come as a big surprise.
link |
01:25:20.780
Which is that despite the fact
link |
01:25:22.860
that the selective serotonin reuptake inhibitors
link |
01:25:24.900
can be effective in reducing the symptoms of OCD,
link |
01:25:27.660
at least somewhat, and certainly more than placebo,
link |
01:25:31.260
there is very little, if any evidence
link |
01:25:33.760
that the serotonin system is disrupted in OCD.
link |
01:25:36.820
And I have to point out that this is a somewhat
link |
01:25:39.480
consistent theme in the field of psychiatry.
link |
01:25:42.260
That is a given drug can be very effective
link |
01:25:45.300
or even partially effective in reducing symptoms
link |
01:25:48.480
or in changing the overall landscape
link |
01:25:50.860
of a psychiatric disorder or illness.
link |
01:25:53.620
And yet there is very little, if any, evidence
link |
01:25:56.880
that that particular system is what's causal for OCD
link |
01:26:01.340
or anxiety or depression, et cetera.
link |
01:26:03.780
This is just the landscape that we're living in
link |
01:26:05.420
in terms of our understanding of the brain and psychiatry
link |
01:26:07.620
and the ways of treating brain disorders.
link |
01:26:09.680
So as a consequence, there are a huge number
link |
01:26:12.460
of academic reviews that clinicians
link |
01:26:14.780
and research scientists have generated
link |
01:26:16.340
and read and share one of the more,
link |
01:26:20.180
I think, thorough ones in recent years
link |
01:26:23.060
was published in 2021.
link |
01:26:24.720
I'll provide a link to this.
link |
01:26:25.660
This is by an excellent, truly excellent researcher
link |
01:26:29.100
from Yale University School of Medicine.
link |
01:26:31.240
I should say not just a researcher,
link |
01:26:32.460
but a clinician scientist, again, an MD, PhD.
link |
01:26:34.980
This is Christopher Pittenger.
link |
01:26:37.140
And the title of the review is
link |
01:26:38.300
pharmacotherapeutic strategies and new targets in OCD.
link |
01:26:44.380
And again, we'll provide a link to it.
link |
01:26:46.180
This is a just gorgeous review describing,
link |
01:26:49.640
as I just told you,
link |
01:26:50.480
that the serotonin system isn't really disrupted in OCD
link |
01:26:53.340
and yet SSRIs can be very effective.
link |
01:26:56.000
The review goes on to explore even what sorts of receptors
link |
01:27:00.080
for serotonin might be involved,
link |
01:27:01.800
if it's in fact the case that serotonin is a culprit
link |
01:27:06.620
in the creation of OCD symptoms.
link |
01:27:11.380
Talk about the serotonin 2A receptor
link |
01:27:13.780
and the serotonin 1A receptor.
link |
01:27:15.140
Why am I mentioning all that detail
link |
01:27:16.780
if in fact it's not clear serotonin is involved?
link |
01:27:19.220
Because I'll just tell you right now,
link |
01:27:21.800
there is currently a lot of interest
link |
01:27:23.140
in whether or not some of the psychedelics,
link |
01:27:25.280
in particular psilocybin,
link |
01:27:26.800
can be effective in the treatment of OCD.
link |
01:27:29.460
Psilocybin has been shown in various clinical trials,
link |
01:27:32.540
in particular the clinical trials done
link |
01:27:34.000
at Johns Hopkins School of Medicine
link |
01:27:35.820
by Matthew Johnson and others.
link |
01:27:37.620
Matthew is on the Huberman Lab Podcast.
link |
01:27:39.380
He's been on the Tim Ferriss Podcast.
link |
01:27:40.980
He's been on the Lex Friedman Podcast.
link |
01:27:42.980
He's a world-class researcher
link |
01:27:44.260
on the use of psychedelics for depression
link |
01:27:46.540
and other psychiatric challenges.
link |
01:27:49.460
And there, psilocybin treatment has been seen,
link |
01:27:52.680
at least in those trials, to be very effective
link |
01:27:54.540
in the treatment of certain kinds of major depression.
link |
01:27:58.040
Currently, the exploration of psilocybin
link |
01:28:00.180
for the treatment of OCD has not yielded similar results,
link |
01:28:03.720
although the studies are ongoing.
link |
01:28:05.420
Again, has not yielded similar effectiveness,
link |
01:28:07.500
but the studies are ongoing.
link |
01:28:09.060
And the serotonin 2A receptor
link |
01:28:11.000
and the serotonin 1A receptors are primary targets
link |
01:28:14.220
for the drug psilocybin.
link |
01:28:16.420
So I figured there were going to be some questions
link |
01:28:17.840
about whether or not psychedelics help with OCD.
link |
01:28:20.740
Thus far, it's inconclusive.
link |
01:28:23.000
If any of you have been part of clinical trials
link |
01:28:25.420
or have knowledge or intuition about this relationship
link |
01:28:28.540
or potential relationship, I should say,
link |
01:28:30.060
between psilocybin or other psychedelics and OCD,
link |
01:28:32.700
please put them in the comment section.
link |
01:28:33.880
We'd love to hear from you.
link |
01:28:37.100
One thing I should point out is that even though serotonin
link |
01:28:40.520
has not been directly implicated in OCD,
link |
01:28:43.020
serotonin and the general systems of serotonin,
link |
01:28:45.660
the circuits in the brain that carry serotonin
link |
01:28:47.500
and depend on it, have been shown
link |
01:28:49.960
to impact cognitive flexibility and inflexibility,
link |
01:28:53.860
which are kind of hallmark themes of OCD.
link |
01:28:56.060
So in animals that have their serotonin depleted
link |
01:28:59.080
or in humans that have very low levels of serotonin,
link |
01:29:01.940
you can see evidence of cognitive inflexibility,
link |
01:29:05.820
challenges in task switching,
link |
01:29:07.460
challenges in switching the rules
link |
01:29:09.060
by which one performs a game,
link |
01:29:10.780
challenges in any kind of cognitive domain switching.
link |
01:29:14.780
And so that does indirectly implicate serotonin
link |
01:29:17.940
in some of the aspects of OCD.
link |
01:29:20.060
Again, when one starts to explore
link |
01:29:21.760
the different transmitter systems that have been explored
link |
01:29:24.200
in animal models and in humans, it's a vast, vast landscape,
link |
01:29:27.780
but serotonergic drugs do seem to be
link |
01:29:30.860
the most effective drugs in treating OCD, despite the fact,
link |
01:29:34.420
again, despite the fact that there's no direct evidence
link |
01:29:37.200
that serotonin systems are the problem in OCD.
link |
01:29:42.080
If you recall the corticostriatal thalamic loop
link |
01:29:45.160
that is so central to the etiology,
link |
01:29:48.900
the presence and the patterns of symptoms in OCD,
link |
01:29:52.460
of course, serotonin is impacting that system.
link |
01:29:54.620
Serotonin is impacting just about every system in the brain,
link |
01:29:57.360
but there's no evidence that tinkering with serotonin levels
link |
01:30:00.580
specifically in that network
link |
01:30:02.780
is what's leading to the improvements in OCD.
link |
01:30:06.500
However, if people go into a fMRI scanner
link |
01:30:10.220
and those people have OCD
link |
01:30:11.540
and they evoke the obsessions and compulsions,
link |
01:30:13.360
you see activity in that corticostriatal thalamic loop.
link |
01:30:17.400
Treatments like SSRIs that reduce the symptoms of OCD
link |
01:30:21.900
equate to a situation where there is less activity
link |
01:30:24.580
in that loop.
link |
01:30:26.100
And I should point out cognitive behavioral therapy,
link |
01:30:29.180
which we have no reason to believe
link |
01:30:30.860
only taps into the serotonin system.
link |
01:30:32.540
I think it would be,
link |
01:30:33.980
the extreme stretch would be false actually
link |
01:30:35.760
to say that cognitive behavioral therapy taps
link |
01:30:38.020
only into the serotonin system.
link |
01:30:39.620
Clearly it's going to affect a huge number of circuits
link |
01:30:41.660
in neurochemical systems.
link |
01:30:43.000
Well, people who do cognitive behavioral therapy
link |
01:30:45.620
and find some relief for OCD,
link |
01:30:47.500
they also show reductions
link |
01:30:49.040
in those corticostriatal thalamic loops.
link |
01:30:51.780
So basically we have a situation
link |
01:30:53.220
where we have a behavioral therapy that works
link |
01:30:55.980
in many people, not all,
link |
01:30:57.860
and we have a pretty good understanding of about why it works.
link |
01:31:00.080
It increases anxiety tolerance
link |
01:31:01.900
and interference with pattern execution,
link |
01:31:06.980
getting people to not engage in the same sorts of behaviors
link |
01:31:10.300
that are detrimental to them.
link |
01:31:12.140
And we have drug treatments that work,
link |
01:31:14.220
at least to some degree,
link |
01:31:15.180
but we don't know how they work
link |
01:31:16.460
or where they work in the brain.
link |
01:31:17.820
One of the things that really unifies
link |
01:31:19.940
the behavioral treatments and the drug treatments
link |
01:31:23.340
is that they take some period of time.
link |
01:31:25.400
Some relief from symptoms seems to show up around four weeks
link |
01:31:28.180
and certainly by eight weeks
link |
01:31:29.840
for both cognitive behavioral therapy and the SSRIs,
link |
01:31:33.180
but it's really at the 10 to 12 week stage
link |
01:31:36.360
when someone's been doing these twice a week
link |
01:31:38.000
cognitive behavioral sessions,
link |
01:31:39.940
where they've been taking a SSRI for 10 to 12 weeks,
link |
01:31:43.600
that the really significant reduction
link |
01:31:45.780
in OCD symptoms starts to really show up.
link |
01:31:49.140
Now, up until now, I've been talking about the fact
link |
01:31:51.120
that people are getting relief from these treatments,
link |
01:31:53.980
but sadly, in the case of OCD,
link |
01:31:57.260
there is a significant population
link |
01:32:00.500
that simply does not respond to CBT
link |
01:32:03.740
or to SSRIs or to their combination,
link |
01:32:06.580
which is why psychiatrists also explore
link |
01:32:09.660
the combination of SSRIs and neuroleptics
link |
01:32:13.440
or drugs that tap into the so-called dopamine system
link |
01:32:16.140
or the glutamate system.
link |
01:32:17.400
These are other neurotransmitters and neuromodulators
link |
01:32:20.020
that impact different circuits in the brain.
link |
01:32:21.780
And just to really remind you
link |
01:32:23.020
what neurotransmitters and neuromodulators do,
link |
01:32:25.140
because this is important to contextualize all this,
link |
01:32:28.080
neurotransmitters are typically involved
link |
01:32:29.720
in the rapid communication between neurons.
link |
01:32:32.820
And the two most common neurotransmitters for that
link |
01:32:34.780
are the neurotransmitter glutamate,
link |
01:32:37.160
which we say is excitatory,
link |
01:32:38.540
meaning when it's released into the synapse,
link |
01:32:40.060
it causes the next neuron to be more active or active,
link |
01:32:43.620
and GABA, which is a neurotransmitter that is inhibitory,
link |
01:32:46.780
meaning when it's released into the synapse,
link |
01:32:48.620
typically, not always,
link |
01:32:49.560
but typically that GABA is going to encourage
link |
01:32:52.260
the next neuron to be less electrically active
link |
01:32:54.460
or even silence its activity.
link |
01:32:57.280
The neuromodulators, by contrast,
link |
01:32:59.740
so not neurotransmitters, but neuromodulators,
link |
01:33:01.940
like dopamine, serotonin, epinephrine, and acetylcholine,
link |
01:33:05.060
and others, operate a little bit differently.
link |
01:33:08.460
They intend to act a little bit more broadly.
link |
01:33:10.580
They can act within the synapse,
link |
01:33:12.300
but they can also change the general patterns
link |
01:33:15.140
of activity in the brain,
link |
01:33:16.340
making certain circuits more likely to be active
link |
01:33:18.780
and other circuits less likely to be active.
link |
01:33:21.380
So when we say dopamine does X or dopamine does Y
link |
01:33:24.700
or serotonin does X or serotonin does Y,
link |
01:33:26.500
they don't really do one thing.
link |
01:33:28.100
They change the sort of overall tonality.
link |
01:33:30.540
They make it more likely or less likely
link |
01:33:32.060
that certain circuits will be active.
link |
01:33:33.820
You can think of them as kind of activating playlists
link |
01:33:36.460
or genres of activity in the brain
link |
01:33:39.500
rather than being involved in the specific communication
link |
01:33:42.340
or specific songs, if you will, in this analogy,
link |
01:33:45.100
or discussions between particular neurons.
link |
01:33:47.380
So when we hear that SSRIs increase serotonin
link |
01:33:51.500
and reduce the symptoms of OCD,
link |
01:33:53.380
or a neuroleptic reduces the amount of dopamine
link |
01:33:56.460
and makes people feel calmer, for instance,
link |
01:33:59.760
or can remove some stereotyped repetitive motor behavior,
link |
01:34:05.020
which they can either generate
link |
01:34:06.820
or reduce motor behavior, it turns out.
link |
01:34:09.380
So when I say that, what I'm referring to is the fact
link |
01:34:11.820
that these neuromodulators are turning up the volume
link |
01:34:14.720
on certain circuits
link |
01:34:15.740
and turning down the volume on other circuits.
link |
01:34:18.500
I say that because if you are going
link |
01:34:21.180
to explore drug treatments, again, with a licensed physician,
link |
01:34:25.420
if you're going to explore drug treatments for OCD,
link |
01:34:28.340
and in particular, if you are not getting results
link |
01:34:31.780
from SSRIs or you're not getting results
link |
01:34:34.380
from cognitive behavioral therapy
link |
01:34:35.620
or the side effect profiles of the drugs
link |
01:34:37.540
that you're taking for OCD are causing problems
link |
01:34:41.340
that you don't want to take them,
link |
01:34:43.080
well, then it's important to understand
link |
01:34:44.960
that anytime you take one of these drugs,
link |
01:34:47.080
they're not acting specifically
link |
01:34:48.780
on the corticostriatal thalamic circuit.
link |
01:34:51.460
That would be wonderful.
link |
01:34:52.300
That's the future of psychiatry.
link |
01:34:54.260
But as now, when you take a drug, it acts systemically.
link |
01:34:58.300
So it's impacting serotonin in your gut.
link |
01:35:00.580
It's also impacting serotonin in other areas of the brain,
link |
01:35:02.740
hence the effects on things like digestion or libido
link |
01:35:06.900
or any number of different things
link |
01:35:08.980
that serotonin is involved in.
link |
01:35:10.860
Likewise, if you take a neuroleptic like haloperidol
link |
01:35:13.980
or something that reduces dopamine transmission,
link |
01:35:17.540
well, then it's going to have some motor effects
link |
01:35:19.340
because dopamine is involved in the generation
link |
01:35:21.380
of motor sequences and smooth limb movement.
link |
01:35:23.660
That's why people with Parkinson's
link |
01:35:24.740
who don't have much dopamine will get a resting tremor,
link |
01:35:27.020
have a hard time generating smooth movement.
link |
01:35:28.580
And so the side effects start to make sense
link |
01:35:31.020
given the huge number of different neural circuits
link |
01:35:33.620
that these different neuromodulators are involved in.
link |
01:35:35.940
I don't say that to be discouraging.
link |
01:35:37.940
I say that to encourage patients
link |
01:35:40.820
and careful systematic exploration
link |
01:35:43.000
of different drug treatments for OCD,
link |
01:35:45.540
always, again, with the careful and close guidance
link |
01:35:50.480
and oversight of a psychiatrist
link |
01:35:52.060
because psychiatrists really understand
link |
01:35:53.660
which side effect profiles make it likely
link |
01:35:56.140
that you can or cannot or will never
link |
01:36:00.460
or maybe someday we'll be able to take a given drug
link |
01:36:02.540
at a given dose.
link |
01:36:03.580
They are the ones that really have that knowledge.
link |
01:36:05.260
This is not the sort of thing that you want a cowboy
link |
01:36:07.280
and go try and figure out yourself.
link |
01:36:09.540
Now, I also want to acknowledge
link |
01:36:11.620
that there are other forms of drug treatments.
link |
01:36:13.500
We touched on psilocybin briefly,
link |
01:36:15.120
but there are other forms of drug treatments
link |
01:36:16.860
that have been explored for OCD.
link |
01:36:19.220
Earlier, we talked a little bit about cannabis.
link |
01:36:21.220
Why would cannabis be a place of exploration at all?
link |
01:36:25.640
Well, first of all,
link |
01:36:26.580
a number of people try and self-medicate for OCD.
link |
01:36:29.580
There is some clinical evidence,
link |
01:36:31.420
I'm not talking about recreational use,
link |
01:36:32.700
I'm talking about clinical evidence
link |
01:36:33.740
that cannabis can reduce anxiety.
link |
01:36:35.600
Now, earlier, we were talking about not reducing anxiety,
link |
01:36:38.820
but learning anxiety tolerance
link |
01:36:41.040
in order to deal with and treat OCD
link |
01:36:44.140
in the context of cognitive behavioral therapies.
link |
01:36:47.820
That doesn't necessarily rule out cannabis
link |
01:36:49.480
as a candidate for the treatment of OCD.
link |
01:36:52.920
And in fact, this has been explored.
link |
01:36:54.620
A study from Dr. Blair Simpson herself looked at this.
link |
01:36:59.200
This was a fairly small scale study.
link |
01:37:00.940
So first of all, I'll give you the title,
link |
01:37:02.260
and again, we'll provide a link.
link |
01:37:03.360
This is entitled Acute Effects of Cannabinoids
link |
01:37:05.500
on Symptoms of Obsessive Compulsive Disorder,
link |
01:37:07.620
Human Laboratory Study.
link |
01:37:09.420
Very briefly, this was 14 adults
link |
01:37:10.980
with OCD, they had prior experience with cannabis.
link |
01:37:14.380
This was randomized, placebo-controlled.
link |
01:37:16.540
The cannabis was smoked.
link |
01:37:19.080
They had different varietals, as they're called.
link |
01:37:21.500
They had a placebo.
link |
01:37:22.400
So this is basically a condition
link |
01:37:24.980
in which certain subjects consumed a cigarette
link |
01:37:28.440
that had 0% THC, others had 7% THC,
link |
01:37:31.980
other groups, that is,
link |
01:37:33.180
or some had 0.4% CBD and THC,
link |
01:37:37.940
so they looked at CBD.
link |
01:37:39.020
I know a lot of people out there are interested in CBD.
link |
01:37:41.320
There's one of the few studies I could find
link |
01:37:42.620
where they explored different percentages of THC and CBD
link |
01:37:46.580
in these cannabis or marijuana cigarettes, basically.
link |
01:37:50.960
The total amount that they consumed,
link |
01:37:52.900
I believe, was 800 milligrams.
link |
01:37:54.620
These, again, are not suggestions.
link |
01:37:56.680
This was just simply reporting what's in this study.
link |
01:37:58.660
You can, again, I'll provide a link.
link |
01:38:01.620
They looked at OCD symptoms ratings.
link |
01:38:04.720
They looked at cardiovascular effects.
link |
01:38:06.820
They had a large number of different things
link |
01:38:08.500
that they explored.
link |
01:38:09.460
And I should say, this study was done in 2020,
link |
01:38:11.740
and it was the first placebo-controlled investigation
link |
01:38:15.060
of cannabis in adults with obsessive compulsive disorder.
link |
01:38:18.060
Pretty interesting.
link |
01:38:19.180
And I'm just reading from their conclusions here.
link |
01:38:21.580
The data suggests that smoked cannabis,
link |
01:38:23.280
whether containing primarily THC or CBD,
link |
01:38:26.480
remember, they looked at different concentrations of those,
link |
01:38:28.500
has little acute impact,
link |
01:38:30.300
meaning immediate impact on OCD symptoms,
link |
01:38:33.820
and yields smaller reductions in anxiety
link |
01:38:35.820
compared to placebo.
link |
01:38:37.140
So they did not see a, when I say a positive effect,
link |
01:38:40.380
I mean a ameliorative effect,
link |
01:38:43.200
an effect in reducing symptoms of OCD from cannabis or CBD,
link |
01:38:47.620
which, you know, it's unfortunate.
link |
01:38:49.660
I think it's unfortunate anytime a treatment doesn't work,
link |
01:38:51.580
but nonetheless, those are the data.
link |
01:38:52.860
I'm sure there are going to be other studies.
link |
01:38:54.500
I'm sure there are also going to be people
link |
01:38:55.680
in the YouTube comments section saying that cannabis
link |
01:38:58.260
and CBD helps their OCD symptoms.
link |
01:39:01.580
At least I anticipate there probably will.
link |
01:39:04.040
Almost everything I say here,
link |
01:39:05.100
somebody will contradict it with something
link |
01:39:06.700
from their experience, which I encourage, by the way.
link |
01:39:08.900
I want to hear about your experience with certain things,
link |
01:39:11.260
even if it's not from randomized placebo-controlled studies.
link |
01:39:14.380
I still find it very interesting to know
link |
01:39:16.140
what people are doing and what they're experiencing.
link |
01:39:18.240
I think that's one of the better uses
link |
01:39:19.740
of social media comment sections
link |
01:39:21.140
is to be able to share some of that,
link |
01:39:22.620
not in an advice-giving way or prescriptive way,
link |
01:39:25.220
but simply as a way to share and encourage
link |
01:39:27.400
different types of exploration.
link |
01:39:29.040
There are other sorts of drug treatments
link |
01:39:30.320
that are gaining popularity for OCD,
link |
01:39:32.940
at least in the research realm.
link |
01:39:34.720
One treatment that is a legal, L-E-G-A-L, right?
link |
01:39:38.180
Sometimes when I say legal,
link |
01:39:39.160
sometimes people think I say illegal,
link |
01:39:40.460
but that is legal, at least by prescription
link |
01:39:43.440
in the United States, is ketamine.
link |
01:39:45.860
The actions of ketamine are somewhat complex.
link |
01:39:49.340
Although we know, for instance,
link |
01:39:50.500
that ketamine acts on the glutamate system,
link |
01:39:52.700
it tends to disrupt the transmission
link |
01:39:56.380
or the relationship, I should say, between glutamate,
link |
01:40:00.260
right, not glutamine, not the amino acid,
link |
01:40:02.080
but glutamate, the neurotransmitter,
link |
01:40:04.260
and the so-called NMDA, the N-methyl-D-aspartate receptor,
link |
01:40:07.860
which is a receptor that's very special
link |
01:40:10.560
in the nervous system,
link |
01:40:11.400
because when glutamate binds to the NMDA receptor,
link |
01:40:14.340
it tends to offer the opportunity
link |
01:40:17.300
for that particular synapse to get stronger,
link |
01:40:19.140
so-called neuroplasticity,
link |
01:40:20.580
and ketamine is essentially an antagonist,
link |
01:40:24.360
although it works through a complicated mechanism,
link |
01:40:26.380
it tends to block that binding of glutamate
link |
01:40:30.420
to the NMDA receptor or the effectiveness of that.
link |
01:40:32.620
Ketamine therapy is now being used quite extensively
link |
01:40:35.640
for the treatment of trauma and for depression.
link |
01:40:37.500
It leads to a dissociative state.
link |
01:40:39.500
It's a so-called dissociative analgesic,
link |
01:40:42.500
and there are a variety of ways in which that happens.
link |
01:40:44.640
We did an episode on depression.
link |
01:40:45.920
We're going to do another entire episode all about ketamine,
link |
01:40:48.840
describing the networks that ketamine impacts, et cetera.
link |
01:40:51.180
Ketamine therapies are being explored for OCD.
link |
01:40:54.020
As of now, the data look somewhat promising,
link |
01:40:57.620
but there's still a lot more work that needs to be done.
link |
01:41:00.500
My read of the data are that the more extensive
link |
01:41:03.700
clinical trials have not happened yet.
link |
01:41:06.380
The smaller studies that have happened
link |
01:41:09.260
reveal that some patients do get some relief
link |
01:41:11.340
from ketamine therapy for OCD,
link |
01:41:13.460
but there was nothing overwhelmingly pointing to the fact
link |
01:41:17.380
that ketamine is a magic bullet for OCD treatment.
link |
01:41:21.520
So cannabis CBD, at least now,
link |
01:41:24.380
even though it's one smaller study,
link |
01:41:26.540
there's no real evidence that it can alleviate OCD symptoms.
link |
01:41:31.720
If there are new studies published soon,
link |
01:41:33.240
I'll be sure to update you.
link |
01:41:34.620
And if you see those studies, please send them to me.
link |
01:41:36.520
Ketamine therapy, the jury is still out.
link |
01:41:38.880
Psilocybin, the jury is still out.
link |
01:41:40.820
These are early days.
link |
01:41:42.400
Another treatment that's becoming somewhat common,
link |
01:41:45.380
or at least people are commonly excited about,
link |
01:41:47.680
is transcranial magnetic stimulation.
link |
01:41:49.980
So this is the use of a magnetic coil.
link |
01:41:52.260
This is completely noninvasive,
link |
01:41:53.880
placed on one portion of the skull,
link |
01:41:56.980
and one can direct magnetic energy
link |
01:42:01.460
toward particular areas of the brain
link |
01:42:03.120
to either suppress or nowadays,
link |
01:42:04.920
you can also activate particular brain regions.
link |
01:42:07.400
There are some interesting data
link |
01:42:08.460
showing that if TMS is applied
link |
01:42:10.460
to areas of the brain involved
link |
01:42:11.900
in the generation of motor action,
link |
01:42:13.980
so the so-called motor areas
link |
01:42:15.740
or supplementary motor areas, as they're called,
link |
01:42:18.580
while people think about or have intrusive thoughts,
link |
01:42:23.140
we know that the TMS coil can interrupt the motor behaviors,
link |
01:42:27.100
the compulsive behaviors,
link |
01:42:29.100
and at least in a small cohort of studies,
link |
01:42:32.220
in a small number of patients within those studies,
link |
01:42:35.080
this has been shown to be effective,
link |
01:42:37.340
not just while the coil is on the head, of course,
link |
01:42:39.420
but after the study has been performed
link |
01:42:41.940
or the treatment's been performed in reducing OCD symptoms
link |
01:42:45.620
by disrupting the tendency for the compulsive behavior
link |
01:42:50.180
to be so automatic.
link |
01:42:51.540
One of the key features of obsessive compulsive disorder
link |
01:42:54.780
is that, especially if it's been around for a while,
link |
01:42:58.620
the person's been dealing with it for a while,
link |
01:43:00.300
there isn't a pattern in which the person thinks,
link |
01:43:03.380
oh, I have this contamination fear, or I need symmetry,
link |
01:43:07.380
or I'm kind of obsessed to count to the number seven,
link |
01:43:09.700
and then they pause and they go, ooh, and then they do it.
link |
01:43:12.860
No, typically there's a very close pairing
link |
01:43:16.220
of the obsession and the compulsion in time
link |
01:43:18.540
so that somebody is walking down the street
link |
01:43:19.940
thinking 1, 2, 3, 4, 5, 6, 7, 1, 2, 3, 4, 5, 6, 7, 7,
link |
01:43:22.340
7, 7, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20,
link |
01:43:23.860
and then they're doing this in such rapid succession
link |
01:43:27.140
because the obsessions are coming up so quickly, right?
link |
01:43:29.420
Thoughts can be generated very quickly,
link |
01:43:31.660
and then they're generating the compulsions
link |
01:43:33.220
as a way to beat down or to try and suppress that anxiety,
link |
01:43:36.680
and then it comes right back up again at even stronger,
link |
01:43:39.060
as I described earlier.
link |
01:43:40.400
So transcranial magnetic stimulation seems to intervene
link |
01:43:43.260
in these various fast processes.
link |
01:43:46.100
Right now, I don't think it's fair to say
link |
01:43:48.300
that TMS is a magic bullet either.
link |
01:43:50.740
I think there's a lot of excitement about TMS,
link |
01:43:52.460
and in particular, I really want to nail this point home.
link |
01:43:55.840
In particular, there's excitement about the combination
link |
01:43:59.500
of TMS with drug treatments,
link |
01:44:01.780
or the combination of TMS with cognitive behavioral therapy,
link |
01:44:05.860
and this is a really important point,
link |
01:44:07.420
not just for sake of discussion
link |
01:44:08.660
about obsessive-compulsive disorder,
link |
01:44:10.200
but also depression, ADHD, schizophrenia,
link |
01:44:14.740
any number of different psychiatric challenges
link |
01:44:17.740
and disorders in most cases are going to respond best
link |
01:44:21.460
to a combination of behavioral treatment that's ongoing
link |
01:44:24.180
that occurs in the laboratory and clinical setting,
link |
01:44:26.040
but also in the home setting where there's homework,
link |
01:44:28.700
maybe even home visits.
link |
01:44:31.140
Drug treatments often, not always,
link |
01:44:33.660
are a terrific augment to those cognitive behavioral
link |
01:44:36.260
therapies or other behavioral therapies,
link |
01:44:38.020
and then now we are living in the age
link |
01:44:40.020
of brain-machine interface.
link |
01:44:41.260
You have companies like Neural Length
link |
01:44:43.020
that I think it's fair to say are going to enter
link |
01:44:45.580
the brain-machine interface world first
link |
01:44:48.180
through the treatment of certain syndromes, right?
link |
01:44:51.900
Movement syndromes or psychiatric syndromes,
link |
01:44:53.900
probably before they start putting electrodes
link |
01:44:56.120
into the brain to stimulate enhanced memory
link |
01:44:58.620
or enhanced cognition, who knows?
link |
01:45:00.020
I don't know exactly what they're doing
link |
01:45:01.820
behind the walls of Neural Link, but I have to imagine,
link |
01:45:04.180
in fact, I would wager, maybe not both arms,
link |
01:45:06.760
but I'll wager my left arm,
link |
01:45:08.300
that the first set of FDA-approved technologies
link |
01:45:13.300
to come out of companies like Neural Link
link |
01:45:15.940
are going to be those for the treatment
link |
01:45:17.100
of things like Parkinson's and movement disorders
link |
01:45:19.180
and cognitive disorders, rather than, shall we say,
link |
01:45:22.140
kind of recreational cognitive enhancement
link |
01:45:24.860
or things of that sort.
link |
01:45:26.060
So transcranial magnetic stimulation is noninvasive.
link |
01:45:28.500
It doesn't involve going down below the skull,
link |
01:45:30.860
can have some effect, but most laboratories
link |
01:45:33.660
that I'm aware of at Stanford and elsewhere
link |
01:45:36.180
that are exploring TMS for things like OCD
link |
01:45:38.360
and other types of psychiatric challenges
link |
01:45:41.420
are using TMS in combination with drug therapies,
link |
01:45:44.540
are using, in some cases, for instance,
link |
01:45:46.940
a laboratory at Stanford, hope to get them on the podcast,
link |
01:45:50.180
psychiatrist Nolan Williams is exploring TMS
link |
01:45:52.940
in combination with psychedelic therapies,
link |
01:45:55.060
not necessarily at the same time,
link |
01:45:56.340
but nonetheless combining them
link |
01:45:58.020
or exploring how they impact brain circuitry.
link |
01:46:00.460
So if you have OCD, should you run out and get TMS
link |
01:46:03.220
or should you try ketamine therapy, of course,
link |
01:46:05.180
with a licensed physician?
link |
01:46:06.380
I think it's too early to say yes.
link |
01:46:08.460
I think the answer is we need to wait and see.
link |
01:46:11.380
I think cognitive behavioral therapy, the SSRIs
link |
01:46:13.700
and some other drug treatments like neuroleptics
link |
01:46:16.460
combined with SSRIs and cognitive behavioral therapy
link |
01:46:19.360
are where the real bulk of the data are.
link |
01:46:22.500
I want to make one additional point about cannabis CBD
link |
01:46:25.120
as it relates to obsessive compulsive disorder.
link |
01:46:27.820
To me, it's not at all surprising that cannabis CBD
link |
01:46:32.100
did not improve symptoms of OCD
link |
01:46:34.340
because in my discussion with Dr. Paul Conte a few weeks ago
link |
01:46:38.260
and as you mentioned, Dr. Conte is indeed a medical doctor,
link |
01:46:40.780
a psychiatrist, we were talking about cannabis
link |
01:46:44.240
and its various uses
link |
01:46:45.220
because it does have some clinical applications.
link |
01:46:48.220
And he mentioned that one of the main effects of cannabis
link |
01:46:51.540
is to tighten focus and to enhance concentration on
link |
01:46:57.620
and thoughts about one particular thing.
link |
01:47:00.420
And in some cases that can be clinically beneficial
link |
01:47:03.060
and in other cases that can be clinically detrimental.
link |
01:47:06.100
If you accept the idea that cannabis increases focus
link |
01:47:11.860
and you think about OCD and the networks involved
link |
01:47:15.860
and you think about the anxiety and the relationship
link |
01:47:18.140
between the obsession and compulsion,
link |
01:47:20.860
well then it shouldn't come as any surprise
link |
01:47:22.620
that cannabis did not improve the symptoms of OCD
link |
01:47:26.100
because if anything, it would increase focus
link |
01:47:28.980
on the obsessions and the compulsions.
link |
01:47:30.820
Now that's not what they observed.
link |
01:47:31.940
They did not see an exacerbation or a worsening
link |
01:47:35.380
of the symptoms of OCD with cannabis.
link |
01:47:37.340
At least that's not my read of the data
link |
01:47:39.100
but they did not see an improvement
link |
01:47:41.060
in OCD symptoms with cannabis or CBD.
link |
01:47:44.100
And to me, that's not surprising
link |
01:47:46.060
given that cannabis CBD seems to increase focus.
link |
01:47:49.540
Next, I'd like to talk about some of the research on
link |
01:47:52.020
and the roles of hormones in OCD
link |
01:47:55.060
because it turns out to be
link |
01:47:55.900
a very interesting relationship there.
link |
01:47:57.840
But before I do, I want to point out something that
link |
01:48:00.260
I realize I probably should have said earlier
link |
01:48:02.460
which is one of the key things for someone with OCD
link |
01:48:05.560
to come to understand if they're going to experience
link |
01:48:08.140
any relief of their symptoms,
link |
01:48:09.780
whether or not they're doing drug treatments
link |
01:48:10.940
or behavioral treatments or otherwise,
link |
01:48:12.980
is that thoughts are not as bad as actions, right?
link |
01:48:18.660
Thoughts are not as bad as actions.
link |
01:48:20.720
One of the kind of rules that people with OCD
link |
01:48:24.060
seem to adopt for themselves is that
link |
01:48:26.900
thoughts are really truly the equivalent of actions.
link |
01:48:30.300
So they'll have an intrusive thought
link |
01:48:31.860
and we haven't spent too much time on this today,
link |
01:48:33.980
but earlier I touched on the fact that
link |
01:48:36.280
some of the intrusive thoughts that people have in OCD
link |
01:48:39.240
are really disturbing.
link |
01:48:40.420
They can be really gross or at least gross to that person.
link |
01:48:44.060
They can evoke imagery that is toxic or infectious
link |
01:48:49.000
or is highly sexualized in a way that is disturbing to them,
link |
01:48:52.840
can be very taboo.
link |
01:48:54.440
This is not uncommon when you start talking to people
link |
01:48:57.140
with OCD and you start pulling on the thread.
link |
01:48:59.460
Again, this would be a psychiatrist
link |
01:49:01.420
who is trained to ask the right questions
link |
01:49:03.580
and gain the comfort and trust of a patient.
link |
01:49:05.900
They start to reveal that these thoughts
link |
01:49:07.680
are really intrusive and kind of disturbing,
link |
01:49:09.620
which is why they feel so compelled
link |
01:49:11.180
to try and suppress them with behaviors.
link |
01:49:13.340
One of the powerful elements of treatment for OCD
link |
01:49:17.260
is to really support the patient
link |
01:49:20.440
and make them realize that thoughts are just thoughts
link |
01:49:24.240
and that everyone has disturbing thoughts.
link |
01:49:26.500
And that oftentimes those disturbing thoughts
link |
01:49:28.340
arise at the most inconvenient
link |
01:49:30.740
and sometimes what seems like
link |
01:49:32.060
the most inappropriate circumstances.
link |
01:49:34.980
And this relates to a whole larger discussion
link |
01:49:37.300
that we could have about what are thoughts
link |
01:49:39.740
and why do they surface
link |
01:49:40.580
and how come when you stand at the edge of a bridge,
link |
01:49:43.500
even if you do not want to jump off,
link |
01:49:45.140
you think about jumping off.
link |
01:49:46.780
And this has to do with the fact that your nervous system
link |
01:49:49.420
as a prediction machine is oftentimes testing possibilities.
link |
01:49:52.640
And sometimes that testing goes way off
link |
01:49:55.220
into the Netherlands of the thought patterns
link |
01:50:00.220
and emotional patterns that we all have inside of us.
link |
01:50:03.340
The big difference between a thought and an action
link |
01:50:05.820
is that, of course, the nervous system is in one case
link |
01:50:09.660
not translating those patterns of thinking
link |
01:50:12.220
into motor sequences.
link |
01:50:14.920
That nerdy way of saying thoughts aren't actions,
link |
01:50:18.620
believe it or not, can be helpful for people
link |
01:50:20.300
if they really think about that
link |
01:50:22.220
and use it as an opportunity to realize that,
link |
01:50:24.900
first of all, they're not crazy.
link |
01:50:27.340
They're not thinking and feeling this stuff
link |
01:50:30.280
because they're bad or evil.
link |
01:50:32.140
And of course, sometimes this can cross over
link |
01:50:34.140
with other elements of life where we place moral judgment
link |
01:50:37.380
on people for certain behaviors.
link |
01:50:38.580
I think that's part of a healthy society, of course.
link |
01:50:40.640
That's where we have laws and punishments
link |
01:50:42.140
and rewards for that matter for certain types of behaviors.
link |
01:50:45.660
But this idea that thoughts are not as bad as actions
link |
01:50:48.220
and that thoughts can be tolerated
link |
01:50:49.740
and the anxiety around thoughts can be tolerated
link |
01:50:52.480
and over time can diminish,
link |
01:50:54.020
that's a very powerful hallmark theme
link |
01:50:56.280
of the treatment of OCD.
link |
01:50:57.420
So I'd be remiss if I didn't mention it.
link |
01:50:59.900
Thoughts are not actions.
link |
01:51:01.860
Actions can harm us.
link |
01:51:03.020
They can harm other people.
link |
01:51:04.500
They can soak up enormous amounts of time.
link |
01:51:08.460
Thoughts can soak up enormous amounts of time.
link |
01:51:10.860
They can be very troubling.
link |
01:51:11.920
They can be very detrimental.
link |
01:51:13.140
We, of course, want to be sensitive to that.
link |
01:51:15.780
But when it really comes down to it,
link |
01:51:18.780
the first step in treatment for OCD is this realization
link |
01:51:22.800
or the approach to the realization
link |
01:51:24.480
that thoughts are not as bad as actions.
link |
01:51:27.260
So what about hormones in OCD?
link |
01:51:29.500
Well, this has been explored,
link |
01:51:30.700
albeit not as extensively as I would have liked to find.
link |
01:51:33.620
But when I went into the literature,
link |
01:51:35.340
I found one particularly interesting study
link |
01:51:38.220
entitled Neurosteroid Levels in Patients
link |
01:51:40.180
with Obsessive Compulsive Disorder for Sathur Erbe.
link |
01:51:43.100
And as always, we'll provide a link to the study.
link |
01:51:47.020
The objective of this study was to explore serum
link |
01:51:49.520
within blood, neurosteroid levels in people with OCD.
link |
01:51:53.700
Why?
link |
01:51:54.540
Well, because of the relationship between OCD and anxiety
link |
01:51:57.320
and the fact that in stress-related disorders,
link |
01:51:59.640
such as anxiety and depression,
link |
01:52:02.220
the hormones have been extensively explored,
link |
01:52:04.100
but not so much in OCD, at least until this study.
link |
01:52:06.760
So they compared serum levels
link |
01:52:08.260
of a number of different hormones, progesterone,
link |
01:52:10.340
pregnenolone, DHEA, cortisol, and testosterone.
link |
01:52:15.340
This was done in 30 patients with OCD
link |
01:52:17.260
and 30 healthy controls.
link |
01:52:19.560
So it's not a huge study,
link |
01:52:20.980
but it's enough to draw some pretty nice conclusions.
link |
01:52:23.980
These subjects were 18 to 49 years old,
link |
01:52:26.860
and the controls were age and sex matched,
link |
01:52:30.300
healthy volunteers, again, no OCD.
link |
01:52:32.820
What was the basic takeaway from the study?
link |
01:52:34.220
The basic takeaway from the study was that
link |
01:52:35.860
in females with OCD, there was evidence
link |
01:52:39.580
for significantly elevated cortisol and DHEA.
link |
01:52:43.620
Now that's interesting because cortisol is well-known
link |
01:52:46.860
to be associated with the stress system,
link |
01:52:48.540
although every day, I should mention,
link |
01:52:50.660
we all, male or female,
link |
01:52:52.980
everybody experiences an increase in cortisol
link |
01:52:55.740
shortly after awakening.
link |
01:52:56.740
That's a healthy increase in cortisol.
link |
01:52:59.000
Late shifted, I mean, late in the day peaks in cortisol,
link |
01:53:03.120
where a shift in that cortisol peak to later in the day
link |
01:53:06.540
is a known correlate of depression and anxiety disorders.
link |
01:53:12.620
So the fact that cortisol is elevated in DHEA,
link |
01:53:15.780
are elevated in female patients with OCD,
link |
01:53:19.260
suggests that cortisol is either reflective of
link |
01:53:23.660
or causal for the increase in anxiety.
link |
01:53:26.780
We don't know the direction of that effect.
link |
01:53:28.880
Now, in the male patients with OCD,
link |
01:53:31.640
there was evidence for increased cortisol,
link |
01:53:33.780
again, not surprising given the role of anxiety in cortisol,
link |
01:53:36.980
or I should say, given the role of cortisol in anxiety
link |
01:53:39.900
and the increasing anxiety seen in OCD,
link |
01:53:42.840
but there were also significant reductions in testosterone,
link |
01:53:45.940
which should also not surprise us
link |
01:53:48.140
because cortisol and testosterone more or less compete
link |
01:53:51.980
in some fashion for their own production.
link |
01:53:54.940
Both are derived from the molecule cholesterol,
link |
01:53:57.860
and there are certain biochemical pathways
link |
01:53:59.620
that can either direct that cholesterol molecule
link |
01:54:01.820
toward cortisol synthesis or testosterone synthesis,
link |
01:54:05.180
but not both.
link |
01:54:06.500
So they compete.
link |
01:54:07.320
So when cortisol goes up in general, not always,
link |
01:54:09.460
but in general, testosterone goes down and vice versa.
link |
01:54:12.540
If you want to learn more about the relationship
link |
01:54:14.280
between cortisol and testosterone,
link |
01:54:15.780
and there are even some tools to try and optimize those
link |
01:54:18.700
ratios in both males and females,
link |
01:54:20.380
you can find that in our episode on optimizing testosterone
link |
01:54:23.100
and estrogen, that's at Hubermanlab.com.
link |
01:54:25.740
Now, I would say the most interesting aspect of this study
link |
01:54:28.940
is not that DHEA and cortisol are elevated in females
link |
01:54:32.680
with OCD or that cortisol and testosterone
link |
01:54:35.640
have this opposite effect,
link |
01:54:36.580
cortisol up and testosterone down in males with OCD,
link |
01:54:40.080
but rather the relationship between all of those,
link |
01:54:43.020
DHEA, cortisol, and testosterone in terms of GABA.
link |
01:54:48.700
GABA, again, being this inhibitory neurotransmitter
link |
01:54:51.540
that tends to quiet certain neuronal pathways.
link |
01:54:56.020
It does different things at different synapses,
link |
01:54:58.780
but in general, the more GABA that's present,
link |
01:55:01.140
the more inhibition that's present,
link |
01:55:02.740
and therefore the more suppression of neural activity.
link |
01:55:05.500
And DHEA is known to be a potent antagonist
link |
01:55:10.500
of the GABA system, okay?
link |
01:55:13.400
So here we have elevated DHEA in females,
link |
01:55:18.500
and I should also mention that testosterone
link |
01:55:21.060
is also known to tap into the GABA system.
link |
01:55:23.800
Typically when testosterone is elevated,
link |
01:55:26.120
GABA transmission at least is slightly elevated.
link |
01:55:29.720
So here we have a situation in which the pattern of hormones
link |
01:55:33.060
in females and males with OCD are different
link |
01:55:37.480
from those in people without OCD,
link |
01:55:40.760
such that GABA transmission is altered,
link |
01:55:43.820
and the net effect would be an overall reduction in GABA.
link |
01:55:47.600
Now, GABA as an inhibitory neurotransmitter,
link |
01:55:51.320
and broadly speaking,
link |
01:55:52.600
is associated with lower levels of anxiety,
link |
01:55:55.720
and it tends to create balance
link |
01:55:57.720
within various neural circuits.
link |
01:55:59.400
Now that's a very broad statement,
link |
01:56:00.600
but we know for instance in epilepsy
link |
01:56:03.520
that GABA levels are reduced,
link |
01:56:04.960
and therefore you get runaway excitation
link |
01:56:06.960
of certain circuits in the brain,
link |
01:56:08.320
and therefore seizures,
link |
01:56:09.640
either petit mal, mini seizures,
link |
01:56:11.440
or grand mal, massive seizures,
link |
01:56:13.300
or even drop seizures,
link |
01:56:14.400
where people completely collapse to the floor in seizure.
link |
01:56:16.800
You may have seen this before.
link |
01:56:18.360
I certainly have.
link |
01:56:19.200
It's very dramatic,
link |
01:56:20.020
and it actually is quite debilitating for people
link |
01:56:22.960
because obviously they don't know
link |
01:56:24.000
when these seizures are coming on most often,
link |
01:56:26.200
and then they can fall into a stove
link |
01:56:28.160
or while driving, et cetera.
link |
01:56:29.880
So the situation with OCD is one in which,
link |
01:56:33.160
for whatever reason,
link |
01:56:34.240
we don't know the direction of effect.
link |
01:56:37.520
Certain hormones are elevated in females,
link |
01:56:39.480
and certain hormones are elevated in males,
link |
01:56:41.240
and those hormones differ between males and females,
link |
01:56:45.560
and yet they both funnel into a system
link |
01:56:48.060
where GABAergic or GABA transmission in the brain
link |
01:56:51.160
is reduced because of this ability
link |
01:56:53.400
for those particular hormones to be antagonists to GABA,
link |
01:56:57.200
and as a consequence,
link |
01:56:59.060
there's likely to be overall levels of increased excitation
link |
01:57:03.480
in certain networks in the brain,
link |
01:57:05.340
and that brings us back
link |
01:57:07.200
to this corticostriatal thalamic loop,
link |
01:57:09.780
this repetitive loop that seems to reinforce,
link |
01:57:12.360
we can say reinforces obsession,
link |
01:57:15.480
leads to anxiety, leads to compulsion,
link |
01:57:17.820
leads to transient relief of anxiety,
link |
01:57:20.340
but then increase in anxiety, increased obsession,
link |
01:57:23.520
anxiety, compulsion, anxiety, compulsion,
link |
01:57:25.440
anxiety, compulsion, and so on and so forth.
link |
01:57:27.740
So I have not found studies
link |
01:57:30.660
that have explored adjusting testosterone levels
link |
01:57:34.320
through exogenous administration,
link |
01:57:36.040
cream or injection or otherwise,
link |
01:57:37.620
or that have focused on reducing DHEA in females.
link |
01:57:42.200
If anyone is aware of such studies,
link |
01:57:43.760
please put them in the comment section on YouTube
link |
01:57:46.840
or send them to us.
link |
01:57:47.800
We have a contact site on the website at HubermanLab.com,
link |
01:57:50.640
but the comment section on YouTube would be best,
link |
01:57:53.240
but because we know that hormones impact neuromodulators
link |
01:57:56.200
and neurotransmitters, as I just described,
link |
01:57:58.040
and that those neuromodulators and neurotransmitters
link |
01:58:00.080
play an intimate role in the generation
link |
01:58:02.200
and the treatment of things like OCD,
link |
01:58:05.280
it stands to reason that manipulations
link |
01:58:08.320
of those hormone systems, however subtle or dramatic,
link |
01:58:11.600
might, I want to highlight, might prove useful
link |
01:58:14.320
in adjusting the symptoms of OCD,
link |
01:58:16.200
and I hope that this is an area
link |
01:58:17.480
that researchers are going to pursue in the very near future
link |
01:58:20.920
because many of the treatments for reducing DHEA
link |
01:58:24.560
or increasing testosterone or reducing cortisol
link |
01:58:27.040
have already made it through FDA approval.
link |
01:58:29.880
They're out there.
link |
01:58:31.320
They're readily prescribed.
link |
01:58:32.380
Many of them are already in generic form,
link |
01:58:33.980
which means that the patents have already lapsed
link |
01:58:36.400
on the first versions of those drugs,
link |
01:58:39.160
so when they're available as generic drugs,
link |
01:58:41.480
very often they're available at significantly lower cost.
link |
01:58:44.680
There's a whole discussion to be had there
link |
01:58:46.040
about patent laws and prescription drugs,
link |
01:58:49.440
but because these drugs are largely available
link |
01:58:52.080
in prescription yet generic form,
link |
01:58:55.680
I think there's a great opportunity
link |
01:58:57.000
to explore how hormones, not just cortisol,
link |
01:59:00.580
testosterone, and DHEA, but the huge category of hormones
link |
01:59:04.080
might impact the symptoms of OCD,
link |
01:59:06.480
especially since many of the symptoms of OCD
link |
01:59:09.200
show up right around the time of puberty.
link |
01:59:11.220
We haven't talked a lot about childhood OCD
link |
01:59:13.080
because we're going to do an entire series
link |
01:59:14.680
on childhood psychiatric disorders and challenges,
link |
01:59:17.600
but many children develop OCD early,
link |
01:59:21.980
as young as three or four, believe it or not,
link |
01:59:24.240
or even six or seven and 10,
link |
01:59:26.000
and in adolescence and certainly around puberty
link |
01:59:28.840
and in young adulthood, it is rare,
link |
01:59:31.400
although it does happen,
link |
01:59:32.560
that people will develop OCD very late in life,
link |
01:59:34.940
around 40 or older, just kind of spontaneously.
link |
01:59:37.680
Most often, when you look at their clinical history,
link |
01:59:39.560
you find that either they were hiding it
link |
01:59:41.560
or it was being suppressed in some way,
link |
01:59:43.300
or if it does spontaneously show up late in life,
link |
01:59:46.080
like mid-30s or in one's 40s,
link |
01:59:50.040
typically there's a traumatic brain injury,
link |
01:59:52.520
could be due to stroke or physical injury to the head
link |
01:59:55.220
or something of that sort.
link |
01:59:57.120
Nonetheless, there is a interesting correlation
link |
02:00:00.600
between the onset of puberty in certain forms of OCD.
link |
02:00:03.320
There's certain forms of, or I should say,
link |
02:00:05.380
there's certain aspects of menopause that can relate to OCD.
link |
02:00:08.120
You can find all these things in the literature,
link |
02:00:10.220
all this to say that hormones impact neurotransmitters
link |
02:00:13.120
and neuromodulators, which clearly impact
link |
02:00:15.000
the kinds of circuits that are involved in OCD,
link |
02:00:17.200
and it makes sense that,
link |
02:00:19.080
and I would hope that there would be an exploration
link |
02:00:21.600
of how these hormones impact OCD
link |
02:00:23.360
in the not too distant future.
link |
02:00:24.700
Now, there is an extensive literature
link |
02:00:26.080
exploring how testosterone therapy,
link |
02:00:27.940
both in males and females,
link |
02:00:30.320
can be effective in some cases
link |
02:00:33.360
in the treatment of anxiety-related disorders,
link |
02:00:36.520
but not, at least to my knowledge, in OCD in particular.
link |
02:00:40.120
So this whole area of the use of testosterone
link |
02:00:43.100
and estrogen therapy is DHEA, cortisol suppression,
link |
02:00:46.280
or maybe even enhancement for the treatment of OCD
link |
02:00:49.860
is essentially a big black box that very soon, I believe,
link |
02:00:54.240
will be lit.
link |
02:00:56.520
I realize that a number of listeners of this podcast
link |
02:00:58.880
are probably interested in the non-typical
link |
02:01:02.560
or holistic treatments for OCD.
link |
02:01:05.520
Dr. Blair Simpson's lab has at least one study
link |
02:01:07.860
exploring the role of mindfulness meditation
link |
02:01:11.360
for the treatment of OCD.
link |
02:01:14.280
There, the data are a little bit complicated,
link |
02:01:17.300
and I should mention that good things are happening,
link |
02:01:21.280
at least in the United States, probably elsewhere as well,
link |
02:01:24.020
but good things are happening
link |
02:01:25.480
in terms of the exploration of things like meditation
link |
02:01:29.040
and other, let's call them non-traditional
link |
02:01:31.120
or holistic forms of treatment for psychiatric disorders
link |
02:01:34.640
because of the division of complementary health
link |
02:01:37.160
that's now been launched
link |
02:01:38.320
by the National Institutes of Health.
link |
02:01:39.600
So whereas before people would think about meditation
link |
02:01:43.520
or yoga nidra or even CBD supplementation for that matter
link |
02:01:48.660
as kind of fringe maybe, or kind of woo,
link |
02:01:50.920
or non-traditional at the very least,
link |
02:01:53.620
the National Institutes of Health in the United States
link |
02:01:55.640
has now devoted an entire division,
link |
02:01:59.200
an entire institute purely for the exploration
link |
02:02:02.360
of things like breathing practices, meditation, et cetera.
link |
02:02:04.700
So there's a cancer institute,
link |
02:02:06.120
there's a hearing and deafness institute,
link |
02:02:07.840
there's a vision institute,
link |
02:02:09.520
and now there's this complementary health institute,
link |
02:02:11.560
which I think is a wonderful addition
link |
02:02:14.560
to the more traditional aspects of medicine.
link |
02:02:17.960
I think no possible useful treatment should be overlooked
link |
02:02:21.960
or unresearched in my opinion,
link |
02:02:23.680
provided that can be done safely.
link |
02:02:25.780
And as I mentioned, Dr. Blair Simpson's lab
link |
02:02:28.600
has looked at the role of mindfulness meditation
link |
02:02:31.600
in the treatment of OCD.
link |
02:02:33.280
Now we should all keep in mind, no pun intended,
link |
02:02:36.940
that most of the data on mindfulness meditation
link |
02:02:39.880
shows that it increases the ability to focus.
link |
02:02:43.800
Now this brings us back to a kind of repeating theme today,
link |
02:02:46.400
which is that increased focus may not be the best thing
link |
02:02:49.280
for somebody with OCD because it might increase focus
link |
02:02:54.080
on the obsession and or compulsion.
link |
02:02:57.000
Turns out that mindfulness meditation can be useful
link |
02:02:59.640
in the treatment of OCD,
link |
02:03:00.960
but mainly by way of how it impacts the focus on
link |
02:03:05.960
and the ability to engage in cognitive behavioral therapies.
link |
02:03:10.000
So it's very unlikely, at least by my read of the data,
link |
02:03:13.260
to be a direct effect of meditation
link |
02:03:15.520
on relieving the symptoms.
link |
02:03:16.660
Rather, it seems that meditation is increasing focus
link |
02:03:19.500
on things like cognitive behavioral therapy homework
link |
02:03:23.000
and to not focus on other things
link |
02:03:24.680
and therefore indirectly improving the symptoms of OCD.
link |
02:03:28.080
Now, somewhat surprisingly, at least to me,
link |
02:03:29.880
there have also been a fairly large number of studies
link |
02:03:32.600
exploring how nutraceuticals,
link |
02:03:35.560
as they're sometimes called,
link |
02:03:36.440
supplements that are available over the counter
link |
02:03:38.600
can impact the treatment of obsessive compulsive disorder.
link |
02:03:41.720
Now there's such an extensive number of different compounds
link |
02:03:44.960
and supplements that fall under the category
link |
02:03:47.280
of nutraceuticals and that have been explored
link |
02:03:49.260
in the treatment of OCD that I'd like to point you
link |
02:03:51.060
to a review that is entitled
link |
02:03:53.640
Nutraceuticals and the Treatment
link |
02:03:54.920
of Obsessive Compulsive Disorder,
link |
02:03:56.960
a Review, excuse me, of Mechanistic and Clinical Evidence.
link |
02:04:00.480
This was published in 2011, so it's over 10 years old.
link |
02:04:04.440
And so by now, I have to imagine that there are
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02:04:07.360
an enormous number of additional substances
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02:04:10.240
that could be explored.
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02:04:11.400
But there are just one or two here that I want to focus on.
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02:04:14.360
Here in this review, they describe effects of 5-HTP
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02:04:18.160
and tryptophan, so things that are in the serotonin pathway,
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02:04:21.040
which would make sense given what we know about the SSRIs
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02:04:23.880
that people would explore how different supplements
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02:04:26.000
that increase serotonergic transmission might impact OCD.
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02:04:30.320
What you find is that they do have significant effects
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02:04:32.980
in improving or reducing the symptoms of OCD
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02:04:36.680
in somewhat similar way to some of the SSRIs.
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02:04:39.400
But you of course have to be careful.
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02:04:41.280
So anything that's going to tap into
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02:04:44.180
a given neurochemical system to the same degree
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02:04:46.820
may very likely have the same sorts of side effects
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02:04:50.120
that a prescription drug would.
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02:04:51.620
One compound that I'd like to focus on
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02:04:53.420
in a little more depth, however,
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02:04:54.700
because it's exciting and interesting to me is inositol.
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02:04:59.240
Inositol is a compound that we are going to talk about
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02:05:01.360
in several future podcasts because, well, first of all,
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02:05:05.060
it seems that it can have pretty impressive effects
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02:05:07.420
on reducing anxiety.
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02:05:09.000
It also can have pretty impressive effects
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02:05:10.540
in improving fertility in particular in women
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02:05:13.340
with polycystic ovarian syndrome.
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02:05:15.820
And here I'm referring specifically to myoinositol
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02:05:18.540
because it comes in several forms.
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02:05:20.140
And it does appear that 900 milligrams of inositol
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02:05:23.740
can improve sleep and can reduce anxiety
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02:05:26.940
perhaps when taken at that dosage or higher dosages.
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02:05:30.200
I will just confess, first of all, I don't have OCD,
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02:05:33.240
although I will also confess that when I was a child,
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02:05:35.480
I had a transient tic.
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02:05:37.180
I've talked about this on podcasts before.
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02:05:39.080
It was a grunting tic.
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02:05:40.120
So when I was about six or seven,
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02:05:41.440
I recall a trip to Washington, D.C. with my family
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02:05:44.740
where I was feeling a strong desire or need even,
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02:05:50.480
as I recall, to grunt in order to clear something
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02:05:53.760
in my throat, but I didn't have anything in my throat.
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02:05:56.160
I didn't have a cold or any post-nasal drip.
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02:05:58.080
It was really just the feeling that I needed to do that
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02:06:00.080
to release some sort of tension.
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02:06:02.360
And I remember my dad at the time telling me,
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02:06:05.280
don't do that, don't do that.
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02:06:06.720
It's not good to grunt or something like that.
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02:06:08.600
I think he saw that it was kind of compulsive behavior.
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02:06:11.120
And so I would actually hide in the backseat
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02:06:12.880
of the rental car and do it, or I'd hide in my room.
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02:06:15.300
Fortunately for me, it was transient.
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02:06:17.020
I think about six months or a year later, it disappeared.
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02:06:19.680
Although I did notice, actually an ex-girlfriend of mine
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02:06:22.760
pointed out that when I get very tired
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02:06:24.500
and I've been working very long hours,
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02:06:26.040
sometimes that grunting tic will reappear.
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02:06:28.560
What does that mean?
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02:06:29.400
Do I have Tourette's?
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02:06:30.320
I don't know, maybe.
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02:06:31.520
I was never diagnosed with Tourette's.
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02:06:32.760
Do I have OCD?
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02:06:34.120
Maybe.
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02:06:35.440
I certainly could be accused of having
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02:06:37.100
obsessive compulsive personality disorder,
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02:06:39.320
which we'll talk about still in a few minutes.
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02:06:42.360
But the point here is that many children
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02:06:45.200
transiently express tics or low-level Tourette's or OCD,
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02:06:49.720
and again, transiently and it disappears over time.
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02:06:52.680
So inositol has been explored
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02:06:54.800
in a bunch of different contexts,
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02:06:56.240
including for tics and OCD, et cetera.
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02:06:59.760
Going back to inositol and its current use,
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02:07:03.300
or I should say my current use,
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02:07:04.360
I've been taking 900 milligrams of inositol
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02:07:07.200
as an addition to my existing toolkit for sleep,
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02:07:10.680
which I've talked about many times on this podcast
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02:07:13.240
and other podcasts,
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02:07:14.480
consists of magnesium threonate, apigenin, and theanine.
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02:07:18.240
If you want to know more about that kit,
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02:07:19.680
you can go to our newsletter,
link |
02:07:21.360
neural network newsletter at hubermanlab.com.
link |
02:07:23.580
The toolkit for sleep is there.
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02:07:24.800
You don't even have to sign up for the newsletter,
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02:07:26.480
but it'll give you a flavor of the sorts of things
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02:07:27.880
that are in the newsletter.
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02:07:29.040
In any case, I've been experimenting a bit
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02:07:32.960
with taking 900 milligrams of myoinositol,
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02:07:35.520
either alone or in combination with that sleep kit.
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02:07:37.600
And I must say the sleep I've been getting on inositol
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02:07:39.880
is extremely deep and does seem to lead
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02:07:43.440
to enhanced levels of focus and alertness during the day.
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02:07:46.000
And perhaps you're noticing that
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02:07:46.920
because I'm talking more quickly on this podcast
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02:07:48.480
than in previous podcasts.
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02:07:49.440
No, I'm just kidding.
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02:07:50.260
I don't think the two things relate
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02:07:51.400
in any kind of causal way.
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02:07:53.360
The point here is that inositol
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02:07:55.420
is known to be pretty effective in reducing anxiety,
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02:07:59.360
but when taken at very high dosages.
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02:08:01.360
Can it do the same at low dosages?
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02:08:03.080
We don't know.
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02:08:03.920
I would consider 900 milligrams a low dose.
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02:08:06.560
Most of this, given the fact
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02:08:08.760
that most of the studies of inositol
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02:08:11.800
have explored very high dosages,
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02:08:13.400
like even 10 or 12 grams per day,
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02:08:16.340
which I must say seems exceedingly high.
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02:08:18.760
And they do report that some of the subjects
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02:08:20.500
in those experiments actually stopped taking the inositol
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02:08:23.360
because of gastric discomfort
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02:08:24.980
or gastric distress as it's called.
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02:08:27.540
So I've reported my results with sleep
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02:08:30.100
in a kind of anecdotal way.
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02:08:32.160
They certainly aren't peer-reviewed studies
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02:08:33.520
that I described about my own experience
link |
02:08:35.640
in an anecdotal way.
link |
02:08:36.880
But nonetheless, it's been explored
link |
02:08:38.960
that things like glycine, which is another,
link |
02:08:42.720
which is an amino acid,
link |
02:08:43.800
which also acts as an inhibitory neurotransmitter
link |
02:08:45.760
in the brain, taken at very high dose,
link |
02:08:47.400
just 60 grams per day.
link |
02:08:49.140
That is a absolutely astonishingly high amount of glycine.
link |
02:08:52.840
I would not recommend taking that much glycine
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02:08:55.080
unless you're part of a study where they tell you to
link |
02:08:57.120
and you know it's safe.
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02:08:58.940
18 grams, excuse me, of inositol.
link |
02:09:01.960
These are very, very high dosages used in these studies.
link |
02:09:04.700
Nonetheless, there's some interesting data about inositol
link |
02:09:08.520
leading to some alleviation of OCD symptoms
link |
02:09:13.600
or partial alleviation of OCD symptoms
link |
02:09:16.520
in as little as two weeks
link |
02:09:18.520
after initiating the supplement protocol.
link |
02:09:21.760
So I think there's a great future for these nutraceuticals,
link |
02:09:23.960
meaning I think more systematic exploration
link |
02:09:26.040
in particular of lower dosages
link |
02:09:27.360
in the context of OCD treatment.
link |
02:09:29.800
And as we saw before for the SSRIs
link |
02:09:33.720
and other prescription drug treatments,
link |
02:09:35.580
I think there really needs to be an exploration
link |
02:09:37.680
of these nutraceuticals in combination
link |
02:09:39.620
with behavioral therapies and who knows,
link |
02:09:41.120
maybe with brain-machine interface
link |
02:09:42.480
like cranial magnetic stimulation as well.
link |
02:09:45.220
Now, way back at the beginning of the episode,
link |
02:09:47.120
I alluded to the fact that OCD is one thing,
link |
02:09:50.420
obsessive compulsive disorder, and it's truly a disorder,
link |
02:09:52.860
and it's truly debilitating, and it's extremely common.
link |
02:09:55.600
And then there's this other thing
link |
02:09:58.000
called obsessive compulsive personality disorder,
link |
02:10:00.360
which is distinct from that,
link |
02:10:01.900
does not have the intrusive component.
link |
02:10:05.000
So people don't feel overwhelmed
link |
02:10:06.600
or overtaken by these thoughts.
link |
02:10:09.640
Rather, they find that the obsessions
link |
02:10:12.480
can sometimes serve them or they even welcome them.
link |
02:10:15.560
And I think many of us know people like this.
link |
02:10:17.660
I perhaps even could be accused or who knows,
link |
02:10:20.120
maybe have been accused of having
link |
02:10:21.600
an obsessive compulsive personality at times.
link |
02:10:25.020
Why do I draw this distinction?
link |
02:10:26.200
Well, first of all, we've come to a point in human history,
link |
02:10:30.000
I think in large part because of social media,
link |
02:10:32.580
but also in large part because there are a number
link |
02:10:34.920
of discussions being held about mental health
link |
02:10:37.680
that have brought terms like trauma, depression, OCD, et cetera
link |
02:10:43.420
into the common vernacular so that people will say,
link |
02:10:47.200
oh, you're so OCD, or someone will say,
link |
02:10:49.680
I was traumatized by that, or I was traumatized by this.
link |
02:10:53.040
We should be very careful, right?
link |
02:10:54.440
I'm certainly not the word police,
link |
02:10:56.760
but we should be very careful in the use