The Science & Treatment of Obsessive Compulsive Disorder (OCD)

00:00:00.000 | - Welcome to the Huberman Lab Podcast,

00:00:02.260 | where we discuss science and science-based tools

00:00:04.900 | for everyday life.

00:00:05.900 | I'm Andrew Huberman,

00:00:10.380 | and I'm a professor of neurobiology and ophthalmology

00:00:13.100 | at Stanford School of Medicine.

00:00:15.020 | Today, we are talking about obsessive-compulsive disorder,

00:00:18.080 | or OCD.

00:00:19.540 | We are also going to talk

00:00:20.520 | about obsessive-compulsive personality disorder,

00:00:23.580 | which, as you will soon learn,

00:00:25.100 | is distinct from obsessive-compulsive disorder.

00:00:28.060 | In fact, many people that refer to themselves

00:00:29.940 | or others as obsessive or compulsive,

00:00:32.160 | or quote-unquote having OCD,

00:00:34.420 | or OCD about this, or OCD about that,

00:00:37.220 | do not have clinically diagnosable OCD.

00:00:40.380 | Rather, many people have obsessive-compulsive

00:00:42.980 | personality disorder.

00:00:44.900 | However, there are many people in the world

00:00:47.460 | that have actual OCD.

00:00:49.980 | And for those people,

00:00:50.900 | there's a tremendous amount of suffering.

00:00:52.620 | In fact, OCD turns out to be number seven

00:00:55.940 | on the list of most debilitating illnesses,

00:00:58.660 | not just psychiatric illnesses, but of all illnesses,

00:01:02.060 | which is remarkable and somewhat frightening.

00:01:05.180 | The good news is,

00:01:06.360 | thanks to the fields of psychiatry,

00:01:08.740 | psychology, and science in general,

00:01:11.300 | there are now excellent treatments for OCD.

00:01:14.020 | We're going to talk about those treatments today.

00:01:16.420 | Those treatments range from behavioral therapies

00:01:18.940 | to drug therapies and brain stimulation,

00:01:22.220 | and even some of the more holistic or natural therapies.

00:01:25.860 | As you'll soon learn,

00:01:27.220 | for certain people, they may want to focus more

00:01:29.260 | on the behavioral therapies,

00:01:30.860 | whereas for others, more on the drug-based therapies,

00:01:34.220 | and so on and so forth.

00:01:35.880 | One extremely interesting and important thing

00:01:37.620 | I learned from this episode

00:01:39.100 | is that the particular sequence

00:01:40.980 | that behavioral and/or drug and/or holistic therapies

00:01:43.940 | are applied is extremely important.

00:01:47.120 | In fact, the outcomes of studies

00:01:48.660 | often depend on whether or not people

00:01:50.180 | start on drug treatment and then follow

00:01:51.940 | with cognitive behavioral treatment or vice versa.

00:01:54.760 | We're going to go into all those details

00:01:56.280 | and how they relate to different types of OCD,

00:01:59.120 | because it turns out there are indeed different types

00:02:01.120 | of obsessions and compulsions,

00:02:02.920 | and the age of onset for OCD, and so on and so forth.

00:02:07.060 | What I can assure you is by the end of this episode,

00:02:09.300 | you'll have a much greater understanding

00:02:11.140 | of what OCD is and what it isn't,

00:02:13.660 | and what obsessive compulsive personality disorder is

00:02:16.720 | and what it is not,

00:02:18.020 | and you'll have a rich array of different therapy options

00:02:21.700 | to explore in yourself or in others

00:02:24.960 | that are suffering from OCD.

00:02:26.260 | And if neither you or others that you know suffer from OCD

00:02:29.420 | or obsessive compulsive personality disorder,

00:02:31.940 | the information covered in today's episode

00:02:34.060 | will also provide insight into how the brain

00:02:36.720 | and nervous system translate thought into action generally.

00:02:39.900 | And also, you're going to learn a lot

00:02:42.140 | about goal-directed behavior generally.

00:02:44.800 | My hope is that by the end of the episode,

00:02:46.300 | you will both understand a lot about this disease state

00:02:48.940 | that we call OCD.

00:02:50.400 | You will have access to information

00:02:52.660 | that will allow you to direct treatments

00:02:54.220 | to yourself or others in better ways,

00:02:56.640 | and that you will gain greater insight into how you function

00:02:59.820 | and how human beings function in general.

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00:03:50.400 | Before we begin, I'd like to emphasize

00:03:52.020 | that this podcast is separate from my teaching

00:03:53.800 | and research roles at Stanford.

00:03:55.380 | It is, however, part of my desire and effort

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00:08:29.100 | Let's talk about OCD or obsessive compulsive disorder.

00:08:32.700 | First of all, as the name suggests,

00:08:34.820 | OCD includes thoughts or obsessions

00:08:37.660 | and compulsions, which are actions.

00:08:40.520 | The obsessions and the compulsions are often linked.

00:08:43.420 | In fact, most of the time,

00:08:44.760 | the obsessions and the compulsions are linked

00:08:46.680 | such that the compulsion, the behavior,

00:08:49.460 | is designed to relieve the obsession.

00:08:52.660 | However, one of the hallmark themes

00:08:54.540 | of obsessive compulsive disorder

00:08:56.560 | is that the obsessions are intrusive.

00:08:59.140 | People don't want to have them.

00:09:00.900 | They don't enjoy having them.

00:09:02.100 | They just seem to pop into people's minds

00:09:03.960 | and they seem to pop into their mind recurrently.

00:09:06.700 | And the compulsions, unlike other sorts of behaviors,

00:09:11.500 | provide brief relief to the obsession,

00:09:14.600 | but then very quickly reinforce or strengthen the obsession.

00:09:18.840 | This is a very key theme to realize

00:09:20.940 | about obsessive compulsive disorder.

00:09:22.480 | So I'm just going to repeat it again.

00:09:24.000 | These two features, first,

00:09:25.640 | the fact that the obsessions are intrusive and recurrent,

00:09:29.920 | as well as the fact that the compulsions, the behaviors,

00:09:32.840 | provide, if anything, only brief relief for the obsessions,

00:09:36.720 | but in most cases simply serve

00:09:38.280 | to make the obsession stronger,

00:09:40.080 | are the hallmark features of obsessive compulsive disorder.

00:09:43.680 | And it turns out to be very important

00:09:45.120 | to keep these in mind as we go forward,

00:09:47.480 | not just because they define obsessive compulsive disorder,

00:09:50.480 | but they also define the sorts of treatments

00:09:52.240 | that will and will not work

00:09:53.920 | for obsessive compulsive disorder.

00:09:55.680 | And then once you understand a little bit

00:09:57.240 | about the neural circuitry

00:09:58.340 | underlying obsessive compulsive disorder,

00:10:00.100 | which we'll talk about in a few moments,

00:10:02.000 | then you will clearly understand

00:10:03.760 | why being a quote unquote obsessive person

00:10:06.080 | or having obsessive compulsive personality

00:10:08.400 | is not the same as OCD.

00:10:10.680 | In fact, we can leap ahead a little bit

00:10:12.600 | and compare and contrast OCD

00:10:14.680 | with obsessive compulsive personality disorder

00:10:17.120 | along one very particular set of features.

00:10:20.160 | Again, I'll go into this in more detail later,

00:10:22.120 | but it's fair to say that OCD is characterized

00:10:25.840 | by these recurrent and intrusive obsessions.

00:10:28.480 | And as I mentioned before,

00:10:29.440 | the fact that those obsessions get stronger

00:10:31.700 | as a function of people performing certain behaviors.

00:10:34.480 | So unlike an itch that you feel

00:10:36.560 | and then you scratch it and it feels better,

00:10:38.300 | OCD is more like an itch that you feel,

00:10:39.920 | you scratch it and the itch intensifies.

00:10:42.840 | That contour or that pattern of behaviors

00:10:45.460 | and thoughts interacting is very different

00:10:47.840 | than obsessive compulsive personality disorder,

00:10:50.300 | which mainly involves a sense of delayed gratification

00:10:54.020 | that people want and somewhat enjoy

00:10:56.500 | because it allows them to function better

00:10:58.320 | or more in line with how they would like

00:10:59.840 | to show up in the world.

00:11:01.280 | So again, OCD has mainly to do with obsessions

00:11:04.380 | that are intrusive and recurrent,

00:11:05.520 | whereas obsessive compulsive personality disorder

00:11:07.920 | does not have that intrusive feature to it.

00:11:10.220 | People do not mind or in fact often invite

00:11:13.220 | or like the particular patterns of thought

00:11:15.580 | that lead them to be compulsive along certain dimensions.

00:11:18.540 | So leaving aside obsessive compulsive personality disorder

00:11:21.280 | for the moment, let's focus a bit more on OCD

00:11:24.020 | and define how it tends to show up in the world.

00:11:26.820 | First of all, OCD is extremely common.

00:11:31.120 | In fact, current estimates are that anywhere from 2.5%

00:11:35.500 | to as high as three or even 4% of people suffer

00:11:39.500 | from true OCD.

00:11:40.980 | That is an astonishingly high number.

00:11:43.860 | Now, the reason the range is so big,

00:11:45.860 | 2.5% all the way up to three or maybe even 4%,

00:11:49.180 | is that a lot of the features of OCD go unnoticed,

00:11:53.700 | both in the clinician's office

00:11:56.140 | and simply because people don't report it

00:11:58.840 | and don't talk about it.

00:12:00.300 | In fact, it is possible to have recurrent

00:12:02.120 | and intrusive obsessions and not engage

00:12:04.600 | in the sorts of behaviors that would ever allow people

00:12:06.760 | to notice that somebody has OCD.

00:12:09.280 | That can be because some of the intrusive thoughts

00:12:12.440 | don't actually lead to overt behaviors like hand-washing

00:12:15.320 | or checking that other people would notice.

00:12:17.260 | It can also be because people learn to disguise

00:12:20.700 | or hide their obsessions and their compulsions out of shame

00:12:24.300 | or fear of looking strange or whatever it might be,

00:12:27.620 | such that they have these obsessive and intrusive thoughts

00:12:30.660 | and they do little micro-behaviors,

00:12:32.540 | like they might tap their fingers on their fly

00:12:34.740 | as a way to avoid, at least in their own mind,

00:12:37.380 | something catastrophic happening.

00:12:39.140 | That might seem crazy to you, it might seem bizarre,

00:12:41.900 | but this is the sort of thing

00:12:43.060 | that operates in a lot of people.

00:12:45.420 | And I really want to emphasize this

00:12:46.940 | because the clinical literature that are out there

00:12:50.060 | really point to the fact that many people have OCD,

00:12:54.020 | full-blown OCD, and never report it

00:12:56.100 | because of the kind of shame and hiding associated with it.

00:12:59.500 | Another thing to point out is that OCD

00:13:02.260 | is extremely debilitating.

00:13:04.720 | I mentioned this a few minutes ago,

00:13:06.100 | but OCD is currently listed as at number seven

00:13:08.980 | in terms of the most debilitating illnesses,

00:13:11.580 | not just mental illnesses or disorders,

00:13:14.980 | but all types of illnesses,

00:13:16.680 | including things like asthma and cancer, et cetera.

00:13:19.500 | So you can imagine with that standing at number seven,

00:13:23.300 | that it is both extremely common

00:13:25.620 | and extremely debilitating.

00:13:27.060 | And as a consequence, it's now realized that many hours,

00:13:31.420 | days, weeks, months, or even years of work performance

00:13:35.540 | or showing up at work, of relational interactions,

00:13:38.920 | really suffer as a consequence of people having OCD.

00:13:41.460 | So this is a vital problem that the scientific

00:13:43.760 | and psychiatric and psychological communities understand.

00:13:46.420 | And it's one of the reasons that I'm doing this podcast.

00:13:49.520 | And of course, I received a ton of interest in OCD

00:13:52.380 | because of this incredibly high incidence of OCD

00:13:55.140 | and how debilitating it is.

00:13:56.940 | We could go really deep into why it's so debilitating.

00:14:00.160 | I don't want to spend too much time on that

00:14:01.380 | because I think most of that is pretty obvious,

00:14:03.100 | but some of it is not.

00:14:04.500 | For instance, one of the things that makes OCD

00:14:06.640 | so debilitating is of course the shame

00:14:08.780 | that we talked about before,

00:14:10.180 | but it's also the fact that when people are focusing

00:14:12.980 | on their obsessions and their compulsions,

00:14:14.600 | they're not able to focus on other things.

00:14:16.560 | That's simply the way that the brain works.

00:14:17.960 | We're not able to focus on too many things at once.

00:14:20.380 | The other thing is that OCD takes a lot of time

00:14:23.580 | out of people's lives.

00:14:25.320 | With recurrent intrusive thoughts happening

00:14:27.700 | at very high frequency or even at moderate frequency,

00:14:30.020 | people are spending a lot of time thinking about this stuff

00:14:32.820 | and they're thinking about the behaviors

00:14:34.740 | they need to engage in and then engaging in the behaviors,

00:14:36.820 | which as I mentioned before,

00:14:37.840 | just serve to strengthen the compulsions.

00:14:39.440 | And so they're not actually doing the other things

00:14:41.540 | that make us functional human beings,

00:14:43.300 | like commuting to work or doing homework or doing work

00:14:46.300 | or listening when people are talking or interacting

00:14:48.780 | or sports or working out.

00:14:49.680 | All the things that make for a rich quality life

00:14:52.720 | are taken over by OCD in many cases.

00:14:56.020 | So while that might be obvious to some,

00:14:57.800 | I'm not sure that it's obvious to everybody

00:14:59.520 | just how much time OCD can occupy.

00:15:02.500 | Another thing you'll soon learn is that sadly,

00:15:05.220 | a lot of the obsessions and compulsions in OCD

00:15:07.860 | often relate to taboo topics.

00:15:09.680 | And that's because the general categories of OCD

00:15:12.720 | fall into three different bins,

00:15:15.440 | checking obsessions and compulsions,

00:15:17.820 | repetition obsessions and compulsions

00:15:20.220 | and order obsessions and compulsions.

00:15:22.380 | The checking ones are somewhat obvious,

00:15:23.960 | checking the stove or checking the locks,

00:15:26.260 | which I think we all tend to do.

00:15:27.680 | I'm somebody typically I'll head off to the car

00:15:30.440 | to commute to work and I'll think,

00:15:32.240 | I locked the front door and I'll go back once.

00:15:34.540 | But I won't go back twice or 50 times.

00:15:36.800 | People with OCD will often go back 20 or 30 times

00:15:40.280 | before they'll actually allow themselves to drive off.

00:15:42.460 | And then it's a real challenge for them

00:15:44.740 | to continue to drive off and discard with the idea

00:15:47.320 | that they didn't check the stove

00:15:48.540 | or they didn't check the locks

00:15:49.620 | or they didn't check something else critical.

00:15:52.300 | Repetition obsessions and compulsions

00:15:54.660 | obviously can dovetail with the checking ones,

00:15:57.840 | but those tend to be things like counting off

00:16:00.000 | of a certain number of numbers,

00:16:02.200 | like one, two, three, four, five, six, seven,

00:16:04.100 | seven, six, five, four, three, two, one.

00:16:05.500 | People will perform that repeatedly, repeatedly, repeatedly

00:16:08.380 | or feel that they have to.

00:16:09.980 | I remember years ago watching a documentary

00:16:12.080 | about the band, the Ramones.

00:16:14.940 | Most people heard of the Ramones, right?

00:16:16.360 | Jeans, t-shirts, aviator glasses.

00:16:18.140 | Everyone had to change their last name to Ramone.

00:16:19.720 | They weren't actually all related to one another,

00:16:21.460 | by the way, you had to change your last name to Ramone.

00:16:23.500 | The Ramones had one band member who was admittedly

00:16:27.360 | and known to others as having OCD.

00:16:29.420 | And during that documentary, which I forget the name,

00:16:32.040 | I think it was called, can't remember.

00:16:33.900 | Anyway, can't remember, hippocampal lapse there.

00:16:37.100 | But in this documentary,

00:16:38.540 | the band members describe Joey Ramone as leaving hotels,

00:16:43.540 | walking down the stairs to the parking lot,

00:16:45.640 | but then having to walk up and down them seven or eight

00:16:47.540 | times and sometimes getting out of the van again

00:16:49.500 | and walking up and down them seven or eight times.

00:16:51.620 | And it always had to be a certain number of times

00:16:53.580 | given a certain number of stairs.

00:16:55.060 | This appears quote unquote crazy.

00:16:56.660 | But of course, we don't want to think of this as crazy.

00:16:58.980 | This is somebody who very likely had full blown OCD.

00:17:03.220 | Now that particular example, believe it or not,

00:17:05.160 | is not all that uncommon.

00:17:07.820 | It just so happens that that example entailed

00:17:10.340 | certain compulsions and behaviors that were overt

00:17:12.740 | and that other people could see.

00:17:14.780 | And you can imagine how that would prevent somebody

00:17:16.860 | from moving about their daily life easily.

00:17:18.540 | A lot of people, as I mentioned before,

00:17:20.320 | have obsessions and compulsions that they hide

00:17:22.740 | and they do these little micro-behaviors

00:17:24.260 | or they'll just count off in their head

00:17:26.380 | as opposed to generating some sort of walking up

00:17:28.600 | and down stairs or tapping or things of that sort.

00:17:31.420 | So we have checking, we have repetition,

00:17:32.960 | and then there's order.

00:17:34.580 | Order oftentimes is thought of as putting cleanliness

00:17:39.420 | or making sure everything is aligned and perfect

00:17:42.120 | and orderly.

00:17:43.720 | And oftentimes that is the case,

00:17:45.360 | but there are other forms of order that people with OCD

00:17:48.080 | can focus on in a obsessive and compulsive way.

00:17:51.680 | Things like incompleteness,

00:17:53.260 | the idea that one can't walk away from something

00:17:56.320 | or stop doing something because something's not right

00:17:58.600 | or complete in that picture.

00:18:00.540 | It could be the way the table is set.

00:18:02.940 | It could be the way that something's written on a page.

00:18:05.060 | It could be an email.

00:18:06.700 | Again, now we're still talking about OCD, the disorder.

00:18:09.640 | We're not talking about

00:18:10.680 | obsessive compulsive personality disorder.

00:18:13.840 | I'm aware of, well, I'll just be direct,

00:18:16.160 | several colleagues of mine, and it's just remarkable,

00:18:18.480 | the order in their emails.

00:18:20.240 | Every email is perfect, punctuated perfect,

00:18:23.260 | grammar perfect, everything's spaced perfect.

00:18:25.880 | Do they have OCD?

00:18:26.800 | Well, they might, they might not.

00:18:27.920 | How would I know unless they disclose that to me?

00:18:31.320 | But they might have obsessive compulsive personality disorder

00:18:34.520 | or they just might be able to generate a lot of order

00:18:37.880 | and they have a lot of discipline

00:18:39.160 | around the way they write and the way they present

00:18:40.920 | any communication with anybody at all.

00:18:43.640 | So if somebody has a OCD that's in the domain of order,

00:18:47.840 | it could be incompleteness and the constant feeling

00:18:50.960 | of something not being completed and a need to complete it.

00:18:54.220 | It can also be in terms of symmetry,

00:18:56.160 | that everything be aligned and symmetric in some way.

00:18:58.680 | This could be seen perhaps in young kids.

00:19:01.880 | This is one example that I read in the literature

00:19:04.020 | of children that need to arrange their stuffed animals

00:19:06.540 | in exact same order every day and in a particular order

00:19:11.640 | to the point where if you were to move the little stuffed

00:19:14.160 | frog over next to the stuffed rabbit,

00:19:15.900 | that the child would have an anxiety reaction to that

00:19:19.520 | and feel literally compelled, driven to fix that,

00:19:23.500 | maybe even multiple times over and over again.

00:19:26.360 | We'll talk about OCD in children

00:19:27.920 | versus adults in a little bit.

00:19:29.400 | And then the other aspect of order,

00:19:31.600 | which is a little bit less than intuitive

00:19:33.880 | is this notion of disgust.

00:19:35.580 | This idea that something is contaminated.

00:19:37.440 | So we often think about OCD and hand-washing behavior

00:19:41.240 | in response to people feeling that something is contaminated,

00:19:44.200 | a space, a towel, et cetera,

00:19:46.260 | or even simply somebody else's hand.

00:19:48.460 | And so they're unwilling to shake somebody's hand.

00:19:50.780 | You can imagine how these different bins of obsessions

00:19:53.480 | and compulsions, checking repetition and order

00:19:56.760 | could be extremely debilitating

00:19:58.040 | depending on how severe they are

00:19:59.440 | and how many different domains of life they show up in.

00:20:02.760 | Because oftentimes in movies,

00:20:04.640 | and even the way I'm describing it now,

00:20:06.640 | it sounds as if, okay, well, somebody has to check the locks,

00:20:09.360 | but they don't have to also check the stove.

00:20:11.180 | Or somebody has the need to count to seven back and forth,

00:20:14.880 | up to seven and down to seven,

00:20:16.060 | seven times a day or something of that sort.

00:20:19.380 | Where they need symmetry in very specific domains of life.

00:20:23.180 | But it turns out that this recurrent

00:20:24.820 | and intrusive aspect of obsessions leads people with OCD

00:20:29.200 | to have checking repetition

00:20:31.900 | and or order compulsions everywhere.

00:20:35.420 | So whether or not somebody is at work or in school

00:20:38.100 | or trying to engage in sport

00:20:39.480 | or trying to engage in relationship

00:20:40.920 | or just something simple like walking down the street,

00:20:43.580 | the obsessions are so intrusive that they show up

00:20:45.880 | and they compel people to do things in that domain,

00:20:48.700 | independent of whether or not

00:20:51.120 | they happen to be in one location or another.

00:20:53.040 | In other words, the thought patterns and the behaviors

00:20:56.620 | take over the environment as opposed to the environment

00:20:59.220 | driving the thought patterns and behaviors.

00:21:01.460 | So it therefore becomes impossible

00:21:03.100 | to ever find a room that's clean enough,

00:21:05.200 | to find a bed that's made well enough,

00:21:07.760 | to find anything that's done well enough

00:21:10.720 | to remove the obsession.

00:21:13.180 | And I know I've said it multiple times now,

00:21:15.080 | but I'm going to say it many times throughout this episode

00:21:18.020 | in a somewhat obsessive, but I believe justified way

00:21:21.940 | that every time that one engages in the compulsion

00:21:25.580 | related to the obsession,

00:21:26.780 | the obsession simply becomes stronger.

00:21:28.920 | So you can imagine what a powerful

00:21:31.320 | and debilitating loop that really is.

00:21:33.340 | So let's drill a little bit deeper

00:21:34.740 | into how the obsessions and compulsions

00:21:36.460 | relate to one another.

00:21:37.860 | If we were to draw a line

00:21:39.100 | between the obsessions and the compulsions,

00:21:41.420 | that line could be described as anxiety.

00:21:45.680 | Now we need to define what anxiety is.

00:21:47.840 | And to be quite honest,

00:21:49.900 | most of psychology and science

00:21:51.820 | can't agree on exactly what anxiety is.

00:21:53.980 | Typically the way we think about fear

00:21:56.220 | is that it's a heightened state of autonomic arousal.

00:21:59.020 | So increased heart rate, increased breathing,

00:22:00.940 | sweating, et cetera,

00:22:02.240 | in response to an immediate and present threat

00:22:04.940 | or perceived threat.

00:22:06.320 | Whereas anxiety, generally speaking

00:22:08.540 | in the scientific literature,

00:22:09.960 | relates to the same sorts of thought patterns

00:22:13.700 | and somatic bodily responses,

00:22:15.820 | heart rate, breathing, et cetera,

00:22:17.540 | but without a clear and present danger

00:22:20.700 | being in the environment or right there.

00:22:22.980 | So that's the way

00:22:23.820 | that we're going to talk about anxiety now.

00:22:25.820 | And anxiety is really what binds the obsessions

00:22:28.580 | and compulsions such that

00:22:29.820 | someone will have an intrusive thought.

00:22:31.660 | So for instance, someone will have the thought that

00:22:34.140 | if they turn left on any street,

00:22:36.900 | that something bad will happen, okay?

00:22:38.780 | That's an obsession.

00:22:39.620 | It's actually not all that uncommon.

00:22:41.380 | Now, how bad and what the specificity

00:22:43.580 | of that bad thing really is will vary.

00:22:45.380 | Some people will think if I turn left,

00:22:47.380 | something generally bad will happen.

00:22:48.820 | It just makes me feel anxious.

00:22:50.140 | So they always insist on going right.

00:22:52.080 | Whereas other people will think if I turn left,

00:22:55.180 | so-and-so will die or I will die

00:22:58.180 | or something terrible will happen.

00:23:00.420 | I'll get a disease or someone else will get a disease

00:23:02.620 | or I'll be cursing myself or somebody else

00:23:04.600 | in some very specific way.

00:23:06.580 | This is unfortunately quite common in people with OCD.

00:23:10.820 | So they have this feeling

00:23:13.520 | and the feeling can be generally

00:23:14.940 | or specifically related to a particular outcome.

00:23:17.200 | But beneath that is a feeling of anxiety,

00:23:20.040 | a quickening of the heartbeat,

00:23:22.060 | a quickening of breathing,

00:23:23.540 | a narrowing of one's visual focus.

00:23:26.260 | I've talked about this before on other podcasts,

00:23:28.080 | the master stress and other podcasts.

00:23:29.700 | But if you haven't heard those,

00:23:31.380 | let me just briefly describe that

00:23:32.740 | when we are in a state of increased

00:23:34.580 | so-called autonomic arousal, alertness, stress, et cetera,

00:23:38.180 | our visual field literally narrows,

00:23:40.400 | the aperture of our visual field gets smaller.

00:23:42.940 | And that's because of the relationship

00:23:44.160 | between the autonomic nervous system and your visual system.

00:23:46.980 | So you start seeing the world

00:23:48.620 | through sort of soda straw view

00:23:50.620 | or through binocular like view

00:23:52.060 | as opposed to seeing the big picture.

00:23:53.580 | Why is that important?

00:23:54.580 | Well, it literally sharpens and narrows your focus

00:23:58.780 | toward the very thing that the obsessions

00:24:00.780 | and the compulsions are focused on.

00:24:02.040 | So the person walking down the street

00:24:03.380 | who sees the opportunity to go left or right

00:24:06.200 | will only see the bad decision.

00:24:09.640 | Their visual field narrows very tightly

00:24:12.500 | along that possibility of taking a left turn.

00:24:15.180 | And I know as I described, this seems totally irrational,

00:24:17.620 | but I want to emphasize

00:24:19.100 | that the person with OCD knows it's irrational.

00:24:22.420 | They might feel crazy because they're having these thoughts,

00:24:25.860 | but they know it makes no sense whatsoever

00:24:27.980 | that left somehow would be different than right

00:24:30.820 | in terms of outcomes in this particular case.

00:24:33.500 | And yet it feels as if it would.

00:24:36.060 | In fact, in some cases, it feels as if they went left,

00:24:38.460 | they would have a full-blown panic attack.

00:24:40.820 | So the idea here is that the obsessions and compulsions

00:24:43.980 | are bound by anxiety, but then by taking a right-hand turn,

00:24:48.240 | again, in this one particular example,

00:24:50.400 | by taking a right-hand turn, there's a very brief,

00:24:53.880 | I should mention very brief relief of that anxiety

00:24:57.660 | at the time of the decision to go right, not left.

00:25:01.700 | And there's an additional drop in anxiety

00:25:05.060 | while one takes the right-hand turn

00:25:07.360 | as opposed to the left-hand turn.

00:25:09.580 | And then, as I alluded to before,

00:25:11.660 | there's a reinforcement of the compulsion.

00:25:14.300 | In other words, by going right,

00:25:16.100 | it doesn't create a situation in the brain

00:25:18.900 | and psychology of the person that,

00:25:21.040 | oh, you know what, I'm not anxious anymore,

00:25:23.320 | left would have probably been okay.

00:25:25.100 | It reinforces the idea that right made me feel better

00:25:28.420 | or turning right made me feel better

00:25:30.220 | and going left would have been that much worse.

00:25:32.660 | Again, it reinforces the obsession even further.

00:25:35.660 | And again, we could swap out right turns and left turns

00:25:40.200 | with something like hand-washing,

00:25:41.860 | the feeling that something is contaminated

00:25:44.140 | and the need to wash one's hands,

00:25:45.740 | even though one already washed their hands

00:25:47.820 | 20, 30, 50 times prior.

00:25:49.980 | And we're actually going to go back to that example

00:25:51.600 | a little bit later when we talk about

00:25:53.620 | one particular category of therapies

00:25:55.460 | that are very effective in many people for OCD,

00:25:58.620 | which are the cognitive, behavioral, and exposure therapies.

00:26:01.420 | 'Cause I think some of you have heard

00:26:02.840 | of cognitive, behavioral, and exposure therapies,

00:26:04.920 | but the way they are used to treat OCD

00:26:07.060 | is very much different than the way they're used to treat

00:26:09.980 | other sorts of anxiety disorders

00:26:12.360 | and other sorts of disorders generally.

00:26:14.680 | So it's fair to say that up to 70% of people with OCD

00:26:19.180 | have some sort of anxiety or elevated anxiety,

00:26:22.860 | either directly related to the OCD

00:26:25.120 | or indirectly related to the OCD.

00:26:26.820 | And it's really hard to tease those apart

00:26:28.460 | because OCD can create its own anxiety.

00:26:31.640 | As I mentioned before, it can even increase its own anxiety.

00:26:34.700 | And there's also an issue of depression.

00:26:37.660 | Having OCD can be very depressing, right?

00:26:40.460 | Especially if some of these OCD thoughts and behaviors

00:26:43.560 | start to really impede people's ability to function in life,

00:26:46.180 | at work, in school, in relationship,

00:26:47.700 | they can start feeling less optimistic about life.

00:26:49.780 | And in fact, some people can become suicidally depressed.

00:26:52.540 | That's how bad OCD can be for us.

00:26:55.340 | So we have to be careful when saying

00:26:57.620 | that 70% of people with OCD also have anxiety

00:27:00.540 | or X number of people with OCD are also depressed

00:27:02.800 | because we don't know whether or not

00:27:04.140 | the depression led the OCD or the other way around,

00:27:06.700 | or whether or not they're operating,

00:27:07.840 | as we say in science, in parallel.

00:27:09.800 | Some of the drug treatments for OCD and depression

00:27:11.820 | and anxiety can tease some of that apart.

00:27:14.420 | And we'll talk about that.

00:27:15.600 | But I think it's fair to say that what binds the obsessions

00:27:19.040 | and compulsions is anxiety,

00:27:20.940 | that there's a feeling of it,

00:27:22.860 | or I should say an urgent feeling of a need

00:27:25.060 | to get rid of the obsession.

00:27:27.040 | And the person feels as if the only way they can do that

00:27:29.700 | is to engage in a particular compulsive behavior.

00:27:32.380 | Some people are probably wondering

00:27:33.680 | if there's a genetic component to OCD.

00:27:36.260 | And indeed there is,

00:27:37.940 | although the nature of it isn't exactly clear.

00:27:40.520 | And oftentimes when people hear

00:27:42.620 | that something has a genetic component,

00:27:44.580 | they think it's always directly inherited from a parent.

00:27:48.180 | And that's not always the case.

00:27:49.620 | There can be genes that surface in siblings

00:27:52.720 | or genes that surface in children

00:27:54.480 | that are not readily apparent

00:27:56.540 | in terms of what we call a phenotype.

00:27:58.020 | So you have a genotype, the gene,

00:27:59.300 | and then you have a phenotype,

00:28:00.420 | the way it shows up as a body form or like eye color,

00:28:04.220 | or how it shows up in terms of a behavior

00:28:06.860 | or behavioral pattern.

00:28:08.840 | Based on twin studies where researchers

00:28:11.780 | have examined identical twins, fraternal twins,

00:28:14.380 | even identical twins that share the same sac in utero,

00:28:18.300 | what we call monochorionic.

00:28:19.660 | So sitting in the same little bag during pregnancy

00:28:22.220 | or in different little bags,

00:28:23.700 | you can see different levels

00:28:24.800 | of what's called genetic concordance.

00:28:26.720 | But if we were to just sort of cut a broad swath

00:28:29.380 | through all of the genetic data,

00:28:31.100 | it's fair to say that about 40 to 50% of OCD cases

00:28:35.300 | have some genetic component,

00:28:36.740 | some mutation or some inherited aspect that's genetic

00:28:40.180 | and that one could point to if they got their genome mapped.

00:28:43.140 | Now, while that's interesting,

00:28:44.260 | I don't think it's terribly useful for most people.

00:28:46.560 | First of all, you can't really control your genes,

00:28:48.920 | at least at this point in history,

00:28:50.720 | even though there are things like epigenetic control

00:28:53.180 | and people are very excited about technologies like CRISPR

00:28:55.740 | for modifying the genome.

00:28:57.280 | In humans at some point,

00:28:59.600 | most people can't control their genetics, right?

00:29:02.580 | You can't pick who your parents were, as they say.

00:29:04.740 | So just know that there is a genetic component

00:29:07.120 | in about half of people with OCD, but not always.

00:29:10.780 | Now, as is typical for this podcast,

00:29:13.260 | I want to focus on some of the neural mechanisms

00:29:15.960 | and chemical systems in the brain and body

00:29:18.100 | that generate obsessive compulsive disorder.

00:29:20.720 | In fact, if you've watched this podcast before,

00:29:23.020 | listened to this podcast before,

00:29:24.580 | this is always how I structure things.

00:29:26.280 | First, we introduce a topic and we explore that topic

00:29:30.000 | in detail and really define what it is and what it isn't.

00:29:32.620 | And then it's very important that we focus on what is known

00:29:36.020 | and what is not known about the biological mechanisms

00:29:39.280 | that generate whatever that thing happens to be,

00:29:41.300 | in this case, OCD

00:29:42.140 | or obsessive compulsive personality disorder.

00:29:44.500 | Now, I want to emphasize that even if you don't have

00:29:46.940 | a background in biology,

00:29:48.740 | I will make this information accessible to you.

00:29:50.720 | And I also want to emphasize that for those of you

00:29:52.820 | that are interested in treatments

00:29:54.400 | and are anxiously awaiting the description of things

00:29:58.300 | that can help with OCD, I encourage you, if you will,

00:30:02.860 | to please try and digest some of the material

00:30:05.320 | about the underlying mechanisms,

00:30:06.620 | because understanding even just a little bit

00:30:08.700 | of those biological mechanisms can really help shed light

00:30:11.760 | on why particular drug and behavioral treatments

00:30:15.060 | and other sorts of treatments work and don't work.

00:30:18.080 | This is especially important in the case of OCD,

00:30:20.940 | where it turns out that the order and type of treatment

00:30:23.560 | can really vary according to individual.

00:30:26.040 | And that's something really special and important about OCD

00:30:28.960 | that we really can't say for a number of the other

00:30:31.160 | sorts of disorders that we've described

00:30:32.720 | on previous podcasts.

00:30:34.320 | So let's take a step back and look at the neural circuitry.

00:30:37.640 | What's going on in the brain and body of people with OCD?

00:30:40.760 | Why the intrusive recurrent thoughts?

00:30:43.360 | Why the compulsions?

00:30:44.360 | Why is that whole system bound by anxiety?

00:30:48.360 | And in some ways, in thinking about that,

00:30:50.420 | I want you to keep in mind that the brain

00:30:53.840 | has two main functions.

00:30:55.580 | The brain's main functions are to take care

00:30:59.560 | of all the housekeeping stuff, make sure digestion works,

00:31:02.000 | make sure the heart beats,

00:31:03.000 | make sure you keep breathing no matter what,

00:31:05.180 | make sure that you can see, you can hear,

00:31:08.180 | you can smell, et cetera, the basic stuff.

00:31:10.520 | And then there's an enormous amount of brain real estate

00:31:13.320 | that's designed to allow you to predict

00:31:15.680 | what's going to happen next,

00:31:16.920 | either in the immediate future or in the long-term future.

00:31:20.040 | And largely that's done based on your knowledge of the past.

00:31:23.160 | So you also have memory systems.

00:31:24.440 | And of course you have systems in the brain and body

00:31:26.980 | that are designed to bind what's happening

00:31:29.740 | at the housekeeping level, like your heart rate,

00:31:31.840 | to your anticipation of what's going to happen next.

00:31:34.320 | So if you're thinking about something very fearful,

00:31:36.040 | your body will have one type of reaction.

00:31:37.620 | If you're thinking about something very pleasant

00:31:39.240 | and relaxing, your body will have another type of reaction.

00:31:41.900 | So whenever I hear about the brain-body distinction,

00:31:44.880 | I have to just remind everybody

00:31:46.960 | that there really is no distinction between brain and body

00:31:49.680 | when you think about it through the nervous system.

00:31:51.420 | The nervous system is the brain, the eyes, the spinal cord,

00:31:54.000 | but of course all their connections

00:31:55.360 | with all the organs of the body

00:31:56.520 | and the connections of all the organs of the body

00:31:58.240 | with the brain, the spinal cord, et cetera.

00:32:00.280 | So as I describe these neural circuits,

00:32:02.840 | I don't want you to think of them

00:32:03.840 | as just things happening in the head.

00:32:05.720 | They are certainly happening in the head.

00:32:07.720 | In fact, the circuits I'll describe most in detail

00:32:10.660 | do exist within the confines of your cranial vault,

00:32:13.260 | that's nerd speak for skull,

00:32:15.000 | but those circuits are driving particular predictions

00:32:19.160 | and therefore particular biases

00:32:21.380 | towards particular actions in your body.

00:32:23.440 | They're creating a state of readiness

00:32:24.980 | or a state of desire to check or desire to count

00:32:28.640 | or desire to avoid, et cetera, et cetera.

00:32:32.060 | So what are these circuits?

00:32:33.420 | Well, there's been a lot of wonderful research

00:32:36.440 | exploring the neural circuits

00:32:38.120 | underlying obsessive compulsive disorder.

00:32:40.760 | And that's mainly been accomplished

00:32:41.920 | through a couple of methods.

00:32:43.480 | Most of those methods when applied in humans

00:32:45.960 | involve getting some look into which brain areas are active

00:32:50.960 | when people are having obsessions

00:32:53.040 | and when people are engaging in compulsions.

00:32:55.740 | Now that might seem simple to do,

00:32:57.360 | but of course your brain is housed inside the cranial vault

00:33:00.480 | and in order to look inside it,

00:33:01.720 | you have to use things like magnetic resonance imaging,

00:33:04.060 | which is just fancy technology for looking at blood flow,

00:33:07.480 | which relates to activation of neurons, nerve cells,

00:33:10.980 | or things like PET, P-E-T imaging,

00:33:14.000 | which has nothing to do with the verb pet

00:33:15.660 | and has nothing to do with your house pet,

00:33:17.560 | has everything to do with positron emission tomography,

00:33:20.420 | which is just another way of seeing

00:33:22.120 | which brain areas are active.

00:33:23.480 | And then you can also use PET to figure out

00:33:25.420 | what sorts of neurochemicals are active,

00:33:27.140 | like dopamine, et cetera.

00:33:29.180 | Many studies, we can fairly say dozens,

00:33:32.620 | if not hundreds of studies have now identified

00:33:35.360 | a particular circuit or loop of brain areas

00:33:38.440 | that are interconnected and very active

00:33:40.920 | in obsessive compulsive disorder.

00:33:43.200 | That loop includes the cortex,

00:33:47.340 | which is kind of the outer shell of the human brain,

00:33:50.880 | the lumpy stuff, as it sometimes appears

00:33:53.680 | if the skull is removed,

00:33:55.160 | and it involves an area called the striatum,

00:33:57.440 | which is involved in action selection

00:33:59.180 | and holding back action.

00:34:00.840 | The striatum is involved in what's commonly called

00:34:03.140 | go and no-go types of behaviors.

00:34:05.420 | So every type of behavior,

00:34:06.360 | like picking up a pen or a mug of coffee,

00:34:08.960 | involves a go type function.

00:34:11.400 | It involves generating an action.

00:34:13.480 | But every time I resist an action,

00:34:16.080 | my nervous system is also doing that

00:34:17.680 | using this brain structure, the striatum,

00:34:20.840 | which includes, among other things, the basal ganglia.

00:34:24.040 | We've talked about that before.

00:34:25.160 | I'm not trying to overload you with terminology here,

00:34:27.140 | but I know some people are interested in terminology.

00:34:29.480 | So you have go behaviors and you have no-go,

00:34:31.440 | resisting of behaviors, not going toward behavior.

00:34:35.720 | The cortex and the striatum

00:34:37.520 | are in this intricate back and forth talk.

00:34:39.960 | It's really loops of connections.

00:34:41.320 | The cortex doesn't tell the striatum what to do.

00:34:43.080 | The striatum doesn't tell the cortex what to do.

00:34:45.060 | They're in a crosstalk.

00:34:45.940 | Like any good relationship,

00:34:47.000 | there's a lot of back and forth communication.

00:34:49.860 | There's a third element in this corticostriatal loop,

00:34:53.680 | as it's called, and that's the thalamus.

00:34:56.040 | Now, the thalamus is not a structure

00:34:57.400 | I've talked a lot about before on this podcast,

00:34:59.580 | but it's one of my favorite structures

00:35:01.440 | to think about and teach about in neuroanatomy,

00:35:03.580 | which I teach back at Stanford

00:35:05.480 | and have taught for many years elsewhere,

00:35:07.440 | because the thalamus is this incredible egg-like structure

00:35:10.580 | in the center of your brain

00:35:12.340 | that has different channels through it,

00:35:14.480 | channels for relaying visual information

00:35:17.380 | or auditory information or touch information

00:35:20.520 | from your environment up into your cortex,

00:35:23.920 | and as a consequence,

00:35:24.760 | making certain things that are happening to you

00:35:27.320 | and around you apparent to you,

00:35:29.480 | making you aware of them,

00:35:30.560 | making you perceive them and suppressing others.

00:35:34.400 | So for instance, right now,

00:35:35.520 | if you're hearing me say this,

00:35:37.120 | your thalamus has what are called auditory nuclei.

00:35:40.400 | There's collections of neurons that respond to sound waves

00:35:44.940 | that are, of course, coming in through your ears,

00:35:46.960 | and your thalamus is active in a way

00:35:49.860 | that those particular regions of your thalamus are allowed,

00:35:53.660 | literally permitted to pass the information

00:35:55.960 | coming from your ears through some other steps,

00:35:58.600 | but then to your thalamus, your auditory thalamus,

00:36:00.580 | then up to your cortex,

00:36:01.600 | and you can hear what I'm saying right now.

00:36:03.880 | At the same time,

00:36:04.840 | your thalamus is surrounded by a kind of a shell,

00:36:07.880 | something called the thalamic reticular nucleus.

00:36:09.960 | Again, you don't have to remember the names,

00:36:11.400 | but this thalamic reticular nucleus

00:36:13.160 | also sometimes called the reticular thalamic nucleus.

00:36:15.720 | This is, believe it or not, a subject of debate in science.

00:36:18.240 | There are people that literally hated each other,

00:36:19.880 | probably still hate each other,

00:36:20.820 | even though one of them's dead,

00:36:22.220 | for decades because they would argue

00:36:23.600 | it was the thalamic reticular nucleus,

00:36:26.120 | the other was reticular thalamic nucleus.

00:36:27.160 | Anyway, these are scientists, they're people,

00:36:29.560 | they tend to debate.

00:36:31.000 | But the thalamic reticular nucleus, as I'm going to call it,

00:36:34.340 | serves as a sort of gate

00:36:36.280 | as to which information is allowed to pass through

00:36:38.760 | up to your conscious experience and which is not.

00:36:41.800 | And that gating mechanism is strongly regulated

00:36:44.160 | by the chemical GABA.

00:36:45.880 | GABA is a neurotransmitter that is inhibitory, as we say.

00:36:50.440 | It serves to shut down or suppress the activity

00:36:53.680 | of other neurons.

00:36:54.960 | So the thalamic reticular nucleus is really saying no.

00:36:59.920 | Touch information cannot come in right now.

00:37:02.160 | You should not be thinking about the contact

00:37:04.820 | of the back of your legs

00:37:05.780 | with the chair that you're sitting on.

00:37:07.560 | Andrew, you should be thinking about

00:37:08.720 | what you're trying to say and what you're hearing

00:37:10.200 | and how your voice sounds

00:37:11.200 | and what you see in front of you, et cetera.

00:37:13.880 | Whereas if I'm about to get an injection from a doctor

00:37:17.280 | or I'm in pain or I'm in pleasure,

00:37:19.520 | I'm going to think about my somatic sensation

00:37:22.200 | at the level of touch.

00:37:23.440 | And I'm probably going to think less about smells

00:37:26.120 | in the room, although I might also think about smells

00:37:28.080 | in the room or what I'm seeing and what I'm hearing.

00:37:30.300 | We can combine all these different sensory modalities,

00:37:33.320 | but the thalamic reticular nucleus really allows us

00:37:36.040 | to funnel, to direct particular categories

00:37:38.680 | of sensory experience into our conscious awareness

00:37:41.400 | and suppress other categories of sensory experience.

00:37:45.600 | In addition, the thalamic reticular nucleus

00:37:48.280 | plays a critical role in which thoughts are allowed

00:37:52.540 | to pass up to our conscious perception

00:37:54.800 | and which ones are not.

00:37:56.680 | So much so that some neuroscientists

00:37:59.360 | and indeed some neuro philosophers,

00:38:01.500 | if you want to call them that,

00:38:02.640 | have theorized or philosophized

00:38:04.360 | that the thalamic reticular nucleus

00:38:07.120 | is actually involved in our consciousness.

00:38:09.320 | Now, consciousness is in a topic

00:38:10.680 | that I really want to talk about this episode.

00:38:12.300 | And it's a very kind of mushy, murky,

00:38:14.640 | as we say in science, it's a schmooey term

00:38:17.120 | because it doesn't really have clear definitions.

00:38:18.920 | So arguments about it often get lost

00:38:20.640 | in the fact that people are arguing about different things.

00:38:22.960 | But when I say consciousness,

00:38:24.400 | what I mean is conscious awareness.

00:38:26.240 | So let's zoom out and take a look at the circuit

00:38:28.760 | that we've got and that we now know

00:38:30.440 | based on neuroimaging studies is intimately involved

00:38:33.880 | in generating obsessions and compulsions in OCD.

00:38:36.720 | We have a cortex or neocortex,

00:38:39.200 | which is involved in perception

00:38:40.720 | and understanding of what's happening.

00:38:42.520 | We have the striatum and basal ganglia,

00:38:44.720 | which are involved in generating behaviors, go,

00:38:47.400 | and suppressing behaviors, no go.

00:38:49.460 | And we have the thalamus,

00:38:51.100 | which collects all of our sensory experience in parallel,

00:38:54.360 | hearing, touch, smell, et cetera.

00:38:56.540 | Not so much smell through the thalamus I should mention,

00:38:58.360 | but the other senses that is.

00:39:00.800 | And then that thalamus is encased

00:39:04.300 | by the thalamic reticular nucleus,

00:39:06.300 | which serves as a kind of a guard saying,

00:39:08.500 | you can pass through and you can pass through,

00:39:09.840 | but you, you, you can't pass through

00:39:12.040 | up to conscious understanding and perception.

00:39:15.240 | So that loop, this corticostriatal thalamic loop,

00:39:18.520 | corticostriatal thalamic loop

00:39:20.600 | is the circuit thought to underlie OCD

00:39:24.560 | and dysfunction in that circuit

00:39:26.360 | is what's thought to underlie OCD.

00:39:28.260 | Now, again, the circuit exists in all of us

00:39:29.920 | and it can operate in healthy ways

00:39:31.220 | or it can operate in ways that make us feel unhealthy

00:39:33.400 | or even suffer from full blown OCD.

00:39:36.460 | How do we know that this circuit is involved in OCD?

00:39:39.640 | Well, there, we can look to some really interesting studies

00:39:42.800 | that involve bringing human subjects into the laboratory

00:39:46.660 | and generating their obsessions and compulsions

00:39:48.980 | and then imaging their brain using any variety of techniques

00:39:51.640 | that we talked about before.

00:39:53.660 | What would such an experiment look like?

00:39:55.180 | Well, in order to do that sort of experiment,

00:39:57.600 | first of all, you need people who have OCD

00:40:00.680 | and of course you need control subjects that don't

00:40:02.880 | and you need to be able to reliably evoke the obsessions

00:40:05.800 | and the compulsions.

00:40:06.760 | Now, it turns out this is most easily,

00:40:08.600 | or I should say most simply done

00:40:11.000 | 'cause it can't be easy for the people with OCD,

00:40:12.860 | but this is most straightforward.

00:40:15.200 | That's the word I was looking for.

00:40:16.280 | Most straightforward when looking at the category

00:40:19.640 | of obsessions and compulsions

00:40:21.320 | that relate to order and cleanliness.

00:40:25.060 | So what they do typically is bring subjects

00:40:27.500 | into the laboratory who have a obsession

00:40:30.380 | about germs and contamination and a compulsion to hand wash.

00:40:34.880 | And they give these people, believe it or not,

00:40:37.640 | a sweaty towel that contains the sweat and the odor

00:40:41.800 | and the liquid basically from somebody else's hands.

00:40:46.440 | In fact, they'll sometimes have someone wipe their own sweat

00:40:49.680 | off the back of their neck and put it on the towel

00:40:51.640 | and then they'll put it in front of the person,

00:40:53.720 | which as you can imagine for someone with OCD

00:40:55.560 | is incredibly anxiety provoking

00:40:57.960 | and almost always evokes these obsessions

00:41:01.040 | about, oh, this is really bad.

00:41:04.360 | This is really bad.

00:41:05.200 | I need to clean, I need to clean, I need to clean.

00:41:07.360 | Now they're doing all this while someone

00:41:08.600 | is in a brain scanner or while they're being imaged

00:41:11.360 | for positron emission tomography.

00:41:13.180 | And then they can also look at the patterns of activation

00:41:15.780 | in the brain while the person is doing hand washing.

00:41:18.960 | Although sometimes the apparatus associated

00:41:20.960 | with these imaging studies

00:41:21.800 | make it hard to do a lot of movement.

00:41:23.300 | They can do these sorts of studies.

00:41:25.320 | They have done these sorts of studies in many subjects

00:41:28.600 | using different variations of what I just described.

00:41:31.640 | And lo and behold, what lights up,

00:41:33.920 | when I say lights up, what sorts of brain regions

00:41:37.700 | are more metabolically active, more blood flow,

00:41:39.640 | more neural activity?

00:41:40.480 | Well, it's this particular corticostriatal thalamic loop.

00:41:44.800 | In addition to that, some of the drug treatments

00:41:47.700 | that are effective in some,

00:41:49.240 | and I want to emphasize some individuals

00:41:51.440 | at suppressing obsessions and or compulsions,

00:41:54.320 | such as the selective serotonin reuptake inhibitors

00:41:57.440 | or SSRIs, which we'll talk about in a little bit.

00:41:59.880 | When people take those drugs,

00:42:02.920 | they see not just a suppression

00:42:04.980 | of the obsession and compulsion,

00:42:08.420 | but also a suppression of these particular neural circuits.

00:42:12.300 | They become less active.

00:42:13.600 | Now I want to emphasize and telegraph

00:42:15.760 | a little bit of what's coming later.

00:42:18.360 | These drugs, like SSRIs, do not work for everybody with OCD.

00:42:22.000 | And as many of you know,

00:42:23.040 | they carry other certain problems and side effects

00:42:25.480 | for many, but not all individuals.

00:42:28.060 | But nonetheless, what we have now is an observation

00:42:31.240 | that this circuit, the corticostriatal thalamic loop,

00:42:33.680 | is active in OCD.

00:42:35.040 | We have a manipulation that when people take a drug

00:42:38.080 | that, at least in those individuals,

00:42:39.480 | is effective in suppressing or eliminating

00:42:41.600 | the obsessions and compulsions.

00:42:42.800 | There's less activity in this loop.

00:42:44.840 | And thanks to some very good animal model studies

00:42:47.580 | that, at least at this point in time,

00:42:49.140 | you really couldn't do in humans,

00:42:51.060 | although soon that may change,

00:42:53.060 | we now know in a causal way that the equivalent circuitry,

00:42:57.320 | A, exists in other animals, such as mice, such as cats,

00:43:01.080 | such as monkeys, and that activation

00:43:04.360 | of those particular corticostriatal thalamic circuits

00:43:08.080 | in animal models can indeed evoke OCD

00:43:11.780 | in an individual that prior to that did not have OCD.

00:43:16.240 | So I'm just going to briefly describe one study.

00:43:18.240 | This is a now classic study published

00:43:20.600 | in the journal Science,

00:43:21.640 | one of the three apex journals in 2013.

00:43:24.760 | The first author on this paper is Suzanne Amari, A-H-M-A-R-I.

00:43:30.360 | I will provide a link to this in the show notes

00:43:32.200 | as a truly landmark paper done in Renee Hen's lab

00:43:35.160 | at Columbia University.

00:43:37.400 | And the title of the paper is

00:43:38.500 | Repeated Corticostriatal Stimulation Generates,

00:43:41.400 | that's the key word here,

00:43:42.240 | Generates Persistent OCD-Like Behavior.

00:43:45.280 | What they did is they took mice, mice do mouse things,

00:43:49.160 | they move around, they play with toys,

00:43:50.640 | they eat, they pee, they mate,

00:43:52.560 | they do various things in their cage, but they also groom.

00:43:55.820 | Humans groom, animals with fur groom.

00:43:59.440 | Well, you hope most people groom, some people overgroom,

00:44:02.140 | some people undergroom, but most people groom.

00:44:04.040 | They'll comb their hair, they'll clean, et cetera.

00:44:05.880 | Those are normal behaviors that humans engage in.

00:44:08.760 | I'm not aware that mice comb their hair,

00:44:09.840 | but mice adjust their hair.

00:44:11.080 | So they'll kind of pet their hair and they'll do this.

00:44:12.880 | They'll sometimes even do it to each other.

00:44:14.620 | We used to have mice in the lab.

00:44:15.680 | Now we only do human studies,

00:44:16.960 | but the mice will groom themselves.

00:44:19.840 | And typical, what we call wild type mice,

00:44:22.340 | not because they're wild, but because they're typical,

00:44:24.580 | will groom themselves at a particular frequency,

00:44:27.640 | but not to the point where their hair is falling out,

00:44:30.020 | not constantly.

00:44:31.000 | They are grooming some of the time

00:44:33.080 | and they're doing other mouse things, other mouse times.

00:44:36.680 | So in this particular study,

00:44:38.060 | what they did is they used some technology,

00:44:41.000 | which actually was discussed on a previous episode

00:44:43.560 | of the Huberman Lab Podcast.

00:44:44.980 | This is technology that was developed by a psychiatrist

00:44:47.360 | and bioengineer by the name of Karl Deisseroth,

00:44:49.280 | one of my colleagues at Stanford School of Medicine.

00:44:52.280 | This is technology that allows researchers

00:44:54.240 | to use the presentation of light

00:44:56.860 | to control neural activity in particular brain areas

00:45:00.740 | in a very high fidelity way.

00:45:03.180 | You control the activity in the cortex or the striatum

00:45:05.640 | or the thalamus when you want and how you want.

00:45:07.800 | It's really a beautiful technology.

00:45:09.620 | In any event, what they did in this study is,

00:45:11.980 | or I should say what Susan Amari and colleagues did

00:45:14.300 | in the study, was to stimulate the corticostriatal circuitry

00:45:19.300 | in animals that did not have any OCD-like behavior.

00:45:22.900 | And when they did that,

00:45:24.140 | those animals started grooming incessantly

00:45:26.420 | to the point where their hair was falling out

00:45:28.300 | or they even, you know,

00:45:29.400 | they didn't take the experiments this far, fortunately,

00:45:31.300 | but the animals would have a tendency

00:45:32.840 | to almost rub themselves raw.

00:45:34.560 | In the same way that somebody who has a compulsion

00:45:37.020 | to hand wash would, sadly, people will hand wash

00:45:40.220 | to the point where their hands are actually bleeding

00:45:41.960 | and raw, it's really that bad.

00:45:43.580 | I know that's tough imagery to imagine.

00:45:45.580 | And you can't even imagine why someone would self-harm

00:45:47.440 | in that way.

00:45:48.280 | But again, that's that incredible anxiety relationship

00:45:51.580 | between the compulsion, excuse me,

00:45:53.020 | the obsession and the compulsion,

00:45:54.900 | and the fact that engaging in the compulsion

00:45:57.580 | simply strengthens the obsession and therefore the anxiety.

00:46:00.580 | So that collection of studies, of data,

00:46:04.580 | fMRI, PET scanning in humans, the treatment with SSRIs,

00:46:08.340 | and these experiments where researchers

00:46:11.980 | have actively triggered these particular circuits

00:46:15.740 | in animal models that previously did not have

00:46:18.740 | too much activity in these circuits,

00:46:20.020 | and then they observe OCD emerging really point squarely

00:46:24.620 | to the fact that the corticosteroidal thalamic loop

00:46:27.460 | is likely to be the basis of OCD.

00:46:30.320 | Now, of course, other circuits could also be involved,

00:46:32.900 | but the corticosteroidal thalamic circuit

00:46:35.460 | seems to be the main circuit generating OCD-like behavior.

00:46:39.340 | That's a lot of mechanism.

00:46:40.660 | Hopefully it was described in a way

00:46:42.560 | that you can digest and understand.

00:46:44.380 | And some of you might be thinking, well, so what?

00:46:46.540 | Why does that help me?

00:46:47.380 | I mean, I can't reach into my brain and turn off my cortex.

00:46:50.060 | I can't reach into my brain and turn off my thalamus.

00:46:52.620 | And indeed, on the one hand, that's true,

00:46:55.460 | but as you'll next learn,

00:46:57.440 | when thinking about the various behavioral treatments

00:46:59.740 | and drug treatments and holistic treatments for OCD,

00:47:03.540 | what you'll notice is that each one taps

00:47:05.460 | into a different component

00:47:06.820 | of this corticosteroidal thalamic loop.

00:47:09.740 | And by understanding that,

00:47:11.660 | you can start to see why certain treatments might work

00:47:14.540 | at one stage of the illness versus others.

00:47:17.280 | You will also start to understand

00:47:18.760 | why obsessive compulsive personality disorder

00:47:22.360 | does not have the same sorts of engagements

00:47:24.700 | of these neural loops,

00:47:25.940 | and yet relies on other aspects of brain and body,

00:47:30.260 | and therefore responds best to other sorts of treatments.

00:47:33.700 | Or in some cases,

00:47:35.380 | people with obsessive compulsive personality disorder

00:47:37.840 | are not even seeking treatment, as I alluded to before.

00:47:40.300 | The point here is that

00:47:41.140 | by understanding the underlying mechanism,

00:47:43.180 | why certain drugs and behavioral treatments work

00:47:45.940 | and don't work will become immediately apparent.

00:47:48.120 | And in thinking about that, in knowing that,

00:47:51.380 | you'll be able to make excellent choices, I believe,

00:47:53.960 | in terms of what sorts of treatments you pursue,

00:47:56.160 | what sorts of treatments you abandon,

00:47:57.880 | and most importantly, the order,

00:48:00.720 | the sequence that you pursue and apply those treatments.

00:48:04.000 | Before we go any further,

00:48:05.060 | I'd like to give people a little bit of a window

00:48:07.140 | into what a diagnosis for OCD would look like.

00:48:10.840 | Give you a sense of the sorts of questions

00:48:13.080 | that a clinician would ask

00:48:15.020 | to determine whether or not somebody has OCD or not.

00:48:18.100 | Now, I want to be clear,

00:48:18.940 | I'm not going to do this in an exhaustive way.

00:48:20.640 | I wouldn't want anyone to self-diagnose,

00:48:22.560 | although I'm hoping that by sharing some of this,

00:48:24.660 | that some of you might get insight

00:48:26.000 | into whether or not you do have obsessions and compulsions

00:48:28.660 | that might qualify for OCD and perhaps even to seek out help.

00:48:33.260 | The most commonly used test of OCD, or for OCD, I should say,

00:48:38.260 | is called the Yale-Brown Obsessive Compulsive Scale.

00:48:41.940 | And this is, you know, scientists love acronyms,

00:48:44.580 | as do the military, and it's the Y-box.

00:48:46.900 | The Y dash B-O-C-S, the Y-box.

00:48:51.320 | So typically, someone will go into the clinic,

00:48:53.680 | either because a family member encouraged them to,

00:48:55.720 | or because they feel that they're suffering

00:48:57.620 | from obsessions and compulsions.

00:48:59.460 | And before the clinician would proceed

00:49:02.440 | with any kind of direct questions,

00:49:03.980 | they would very clearly define

00:49:05.520 | what obsessions and compulsions are.

00:49:06.900 | And here I'm actually reading from the Y-box.

00:49:09.160 | So quote, "Obsessions are unwelcome and distressing ideas,

00:49:11.660 | thoughts, images, or impulses

00:49:13.060 | that repeatedly enter your mind.

00:49:14.440 | They may seem to occur against your will.

00:49:16.560 | They may be repugnant to you.

00:49:17.820 | You may recognize them as senseless,

00:49:19.500 | and they may not fit your personality."

00:49:22.320 | Then there are compulsions.

00:49:23.740 | Quote, "Compulsions, on the other hand,

00:49:25.540 | are behaviors or acts that you feel driven to perform,

00:49:27.660 | although you may recognize them as senseless or excessive.

00:49:30.900 | At times, you may try to resist doing them,

00:49:32.880 | but this may prove difficult.

00:49:34.220 | You may experience anxiety that does not diminish

00:49:36.700 | until the behavior is completed."

00:49:38.380 | And as I mentioned before,

00:49:39.300 | in many cases, immediately after the behavior is completed,

00:49:42.280 | the anxiety doesn't just return, it indeed can strengthen.

00:49:45.580 | Now, there are a tremendous number of questions

00:49:46.860 | on the Y-box.

00:49:47.700 | So I'm just going to highlight

00:49:49.640 | a few of the general categories.

00:49:51.240 | Typically, the person will fill out a checklist.

00:49:54.740 | So they will designate whether or not,

00:49:57.560 | currently or in the past,

00:49:59.180 | they have, for instance, aggressive obsessions,

00:50:02.160 | fear that one might harm themselves,

00:50:04.180 | fear that one might harm others,

00:50:05.860 | fear that they'll steal things,

00:50:07.060 | fear that they will act on unwanted impulses,

00:50:09.880 | currently or in the past or both.

00:50:12.020 | That's one category.

00:50:13.080 | The other one are contamination obsessions.

00:50:14.820 | So concern with dirt or germs,

00:50:16.500 | bothered by sticky substances or residues,

00:50:18.500 | et cetera, et cetera.

00:50:19.560 | So a bunch of different categories that include,

00:50:22.060 | for instance, sexual obsessions,

00:50:24.280 | what are called saving obsessions,

00:50:26.460 | even moral obsessions,

00:50:28.420 | excess concern with right or wrong or morality,

00:50:30.860 | concerned with sacrilege and blasphemy,

00:50:33.900 | obsession with need for symmetry and exactness.

00:50:35.780 | Again, all of these questions being answered

00:50:37.700 | as either present in the past or not present in the past,

00:50:40.980 | present currently or not present currently.

00:50:43.340 | And then the test generally transitions over

00:50:47.580 | to questions about target symptoms.

00:50:49.820 | They really trying to get people to identify

00:50:52.020 | if they have obsessions, what are their exact obsessions?

00:50:54.620 | Now, this turns out to be really important

00:50:56.160 | because as we talk about some of the therapies

00:50:58.140 | that really work,

00:50:59.860 | I'll just give away a little bit

00:51:01.220 | of why they work best in certain cases

00:51:04.020 | and why they don't work as well in other cases,

00:51:06.760 | it turns out that it becomes very important

00:51:09.360 | for the clinician and the patient

00:51:11.300 | to not just identify the obsessions

00:51:13.840 | and the compulsions generally

00:51:15.460 | in a kind of a generic or top contour way,

00:51:17.980 | but to really encourage or even force the patient

00:51:21.180 | to define very precisely

00:51:23.900 | what the biggest most catastrophic fear is,

00:51:27.480 | what the obsession really relates to.

00:51:29.720 | That turns out to be very important

00:51:31.380 | in disrupting this corticostriatal thalamic loop

00:51:34.460 | and getting relief from symptoms one way or the other.

00:51:37.620 | So the Yale Brown Obsessive Compulsive Scale, this Y-box,

00:51:41.080 | again, is very extensive.

00:51:42.380 | It goes on for dozens of pages actually

00:51:45.660 | and has all these different categories,

00:51:47.960 | not so much designed to just pinpoint

00:51:50.760 | what people obsess about or what they feel compelled to do,

00:51:54.760 | but to also try and identify

00:51:56.860 | what is the fear that's driving all this, right?

00:51:59.940 | In the way that we've set this up thus far,

00:52:02.140 | we've been talking about obsessions and compulsions

00:52:03.980 | as kind of existing in a vacuum.

00:52:05.900 | You're obsessed about germs

00:52:07.220 | and you're compelled to wash your hands,

00:52:09.100 | obsessed about germs, compelled to wash your hands,

00:52:10.800 | or obsessed about symmetry,

00:52:12.160 | compelled to put right angles on everything,

00:52:14.200 | or obsessed about counting and therefore counting, et cetera.

00:52:17.360 | But beneath that is a cognitive component

00:52:21.380 | that is not at all apparent

00:52:23.240 | from someone describing their obsession

00:52:26.260 | and from someone describing or displaying their compulsion.

00:52:29.520 | The deeper layer to all that is what is the fear exactly

00:52:34.280 | if one were to not perform the compulsion?

00:52:37.780 | Meaning what is the fear that's driving the obsession?

00:52:41.060 | So that brings us to a very powerful category of treatments

00:52:45.340 | that I should say does not work in everybody with OCD,

00:52:49.420 | but works in many people with OCD

00:52:52.000 | and really speaks to the underlying neural circuitry

00:52:56.260 | that generates OCD and how to interrupt it.

00:52:58.660 | And that is the treatment of cognitive behavioral therapy

00:53:02.180 | and in particular exposure-based cognitive behavioral therapy.

00:53:06.600 | So we're going to talk about cognitive behavioral therapy

00:53:08.400 | and exposure therapy now, but right at the outset,

00:53:11.820 | I want to distinguish the kinds of cognitive behavioral

00:53:14.040 | therapy and exposure therapies that are done

00:53:15.760 | for obsessive compulsive disorder,

00:53:17.400 | the sorts of cognitive behavioral therapies that are done

00:53:19.600 | for other types of mental challenges and disorders.

00:53:23.020 | Because cognitive behavioral therapy for OCD

00:53:27.480 | really has everything to do with identifying

00:53:30.160 | the utmost fear.

00:53:31.940 | In some sense, we can think of fears

00:53:34.080 | as kind of along a hierarchy, right?

00:53:35.840 | In the example earlier of somebody being afraid

00:53:38.400 | to turn left and therefore feeling compelled to turn right,

00:53:41.840 | you would want to take that person and really understand

00:53:44.600 | what do they fear most about turning left?

00:53:47.440 | Now, they might not be aware of it.

00:53:48.980 | They might not be conscious to what that really is,

00:53:51.360 | but if you were to probe them in a clinical setting,

00:53:53.680 | you would eventually get to an answer.

00:53:55.060 | That answer could be at first, I don't know,

00:53:58.440 | it's just bad.

00:53:59.280 | I don't know why it's bad, it makes no sense,

00:54:01.200 | but it's just bad, I do not want to go left.

00:54:03.400 | I don't know why, I don't know why.

00:54:04.800 | But if you were to push that person a little bit

00:54:07.040 | in a respectful and kind and caring way

00:54:10.280 | aimed at their treatment,

00:54:11.120 | if you were to push them and say,

00:54:11.960 | "Well, what do you mean by bad?"

00:54:13.600 | If you turn left, do you think the world would end?

00:54:16.180 | They might say, "No, the world's not going to end,

00:54:17.800 | but someone is going to die suddenly."

00:54:20.940 | I know that sounds crazy,

00:54:21.920 | but somebody is going to die suddenly.

00:54:24.080 | This almost sounds like superstition.

00:54:25.720 | We'll talk about superstitions later,

00:54:26.960 | but indeed it is somewhat superstitious.

00:54:29.320 | So for instance, you would say, "Who's going to die?"

00:54:32.040 | And they'd say, "I don't know."

00:54:33.640 | And you'd say, "No, really, who's going to die?"

00:54:35.800 | If you think about this, are you going to die?

00:54:37.400 | Is so-and-so going to die?

00:54:38.440 | And very often, very often,

00:54:41.660 | what you find is that people will start to reveal

00:54:46.400 | the underlying obsession at a level of detail

00:54:50.200 | that both to the clinician and to them

00:54:52.140 | can be somewhat astonishing,

00:54:53.340 | even though they've been living with that detail

00:54:55.140 | in their mind for a very long time.

00:54:57.200 | Now, how could somebody start to reveal detail

00:54:59.120 | about something that's existed in their mind

00:55:00.760 | for a very long time, but not known about it, right?

00:55:04.200 | Not been aware of it.

00:55:05.420 | Now, some of you might think,

00:55:06.260 | "Oh, it's repressed or something."

00:55:07.960 | That's not at all what's happening.

00:55:10.320 | If you think about the architecture of OCD,

00:55:12.560 | typically people will have an obsession

00:55:14.440 | and then they'll engage in the compulsion

00:55:16.120 | as quickly as they can to relieve that obsession.

00:55:18.620 | So in many ways, the disease itself prevents people

00:55:21.560 | from ever getting to the bottom of that trough,

00:55:24.500 | ever getting to the point where they really clearly

00:55:26.680 | articulate to themselves exactly what it is that they fear.

00:55:30.540 | But it becomes so essential to articulate exactly

00:55:34.080 | what it is that they fear

00:55:35.900 | for a somewhat counterintuitive reason.

00:55:37.800 | You might think, "Oh, the moment they realize

00:55:40.040 | exactly what they fear, everything lifts.

00:55:42.480 | The circuit turns off and they just feel better

00:55:44.360 | because they realized it."

00:55:45.820 | I wish I could tell you that's the case,

00:55:47.040 | but it turns out it's the opposite.

00:55:48.820 | What the clinician is actually trying to do

00:55:51.160 | is get people to feel more anxiety, not less.

00:55:55.180 | What they're trying to get them to do is to short circuit,

00:55:58.280 | no pun intended, to intervene in their own neural circuit,

00:56:01.600 | I should say, with that relief of anxiety, however brief,

00:56:06.600 | brought on by engaging in the compulsion

00:56:09.340 | related to the obsession.

00:56:10.680 | So whereas typically someone would feel the obsession with,

00:56:14.800 | "Oh, I don't want to turn left

00:56:16.240 | 'cause something bad is going to happen,

00:56:17.300 | someone's going to die," and then they turn right,

00:56:19.700 | they never get the option or the opportunity

00:56:22.620 | to really explore what would happen were they to turn left

00:56:26.600 | or to not be able to turn right.

00:56:28.480 | By forcing them down the path of inquiry

00:56:30.960 | that leads them to the place

00:56:32.220 | where they very clearly identify the fear, the anxiety,

00:56:37.160 | it raises the anxiety in them,

00:56:39.520 | and that's actually what the clinician is after.

00:56:43.680 | Cognitive behavioral therapy and exposure therapy

00:56:47.080 | in the context of OCD most often involves

00:56:50.040 | trying to get people to tolerate, not relieve their anxiety.

00:56:54.880 | This is extremely important,

00:56:56.280 | and I realize there's variation to this

00:56:58.580 | depending on the style of cognitive behavioral therapy,

00:57:01.600 | the style of exposure therapy,

00:57:02.920 | but almost across the board, the goal, again,

00:57:06.680 | is to get people to feel the anxiety

00:57:09.520 | that normally they are able to at least partially relieve,

00:57:12.840 | however briefly, by engaging in the compulsion.

00:57:15.840 | So if we think back to that circuit

00:57:18.160 | of corticostriatal thalamic, what's going on here?

00:57:21.080 | Where is CBT intervening?

00:57:23.420 | What part of the circuit is getting interrupted?

00:57:26.340 | Well, as you recall,

00:57:27.180 | the cortex is involved in conscious perception,

00:57:29.360 | the thalamus and that thalamic reticular nucleus

00:57:31.580 | are involved in the passage of certain types of experience

00:57:36.100 | up to our conscious perception, not others,

00:57:38.060 | and the striatum is involved in this go/no-go type behavior.

00:57:42.420 | When OCD is really expressing itself in its fullness,

00:57:47.220 | people feel an anxiety around a particular thought,

00:57:50.120 | and they either have a go, for instance, wash hands,

00:57:54.600 | or a no-go, do not turn left type reaction.

00:57:58.500 | By having people progressively in a kind of hierarchical way

00:58:03.560 | reveal their precise source of anxiety,

00:58:06.560 | their utmost fear in this context,

00:58:08.760 | what happens is they feel enormous amounts

00:58:12.040 | of autonomic arousal.

00:58:13.800 | Now, in the context of anxiety treatment

00:58:16.360 | or other types of treatments,

00:58:17.640 | the goal would be to teach people to dampen,

00:58:19.720 | to lessen their anxiety through breathing techniques

00:58:22.320 | or through visualization techniques

00:58:24.760 | or through self-talk or through social support,

00:58:27.200 | any of the number of things that are well known

00:58:28.920 | to help people self-regulate their own anxiety.

00:58:31.360 | Here, it's the opposite.

00:58:32.840 | What they're trying to get the patient to do

00:58:35.080 | is to really feel the anxiety at its maximum,

00:58:38.280 | but then do the exact opposite

00:58:40.120 | of whatever the normal compulsion is.

00:58:41.800 | So if normally the compulsion is to wash one's hands,

00:58:44.280 | then the idea is to suppress hand washing

00:58:46.640 | while being in the experience of the utmost anxiety.

00:58:49.800 | Or in the case of not turning left,

00:58:52.680 | the person is expected to,

00:58:55.280 | or would hopefully be able to actually turn left.

00:58:59.240 | And as you can imagine,

00:59:02.320 | that would evoke tremendous anxiety

00:59:04.020 | and yet to tolerate that anxiety.

00:59:06.080 | Now, I want to be very clear.

00:59:06.960 | This is not the sort of thing you want to do on your own.

00:59:08.920 | This is not the sort of thing you want to do for a friend.

00:59:10.840 | This is done by trained licensed psychologists

00:59:14.400 | and psychiatrists.

00:59:15.920 | But nonetheless, it really points to the fact

00:59:19.200 | that as a anxiety-related disorder,

00:59:22.520 | OCD is distinct from other types of anxiety

00:59:25.640 | and anxiety-related disorders,

00:59:27.600 | things like PTSD and panic disorder, et cetera,

00:59:30.380 | because the goal again is to bring the person

00:59:32.920 | right up close to the thing that they fear the most

00:59:36.360 | and then to interrupt the circuit.

00:59:38.620 | And now you should be able to know just intuitively,

00:59:42.640 | because you understand the mechanisms,

00:59:44.540 | that the circuit you're trying to disrupt

00:59:46.240 | is the pattern of information flow

00:59:49.320 | from the thinking part of the brain,

00:59:50.960 | the perception part of the brain,

00:59:52.000 | which is the cortex, to the striatum, right?

00:59:55.200 | The striatum has these neurons which are active

00:59:58.520 | that essentially are,

00:59:59.960 | I know it sounds a little bit

01:00:00.800 | like a discussion about free will,

01:00:02.040 | but they're trying to get the person

01:00:03.620 | to generate a certain behavior

01:00:04.880 | or suppress a certain behavior.

01:00:06.780 | And as anxiety ramps up,

01:00:08.240 | it's sort of a hydraulic pressure to do that very thing

01:00:11.680 | that they've done for so long and they suffer from so much.

01:00:14.600 | We talked about hydraulic pressure

01:00:16.020 | in the context of aggression, in the aggression episode.

01:00:18.760 | This is very similar, right?

01:00:20.760 | There's a kind of a, now when I say hydraulic pressure,

01:00:23.460 | it's not actual hydraulic pressure.

01:00:24.860 | It's the confluence of a lot of different systems.

01:00:26.900 | It's neurochemical, as we'll soon learn.

01:00:28.580 | It's hormonal, it's electrical.

01:00:30.460 | It's a lot of different things operating in parallel.

01:00:32.820 | So we can't point to one chemical or transmitter.

01:00:35.420 | What's happening is the person is feeling compelled

01:00:37.380 | to act, act, act, to relieve the anxiety.

01:00:39.660 | And through a progressive type of exposure, right?

01:00:43.400 | You don't throw people in the deep end

01:00:45.000 | in this kind of therapy right off the bat.

01:00:47.480 | You gradually ratchet them toward

01:00:49.180 | or move them toward the discussion

01:00:50.880 | of exactly what they fear the most,

01:00:52.380 | and then eventually move them toward the interruption

01:00:54.760 | of the compulsion as they're feeling

01:00:56.980 | this extremely elevated anxiety,

01:00:58.740 | of course, within the context

01:00:59.880 | of a supportive clinical setting.

01:01:02.560 | But in doing that, what you are teaching people

01:01:05.260 | is that the anxiety can exist without the need

01:01:08.500 | to engage in the compulsion.

01:01:10.100 | Now, some of this might sound to people like,

01:01:12.860 | oh, this is a lot of the kind of fancy

01:01:14.260 | psychological neuroscience speak

01:01:15.860 | around something that's kind of intuitive.

01:01:17.360 | But I think for most people, this is not intuitive.

01:01:20.820 | And for people with OCD, there's no really other way

01:01:25.220 | to put it, the impulse, the compulsion to avoid anxiety

01:01:29.460 | is such a powerful driving force

01:01:31.740 | that it should now make sense to you

01:01:33.020 | as to why being able to tolerate anxiety

01:01:35.740 | and really sit with it and do the exact opposite

01:01:38.100 | of what you're normally compelled to do

01:01:39.680 | is going to be the path to treatment.

01:01:41.460 | And indeed, CBT has been shown to be enormously effective,

01:01:45.000 | again, for a large number of people with OCD,

01:01:47.820 | but not all of them.

01:01:48.940 | And oftentimes, it requires that it also be used

01:01:52.340 | in concert with certain drug treatments,

01:01:54.180 | which we're going to talk about in a moment.

01:01:56.220 | Next, let's talk about some of the really unique features

01:01:58.580 | of cognitive behavioral therapy and exposure therapy

01:02:00.740 | in the context of OCD that you often don't see

01:02:04.300 | in the use of CBT, that is cognitive behavioral therapy,

01:02:08.260 | for other types of psychiatric challenges and disorders.

01:02:12.020 | The first element is one of staircasing.

01:02:15.380 | And I already mentioned this before,

01:02:17.020 | but this gradual and progressive increase in the anxiety

01:02:22.020 | that you're trying to evoke from the patient,

01:02:24.500 | from the person suffering from OCD.

01:02:26.960 | That's done in the context of the office or the laboratory,

01:02:31.060 | again, by a trained and licensed clinician.

01:02:34.680 | But then the person leaves, right?

01:02:36.760 | They leave the office, they leave the laboratory.

01:02:40.180 | And a very vital component of CBT and exposure therapy

01:02:43.860 | for people with OCD is that they have and perform

01:02:47.140 | what's called homework, is literally what they call.

01:02:50.120 | This might be seen in other sorts of treatments,

01:02:51.940 | but for OCD, homework is extremely important

01:02:55.280 | because within the context of a laboratory experiment

01:02:57.780 | or the clinic, patients often feel so much support

01:03:00.780 | that they can tolerate those heightened levels of anxiety

01:03:02.900 | and interrupt their compulsions.

01:03:04.740 | Whereas when they get home, oftentimes the familiarity

01:03:07.220 | of the environment brings them to a place

01:03:09.160 | where all of a sudden those obsessions and compulsions

01:03:11.580 | start interacting the same way

01:03:13.160 | and they have a very hard time suppressing the behaviors.

01:03:16.620 | Why would that be?

01:03:17.700 | Well, in neuroscience, we have a phrase,

01:03:20.300 | it's called condition place preference

01:03:21.980 | and condition place avoidance.

01:03:23.640 | There's some other phrases too,

01:03:24.680 | but basically it all has to do with a simple thing,

01:03:27.700 | which is when you feel something repeatedly

01:03:30.740 | in a given environment or sometimes even once

01:03:32.700 | within a given environment, you tend to feel

01:03:35.300 | that same thing again when you return to that

01:03:37.380 | or similar environments.

01:03:38.700 | Okay, so condition place blank or condition place,

01:03:40.780 | that is simply fancy nerd speak for the fact that

01:03:44.340 | when you're in a place and something good happens,

01:03:46.340 | you tend to feel good if you return to that place

01:03:48.040 | or a place like it, or if something bad happens

01:03:50.620 | in a given place, you tend to feel bad

01:03:52.060 | when you return to that place or a place like it.

01:03:54.860 | I think the most salient example that leaps to mind

01:03:57.260 | is unfortunately the category of bad,

01:03:58.940 | but I had some friends years ago visit San Francisco.

01:04:02.420 | There's been an ongoing, it seems like

01:04:04.500 | it's been happening forever,

01:04:05.460 | but this is really in the last decade of daytime break-ins

01:04:08.140 | and nighttime break-ins into cars to steal anything

01:04:12.220 | from computers to what seems to be like a box of tissues.

01:04:14.600 | And there are numerous reasons for this.

01:04:16.460 | I don't want to get into,

01:04:17.280 | it's not the topic of today's podcast,

01:04:18.700 | but I will use this as an opportunity to say,

01:04:20.120 | if you're visiting anywhere in the Bay Area,

01:04:21.960 | do not leave anything in your car

01:04:23.100 | because the window will get broken into

01:04:24.900 | sometimes in broad daylight.

01:04:26.380 | Some good friends of mine were visiting the Bay Area

01:04:28.460 | and I texted them and said,

01:04:30.920 | hey, by the way, when you're headed to dinner, guys,

01:04:32.900 | make sure you bring in all your luggage and computers,

01:04:36.300 | however inconvenient that might be.

01:04:38.340 | They wrote back, too late, everything got stolen.

01:04:41.260 | So some years ago now,

01:04:42.300 | I think five, six years ago this happened.

01:04:44.620 | Sadly, everything got stolen.

01:04:46.560 | Most of it could be replaced,

01:04:47.540 | but some of it was very sentimental to them.

01:04:49.620 | Every time we talk,

01:04:51.860 | every time we consider having a meeting

01:04:53.280 | in a particular city, this comes up as I don't want,

01:04:56.020 | I don't want to be there,

01:04:56.860 | I don't like that city anymore, et cetera.

01:04:58.300 | And of course, San Francisco

01:04:59.140 | has some wonderful redeeming features,

01:05:00.580 | but it only takes one bad incident in one location

01:05:03.560 | to kind of color the whole picture dark, so to speak.

01:05:07.820 | The brain works that way.

01:05:09.060 | The brain generalizes.

01:05:10.620 | It's not a very specific organ.

01:05:12.320 | Again, it's a prediction machine

01:05:13.620 | in addition to other things.

01:05:15.020 | So in the case of CBT therapy,

01:05:17.780 | the reason there's homework is that when people go home,

01:05:20.820 | oftentimes that's when they relapse,

01:05:23.400 | if you want to call it that,

01:05:24.420 | back into their obsessions and compulsions.

01:05:26.260 | And that location, that conditioned place

01:05:30.380 | is where it becomes most important

01:05:31.940 | to challenge the anxiety and to deal with the anxiety,

01:05:34.860 | to not try and suppress the anxiety

01:05:36.420 | through compulsions or other means.

01:05:38.860 | And when I say other means, I want to highlight something.

01:05:41.700 | We'll come up again a little bit later in the podcast

01:05:43.780 | that substance abuse is very common in people with OCD

01:05:47.280 | because of the anxiety component

01:05:48.920 | and also because of people's feelings

01:05:50.760 | that they just can't escape from the thoughts

01:05:52.660 | or behavioral patterns that are so characteristic of OCD.

01:05:57.000 | So alcohol abuse or cannabis abuse

01:05:59.340 | or other forms of narcotics abuse are very common in OCD.

01:06:04.340 | Later, we'll talk about whether or not cannabis

01:06:06.920 | can or cannot help with OCD.

01:06:09.920 | But needless to say, suppressing anxiety

01:06:13.340 | is exactly the wrong direction that one should take

01:06:16.600 | if the goal is to ultimately relieve or eliminate the OCD.

01:06:21.480 | So we now have two characteristics of CBT exposure therapy

01:06:25.240 | that are extremely important for OCD

01:06:27.000 | and somewhat unique to the treatment of OCD.

01:06:29.060 | And that's the staircasing up towards the really bad fear,

01:06:31.660 | the really severe and specific articulation

01:06:34.920 | and understanding and feeling of how bad things

01:06:37.320 | really would be if someone engaged in a particular behavior

01:06:40.540 | or avoided a particular behavior.

01:06:42.000 | Then there's the component of homework

01:06:43.920 | given by the clinician for the person to be able

01:06:46.420 | to create a broader set of contexts

01:06:49.540 | in which they can deal with the anxiety,

01:06:52.680 | not engage in the compulsions.

01:06:54.420 | And then a very unique feature of treatment of OCD

01:06:57.660 | that you don't see in many other psychiatric disorders

01:07:00.800 | are home visits.

01:07:02.140 | I find this fascinating.

01:07:03.620 | I think that the field of psychiatry and psychology

01:07:06.480 | traditionally doesn't allow for or invite home visits.

01:07:10.700 | But this component of context, location and context

01:07:15.020 | being so vital to the treatment and relief of OCD

01:07:19.860 | has inspired many psychiatrists and psychologists

01:07:23.620 | to get permission to do home visits

01:07:26.080 | where they actually go visit their patients

01:07:27.700 | in their native setting, in their home cages, right?

01:07:30.180 | They're not mice, but in their home home cages, right?

01:07:32.760 | I'm being facetious here, but people,

01:07:34.340 | mice live in cages, at least in the laboratory,

01:07:36.100 | and humans generally live in houses or elsewhere.

01:07:39.500 | So they visit them in their home

01:07:42.420 | in order to see how they're interacting

01:07:44.580 | and the particular locations that evoke the most anxiety

01:07:47.700 | and the least anxiety.

01:07:48.620 | Some of the, I don't want to call them crutches,

01:07:50.540 | but some of the tools that people are using

01:07:53.140 | to confront and deal with the obsessions and compulsions,

01:07:56.900 | and in particular, to try and identify

01:07:59.140 | some of the tools and tricks that people are using

01:08:03.200 | to try and avoid that heightened anxiety.

01:08:05.320 | Because once again, and I know I'm repeating myself,

01:08:07.740 | but I think this is just so vital and so unique

01:08:10.140 | about OCD and the treatment of OCD,

01:08:12.460 | the critical need for the patient to be able to tolerate

01:08:15.400 | extremely elevated levels of anxiety is so crucial.

01:08:20.140 | So if people are avoiding certain rooms in the house,

01:08:23.140 | or if people are avoiding certain foods

01:08:25.940 | or certain locations in the kitchen,

01:08:27.640 | the clinician can start to identify that

01:08:29.500 | by mere observation.

01:08:31.200 | And I should mention here that patients are not always aware

01:08:35.140 | of how they are interacting with their home environment.

01:08:37.780 | Some of these patterns are so deeply ingrained in people

01:08:41.060 | that they don't even realize that they're constantly

01:08:43.280 | turning to the left, or they don't even realize

01:08:45.180 | that they're only washing their hands

01:08:46.700 | on one side of the sink.

01:08:47.760 | And so the clinician, by visiting the home,

01:08:49.980 | can start to interrogate a bit in a polite way,

01:08:52.680 | in a friendly, in a supportive way,

01:08:54.300 | as to do you ever think about why you always flip the faucet

01:08:58.600 | to the left or flip the faucet to the right, et cetera.

01:09:01.480 | Now, we all do a lot of things that are habitual.

01:09:05.740 | We all do things that are somewhat regular from day to day.

01:09:10.060 | In fact, I would invite you to ask yourself,

01:09:13.080 | do you always put your toothbrush in the same location?

01:09:16.480 | Do you always cap the toothbrush before or after you use it?

01:09:19.360 | What sorts of things do you do?

01:09:20.200 | Do you wipe the little threading on the toothpaste or not?

01:09:23.540 | I'm somebody, I confess that I have,

01:09:26.400 | well, I have about 3,500 pet peeves,

01:09:28.720 | but one of my pet peeves is toothpaste

01:09:30.420 | kind of on the thread of the toothpaste.

01:09:32.500 | It really bothers me, I don't know why.

01:09:34.200 | Almost as much as trying to wipe it off bothers me,

01:09:36.840 | which creates a certain challenge.

01:09:38.160 | And if I talk about this any further,

01:09:39.700 | then I think I would qualify

01:09:40.720 | for obsessive compulsive personality disorder.

01:09:43.420 | But I have to say,

01:09:44.260 | I don't experience a ton of anxiety about it.

01:09:45.840 | It doesn't govern my life.

01:09:47.000 | In fact, I realized that right now

01:09:48.680 | there are tubes of toothpaste

01:09:50.640 | that have toothpaste along the thread

01:09:52.160 | everywhere in the world, and it doesn't really bother me.

01:09:54.400 | I can still sit here

01:09:55.800 | and provide some information about OCD to you.

01:09:58.560 | It's not intrusive, at least not to my awareness.

01:10:02.200 | So by the home visit,

01:10:03.920 | the therapist can really start to explore

01:10:06.080 | through direct questioning

01:10:08.040 | and can allow the patient to explore

01:10:09.780 | through direct questioning of themselves

01:10:11.420 | the things that it might be conscious of

01:10:12.760 | and the things that they might not be conscious of

01:10:15.220 | that would qualify for OCD.

01:10:17.580 | So I'd like to just briefly summarize

01:10:19.220 | the key elements of cognitive behavioral therapy

01:10:21.940 | and exposure therapy

01:10:23.340 | and how they can be combined with drug treatments

01:10:26.160 | that are very effective.

01:10:27.360 | Much of what I'm going to talk about next

01:10:29.860 | relates to the data and indeed the practice

01:10:33.500 | of an incredible research scientist and clinician.

01:10:38.200 | So this is Helen Blair Simpson,

01:10:40.080 | or I should say Dr. Helen Blair Simpson,

01:10:42.080 | because she is indeed an MD, medical doctor,

01:10:44.380 | and a PhD research scientist

01:10:46.000 | at Columbia University School of Medicine.

01:10:49.180 | And one of the world's foremost experts,

01:10:52.240 | if not the expert,

01:10:53.500 | I would put her in a category

01:10:54.740 | of maybe just one to three people

01:10:56.700 | who is most knowledgeable about the mechanisms of OCD,

01:11:01.420 | is actively researching OCD in humans,

01:11:04.700 | trying to find new treatments,

01:11:06.100 | trying to unveil new mechanisms

01:11:08.740 | and expand on our current understanding,

01:11:10.740 | and who also treats OCD quite actively in her own clinic.

01:11:14.600 | Dr. Simpson gave a beautiful presentation

01:11:19.280 | in which she summarized some of the core elements of CBT

01:11:22.540 | and exposure therapy

01:11:23.700 | for the treatment of obsessive compulsive disorders.

01:11:26.140 | She describes that the key procedures are exposures,

01:11:29.260 | of course, done in person,

01:11:32.020 | and with the actual thing

01:11:33.520 | that evokes the obsessions and compulsions.

01:11:36.400 | So this could be the sweaty towel as described earlier,

01:11:39.600 | or could be any number of different triggers

01:11:42.960 | done with the patient in real time.

01:11:45.020 | So in vivo, as we say.

01:11:47.060 | And it could also be things that are imaginal,

01:11:50.220 | sitting somebody down in a chair in an office and saying,

01:11:53.300 | okay, I want you to imagine the thing

01:11:55.940 | that triggers the intrusive thought,

01:11:57.300 | or let's just focus on the intrusive thought as it arises,

01:12:01.000 | and then to explore and expose the patient

01:12:03.140 | to their obsessions and compulsions that way.

01:12:04.740 | So it can be real or it can be imaginal.

01:12:06.900 | And the goal, of course, then is to gradually

01:12:10.240 | and progressively increase the level of anxiety,

01:12:12.420 | but then to intervene in so-called ritual prevention,

01:12:15.340 | to prevent the person from engaging in the compulsion.

01:12:18.280 | The goals, again, I'm paraphrasing here,

01:12:20.900 | are to, as she states,

01:12:22.640 | disconfirm fears and challenge the beliefs about

01:12:27.420 | the obsessions and compulsions,

01:12:29.720 | to intervene in the thoughts and the behaviors,

01:12:31.560 | and to break the habit of ritualizing and avoiding.

01:12:34.080 | Now, how is this typically done?

01:12:35.420 | What are the nuts and bolts of this procedure?

01:12:38.460 | Typically, this is done through two planning sessions

01:12:42.280 | with the patient.

01:12:43.120 | So describing to the patient what will happen

01:12:45.420 | and when it will happen and how long it will happen,

01:12:47.760 | so they're not just thrown into this out of the blue.

01:12:51.080 | And then 15 exposure sessions done twice a week or more.

01:12:55.680 | So the one thing to really understand

01:12:57.080 | about cognitive behavioral therapy

01:12:58.480 | is that it can take some period of time,

01:13:00.200 | several or more weeks, as many as 10 or 12 weeks.

01:13:03.440 | However, as you'll soon learn,

01:13:05.120 | many of the drug treatments that are effective

01:13:06.880 | in treating OCD, either alone or in combination

01:13:09.720 | with behavioral therapies,

01:13:10.860 | also can take eight, 10, 12 weeks or longer.

01:13:13.920 | And many of those never work at all.

01:13:16.040 | So even though 10 to 12 weeks

01:13:17.720 | seems like a long period of time,

01:13:19.120 | it's actually pretty standard.

01:13:20.360 | If you'd like to see more complete description

01:13:22.540 | of the protocols for cognitive behavioral therapy

01:13:24.580 | and exposure therapy for OCD,

01:13:26.680 | I'll provide links to two papers, COSAC and FOA,

01:13:29.680 | F-O-A, which is published in 1997,

01:13:32.280 | which might seem like a long time ago,

01:13:33.560 | but nonetheless, the protocols are still very useful.

01:13:36.480 | And then the second paper is by that last author,

01:13:38.640 | Faux et al. in 2012,

01:13:40.720 | and we'll provide links to both of those.

01:13:42.900 | In addition, Dr. Blair Simpson and others have explored

01:13:46.960 | what are the best treatments for patients with OCD

01:13:50.360 | by comparing cognitive behavioral therapy alone,

01:13:53.600 | placebo, so essentially no intervention,

01:13:57.020 | or something that takes an equivalent amount of time

01:13:59.080 | but is not thought to be effective in treatment,

01:14:03.040 | as well as selective serotonin reuptake inhibitors.

01:14:07.340 | So what is an SSRI?

01:14:09.400 | An SSRI is a drug that prevents the reuptake

01:14:13.040 | of serotonin at the synapse.

01:14:14.780 | What are synapses?

01:14:15.620 | They're the little spaces between neurons

01:14:17.520 | where neurons communicate with one another

01:14:19.520 | by vomiting little bits of chemical into the space,

01:14:22.660 | the synapse, and then those chemicals

01:14:25.200 | either evoke or suppress the electrical activity

01:14:27.840 | of the next neuron across the synapse.

01:14:30.680 | And in this case, the neurotransmitter,

01:14:32.560 | the chemical that we're referring to is serotonin.

01:14:34.960 | SSRI, selective serotonin reuptake inhibitors,

01:14:38.640 | prevent the reuptake of the chemical that's left,

01:14:42.980 | in this case, the serotonin that's left in the synapse

01:14:45.360 | after that, I called it vomiting to be dramatic,

01:14:48.080 | but it's not actually a vomiting,

01:14:49.120 | the extrusion of the chemical into the synapse.

01:14:52.640 | And as a consequence, there's more serotonin around

01:14:55.760 | to have more of an effect over time,

01:14:57.680 | the net effect being more serotonergic transmission,

01:15:00.640 | more serotonin overall.

01:15:02.640 | So not more serotonin being made,

01:15:04.420 | more serotonin being available for use.

01:15:06.840 | That's what an SSRI does.

01:15:08.640 | So they compared cognitive behavioral therapy, SSRIs,

01:15:13.420 | they also had the placebo group,

01:15:14.640 | and they had cognitive behavioral therapy,

01:15:16.160 | plus the selective serotonin reuptake inhibitor.

01:15:19.920 | This was a 12-week study done as described before,

01:15:22.640 | two times a week over the course of 12 weeks.

01:15:25.360 | First of all, the most important thing, of course,

01:15:28.360 | placebo did nothing.

01:15:29.500 | It did not relieve the OCD to any significant degree, right?

01:15:34.500 | How did they know that?

01:15:35.640 | They gave them the Y-box test that we talked about before,

01:15:37.760 | the Yale-Brown test with all those questions

01:15:41.500 | of which I read a few.

01:15:42.920 | So the OCD severity that one has to have on the Y-box

01:15:47.460 | is measured in terms of an index

01:15:49.200 | that goes from here from eight all the way up to 28.

01:15:52.840 | That shouldn't mean anything.

01:15:53.840 | So the number eight is kind of meaningless here.

01:15:55.840 | It's in terms of an index

01:15:56.880 | that's only meaningful for the Y-box.

01:15:59.420 | But if somebody has a threshold of 16 or higher,

01:16:02.720 | it means that they're still having

01:16:04.080 | somewhat debilitating symptoms

01:16:05.400 | or very debilitating symptoms.

01:16:07.120 | Placebo did not reduce the obsessions or compulsions

01:16:10.400 | to any significant degree.

01:16:12.240 | However, and I think quite excitingly,

01:16:14.440 | cognitive behavioral therapy had a dramatic effect

01:16:19.000 | in reducing the obsessions and compulsions

01:16:22.280 | such that by four weeks,

01:16:23.980 | that score that in this case range from eight to 28

01:16:27.240 | dropped all the way from 25 down to about 11.

01:16:31.360 | So it was a huge drop in the severity of the symptoms.

01:16:35.160 | Now what's really interesting

01:16:36.560 | is that when you look at the effects of SSRIs

01:16:39.440 | in the treatment of OCD symptoms,

01:16:42.860 | they had a significant effect

01:16:44.780 | in reducing the symptoms of OCD

01:16:47.000 | that showed up first at four weeks

01:16:48.740 | and then continued to eight weeks.

01:16:51.260 | In fact, there was a progressive and further reduction

01:16:54.400 | in OCD symptoms from the four to eight week period.

01:16:57.080 | Again, these are the people just taking the SSRI.

01:16:59.920 | And then it sort of flattened out a little bit

01:17:01.600 | such that by 12 weeks,

01:17:03.060 | there was still a significant reduction in OCD symptoms

01:17:05.720 | for people taking SSRIs as compared to placebo.

01:17:08.980 | But the severity of their symptoms was still much greater

01:17:13.220 | than those receiving cognitive behavioral therapy alone.

01:17:16.540 | So at least in this study,

01:17:18.120 | and I should tell you which study it is,

01:17:19.620 | this is Faux Lebowitz et al. 2005

01:17:21.960 | in the American Journal of Psychiatry.

01:17:23.360 | We'll also provide a link to this

01:17:24.760 | so you can peruse the data if you like.

01:17:27.020 | But at least in this study,

01:17:28.400 | cognitive behavioral therapy was the most effective.

01:17:31.320 | Selective serotonin reuptake inhibitors, less effective.

01:17:35.080 | So what happens when you combine them?

01:17:36.680 | Well, they explored that as well.

01:17:38.120 | And the combination of cognitive behavioral therapy

01:17:40.600 | and the SSRIs together did not lead

01:17:44.420 | to any further decrease in OCD symptoms.

01:17:47.420 | This points to the idea that cognitive behavioral therapy

01:17:51.440 | is the most effective treatment.

01:17:52.780 | And again, when I say cognitive behavioral therapy,

01:17:54.520 | now I'm still referring to cognitive behavioral

01:17:56.480 | slash exposure therapy done in the way

01:17:58.720 | that I detailed before, twice a week for 12 weeks or more.

01:18:01.900 | So all of the data, at least in this study,

01:18:03.660 | point to the fact that cognitive behavioral therapy

01:18:05.840 | is really effective and the most effective.

01:18:08.400 | Does it alleviate OCD symptoms for everybody?

01:18:11.880 | No. Is it very time consuming?

01:18:13.440 | Yes. Twice a week for two sessions or more of 15 minutes,

01:18:17.680 | sometimes in the office, plus there's homework,

01:18:19.740 | plus in an ideal case, there's also home visits

01:18:22.260 | from the psychiatrist or psychologist.

01:18:24.200 | That's a lot of investment, a lot of time investment

01:18:28.500 | to say nothing of the potential financial investment.

01:18:31.560 | Now, Dr. Blair Simpson has given some beautiful talks

01:18:34.320 | where she describes these data and also emphasizes the fact

01:18:39.040 | that despite the demonstrated power

01:18:42.260 | of cognitive behavioral therapy for the treatment of OCD,

01:18:45.120 | most people are given drug treatments

01:18:46.560 | simply because of the availability of those drug treatments.

01:18:49.020 | Now, when I say most people, I want to emphasize

01:18:51.000 | that I'm referring to most people

01:18:52.840 | who actually go seek treatment,

01:18:54.720 | because a really important thing to realize

01:18:56.780 | is that most people with OCD

01:18:58.680 | do not actually go seek evidence-based treatment.

01:19:01.880 | I want to repeat that.

01:19:02.700 | Most people with OCD do not seek evidence-based treatment,

01:19:05.540 | which is a tragic thing.

01:19:06.820 | One of the motivations for doing this podcast episode

01:19:09.540 | is to try and encourage people

01:19:11.100 | who think they may have persistent obsessions

01:19:13.180 | and compulsions to seek treatment, but most people don't

01:19:17.980 | for a variety of reasons we spelled out earlier,

01:19:20.620 | shame, et cetera.

01:19:22.640 | Of those that do, the first line of attack

01:19:25.320 | is typically a prescription, most often an SSRI,

01:19:29.340 | although not always just SSRIs,

01:19:31.340 | because soon we'll talk about the somewhat common use

01:19:35.420 | of also prescribing a low dose of a neuroleptic

01:19:39.220 | or an antipsychotic, not always, but often.

01:19:42.540 | So the important thing to understand here

01:19:44.740 | is that excellent researchers like Dr. Simpson

01:19:47.540 | understand that while there are treatments

01:19:49.880 | that we could say are best or are ideal based on the data,

01:19:53.700 | that doesn't necessarily mean that's what's being deployed

01:19:56.700 | most often in the general public.

01:19:58.640 | As a consequence, Dr. Simpson and others have explored

01:20:02.680 | in a very practical way, whether or not it matters

01:20:05.800 | if somebody is getting SSRI treatment

01:20:09.820 | and is experiencing that reduction in OCD symptoms

01:20:14.240 | that as you may recall is more than what they would

01:20:17.900 | experience with placebo alone, but not as dramatic

01:20:21.000 | a reduction in OCD symptoms as they would get

01:20:22.940 | with cognitive behavioral therapy.

01:20:25.040 | And as I mentioned before, there was this exploration

01:20:27.500 | of combining drug treatment and cognitive behavioral therapy

01:20:30.320 | from the outset, but they also quite impressively explored

01:20:34.120 | what happens when people who are already taking SSRIs

01:20:37.240 | initiate cognitive behavioral therapy.

01:20:39.480 | This is a really wonderful thing that they've done this

01:20:41.700 | because in doing that, first of all, they're acknowledging

01:20:44.800 | that there are many people out there who have sought

01:20:46.840 | treatment and are getting some relief from those SSRIs,

01:20:49.780 | but it perhaps is not as much relief as they could get.

01:20:52.540 | And they are actively acknowledging that many people

01:20:56.300 | are getting these drug treatments first.

01:20:58.240 | In fact, most often people are getting

01:20:59.560 | these drug treatments first.

01:21:01.200 | So what happens when you add in cognitive behavioral therapy?

01:21:04.580 | Well, the good news is when you add cognitive

01:21:06.220 | behavioral therapy to someone who's already taking SSRIs,

01:21:10.800 | that further improves their symptoms.

01:21:13.200 | Now that's different than the results that I described

01:21:16.880 | before from the same laboratory in fact,

01:21:20.440 | that if you combine cognitive behavioral therapy

01:21:23.500 | with SSRIs from the outset, there's no additional benefit

01:21:27.160 | of SSRI, however, as I just described,

01:21:30.800 | if someone is already taking an SSRI

01:21:33.000 | and they're experiencing a reduction in their OCD symptoms

01:21:37.340 | by adding in cognitive behavioral therapy,

01:21:40.060 | there's a further reduction in the symptoms of OCD.

01:21:44.280 | It's very important.

01:21:45.120 | So for those of you that have sought treatment

01:21:46.740 | and you're taking a SSRI, or if you're thinking

01:21:49.700 | about treatment and you're prescribed an SSRI,

01:21:52.060 | the ideal scenario really would be to combine

01:21:54.240 | the drug treatment with cognitive behavioral therapy,

01:21:56.420 | or in some cases, maybe cognitive behavioral therapy alone,

01:21:58.780 | although that's a decision that you really have to make

01:22:00.940 | with the close advice and oversight of a licensed physician,

01:22:05.940 | because of course these are prescription drugs.

01:22:08.660 | And anytime you're going to add or remove a prescription drug

01:22:11.380 | or change dosage, you really want to do that

01:22:13.300 | in close discussion with and on the advice of your physician.

01:22:16.580 | I don't just say that to protect me,

01:22:17.680 | I say that to protect you,

01:22:18.580 | and 'cause it's just the right thing to do.

01:22:20.660 | So again, cognitive behavioral therapy is extremely powerful.

01:22:23.860 | Drug treatments seem less powerful,

01:22:25.860 | though if you're already on a drug treatment,

01:22:27.320 | adding cognitive behavioral therapy can really help.

01:22:29.620 | So I've been talking about SSRIs

01:22:30.980 | and described a little bit about how they work

01:22:32.520 | at a kind of superficial level

01:22:33.780 | of keeping more serotonin in the synapse

01:22:36.540 | so that more serotonin can be in action

01:22:39.540 | as opposed to gobbled back up by those neurons.

01:22:42.540 | I should just mention what some of the selective serotonin

01:22:44.500 | reuptake inhibitors are.

01:22:46.180 | So things like clomipramine,

01:22:49.480 | which is not entirely selective.

01:22:52.700 | I should say that that one generally falls

01:22:54.820 | into a category of less selective,

01:22:56.580 | so it can impair or can enhance

01:23:01.260 | some of the other neurotransmitter neuromodulator systems

01:23:04.060 | like epinephrine, et cetera.

01:23:05.820 | The selective serotonin reuptake inhibitors are,

01:23:09.380 | at least the classic ones are fluoxetine, Prozac,

01:23:11.900 | fluvoxamine, fluvox, peroxetine, sertraline,

01:23:15.560 | citalopram, et cetera, et cetera.

01:23:19.060 | There are about six classic SSRIs.

01:23:21.880 | Some of them like citalopram are used in children

01:23:25.260 | and are available in pediatric doses.

01:23:27.840 | Some like Prozac may or may not be used in children.

01:23:30.620 | The details of which SSRIs, et cetera,

01:23:33.700 | is a very extensive literature and discussion.

01:23:36.140 | And I think it's safe to say that which drugs to use

01:23:40.280 | and at which dosage and whether or not to continue,

01:23:43.700 | excuse me, the same dosage over time

01:23:45.080 | depends a lot on the individual variation

01:23:47.920 | that people express and the responses that they have.

01:23:50.460 | All of these drugs, in fact,

01:23:51.980 | I think we can say all drugs have side effects.

01:23:54.880 | The question is how detrimental those side effects are

01:23:58.540 | to daily life.

01:23:59.380 | The SSRIs are well-known to have effects on appetite.

01:24:02.360 | In some cases, they abolish appetite.

01:24:04.880 | In some cases, they just reduce it a little bit.

01:24:06.920 | In some cases, they increase appetite,

01:24:09.120 | really is highly individual.

01:24:10.740 | They can have effects on libido.

01:24:12.320 | For instance, they can reduce sex drive,

01:24:14.680 | sometimes in a dose-dependent way,

01:24:17.140 | sometimes in a way that's more like a step function

01:24:19.320 | where people are fine at say five or 10 milligrams,

01:24:22.080 | but then they get to 15 milligrams

01:24:24.960 | and there's a cliff for their libido.

01:24:27.900 | That can happen, it really depends.

01:24:30.520 | Please don't take those dosages as exact values

01:24:32.660 | 'cause this is going to depend on what they're being used for

01:24:35.740 | depression or anxiety or OCD.

01:24:37.580 | And it's also going to depend on the drug, et cetera,

01:24:39.500 | just throughout those numbers as a way to illustrate

01:24:41.980 | what a kind of a step function would look like.

01:24:43.860 | It's not gradual, it's immediate at a given dose

01:24:46.180 | is what that means.

01:24:47.660 | The other thing is that some of these drugs

01:24:50.860 | will have transient effects,

01:24:52.860 | so side effects that show up and then disappear,

01:24:54.700 | or sadly, people will sometimes take these drugs for a while

01:24:57.620 | and then side effects will surface later

01:24:59.080 | that weren't there previously,

01:25:00.860 | depending on life factors and nutrition factors.

01:25:03.020 | So it's a very complicated landscape overall.

01:25:05.820 | And that's why it's really important

01:25:06.860 | to explore any kind of drug treatment,

01:25:08.460 | SSRI or otherwise, really in close communication

01:25:11.360 | with a psychiatrist who really understands

01:25:13.340 | the pharmacokinetics and has a lot of patient history

01:25:15.620 | and experience with them.

01:25:17.100 | So what I'm about to tell you next

01:25:18.340 | is most certainly going to come as a big surprise,

01:25:20.780 | which is that despite the fact

01:25:22.860 | that the selective serotonin reuptake inhibitors

01:25:24.900 | can be effective in reducing the symptoms of OCD,

01:25:27.660 | at least somewhat, and certainly more than placebo,

01:25:31.260 | there is very little, if any, evidence

01:25:33.760 | that the serotonin system is disrupted in OCD.

01:25:36.820 | And I have to point out that this is a somewhat

01:25:39.480 | consistent theme in the field of psychiatry.

01:25:42.260 | That is, a given drug can be very effective

01:25:45.300 | or even partially effective in reducing symptoms

01:25:48.480 | or in changing the overall landscape

01:25:50.860 | of a psychiatric disorder or illness.

01:25:53.620 | And yet there is very little, if any, evidence

01:25:56.880 | that that particular system is what's causal

01:25:59.780 | for OCD or anxiety or depression, et cetera.

01:26:03.780 | This is just the landscape that we're living in

01:26:05.420 | in terms of our understanding of the brain and psychiatry

01:26:07.620 | and the ways of treating brain disorders.

01:26:09.700 | So as a consequence, there are a huge number

01:26:12.460 | of academic reviews that clinicians and research scientists

01:26:15.680 | have generated and read and share.

01:26:18.300 | One of the more, I think, thorough ones in recent years

01:26:23.060 | was published in 2021.

01:26:24.720 | I'll provide a link to this.

01:26:25.660 | This is by an excellent, truly excellent researcher

01:26:29.080 | from Yale University School of Medicine.

01:26:31.240 | I should say not just a researcher,

01:26:32.460 | but a clinician scientist, again, an MD, PhD.

01:26:34.980 | This is Christopher Pittenger.

01:26:37.180 | And the title of the review is

01:26:38.260 | "Pharmacotherapeutic Strategies and New Targets in OCD."

01:26:43.260 | And again, we'll provide a link to it.

01:26:46.700 | This is a just gorgeous review describing,

01:26:49.640 | as I just told you, that the serotonin system

01:26:51.420 | isn't really disrupted in OCD,

01:26:53.340 | and yet SSRIs can be very effective.

01:26:56.000 | The review goes on to explore even what sorts of receptors

01:27:00.080 | for serotonin might be involved,

01:27:01.800 | if it's in fact the case that serotonin is a culprit

01:27:06.620 | in the creation of OCD symptoms.

01:27:10.160 | Talk about the serotonin 2A receptor

01:27:13.780 | and the serotonin 1A receptor.

01:27:15.140 | Why am I mentioning all that detail if, in fact,

01:27:17.700 | it's not clear serotonin is involved?

01:27:19.200 | Because I'll just tell you right now,

01:27:21.780 | there is currently a lot of interest in whether or not

01:27:24.060 | some of the psychedelics, in particular psilocybin,

01:27:26.800 | can be effective in the treatment of OCD.

01:27:29.460 | Psilocybin has been shown in various clinical trials,

01:27:32.540 | in particular the clinical trials done

01:27:34.020 | at Johns Hopkins School of Medicine by Matthew Johnson

01:27:36.880 | and others.

01:27:37.720 | Matthew is on the Huberman Lab Podcast.

01:27:39.380 | He's been on the Tim Ferriss Podcast.

01:27:40.980 | He's been on the Lex Friedman Podcast.

01:27:42.980 | He's a world-class researcher on the use of psychedelics

01:27:45.320 | for depression and other psychiatric challenges.

01:27:49.460 | And there, psilocybin treatment has been seen,

01:27:52.680 | at least in those trials, to be very effective

01:27:54.540 | in the treatment of certain kinds of major depression.

01:27:58.020 | Currently, the exploration of psilocybin

01:28:00.180 | for the treatment of OCD has not yielded similar results,

01:28:03.720 | although the studies are ongoing.

01:28:05.420 | Again, has not yielded similar effectiveness,

01:28:07.500 | but the studies are ongoing.

01:28:09.080 | And the serotonin 2A receptor and the serotonin 1A receptors

01:28:12.740 | are primary targets for the drug psilocybin.

01:28:16.420 | So I figured there were going to be some questions

01:28:17.840 | about whether or not psychedelics help with OCD.

01:28:20.740 | Thus far, it's inconclusive.

01:28:23.000 | If any of you have been part of clinical trials

01:28:25.440 | or have knowledge or intuition about this relationship,

01:28:28.540 | or potential relationship, I should say,

01:28:30.060 | between psilocybin or other psychedelics and OCD,

01:28:32.700 | please put them in the comment section.

01:28:33.880 | We'd love to hear from you.

01:28:35.940 | One thing I should point out is that even though

01:28:39.800 | serotonin has not been directly implicated in OCD,

01:28:43.020 | serotonin and the general systems of serotonin,

01:28:45.680 | the circuits in the brain that carry serotonin

01:28:47.500 | and depend on it, have been shown

01:28:49.960 | to impact cognitive flexibility and inflexibility,

01:28:53.860 | which are kind of hallmark themes of OCD.

01:28:56.080 | So in animals that have their serotonin depleted,

01:28:59.080 | or in humans that have very low levels of serotonin,

01:29:01.920 | you can see evidence of cognitive inflexibility,

01:29:05.820 | challenges in task switching,

01:29:07.440 | challenges in switching the rules

01:29:09.040 | by which one performs a game,

01:29:10.780 | challenges in any kind of cognitive domain switching.

01:29:14.780 | And so that does indirectly implicate serotonin

01:29:17.960 | in some of the aspects of OCD.

01:29:20.060 | Again, when one starts to explore

01:29:21.760 | the different transmitter systems that have been explored

01:29:24.200 | in animal models and in humans, it's a vast, vast landscape,

01:29:27.780 | but serotonergic drugs do seem to be the most effective drugs

01:29:32.100 | in treating OCD, despite the fact, again,

01:29:34.740 | despite the fact that there's no direct evidence

01:29:37.200 | that serotonin systems are the problem in OCD.

01:29:42.080 | If you recall the corticostriatal thalamic loop

01:29:45.160 | that is so central to the etiology,

01:29:48.900 | the presence and the patterns of symptoms in OCD,

01:29:52.460 | of course, serotonin is impacting that system.

01:29:54.620 | Serotonin is impacting just about every system in the brain,

01:29:57.360 | but there's no evidence that tinkering

01:29:59.640 | with serotonin levels specifically in that network

01:30:02.760 | is what's leading to the improvements in OCD.

01:30:06.480 | However, if people go into a fMRI scanner

01:30:10.220 | and those people have OCD

01:30:11.520 | and they evoke the obsessions and compulsions,

01:30:13.360 | you see activity in that corticostriatal thalamic loop.

01:30:17.400 | Treatments like SSRIs that reduce the symptoms of OCD

01:30:21.880 | equate to a situation where there is less activity

01:30:24.560 | in that loop.

01:30:26.100 | And I should point out cognitive behavioral therapy,

01:30:29.200 | which we have no reason to believe

01:30:30.860 | only taps into the serotonin system.

01:30:32.540 | I think it would be, extreme strategy would be false,

01:30:35.460 | actually, to say that cognitive behavioral therapy

01:30:37.440 | taps only into the serotonin system.

01:30:39.600 | Clearly, it's going to affect a huge number of circuits

01:30:41.660 | in neurochemical systems.

01:30:43.000 | Well, people who do cognitive behavioral therapy

01:30:45.620 | and find some relief for OCD,

01:30:47.520 | they also show reductions

01:30:49.040 | in those corticostriatal thalamic loops.

01:30:51.780 | So basically, we have a situation

01:30:53.200 | where we have a behavioral therapy

01:30:55.000 | that works in many people, not all,

01:30:57.840 | and we have a pretty good understanding

01:30:59.060 | of about why it works.

01:31:00.080 | It increases anxiety tolerance

01:31:01.920 | and interference with pattern execution,

01:31:06.920 | getting people to not engage in the same sorts of behaviors

01:31:10.300 | that are detrimental to them.

01:31:12.140 | And we have drug treatments that work,

01:31:14.220 | at least to some degree,

01:31:15.180 | but we don't know how they work

01:31:16.460 | or where they work in the brain.

01:31:17.820 | One of the things that really unifies

01:31:19.960 | the behavioral treatments and the drug treatments

01:31:23.360 | is that they take some period of time.

01:31:25.400 | Some relief from symptoms seems to show up around four weeks

01:31:28.160 | and certainly by eight weeks

01:31:29.840 | for both cognitive behavioral therapy and the SSRIs,

01:31:33.180 | but it's really at the 10 to 12 week stage

01:31:36.360 | when someone's been doing these twice a week

01:31:38.000 | cognitive behavioral sessions,

01:31:39.940 | where they've been taking a SSRI for 10 to 12 weeks,

01:31:43.600 | that the really significant reduction in OCD symptoms

01:31:47.640 | starts to really show up.

01:31:49.140 | Now, up until now, I've been talking about the fact

01:31:51.120 | that people are getting relief from these treatments.

01:31:53.960 | But sadly, in the case of OCD,

01:31:57.240 | there is a significant population

01:32:00.520 | that simply does not respond to CBT or to SSRIs

01:32:05.440 | or to their combination,

01:32:06.560 | which is why psychiatrists also explore the combination

01:32:10.520 | of SSRIs and neuroleptics,

01:32:13.440 | or drugs that tap into the so-called dopamine system

01:32:16.120 | or the glutamate system.

01:32:17.400 | These are other neurotransmitters and neuromodulators

01:32:20.000 | that impact different circuits in the brain.

01:32:21.780 | And just to really remind you

01:32:23.040 | what neurotransmitters and neuromodulators do,

01:32:25.120 | because this is important to contextualize all this,

01:32:28.080 | neurotransmitters are typically involved

01:32:29.720 | in the rapid communication between neurons.

01:32:32.800 | And the two most common neurotransmitters for that

01:32:34.800 | are the neurotransmitter glutamate,

01:32:37.160 | which we say is excitatory,

01:32:38.560 | meaning when it's released into the synapse,

01:32:40.080 | it causes the next neuron to be more active or active,

01:32:43.600 | and GABA, which is a neurotransmitter that is inhibitory,

01:32:46.800 | meaning when it's released into the synapse,

01:32:48.620 | typically, not always, but typically,

01:32:50.640 | that GABA is going to encourage the next neuron

01:32:53.040 | to be less electrically active or even silence its activity.

01:32:56.100 | The neuromodulators, by contrast,

01:32:59.760 | so not neurotransmitters, but neuromodulators,

01:33:01.920 | like dopamine, serotonin, epinephrine,

01:33:03.920 | and acetylcholine, and others,

01:33:05.780 | operate a little bit differently.

01:33:08.460 | They intend to act a little bit more broadly.

01:33:10.560 | They can act within the synapse,

01:33:12.320 | but they can also change the general patterns

01:33:15.160 | of activity in the brain,

01:33:16.340 | making certain circuits more likely to be active

01:33:18.800 | and other circuits less likely to be active.

01:33:21.400 | So when we say dopamine does X or dopamine does Y

01:33:24.720 | or serotonin does X or serotonin does Y,

01:33:26.480 | they don't really do one thing.

01:33:28.080 | They change the sort of overall tonality.

01:33:30.520 | They make it more likely or less likely

01:33:32.060 | that certain circuits will be active.

01:33:33.820 | You can think of them as kind of activating playlists

01:33:36.460 | or genres of activity in the brain

01:33:39.500 | rather than being involved in the specific communication

01:33:42.320 | or specific songs, if you will, in this analogy,

01:33:45.100 | or discussions between particular neurons.

01:33:47.380 | So when we hear that SSRIs increase serotonin

01:33:51.480 | and reduce the symptoms of OCD,

01:33:53.400 | or a neuroleptic reduces the amount of dopamine

01:33:56.480 | and makes people feel calmer, for instance,

01:33:59.760 | or can remove some stereotype repetitive motor behavior,

01:34:04.760 | which they can either generate

01:34:06.820 | or reduce motor behavior, it turns out.

01:34:09.400 | So when I say that, what I'm referring to is the fact

01:34:11.800 | that these neuromodulators are turning up the volume

01:34:14.720 | on certain circuits and turning down the volume

01:34:16.900 | on other circuits.

01:34:18.520 | I say that because if you are going to explore

01:34:22.040 | drug treatments, again, with a licensed physician,

01:34:25.400 | if you're going to explore drug treatments for OCD,

01:34:28.340 | and in particular, if you are not getting results

01:34:31.760 | from SSRIs or you're not getting results

01:34:34.400 | from cognitive behavioral therapy

01:34:35.620 | or the side effect profiles of the drugs

01:34:37.540 | that you're taking for OCD are causing problems

01:34:41.360 | that you don't want to take them,

01:34:43.080 | well, then it's important to understand

01:34:44.960 | that anytime you take one of these drugs,

01:34:47.080 | they're not acting specifically

01:34:48.780 | on the corticostriatal thalamic circuit.

01:34:51.460 | That would be wonderful.

01:34:52.300 | That's the future of psychiatry.

01:34:54.280 | But as now, when you take a drug, it acts systemically.

01:34:58.300 | So it's impacting serotonin in your gut.

01:35:00.560 | It's also impacting serotonin in other areas of the brain.

01:35:02.760 | Hence the effects on things like digestion or libido

01:35:06.920 | or any number of different things

01:35:08.960 | that serotonin is involved in.

01:35:10.860 | Likewise, if you take a neuroleptic,

01:35:12.400 | like haloperidol or something

01:35:14.360 | that reduces dopamine transmission,

01:35:17.540 | well, then it's going to have some motor effects

01:35:19.340 | 'cause dopamine is involved in the generation

01:35:21.400 | of motor sequences and smooth limb movement.

01:35:23.660 | That's why people with Parkinson's

01:35:24.760 | who don't have much dopamine will get a resting tremor,

01:35:27.040 | have a hard time generating smooth movement.

01:35:28.600 | And so the side effects start to make sense

01:35:31.040 | given the huge number of different neural circuits

01:35:33.600 | that these different neuromodulators are involved in.

01:35:35.960 | I don't say that to be discouraging.

01:35:37.960 | I say that to encourage patients

01:35:40.800 | and careful systematic exploration

01:35:43.000 | of different drug treatments for OCD.

01:35:45.520 | Always again, with the careful and close guidance

01:35:50.480 | and oversight of a psychiatrist

01:35:52.040 | because psychiatrists really understand

01:35:53.680 | which side effect profiles make it likely

01:35:56.160 | that you can or cannot or will never,

01:36:00.480 | or maybe someday we'll be able to take a given drug

01:36:02.560 | at a given dose.

01:36:03.580 | They are the ones that really have that knowledge.

01:36:05.260 | This is not the sort of thing that you want a cowboy

01:36:07.280 | and go try and figure out yourself.

01:36:09.520 | Now, I also want to acknowledge

01:36:11.620 | that there are other forms of drug treatments.

01:36:13.480 | We touched on psilocybin briefly,

01:36:15.120 | but there are other forms of drug treatments

01:36:16.860 | that have been explored for OCD.

01:36:19.200 | Earlier, we talked a little bit about cannabis.

01:36:21.200 | Why would cannabis be a place of exploration at all?

01:36:25.640 | Well, first of all,

01:36:26.580 | a number of people try and self-medicate for OCD.

01:36:29.600 | There is some clinical evidence,

01:36:31.360 | I'm not talking about recreational use,

01:36:32.680 | I'm talking about clinical evidence

01:36:33.760 | that cannabis can reduce anxiety.

01:36:35.600 | Now, earlier we were talking about not reducing anxiety,

01:36:38.800 | but learning anxiety tolerance in order to deal with

01:36:43.120 | and treat OCD in the context of cognitive behavioral

01:36:46.120 | therapies.

01:36:47.800 | That doesn't necessarily rule out cannabis

01:36:49.480 | as a candidate for the treatment of OCD.

01:36:52.920 | And in fact, this has been explored.

01:36:54.620 | A study from Dr. Blair Simpson herself looked at this.

01:36:59.200 | This was a fairly small scale study.

01:37:00.940 | So first of all, I'll give you the title,

01:37:02.240 | and again, we'll provide a link.

01:37:03.360 | This is entitled Acute Effects of Cannabinoids

01:37:05.500 | on Symptoms of Obsessive Compulsive Disorder,

01:37:07.600 | a human laboratory study.

01:37:09.420 | Very briefly, this was 14 adults with OCD.

01:37:12.080 | They had prior experience with cannabis.

01:37:14.380 | This was randomized, placebo controlled.

01:37:16.540 | The cannabis was smoked.

01:37:19.080 | They had different varietals, as they're called.

01:37:21.500 | They had a placebo.

01:37:22.400 | So this is basically a condition in which certain subjects

01:37:26.780 | consumed a cigarette that had 0% THC,

01:37:30.200 | others had 7% THC, other groups that is,

01:37:33.200 | or some had 0.4% CBD and THC.

01:37:37.960 | So they looked at CBD.

01:37:39.000 | I know a lot of people out there interested in CBD.

01:37:41.320 | There's one of the few studies I could find

01:37:42.640 | where they explore different percentages of THC and CBD

01:37:46.600 | in these cannabis or marijuana cigarettes, basically.

01:37:50.960 | The total amount that they consumed,

01:37:52.900 | I believe was 800 milligrams.

01:37:54.640 | These again are not suggestions.

01:37:56.680 | This is just simply reporting what's in this study.

01:37:58.660 | You can, again, I'll provide a link.

01:38:01.600 | They looked at OCD symptoms ratings.

01:38:04.720 | They looked at cardiovascular effects.

01:38:06.820 | They had a large number of different things

01:38:08.520 | that they explored.

01:38:09.460 | And I should say this study was done in 2020,

01:38:11.880 | and it was the first placebo controlled investigation

01:38:15.040 | of cannabis in adults with obsessive compulsive disorder.

01:38:18.040 | Pretty interesting.

01:38:19.180 | And I'm just reading from their conclusions here.

01:38:21.580 | The data suggests that smoked cannabis,

01:38:23.280 | whether containing primarily THC or CBD,

01:38:26.480 | remember they looked at different concentrations of those,

01:38:28.480 | has little acute impact,

01:38:30.280 | meaning immediate impact on OCD symptoms

01:38:32.640 | and yield smaller reductions in anxiety compared to placebo.

01:38:37.140 | So they did not see a, when I say a positive effect,

01:38:40.400 | I mean a ameliorative effect,

01:38:43.200 | an effect in reducing symptoms of OCD from cannabis or CBD,

01:38:47.640 | which, you know, it's unfortunate.

01:38:49.680 | I think it's unfortunate anytime a treatment doesn't work,

01:38:51.560 | but nonetheless, those are the data.

01:38:52.840 | I'm sure there are going to be other studies.

01:38:54.520 | I'm sure there are also going to be people

01:38:55.680 | in the YouTube comments section

01:38:56.880 | saying that cannabis and CBD helps their OCD symptoms.

01:39:01.600 | At least I anticipate there probably will.

01:39:04.040 | Almost everything I say here,

01:39:05.120 | somebody will contradict it with something

01:39:06.700 | from their experience, which I encourage, by the way.

01:39:08.900 | I want to hear about your experience with certain things,

01:39:11.280 | even if it's not from randomized placebo controlled studies,

01:39:14.360 | I still find it very interesting

01:39:15.840 | to know what people are doing and what they're experiencing.

01:39:18.240 | I think that's one of the better uses

01:39:19.740 | of social media comment sections

01:39:21.140 | is to be able to share some of that,

01:39:22.600 | not in an advice giving way or prescriptive way,

01:39:25.220 | but simply as a way to share

01:39:26.960 | and encourage different types of exploration.

01:39:29.040 | There are other sorts of drug treatments

01:39:30.320 | that are gaining popularity for OCD,

01:39:32.940 | at least in the research realm.

01:39:34.720 | One treatment that is a legal, L-E-G-A-L, right?

01:39:38.180 | Sometimes when I say legal,

01:39:39.160 | sometimes people think I say illegal,

01:39:40.460 | but that is legal, at least by prescription

01:39:43.440 | in the United States, is ketamine.

01:39:45.840 | The actions of ketamine are somewhat complex.

01:39:49.340 | Although we know, for instance,

01:39:50.500 | that ketamine acts on the glutamate system,

01:39:52.700 | it tends to disrupt the transmission

01:39:56.400 | or the relationship, I should say,

01:39:58.480 | between glutamate, right?

01:40:00.480 | Not glutamine, not the amino acid,

01:40:02.080 | but glutamate, the neurotransmitter,

01:40:04.260 | and the so-called NMDA, the N-methyl-D-aspartate receptor,

01:40:07.860 | which is a receptor that's very special

01:40:10.560 | in the nervous system,

01:40:11.400 | because when glutamate binds to the NMDA receptor,

01:40:14.320 | it tends to offer the opportunity

01:40:17.300 | for that particular synapse to get stronger,

01:40:19.140 | so-called neuroplasticity.

01:40:20.580 | And ketamine is essentially an antagonist,

01:40:24.360 | although it works through a complicated mechanism,

01:40:26.360 | it tends to block that binding of glutamate

01:40:30.440 | to the NMDA receptor or the effectiveness of that.

01:40:32.640 | Ketamine therapy is now being used quite extensively

01:40:35.640 | for the treatment of trauma and for depression.

01:40:37.520 | It leads to a dissociative state.

01:40:39.520 | It's a so-called dissociative analgesic.

01:40:42.480 | And there are a variety of ways in which that happens.

01:40:44.640 | We did an episode on depression.

01:40:45.920 | We're going to do another entire episode

01:40:47.400 | all about ketamine,

01:40:48.840 | describing the networks that ketamine impacts, et cetera.

01:40:51.200 | Ketamine therapies are being explored for OCD.

01:40:54.020 | As of now, the data look somewhat promising,

01:40:57.620 | but there's still a lot more work that needs to be done.

01:41:00.500 | My read of the data

01:41:01.720 | are that the more extensive clinical trials

01:41:05.300 | have not happened yet.

01:41:06.380 | The smaller studies that have happened

01:41:09.260 | reveal that some patients do get some relief

01:41:11.340 | from ketamine therapy for OCD,

01:41:13.480 | but there was nothing overwhelmingly pointing to the fact

01:41:17.360 | that ketamine is a magic bullet for OCD treatment.

01:41:21.520 | So cannabis CBD, at least now,

01:41:24.400 | even though it's one smaller study,

01:41:26.540 | there's no real evidence that it can alleviate OCD symptoms.

01:41:30.820 | If there are new studies published soon,

01:41:33.240 | I'll be sure to update you.

01:41:34.600 | And if you see those studies, please send them to me.

01:41:36.520 | Ketamine therapy, the jury is still out.

01:41:38.880 | Psilocybin, the jury is still out.

01:41:40.800 | These are early days.

01:41:42.400 | Another treatment that's becoming somewhat common,

01:41:45.400 | or at least people are commonly excited about

01:41:47.680 | is transcranial magnetic stimulation.

01:41:49.960 | So this is the use of a magnetic coil.

01:41:52.260 | This is completely noninvasive,

01:41:53.880 | placed on one portion of the skull,

01:41:56.980 | and one can direct magnetic energy

01:42:01.440 | toward particular areas of the brain

01:42:03.120 | to either suppress or nowadays,

01:42:04.920 | you can also activate particular brain regions.

01:42:07.400 | There are some interesting data showing that if TMS

01:42:09.480 | is applied to areas of the brain

01:42:11.500 | involved in the generation of motor action,

01:42:13.960 | so the so-called motor areas or supplementary motor areas

01:42:17.240 | as they're called, while people think about

01:42:20.720 | or have intrusive thoughts,

01:42:23.160 | we know that the TMS coil can interrupt the motor behaviors,

01:42:27.120 | the compulsive behaviors,

01:42:29.080 | and at least in a small cohort of studies,

01:42:32.220 | in a small number of patients within those studies,

01:42:35.080 | this has been shown to be effective,

01:42:37.360 | not just while the coil is on the head, of course,

01:42:39.400 | but after the study has been performed

01:42:41.920 | or the treatment's been performed

01:42:43.440 | in reducing OCD symptoms by disrupting the tendency

01:42:47.820 | for the compulsive behavior to be so automatic.

01:42:51.540 | One of the key features of obsessive compulsive disorder

01:42:54.760 | is that, especially if it's been around for a while,

01:42:58.620 | the person's been dealing with it for a while,

01:43:00.320 | there isn't a pattern in which the person thinks,

01:43:03.380 | oh, I have this contamination fear, or I need symmetry,

01:43:07.360 | or I'm kind of obsessed to count to the number seven,

01:43:09.680 | and then they pause and they go, ooh, and then they do it.

01:43:12.860 | No, typically, there's a very close pairing

01:43:16.240 | of the obsession and the compulsion in time

01:43:18.540 | so that somebody's walking down the street

01:43:19.920 | thinking, one, two, three, four, five, six, seven,

01:43:21.160 | one, two, three, four, five, six, seven, seven,

01:43:22.360 | seven, seven, seven, seven, seven, seven,

01:43:23.800 | and they're doing this in such rapid succession

01:43:27.100 | because the obsessions are coming up so quickly, right?

01:43:29.380 | Thoughts can be generated very quickly,

01:43:31.640 | and then they're generating the compulsions

01:43:33.180 | as a way to beat down or to try and suppress that anxiety,

01:43:36.640 | and then it comes right back up again

01:43:38.080 | at even stronger, as I described earlier.

01:43:40.360 | So transcranial magnetic stimulation

01:43:42.440 | seems to intervene in these very fast processes.

01:43:45.060 | Right now, I don't think it's fair to say

01:43:48.260 | that TMS is a magic bullet either.

01:43:50.740 | I think there's a lot of excitement about TMS,

01:43:52.440 | and in particular, I really want to nail this point home.

01:43:55.840 | In particular, there's excitement about the combination

01:43:59.480 | of TMS with drug treatments or the combination of TMS

01:44:03.760 | with cognitive behavioral therapy,

01:44:05.860 | and this is a really important point,

01:44:07.440 | not just for sake of discussion

01:44:08.660 | about obsessive-compulsive disorder,

01:44:10.200 | but also depression, ADHD, schizophrenia,

01:44:14.720 | any number of different psychiatric challenges

01:44:17.720 | and disorders in most cases are going to respond best

01:44:21.440 | to a combination of behavioral treatment that's ongoing

01:44:24.160 | that occurs in the laboratory and clinical setting,

01:44:26.040 | but also in the home setting where there's homework,

01:44:28.700 | maybe even home visits.

01:44:29.900 | Drug treatments often, not always,

01:44:33.640 | are a terrific augment to those cognitive behavioral

01:44:36.260 | therapies or other behavioral therapies,

01:44:38.020 | and then now we are living in the age of

01:44:40.180 | brain-machine interface.

01:44:41.260 | You have companies like Neuralink that,

01:44:43.580 | I think it's fair to say,

01:44:44.420 | are going to enter the brain-machine interface world

01:44:47.660 | first through the treatment of certain syndromes, right?

01:44:51.920 | Movement syndromes or psychiatric syndromes,

01:44:53.900 | probably before they start putting electrodes

01:44:56.120 | into the brain to stimulate enhanced memory

01:44:58.620 | or enhanced cognition.

01:44:59.580 | Who knows?

01:45:00.420 | I don't know exactly what they're doing

01:45:01.820 | behind the walls of Neuralink, but I have to imagine,

01:45:04.180 | in fact, I would wager, maybe not both arms,

01:45:06.760 | but I'll wager my left arm,

01:45:08.300 | that the first set of FDA-approved technologies

01:45:13.300 | to come out of companies like Neuralink

01:45:15.940 | are going to be those for the treatment of things

01:45:17.360 | like Parkinson's and movement disorders

01:45:19.180 | and cognitive disorders,

01:45:20.100 | rather than, shall we say, kind of recreational

01:45:23.980 | cognitive enhancement or things of that sort.

01:45:26.060 | So transcranial magnetic stimulation is noninvasive.

01:45:28.500 | It doesn't involve going down below the skull,

01:45:30.860 | can have some effect,

01:45:31.900 | but most laboratories that I'm aware of

01:45:34.260 | at Stanford and elsewhere

01:45:36.180 | that are exploring TMS for things like OCD

01:45:38.360 | and other types of psychiatric challenges

01:45:41.420 | are using TMS in combination with drug therapies,

01:45:44.540 | are using, in some cases,

01:45:46.340 | for instance, a laboratory at Stanford,

01:45:48.280 | hope to get them on the podcast,

01:45:50.180 | a psychiatrist, Nolan Williams,

01:45:51.760 | is exploring TMS in combination with psychedelic therapies,

01:45:55.080 | not necessarily at the same time,

01:45:56.340 | but nonetheless combining them

01:45:58.020 | or exploring how they impact brain circuitry.

01:46:00.480 | So if you have OCD, should you run out and get TMS

01:46:03.200 | or should you try ketamine therapy,

01:46:04.880 | of course, with a licensed physician?

01:46:06.380 | I think it's too early to say yes.

01:46:08.460 | I think the answer is we need to wait and see.

01:46:11.360 | I think cognitive behavioral therapy,

01:46:12.900 | the SSRIs and some other drug treatments

01:46:15.080 | like neuroleptics combined with SSRIs

01:46:17.580 | and cognitive behavioral therapy

01:46:19.360 | are where the real bulk of the data are.

01:46:22.500 | I want to make one additional point about cannabis CBD

01:46:25.120 | as it relates to obsessive compulsive disorder.

01:46:27.820 | To me, it's not at all surprising

01:46:30.160 | that cannabis CBD did not improve symptoms of OCD

01:46:34.340 | because in my discussion with Dr. Paul Conte a few weeks ago,

01:46:38.260 | and as you mentioned, Dr. Conte is indeed a medical doctor,

01:46:40.780 | a psychiatrist, we were talking about cannabis

01:46:44.240 | and its various uses

01:46:45.220 | because it does have some clinical applications.

01:46:48.220 | And he mentioned that one of the main effects of cannabis

01:46:51.540 | is to tighten focus and to enhance concentration on

01:46:56.540 | and thoughts about one particular thing.

01:47:00.420 | And in some cases that can be clinically beneficial

01:47:03.060 | and in other cases that can be clinically detrimental.

01:47:06.100 | If you accept the idea that cannabis increases focus

01:47:11.100 | and you think about OCD and the networks involved

01:47:15.860 | and you think about the anxiety and the relationship

01:47:18.120 | between the obsession and compulsion,

01:47:20.860 | well then it shouldn't come as any surprise

01:47:22.620 | that cannabis did not improve the symptoms of OCD

01:47:26.100 | because if anything, it would increase focus

01:47:28.980 | on the obsessions and the compulsions.

01:47:30.820 | Now that's not what they observed.

01:47:31.920 | They did not see an exacerbation or a worsening

01:47:35.380 | of the symptoms of OCD with cannabis.

01:47:37.340 | At least that's not my read of the data,

01:47:39.100 | but they did not see an improvement

01:47:41.060 | in OCD symptoms with cannabis or CBD.

01:47:44.100 | And to me, that's not surprising

01:47:46.060 | given that cannabis CBD seems to increase focus.

01:47:49.540 | Next, I'd like to talk about some of the research on

01:47:52.020 | and the roles of hormones in OCD

01:47:55.060 | because it turns out to be

01:47:55.900 | a very interesting relationship there.

01:47:57.840 | But before I do, I want to point out something that

01:48:00.260 | I realize I probably should have said earlier,

01:48:02.460 | which is one of the key things for someone with OCD

01:48:05.560 | to come to understand if they're going to experience

01:48:08.160 | any relief of their symptoms,

01:48:09.780 | whether or not they're doing drug treatments

01:48:10.940 | or behavioral treatments or otherwise,

01:48:12.960 | is that thoughts are not as bad as actions, right?

01:48:17.960 | Thoughts are not as bad as actions.

01:48:20.720 | One of the kind of rules that people with OCD

01:48:24.080 | seem to adopt for themselves

01:48:26.120 | is that thoughts are really truly the equivalent of actions.

01:48:30.280 | So they'll have an intrusive thought,

01:48:31.840 | and we haven't spent too much time on this today,

01:48:33.960 | but earlier I touched on the fact that

01:48:36.280 | some of the intrusive thoughts that people have in OCD

01:48:39.240 | are really disturbing.

01:48:40.420 | They can be really gross or at least gross to that person.

01:48:44.080 | They can evoke imagery that is toxic or infectious

01:48:49.000 | or is highly sexualized in a way that is disturbing to them,

01:48:52.840 | can be very taboo.

01:48:54.440 | This is not uncommon when you start talking to people

01:48:57.160 | with OCD and you start pulling on the thread.

01:48:59.460 | Again, this would be a psychiatrist who was trained

01:49:02.480 | to ask the right questions and gain the comfort

01:49:04.720 | and trust of a patient.

01:49:05.880 | They start to reveal that these thoughts

01:49:07.680 | are really intrusive and kind of disturbing,

01:49:09.600 | which is why they feel so compelled

01:49:11.180 | to try and suppress them with behaviors.

01:49:13.320 | One of the powerful elements of treatment for OCD

01:49:17.240 | is to really support the patient

01:49:20.440 | and make them realize that thoughts are just thoughts.

01:49:24.240 | And that everyone has disturbing thoughts.

01:49:26.480 | And that oftentimes those disturbing thoughts arise

01:49:28.900 | at the most inconvenient and sometimes what seems like

01:49:32.060 | the most inappropriate circumstances.

01:49:34.960 | And this relates to a whole larger discussion

01:49:37.320 | that we could have about what are thoughts

01:49:39.740 | and why do they surface?

01:49:40.580 | And how come when you stand at the edge of a bridge,

01:49:43.480 | even if you do not want to jump off,

01:49:45.160 | you think about jumping off.

01:49:46.780 | And this has to do with the fact that your nervous system

01:49:49.400 | as a prediction machine is oftentimes testing possibilities.

01:49:52.640 | And sometimes that testing goes way off

01:49:55.220 | into the Netherlands of the thought patterns

01:50:00.220 | and emotional patterns that we all have inside of us.

01:50:03.320 | The big difference between a thought and an action

01:50:05.820 | is that of course the nervous system is one case

01:50:09.660 | not translating those patterns of thinking

01:50:12.240 | into motor sequences.

01:50:13.980 | That nerdy way of saying thoughts aren't actions,

01:50:18.620 | believe it or not, can be helpful for people

01:50:20.300 | if they really think about that and use it as an opportunity

01:50:23.700 | to realize that first of all, they're not crazy.

01:50:27.320 | They're not thinking and feeling this stuff

01:50:30.280 | because they're bad or evil.

01:50:32.160 | And of course, sometimes this can cross over

01:50:34.160 | with other elements of life where we place moral judgment

01:50:37.380 | on people for certain behaviors.

01:50:38.560 | I think that's part of a healthy society of course,

01:50:40.640 | that's where we have laws and punishments

01:50:42.160 | and rewards for that matter for certain types of behaviors.

01:50:45.660 | But this idea that thoughts are not as bad as actions

01:50:48.220 | and that thoughts can be tolerated

01:50:49.740 | and the anxiety around thoughts can be tolerated

01:50:52.480 | and over time can diminish,

01:50:54.020 | that's a very powerful hallmark theme

01:50:56.280 | of the treatment of OCD.

01:50:57.420 | So I'd be remiss if I didn't mention it.

01:50:59.900 | Thoughts are not actions.

01:51:01.860 | Actions can harm us, they can harm other people,

01:51:04.500 | they can soak up enormous amounts of time.

01:51:08.460 | Thoughts can soak up enormous amounts of time,

01:51:10.860 | they can be very troubling, they can be very detrimental,

01:51:13.140 | we of course want to be sensitive to that.

01:51:15.780 | But when it really comes down to it,

01:51:18.780 | the first step in treatment for OCD is this realization

01:51:22.800 | or the approach to the realization

01:51:24.480 | that thoughts are not as bad as actions.

01:51:27.260 | So what about hormones in OCD?

01:51:29.520 | Well, this has been explored,

01:51:30.700 | albeit not as extensively as I would have liked to find,

01:51:33.620 | but when I went into the literature,

01:51:35.340 | I found one particularly interesting study

01:51:38.220 | entitled "Neurosteroid Levels in Patients

01:51:40.180 | with Obsessive Compulsive Disorder" for Sathur Erbe

01:51:43.100 | and as always, we'll provide a link to the study.

01:51:47.020 | The objective of this study was to explore serum

01:51:49.520 | within blood, neurosteroid levels in people with OCD.

01:51:53.700 | Why?

01:51:54.540 | Well, because of the relationship between OCD and anxiety

01:51:57.340 | and the fact that in stress-related disorders

01:51:59.640 | such as anxiety and depression,

01:52:01.220 | the hormones have been extensively explored,

01:52:04.100 | but not so much in OCD, at least until this study.

01:52:06.760 | So they compared serum levels

01:52:08.260 | of a number of different hormones,

01:52:09.720 | progesterone, pregnenolone, DHEA, cortisol, and testosterone.

01:52:15.340 | This was done in 30 patients with OCD

01:52:17.260 | and 30 healthy controls.

01:52:19.580 | So it's not a huge study,

01:52:20.980 | but it's enough to draw some pretty nice conclusions.

01:52:23.980 | These subjects were 18 to 49 years old

01:52:26.880 | and the controls were age and sex-matched,

01:52:30.300 | healthy volunteers, again, no OCD.

01:52:32.820 | What was the basic takeaway from the study?

01:52:34.220 | The basic takeaway from the study was that in females

01:52:36.860 | with OCD, there was evidence

01:52:39.580 | for significantly elevated cortisol and DHEA.

01:52:43.620 | Now that's interesting because cortisol is well-known

01:52:46.860 | to be associated with the stress system,

01:52:48.540 | although every day, I should mention,

01:52:50.660 | we all, male or female,

01:52:52.980 | everybody experiences an increase in cortisol

01:52:55.740 | shortly after awakening.

01:52:56.740 | That's a healthy increase in cortisol.

01:52:59.000 | Late shifted, I mean late in the day peaks in cortisol,

01:53:03.120 | where a shift in that cortisol peak to later in the day

01:53:06.540 | is a known correlate of depression and anxiety disorders.

01:53:12.620 | So the fact that cortisol is elevated in DHEA,

01:53:15.780 | are elevated in female patients with OCD,

01:53:19.260 | suggests that the cortisol is either reflective of

01:53:23.660 | or causal for the increase in anxiety.

01:53:26.780 | We don't know the direction of that effect.

01:53:28.880 | Now, in the male patients with OCD,

01:53:31.660 | there was evidence for increased cortisol,

01:53:33.800 | again, not surprising given the role of anxiety in cortisol,

01:53:36.980 | or I should say, given the role of cortisol in anxiety

01:53:39.900 | and the increasing anxiety seen in OCD,

01:53:42.840 | but there are also significant reductions in testosterone,

01:53:45.940 | which should also not surprise us

01:53:48.140 | because cortisol and testosterone more or less compete

01:53:51.980 | in some fashion for their own production.

01:53:54.940 | Both are derived from the molecule cholesterol,

01:53:57.900 | and there are certain biochemical pathways

01:53:59.620 | that can either direct that cholesterol molecule

01:54:01.820 | toward cortisol synthesis or testosterone synthesis,

01:54:05.180 | but not both, so they compete.

01:54:07.280 | So when cortisol goes up in general, not always,

01:54:09.460 | but in general, testosterone goes down and vice versa.

01:54:12.540 | If you want to learn more about the relationship

01:54:14.300 | between cortisol and testosterone,

01:54:15.780 | and there are even some tools

01:54:16.680 | to try and optimize those ratios in both males and females,

01:54:20.380 | you can find that in our episode

01:54:21.660 | on optimizing testosterone and estrogen,

01:54:23.680 | that's at Hubermanlab.com.

01:54:25.760 | Now, I would say the most interesting aspect of this study

01:54:28.940 | is not that DHEA and cortisol are elevated in females

01:54:32.680 | with OCD or that cortisol and testosterone

01:54:35.640 | have this opposite effect,

01:54:36.580 | cortisol up and testosterone down in males with OCD,

01:54:40.080 | but rather the relationship between all of those,

01:54:43.020 | DHEA, cortisol, and testosterone in terms of GABA.

01:54:48.020 | GABA, again, being this inhibitory neurotransmitter

01:54:51.540 | that tends to quiet certain neuronal pathways.

01:54:56.020 | It does different things at different synapses,

01:54:58.780 | but in general, the more GABA that's present,

01:55:01.140 | the more inhibition that's present,

01:55:02.720 | and therefore the more suppression of neural activity.

01:55:05.500 | And DHEA is known to be a potent antagonist

01:55:10.500 | of the GABA system, okay?

01:55:13.420 | So here we have elevated DHEA in females,

01:55:18.420 | and I should also mention that testosterone

01:55:21.060 | is also known to tap into the GABA system.

01:55:23.800 | Typically when testosterone is elevated,

01:55:26.100 | GABA transmission at least is slightly elevated.

01:55:29.700 | So here we have a situation in which the pattern of hormones

01:55:33.060 | in females and males with OCD are different

01:55:37.460 | from those in people without OCD,

01:55:40.740 | such that GABA transmission is altered

01:55:43.820 | and the net effect would be an overall reduction in GABA.

01:55:47.600 | Now, GABA as an inhibitory neurotransmitter,

01:55:51.340 | and broadly speaking is associated

01:55:53.620 | with lower levels of anxiety,

01:55:55.720 | and it tends to create balance

01:55:57.700 | within various neural circuits.

01:55:59.420 | Now that's a very broad statement,

01:56:00.600 | but we know for instance in epilepsy

01:56:03.500 | that GABA levels are reduced,

01:56:04.980 | and therefore you get runaway excitation

01:56:06.960 | of certain circuits in the brain,

01:56:08.320 | and therefore seizures, either petit mal, mini seizures,

01:56:11.440 | or grand mal, massive seizures, or even drop seizures

01:56:14.400 | where people completely collapse to the floor in seizure.

01:56:16.780 | You may have seen this before.

01:56:18.360 | I certainly have, it's very dramatic,

01:56:19.920 | and it actually is quite debilitating for people

01:56:22.960 | because obviously they don't know

01:56:23.980 | when these seizures are coming on most often,

01:56:26.200 | and then they can fall into a stove

01:56:28.160 | or while driving, et cetera.

01:56:29.880 | So the situation with OCD is one in which,

01:56:33.160 | for whatever reason, we don't know the direction of effect,

01:56:36.360 | certain hormones are elevated in females,

01:56:39.480 | and certain hormones are elevated in males,

01:56:41.240 | and those hormones differ between males and females,

01:56:45.540 | and yet they both funnel into a system

01:56:48.060 | where GABAergic or GABA transmission in the brain

01:56:51.160 | is reduced because of this ability

01:56:53.400 | for those particular hormones to be antagonists to GABA,

01:56:57.180 | and as a consequence, there's likely to be overall levels

01:57:01.740 | of increased excitation in certain networks in the brain,

01:57:05.340 | and that brings us back

01:57:07.180 | to this corticostriatal thalamic loop,

01:57:09.780 | this repetitive loop that seems to reinforce,

01:57:12.340 | or we can say reinforces obsession, leads to anxiety,

01:57:16.520 | leads to compulsion, leads to transient relief of anxiety,

01:57:20.340 | but then increase in anxiety, increased obsession,

01:57:23.500 | anxiety, compulsion, anxiety, compulsion,

01:57:25.420 | anxiety, compulsion, and so on and so forth.

01:57:27.740 | So I have not found studies

01:57:30.660 | that have explored adjusting testosterone levels

01:57:34.320 | through exogenous administration,

01:57:36.060 | cream or injection or otherwise,

01:57:37.620 | or that have focused on reducing DHEA in females.

01:57:42.200 | If anyone is aware of such studies,

01:57:43.780 | please put them in the comment section on YouTube

01:57:46.820 | or send them to us.

01:57:47.820 | We have a contact site on the website at HubermanLab.com,

01:57:50.620 | but the comment section on YouTube would be best,

01:57:53.240 | but because we know that hormones impact neuromodulators

01:57:56.260 | and neurotransmitters, as I just described,

01:57:58.020 | and that those neuromodulators and neurotransmitters

01:58:00.080 | play an intimate role in the generation

01:58:02.200 | and the treatment of things like OCD,

01:58:05.280 | it stands to reason that manipulations

01:58:08.320 | of those hormone systems, however subtle or dramatic,

01:58:11.600 | might, I want to highlight, might prove useful

01:58:14.320 | in adjusting the symptoms of OCD,

01:58:16.220 | and I hope that this is an area

01:58:17.480 | that researchers are going to pursue in the very near future

01:58:20.900 | because many of the treatments for reducing DHEA

01:58:24.540 | or increasing testosterone or reducing cortisol

01:58:27.060 | have already made it through FDA approval.

01:58:29.880 | They're out there, they're readily prescribed.

01:58:32.380 | Many of them are already in generic form,

01:58:33.980 | which means that the patents have already lapsed

01:58:36.400 | on the first versions of those drugs,

01:58:39.160 | so when they're available as generic drugs,

01:58:41.480 | very often they're available at significantly lower cost.

01:58:44.660 | There's a whole discussion to be had there

01:58:46.020 | about patent laws and prescription drugs,

01:58:49.460 | but because these drugs are largely available

01:58:52.080 | in prescription yet generic form,

01:58:55.680 | I think there's a great opportunity to explore

01:58:57.760 | how hormones, not just cortisol, testosterone, and DHEA,

01:59:01.720 | but the huge category of hormones

01:59:04.080 | might impact the symptoms of OCD,

01:59:06.480 | especially since many of the symptoms of OCD

01:59:09.200 | show up right around the time of puberty.

01:59:11.220 | We haven't talked a lot about childhood OCD

01:59:13.080 | 'cause we're going to do an entire series

01:59:14.680 | on childhood psychiatric disorders and challenges,

01:59:17.620 | but many children develop OCD early,

01:59:21.980 | as young as three or four, believe it or not,

01:59:24.240 | or even six or seven and 10,

01:59:26.000 | and in adolescence and certainly around puberty

01:59:28.840 | and in young adulthood.

01:59:30.500 | It is rare, although it does happen,

01:59:32.560 | that people will develop OCD very late in life,

01:59:34.940 | around 40 or older, just kind of spontaneously.

01:59:37.700 | Most often when you look at their clinical history,

01:59:39.580 | you find that either they were hiding it

01:59:41.560 | or it was being suppressed in some way,

01:59:43.300 | or if it does spontaneously show up late in life,

01:59:46.100 | like mid thirties or in ones forties,

01:59:49.040 | typically there's a traumatic brain injury.

01:59:52.520 | It could be due to stroke or physical injury to the head

01:59:55.220 | or something of that sort.

01:59:57.120 | Nonetheless, there is a interesting correlation

02:00:00.600 | between the onset of puberty in certain forms of OCD.

02:00:03.320 | There's certain forms of, or I should say,

02:00:05.380 | there's certain aspects of menopause that can relate to OCD.

02:00:08.120 | You can find all these things in the literature,

02:00:10.220 | all this to say that hormones impact neurotransmitters

02:00:13.120 | and neuromodulators, which clearly impact

02:00:15.020 | the kinds of circuits that are involved in OCD,

02:00:17.180 | and it makes sense that,

02:00:19.100 | and I would hope that there would be an exploration

02:00:21.580 | of how these hormones impact OCD

02:00:23.360 | in the not too distant future.

02:00:24.700 | Now, there is an extensive literature

02:00:26.100 | exploring how testosterone therapy,

02:00:27.940 | both in males and females, can be effective in some cases

02:00:32.940 | in the treatment of anxiety-related disorders,

02:00:36.520 | but not, at least to my knowledge, in OCD in particular.

02:00:40.100 | So this whole area of the use of testosterone

02:00:43.100 | and estrogen therapies, DHEA, cortisol suppression,

02:00:46.260 | or maybe even enhancement for the treatment of OCD

02:00:49.860 | is essentially a big black box

02:00:52.300 | that very soon I believe will be lit.

02:00:56.500 | I realize that a number of listeners of this podcast

02:00:58.900 | are probably interested in the non-typical

02:01:02.540 | or holistic treatments for OCD.

02:01:05.500 | Dr. Blair Simpson's lab has at least one study

02:01:07.860 | exploring the role of mindfulness meditation

02:01:11.360 | for the treatment of OCD.

02:01:14.280 | There, the data are a little bit complicated,

02:01:17.300 | and I should mention that good things are happening,

02:01:21.520 | at least in the United States, probably elsewhere as well,

02:01:24.020 | but good things are happening in terms of the exploration

02:01:27.620 | of things like meditation and other,

02:01:29.880 | let's call them non-traditional or holistic forms

02:01:32.020 | of treatment for psychiatric disorders

02:01:34.660 | because of the division of complementary health

02:01:37.180 | that's now been launched

02:01:38.300 | by the National Institutes of Health.

02:01:39.580 | So whereas before people would think about meditation

02:01:43.520 | or yoga nidra or even CBD supplementation for that matter

02:01:48.520 | as kind of fringe maybe or kind of woo

02:01:50.920 | or non-traditional at the very least,

02:01:53.620 | the National Institutes of Health in the United States

02:01:55.640 | has now devoted an entire division,

02:01:59.200 | an entire institute purely for the exploration

02:02:02.360 | of things like breathing practices, meditation, et cetera.

02:02:04.700 | So there's a cancer institute,

02:02:06.120 | there's a hearing and deafness institute,

02:02:07.840 | there's a vision institute,

02:02:09.520 | and now there's this complementary health institute,

02:02:11.540 | which I think is a wonderful addition

02:02:14.560 | to the more traditional aspects of medicine.

02:02:17.960 | I think no possible useful treatment should be overlooked

02:02:21.960 | or unresearched in my opinion,

02:02:23.680 | provided that can be done safely.

02:02:25.780 | And as I mentioned, Dr. Blair Simpson's lab

02:02:28.600 | has looked at the role of mindfulness meditation

02:02:31.580 | in the treatment of OCD.

02:02:33.280 | Now, we should all keep in mind, no pun intended,

02:02:36.940 | that most of the data on mindfulness meditation

02:02:39.880 | shows that it increases the ability to focus.

02:02:43.800 | Now, this brings us back to a kind of repeating theme today,

02:02:46.400 | which is that increased focus may not be the best thing

02:02:49.280 | for somebody with OCD because it might increase focus

02:02:54.080 | on the obsession and or compulsion.

02:02:57.000 | Turns out that mindfulness meditation

02:02:58.780 | can be useful in the treatment of OCD,

02:03:00.940 | but mainly by way of how it impacts the focus on

02:03:05.980 | and the ability to engage in cognitive behavioral therapies.

02:03:10.000 | So it's very unlikely, at least by my read of the data,

02:03:13.260 | to be a direct effect of meditation

02:03:15.500 | on relieving the symptoms.

02:03:16.660 | Rather, it seems that meditation is increasing focus

02:03:19.500 | on things like cognitive behavioral therapy homework

02:03:23.020 | and to not focus on other things

02:03:24.680 | and therefore indirectly improving the symptoms of OCD.

02:03:28.080 | Now, somewhat surprisingly, at least to me,

02:03:29.880 | there have also been a fairly large number of studies

02:03:32.600 | exploring how nutraceuticals,

02:03:35.560 | as they're sometimes called supplements,

02:03:37.340 | that are available over the counter

02:03:38.600 | can impact the treatment of obsessive compulsive disorder.

02:03:41.720 | Now, there's such an extensive number of different compounds

02:03:44.960 | and supplements that fall under the category

02:03:47.300 | of nutraceuticals and that have been explored

02:03:49.260 | in the treatment of OCD that I'd like to point you

02:03:51.060 | to a review that is entitled

02:03:53.540 | "Nutraceuticals and the Treatment

02:03:54.920 | of Obsessive Compulsive Disorder,"

02:03:56.960 | a review, excuse me, of mechanistic and clinical evidence.

02:04:00.480 | This was published in 2011, so it's over 10 years old.

02:04:04.460 | And so by now, I have to imagine

02:04:06.700 | that there are an enormous number of additional substances

02:04:10.260 | that could be explored.

02:04:11.400 | But there are just one or two here that I want to focus on.

02:04:14.340 | Here in this review, they describe effects of 5-HTP

02:04:18.140 | and tryptophan, so things that are in the serotonin pathway,

02:04:21.020 | which would make sense given what we know about the SSRIs

02:04:23.860 | that people would explore how different supplements

02:04:26.020 | that increase serotonergic transmission might impact OCD.

02:04:30.320 | What you find is that they do have significant effects

02:04:32.980 | in improving or reducing the symptoms of OCD

02:04:36.680 | in somewhat similar way to some of the SSRIs.

02:04:39.420 | But you, of course, have to be careful.

02:04:41.380 | Anything that's going to tap into a given neurochemical system

02:04:45.380 | to the same degree may very likely

02:04:48.780 | have the same sorts of side effects

02:04:50.120 | that a prescription drug would.

02:04:51.620 | One compound that I'd like to focus on

02:04:53.440 | in a little more depth, however,

02:04:54.700 | because it's exciting and interesting to me is inositol.

02:04:59.260 | Inositol is a compound that we are going to talk about

02:05:01.360 | in several future podcasts because, well, first of all,

02:05:05.060 | it seems that it can have impressive effects

02:05:07.420 | on reducing anxiety.

02:05:09.000 | It also can have pretty impressive effects

02:05:10.540 | in improving fertility, in particular in women

02:05:13.360 | with polycystic ovarian syndrome.

02:05:15.820 | And here I'm referring specifically to myoinositol

02:05:18.520 | because it comes in several forms.

02:05:20.140 | And it does appear that 900 milligrams of inositol

02:05:23.740 | can improve sleep and can reduce anxiety,

02:05:26.940 | perhaps when taken at that dosage or higher dosages.

02:05:30.200 | I will just confess, first of all, I don't have OCD,

02:05:33.260 | although I will also confess that when I was a child,

02:05:35.480 | I had a transient tic.

02:05:37.180 | I've talked about this on podcasts before.

02:05:39.080 | It was a grunting tic.

02:05:40.100 | So when I was about six or seven,

02:05:41.440 | I recall a trip to Washington, D.C. with my family

02:05:44.740 | where I was feeling a strong desire or need even,

02:05:49.740 | as I recall, to grunt in order to clear something

02:05:53.760 | in my throat, but I didn't have anything in my throat.

02:05:56.160 | I didn't have a cold or any post-nasal drip.

02:05:58.080 | It was really just the feeling that I needed to do that

02:06:00.100 | to release some sort of tension.

02:06:02.340 | And I remember my dad at the time telling me,

02:06:05.300 | "Don't do that.

02:06:06.140 | "You know, don't do that.

02:06:06.960 | "It's not good to grunt," or something like that.

02:06:08.600 | I think he saw that it was kind of compulsive behavior.

02:06:11.140 | And so I would actually hide in the back seat

02:06:12.880 | of the rental car and do it, or I'd hide in my room.

02:06:15.300 | Fortunately for me, it was transient.

02:06:17.020 | I think about six months or a year later, it disappeared.

02:06:19.680 | Although I did notice, actually an ex-girlfriend of mine

02:06:22.760 | pointed out that when I get very tired

02:06:24.500 | and I've been working very long hours,

02:06:26.040 | sometimes that grunting tic will reappear.

02:06:28.580 | What does that mean?

02:06:29.420 | Do I have Tourette's?

02:06:30.320 | I don't know.

02:06:31.160 | Maybe I was never diagnosed with Tourette's.

02:06:32.760 | Do I have OCD?

02:06:34.120 | Maybe.

02:06:35.440 | I certainly could be accused of having

02:06:37.100 | obsessive compulsive personality disorder,

02:06:39.320 | which we'll talk about still in a few minutes.

02:06:42.380 | But the point here is that many children

02:06:45.200 | transiently express tics or low-level Tourette's or OCD,

02:06:49.720 | and again, transiently, and it disappears over time.

02:06:52.680 | So inositol has been explored

02:06:54.800 | in a bunch of different contexts,

02:06:56.240 | including for tics and OCD, et cetera.

02:06:59.760 | Going back to inositol and its current use,

02:07:03.300 | or I should say my current use,

02:07:04.360 | I've been taking 900 milligrams of inositol

02:07:07.200 | as an addition to my existing toolkit for sleep,

02:07:10.680 | which I've talked about many times on this podcast

02:07:13.240 | and other podcasts,

02:07:14.480 | consists of magnesium threonate, apigenin, and theanine.

02:07:18.260 | If you want to know more about that kit,

02:07:19.680 | you can go to our newsletter,

02:07:21.360 | neural network newsletter at hubermanlab.com.

02:07:23.580 | The toolkit for sleep is there.

02:07:24.800 | You don't even have to sign up for the newsletter,

02:07:26.480 | but it'll give you a flavor of the sorts of things

02:07:27.880 | that are in the newsletter.

02:07:29.040 | In any case, I've been experimenting a bit

02:07:32.960 | with taking 900 milligrams of myoinositol,

02:07:35.520 | either alone or in combination with that sleep kit,

02:07:37.600 | and I must say the sleep I've been getting on inositol

02:07:39.880 | is extremely deep and does seem to lead

02:07:43.440 | to enhanced levels of focus and alertness during the day,

02:07:46.000 | and perhaps you're noticing that

02:07:46.920 | 'cause I'm talking more quickly on this podcast

02:07:48.480 | than in previous podcasts.

02:07:49.420 | No, I'm just kidding.

02:07:50.260 | I don't think the two things relate

02:07:51.400 | in any kind of causal way.

02:07:53.360 | The point here is that inositol is known

02:07:56.380 | to be pretty effective in reducing anxiety,

02:07:59.360 | but when taken at very high dosages.

02:08:01.360 | Can it do the same at low dosages?

02:08:03.100 | We don't know.

02:08:03.940 | I would consider 900 milligrams a low dose.

02:08:06.560 | Most of this, given the fact that most of the studies

02:08:10.140 | of inositol have explored very high dosages,

02:08:13.400 | like even 10 or 12 grams per day,

02:08:16.340 | which I must say seems exceedingly high,

02:08:18.780 | and they do report that some of the subjects

02:08:20.500 | in those experiments actually stopped taking the inositol

02:08:23.360 | because of gastric discomfort or gastric distress

02:08:26.260 | as it's called.

02:08:27.540 | So I've reported my results with sleep

02:08:30.100 | in a kind of anecdotal way.

02:08:32.160 | They certainly aren't peer-reviewed studies

02:08:33.520 | that I described about my own experience

02:08:35.640 | in an anecdotal way.

02:08:36.880 | But nonetheless, it's been explored that things like glycine,

02:08:41.460 | which is another, which is an amino acid,

02:08:43.800 | which also acts as an inhibitory neurotransmitter

02:08:45.760 | in the brain, taken at very high dosages,

02:08:47.600 | 60 grams per day.

02:08:49.140 | That is a absolutely astonishingly high amount of glycine.

02:08:52.840 | I would not recommend taking that much glycine

02:08:55.080 | unless you're part of a study where they tell you to

02:08:57.100 | and you know it's safe.

02:08:58.940 | 18 grams, excuse me, of inositol.

02:09:01.960 | These are very, very high dosages used in these studies.

02:09:04.700 | Nonetheless, there's some interesting data about inositol

02:09:08.520 | leading to some alleviation of OCD symptoms

02:09:13.520 | or partial alleviation of OCD symptoms

02:09:16.520 | in as little as two weeks

02:09:18.520 | after initiating the supplement protocol.

02:09:21.760 | So I think there's a great future for these nutraceuticals,

02:09:23.960 | meaning I think more systematic exploration,

02:09:26.040 | in particular of lower dosages

02:09:27.360 | in the context of OCD treatment.

02:09:29.800 | And as we saw before for the SSRIs

02:09:33.720 | and other prescription drug treatments,

02:09:35.580 | I think there really needs to be an exploration

02:09:37.680 | of these nutraceuticals in combination

02:09:39.620 | with behavioral therapies and who knows,

02:09:41.120 | maybe with brain-machine interface

02:09:42.480 | like cranial magnetic stimulation as well.

02:09:45.220 | Now, way back at the beginning of the episode,

02:09:47.120 | I alluded to the fact that OCD is one thing,

02:09:50.420 | obsessive compulsive disorder,

02:09:51.680 | and it's truly a disorder and it's truly debilitating

02:09:54.080 | and it's extremely common.

02:09:55.600 | And then there's this other thing

02:09:58.000 | called obsessive compulsive personality disorder,

02:10:00.360 | which is distinct from that,

02:10:01.900 | does not have the intrusive component.

02:10:05.000 | So people don't feel overwhelmed

02:10:06.600 | or overtaken by these thoughts.

02:10:09.640 | Rather, they find that the obsessions

02:10:12.480 | can sometimes serve them or they even welcome them.

02:10:15.560 | And I think many of us know people like this.

02:10:17.660 | I perhaps even could be accused or who knows,

02:10:20.120 | maybe have been accused of having an obsessive compulsive

02:10:23.080 | personality at times.

02:10:25.000 | Why do I draw this distinction?

02:10:26.180 | Well, first of all, we've come to a point in human history,

02:10:30.000 | I think in large part because of social media,

02:10:32.580 | but also in large part because there are a number

02:10:34.920 | of discussions being held about mental health

02:10:37.680 | that have brought terms like trauma, depression, OCD,

02:10:42.440 | et cetera, into the common vernacular

02:10:45.920 | so that people will say, "Oh, you're so OCD,"

02:10:48.800 | or someone will say, "I was traumatized by that,"

02:10:51.060 | or, "I was traumatized by this."

02:10:53.040 | We should be very careful, right?

02:10:54.440 | I'm certainly not the word police,

02:10:56.760 | but we should be very careful in the use

02:10:59.640 | of certain types of language, especially language

02:11:02.580 | that has real psychiatric and psychological definitions

02:11:06.780 | because it can really draw us off course

02:11:09.720 | in providing relief for some of these syndromes.

02:11:11.900 | For instance, the word trauma is thrown around

02:11:15.280 | left and right nowadays, "I was traumatized by this,"

02:11:17.680 | or, "That caused trauma," or, "You're giving me trauma."

02:11:20.520 | Listen, I realize that many people are traumatized

02:11:23.800 | by certain events, including things that are said to them.

02:11:26.600 | I absolutely acknowledge that.

02:11:27.940 | Hence, our episodes on trauma and trauma treatment,

02:11:31.040 | several of them, in fact, Dr. Conti, Dr. David Spiegel,

02:11:35.920 | and then dedicated solo episodes with just me blabbing

02:11:39.120 | about trauma and trauma treatment.

02:11:41.640 | But as Dr. Conti so appropriately pointed out,

02:11:45.880 | trauma is really something that changes our neural circuitry

02:11:50.780 | and therefore our thoughts and our behaviors

02:11:52.640 | in a very persistent way that is detrimental to us.

02:11:55.500 | Not every bad event is traumatizing.

02:11:57.620 | Not everything that we dislike or even that we hate

02:11:59.840 | or that feels terrible to us is traumatizing.

02:12:02.020 | For something to reach the level of trauma,

02:12:04.840 | it really needs to change our neural circuitry

02:12:07.680 | and therefore our thoughts and our behaviors

02:12:09.640 | in a persistent way that is maladaptive for us.

02:12:12.560 | Similarly, just calling someone obsessive is one thing,

02:12:17.160 | saying that someone has OCD or assuming one has OCD

02:12:20.080 | simply because they have a personality or a phenotype,

02:12:22.960 | as we say, where they need things in perfect order,

02:12:25.240 | like I find myself correcting these pens,

02:12:27.040 | making sure that the caps are facing in the same direction,

02:12:30.420 | for instance, right now.

02:12:32.600 | That is not the same as OCD.

02:12:35.240 | If, for instance, I can tolerate these pens

02:12:37.160 | being at different orientation

02:12:38.420 | or even throw the cap on the floor or something,

02:12:40.200 | it doesn't create a lot of anxiety for me.

02:12:42.000 | I confess I agree it's a little bit in the moment,

02:12:44.160 | but then I can forget about it and move on.

02:12:45.960 | That's one of the key distinctions

02:12:47.680 | between obsessive compulsive personality disorder

02:12:50.600 | and obsessive compulsive disorder in its strictest form.

02:12:54.800 | Now, once one hears that OCD is different

02:12:57.360 | than obsessive compulsive personality disorder

02:12:59.880 | because of this difference

02:13:01.040 | in how intrusive the thoughts are or not,

02:13:03.680 | then that's useful, but it really doesn't tell us anything

02:13:07.200 | about what is happening mechanistically

02:13:09.400 | in one situation or another.

02:13:11.520 | Fortunately, there are beautiful data,

02:13:13.460 | again, from Dr. Blair Simpson's lab,

02:13:15.720 | and you can tell based on the number of studies

02:13:17.900 | that I've referred to from her laboratory,

02:13:19.560 | that she's truly one of the luminaries in this field,

02:13:22.880 | that there really are some fundamental wiring differences

02:13:26.740 | and behavioral differences and psychological differences

02:13:29.540 | between people who have obsessive compulsive disorder

02:13:32.360 | and those who have obsessive compulsive

02:13:34.160 | personality disorder.

02:13:36.440 | So this is a study first authored by Pinto, P-I-N-T-O,

02:13:39.960 | entitled "Capacity to Delay Reward

02:13:42.220 | Differentiates Obsessive Compulsive Disorder

02:13:44.200 | and Obsessive Compulsive Personality Disorder."

02:13:47.400 | And the methods in this study were to take 25 people with OCD

02:13:50.840 | and 25 people with obsessive compulsive personality disorder

02:13:54.800 | and 25 people who have both,

02:13:57.360 | because it is possible to have both,

02:13:58.840 | and that's important to point out,

02:13:59.920 | and 25 so-called healthy controls,

02:14:02.000 | people that don't have obsessive compulsive

02:14:03.680 | personality disorder or obsessive compulsive disorder.

02:14:07.160 | They take clinical assessments,

02:14:08.720 | and then they took a number of tests

02:14:11.200 | that probed their ability to defer gratification,

02:14:15.680 | something called in the laboratory,

02:14:17.020 | we call it delayed discounting.

02:14:18.560 | So their ability to defer gratification through a task

02:14:23.040 | where they can either accept reward right away

02:14:25.260 | or accept reward later.

02:14:26.400 | Some of you may have heard of the two marshmallow task.

02:14:28.880 | This is based on a study that was performed years ago

02:14:31.560 | on young children at Stanford and elsewhere,

02:14:33.720 | where they take young children into a room.

02:14:36.140 | They offer them a marshmallow.

02:14:39.140 | Kids like marshmallows generally.

02:14:41.260 | And you say, "You can eat the marshmallow right now,

02:14:44.240 | or you can wait some period of time.

02:14:46.400 | And if you are able to wait and not eat the marshmallow,

02:14:49.360 | you can have two marshmallows."

02:14:50.960 | And in general, children want two marshmallows

02:14:53.140 | more than they want one marshmallow.

02:14:54.660 | So really what you're probing is their ability

02:14:56.980 | to access delayed gratification.

02:14:59.000 | And they're very entertaining,

02:15:01.540 | even truly amusing videos of this on the internet.

02:15:06.540 | So if you just do two marshmallow task video

02:15:09.440 | and you go into YouTube,

02:15:10.280 | what you'll find is that the children will use

02:15:12.220 | all sorts of strategies to delay gratification.

02:15:16.100 | Some of the kids will cover the marshmallow.

02:15:18.700 | Others will talk to the marshmallow and say,

02:15:20.260 | "I know you're not that delicious.

02:15:21.660 | You look delicious, but no, you're not delicious."

02:15:23.380 | They'll engage with the marshmallow

02:15:24.700 | in all sorts of cute ways.

02:15:25.740 | They'll turn around and try and, you know, avoidance,

02:15:27.920 | which actually speaks to a whole category of behaviors

02:15:30.960 | that people with OCD also use.

02:15:32.560 | I'm not saying these kids had OCD,

02:15:34.200 | but avoidance behaviors are very much a component of OCD.

02:15:38.620 | People really trying to avoid the thing

02:15:40.400 | that evokes the obsession.

02:15:43.420 | Well, some kids are able to delay gratification, some aren't.

02:15:47.180 | And it's debatable as to whether or not

02:15:48.640 | the kids that are able to delay gratification

02:15:50.480 | go on to have more successful lives or not.

02:15:52.340 | Initially, that was the conclusion of those studies.

02:15:54.140 | There's still a lot of debate about it.

02:15:55.380 | We'll bring an expert on to give us

02:15:57.020 | the final conclusion on this 'cause there is one

02:15:58.800 | and it's very interesting and not intuitive.

02:16:01.020 | Nonetheless, adults are also faced with decisions

02:16:04.560 | every day, all day as to whether or not

02:16:06.660 | they can delay gratification.

02:16:08.840 | And this study used a, not a two marshmallow task,

02:16:13.340 | but a game that involved rewards where people could delay

02:16:17.340 | in order to get greater rewards later.

02:16:19.280 | What is the conclusion?

02:16:20.640 | Well, first of all, obsessive compulsive

02:16:23.000 | and obsessive compulsive personality disorder subjects

02:16:25.980 | both showed impairments in their psychosocial functioning

02:16:30.660 | and quality of life.

02:16:31.820 | They had compulsive behavior.

02:16:34.240 | So these are people that are suffering in their life

02:16:36.300 | because their compulsions are really strong.

02:16:39.060 | So it's not just being really nitpicky or really orderly

02:16:42.020 | in one case and having full blown OCD in the other,

02:16:44.140 | both sets of subjects are challenged in life

02:16:47.300 | because they're having relationship issues

02:16:49.100 | or job related issues, et cetera,

02:16:50.660 | because they are that compulsive.

02:16:53.340 | However, the individuals with obsessive compulsive

02:16:56.460 | personality disorder,

02:16:58.540 | they discounted the value of delayed gratification

02:17:01.900 | significantly less than those

02:17:03.260 | with obsessive compulsive disorder.

02:17:05.360 | What do I mean?

02:17:07.420 | They are both impairing disorders

02:17:09.020 | that are marked by compulsive behaviors.

02:17:10.540 | Here I'm paraphrasing, but they can be differentiated

02:17:13.420 | by the presence of obsessions in OCD.

02:17:15.460 | So obsessions in OCD.

02:17:17.380 | People with OCD are absolutely fixated on certain ideas

02:17:22.740 | and those ideas are intrusive.

02:17:24.260 | Again, that's the hallmark theme.

02:17:26.180 | And by an excessive capacity to delay reward

02:17:29.180 | in obsessive compulsive personality disorder.

02:17:31.420 | That is people who have obsessive compulsive personality

02:17:34.380 | disorder are really good at delaying gratification.

02:17:38.180 | So they are able to concentrate very intensely

02:17:41.620 | and perform very intensely in ways that allow them

02:17:45.000 | to instill order such that they can delay reward.

02:17:49.300 | Now you can see why this contour of symptoms,

02:17:53.620 | meaning that the people with OCD

02:17:57.300 | are experiencing intrusive thoughts,

02:18:00.900 | whereas the people with obsessive compulsive

02:18:03.000 | personality disorder show an enhanced ability

02:18:06.140 | to defer gratification.

02:18:07.800 | You could see how that would lead

02:18:11.340 | to very different outcomes.

02:18:12.780 | People with obsessive compulsive personality disorder

02:18:15.540 | can actually leverage that personality disorder

02:18:18.580 | to perform better in certain domains of life.

02:18:21.060 | Not all domains of life, because remember again,

02:18:23.020 | these people are in this study and they're showing up

02:18:26.520 | as experiencing challenges in life

02:18:28.220 | because of their obsessive compulsive personality disorder.

02:18:31.380 | Nonetheless, people with obsessive compulsive

02:18:33.800 | personality disorder, you can imagine would be very good

02:18:36.580 | at say architecture or anything that involves instilling

02:18:40.620 | a ton of order, maybe sushi chef, for instance,

02:18:43.460 | maybe a chef in general.

02:18:44.780 | I know chefs that just kind of throw things around

02:18:46.740 | like the chef on "The Muppets" and just throw things

02:18:50.060 | everywhere and still produce amazing food.

02:18:51.520 | And then there's some people

02:18:52.360 | where they're incredibly exacting.

02:18:54.260 | They're just incredibly precise.

02:18:55.780 | I think that movie, what is it, "Hero Dreams of Sushi,"

02:18:58.400 | that movie is incredible.

02:19:00.340 | Certainly not saying he has obsessive compulsive

02:19:02.140 | personality disorder, but I think it's fair to say

02:19:04.300 | that he is obsessive or extremely meticulous

02:19:08.420 | and orderly about everything from start to finish.

02:19:10.900 | You can imagine a huge array of different occupations

02:19:13.720 | and life endeavors where this would be beneficial.

02:19:16.340 | Science being one of them, where data collection

02:19:18.480 | and analysis is exceedingly important that one be precise,

02:19:22.020 | or mathematics or physics or engineering,

02:19:25.660 | anything where precision has a payoff

02:19:28.180 | and gaining precision takes time and delay

02:19:32.060 | of immediate gratification.

02:19:34.180 | You can imagine that obsessive compulsive

02:19:35.740 | personality disorder would synergize well

02:19:38.040 | with those sorts of activities and professions.

02:19:40.180 | Whereas obsessive compulsive disorder is really intrusive.

02:19:43.100 | It's preventing functionality in many different

02:19:46.420 | domains of life.

02:19:47.700 | So the key takeaway here is that when we use the words

02:19:52.460 | obsessive compulsive, or we call someone

02:19:54.540 | obsessive compulsive, or we are trying to evaluate

02:19:56.740 | whether or not we are obsessive compulsive,

02:19:58.460 | it's very important that we highlight

02:20:02.200 | that obsessive compulsive disorder is very intrusive.

02:20:05.460 | It involves intrusive thoughts and it interrupts

02:20:07.860 | with normal functioning in life.

02:20:09.080 | Whereas obsessive compulsive personality disorder,

02:20:11.460 | while it can interrupt normal functioning in life,

02:20:14.220 | it also can be productive.

02:20:16.540 | It can enhance functioning in life, not just in work,

02:20:19.020 | but perhaps at home as well.

02:20:21.080 | If you are somebody and you have family members

02:20:23.400 | that really place enormous value on having a beautiful

02:20:26.220 | and highly organized home,

02:20:27.540 | well then it could lend itself well to that.

02:20:29.900 | It's going to be a matter of degrees, of course.

02:20:31.560 | None of these things is an absolute,

02:20:33.100 | it's going to be on a continuum.

02:20:34.260 | But I think it is fair to say that obsessive compulsive

02:20:36.640 | disorder, whether or not in mild, moderate or severe form

02:20:40.380 | is impairing normal functioning.

02:20:43.380 | Whereas obsessive compulsive personality disorder,

02:20:45.900 | there's a range of expressions of that,

02:20:48.220 | some of which can be adaptive,

02:20:49.540 | some of which can be maladaptive.

02:20:51.020 | And again, it's all going to depend on context.

02:20:53.640 | Before we conclude, I do want to touch on something

02:20:56.580 | that I think a lot of people experience

02:20:58.500 | and that's superstitions.

02:21:00.560 | Superstitions are fascinating

02:21:02.060 | and there's some fascinating research on superstitions.

02:21:05.600 | One particular study that I'm a big fan of

02:21:08.620 | is the work of Ben Solevsky at Harvard.

02:21:11.220 | He studies motor sequences and motor learning.

02:21:14.520 | And he has beautiful data on how people learn,

02:21:17.500 | for instance, a tennis swing

02:21:19.480 | and the patterns that they engage in early on.

02:21:23.140 | And then the patterns of swinging that they,

02:21:25.260 | swinging the racket that is,

02:21:26.620 | that they engage in later as they acquire more skill.

02:21:29.700 | And basically the takeaway is that the amount of error

02:21:32.900 | or variation from swing to swing is dramatically reduced

02:21:36.980 | as they acquire skill.

02:21:39.120 | That's all fine and good.

02:21:41.320 | And there's some beautiful mechanistic data

02:21:43.580 | that he and others have discovered

02:21:46.120 | to support how that comes to be.

02:21:48.200 | But they also explore animal models,

02:21:50.900 | in particular rats pressing sequences of buttons and levers

02:21:55.300 | to obtain a reward.

02:21:57.300 | Believe it or not, rats are pretty smart.

02:21:59.480 | I've seen this with my own eyes.

02:22:00.940 | You can teach a rat to press a lever for a pellet of food.

02:22:04.420 | Rats can also learn to press levers

02:22:07.340 | in a particular sequence in order to gain a piece of food.

02:22:11.260 | And they can actually learn to press an enormous number

02:22:15.300 | of levers in very particular sequences

02:22:17.220 | in order to obtain pellets of food.

02:22:19.180 | You can also give them little buttons to press

02:22:21.520 | or even a paddle to, or I should say a pedal, excuse me,

02:22:25.880 | to stomp on with their foot

02:22:27.360 | in order to obtain a pedal of food.

02:22:29.140 | Basically rats can learn exactly what they need to do

02:22:32.060 | in order to obtain a piece of food,

02:22:34.740 | especially if they're made a little bit hungry first.

02:22:37.540 | Benson's lab has published beautiful data showing

02:22:40.900 | that as animals and humans

02:22:43.620 | come to learn a particular motor sequence,

02:22:45.760 | very often they will introduce motor patterns

02:22:49.060 | in that sequence that are irrelevant to the outcome

02:22:52.820 | and yet that persist.

02:22:54.560 | If you've ever watched a game of baseball,

02:22:56.140 | you've seen this before.

02:22:58.060 | Oftentimes the pitcher up on the mound

02:23:00.260 | will bring the ball to their chin.

02:23:03.940 | They'll look over their shoulder,

02:23:05.500 | they'll look back over the other shoulder,

02:23:07.780 | and then they will, of course,

02:23:09.860 | reel back and pitch the ball.

02:23:11.760 | But if you watch closely,

02:23:12.980 | oftentimes there are components in the motor sequence

02:23:15.460 | which are completely unrelated to the pitch.

02:23:17.940 | They're not looking necessarily to see

02:23:19.600 | if someone's stealing a base.

02:23:21.120 | They're not necessarily looking down at home plate

02:23:24.220 | where the batter is.

02:23:25.980 | They're also doing things like

02:23:27.540 | touching the back of their ear

02:23:28.620 | before they bring the ball to their chin

02:23:30.460 | or adjusting their hat.

02:23:31.620 | And if you watch individual pitchers,

02:23:33.220 | what you'll find is that they'll do the same sequence

02:23:35.220 | of completely irrelevant motor patterns

02:23:38.260 | before each and every single pitch.

02:23:40.560 | Similarly, rats that have been trained to, for instance,

02:23:43.900 | hit two levers and step on a pedal

02:23:47.060 | with their left hind foot

02:23:49.140 | and then tap a button up above that is the red button

02:23:53.180 | will do that to gain a piece of food.

02:23:55.640 | But sometimes they'll also introduce a pattern

02:23:57.700 | into that motor sequence

02:23:58.980 | where they will shake their tail a little bit

02:24:01.660 | or they'll turn their head a little bit

02:24:02.780 | or they'll move their ears a little bit, et cetera.

02:24:05.620 | Motor patterns that have nothing to do

02:24:07.400 | with obtaining the particular outcome in mind.

02:24:10.940 | In other words, you could eliminate certain components

02:24:13.560 | of the motor sequence and it would not matter.

02:24:15.380 | The rat would still get the pellet.

02:24:16.580 | The pitcher would still be able to pitch.

02:24:19.500 | And yet that can introduce because somehow

02:24:21.660 | because they were performed again and again,

02:24:25.660 | prior to successful trials,

02:24:28.780 | the rat or the human baseball pitcher

02:24:32.380 | comes to believe in some way

02:24:34.420 | that it was involved in generating the outcome,

02:24:37.160 | hence superstition, right?

02:24:39.100 | I confess I have a few superstitions.

02:24:41.380 | I occasionally will knock on wood.

02:24:43.420 | I'll say something that I want to happen

02:24:45.000 | and I'll say, oh, knock on wood and I'll just do it.

02:24:47.060 | And occasionally I'll challenge myself and think,

02:24:49.600 | ah, I don't want to knock,

02:24:50.640 | don't knock on wood, Andrew, don't do that.

02:24:52.300 | You know, no one,

02:24:53.260 | I don't think anyone wants to be superstitious.

02:24:55.340 | I certainly don't.

02:24:56.220 | And so every once in a while, I'll just challenge it

02:24:57.980 | and I won't actually knock on wood.

02:25:00.860 | I'm admitting this to you to kind of,

02:25:02.660 | I guess, normalize some of this.

02:25:05.460 | Some people have superstitions that border on

02:25:09.180 | or even become compulsions.

02:25:12.000 | They really come to believe that if they don't knock on wood

02:25:14.900 | that something terrible is going to happen,

02:25:16.300 | maybe something in particular.

02:25:18.220 | Or in the case of the baseball pitcher,

02:25:19.860 | they come to believe that if they don't touch

02:25:21.580 | their right ear before they reel back on the pitch,

02:25:24.560 | that the pitch won't be any good

02:25:27.820 | or that they're going to lose the game.

02:25:29.140 | I don't know what their thought process is.

02:25:30.540 | Now, I also don't know what the rat is thinking,

02:25:32.700 | but the rat is clearly doing something

02:25:36.160 | or thinking something is related to the final outcome.

02:25:40.000 | I don't know of any studies where they've intervened

02:25:42.240 | with the particular superstition-like behaviors of the rat

02:25:46.020 | to see whether or not the rat somehow doesn't continue

02:25:49.620 | to do the motor sequence to get the pellet.

02:25:51.320 | We don't know.

02:25:52.160 | The rats, I don't speak rat, most people don't.

02:25:54.260 | Or if you speak to a rat, if it speaks back,

02:25:56.400 | it's not in English.

02:25:57.240 | Anyway, the point is that superstitions are beliefs

02:26:01.480 | that we on an individual scale come to believe

02:26:05.840 | are linked to the probability of an outcome

02:26:09.480 | when in fact we know,

02:26:11.560 | we actually know in our rational minds,

02:26:14.000 | they have no real relationship to the outcome.

02:26:16.960 | Superstitions can become full-blown compulsions

02:26:20.960 | and obsessions when we repeat them often enough

02:26:25.160 | that they become automatic.

02:26:26.560 | And I think this is what we observe most of the time

02:26:28.860 | when we see a pitcher touching their ear,

02:26:31.360 | or for instance, in tennis, you see this a lot.

02:26:33.680 | You'll see someone, they'll slap their shoes often.

02:26:36.940 | I see this, they'll slap the undersides of their soles.

02:26:39.540 | They may tell themselves that this is, I don't know,

02:26:41.680 | maybe moving out some of the dust or something

02:26:43.520 | in the bottoms of their soles that gives them more traction

02:26:45.700 | and they want that to be ready for the serve

02:26:47.520 | or something like that.

02:26:48.900 | And maybe there's some truth to that.

02:26:50.280 | But here, what we're referring to are behaviors

02:26:53.440 | that really have no rational relationship to the outcome.

02:26:56.120 | And yet we perform in a compulsive way.

02:26:58.340 | People with OCD, yes, tend to have more superstitions.

02:27:03.340 | People with more superstitions, yes,

02:27:05.520 | tend to have a tendency towards OCD.

02:27:08.360 | And I should mention obsessive compulsive

02:27:10.680 | personality disorder.

02:27:12.120 | If you think way back to the first part of this episode,

02:27:15.760 | when I was just describing what the brain does, right?

02:27:17.960 | What does your brain do?

02:27:18.780 | Housekeeping functions to keep you alive.

02:27:20.680 | And it's a prediction machine.

02:27:22.960 | Your neural circuits, you have an enormous amount

02:27:26.640 | of biological investment of real estate,

02:27:29.200 | literally cells and chemicals that are there

02:27:31.680 | to try and make your world predictable

02:27:34.600 | and to try and give you control

02:27:36.560 | or at least the sense of control over that world.

02:27:39.340 | And that's a normal process.

02:27:42.300 | Low-level superstitions, moderate superstitions

02:27:45.880 | represent a kind of a healthy range, I would say,

02:27:50.100 | of behaviors that are aimed at generating predictability

02:27:55.080 | that don't disrupt normal function.

02:27:57.220 | Obsessive compulsive personality disorder,

02:27:59.180 | provided it's not too severe,

02:28:00.380 | would I think represent the next level along that continuum.

02:28:04.420 | And then obsessive compulsive disorder,

02:28:06.300 | as I pointed out earlier,

02:28:07.720 | is really a case of highly debilitating, highly intrusive,

02:28:11.620 | really overtake of neural circuitry

02:28:14.180 | over our thoughts and behaviors

02:28:15.520 | that requires very dedicated, very persistent.

02:28:19.800 | And very effective treatments

02:28:22.180 | in order to stop those obsessions and compulsions

02:28:25.180 | and the anxiety that links them somewhat counterintuitively

02:28:29.100 | by teaching people to tolerate

02:28:31.580 | that level of increased anxiety and interrupt those patterns.

02:28:35.020 | Unfortunately, as we described earlier,

02:28:36.980 | such treatments exist.

02:28:38.340 | Cognitive behavioral therapy, drug treatments like SSRIs,

02:28:42.060 | though also drug treatments

02:28:43.340 | that tap into the glutamate system

02:28:46.220 | and into perhaps also the dopamine system,

02:28:49.600 | the so-called neuroleptics.

02:28:50.860 | And then as we described,

02:28:53.300 | there's now an extensive exploration

02:28:54.900 | of things like ketamine, psilocybin, cannabis.

02:28:58.200 | The initial studies don't seem to hold much promise

02:29:00.380 | for cannabis and CBD in the treatment of OCD,

02:29:02.540 | but who knows, maybe more studies will come along

02:29:04.700 | that will change that story.

02:29:06.620 | And then of course, brain-machine interface,

02:29:08.080 | like transcranial magnetic stimulation.

02:29:10.100 | And then just to remind you what I already told you before,

02:29:12.660 | combinations of behavioral and drug treatments

02:29:15.360 | and brain-machine interface,

02:29:16.600 | I think is really where the future lies.

02:29:18.380 | Fortunately, good treatments exist.

02:29:20.960 | We cannot say that any one individual treatment

02:29:24.960 | works for everybody.

02:29:26.180 | There are fairly large percentages of people

02:29:29.380 | that won't respond to one set of treatments or another,

02:29:31.480 | and therefore one has to try different ones.

02:29:34.040 | And then there are the so-called supplementation-based

02:29:37.780 | or more holistic therapies.

02:29:39.760 | Today, I've tried to cover each and all of these

02:29:41.940 | in a fairly substantial amount of detail.

02:29:44.860 | I realize this is a fairly long episode.

02:29:47.620 | That is intentional.

02:29:49.560 | Much like our episode on ADHD,

02:29:51.740 | on attention deficit hyperactivity disorder,

02:29:54.140 | I received an enormous number of requests to talk about OCD.

02:29:57.820 | And my decision to make this a very long

02:30:00.060 | and detailed episode about OCD

02:30:02.980 | really doesn't stem from any desire

02:30:04.620 | to subject you to too much information

02:30:07.540 | or to avoid the opportunity to just list things off.

02:30:11.580 | What I've tried to provide is an opportunity

02:30:13.580 | to really drill deep into the neural circuitry

02:30:15.960 | and an understanding of where OCD comes from,

02:30:18.360 | how OCD is different from things like

02:30:20.760 | the personality disorders that I described,

02:30:22.940 | and also to give you a sense of how the individual

02:30:26.820 | behavioral and drug treatments work and perhaps don't work

02:30:29.900 | so that you can really make the best informed choices.

02:30:32.460 | Again, highlighting the fact that OCD

02:30:34.580 | is an extremely common,

02:30:36.740 | extremely common and yet extremely debilitating condition,

02:30:40.420 | and one that I hope that if any of you have

02:30:42.420 | or that you know people that have it,

02:30:43.980 | that you'll both gain sympathy and understanding

02:30:46.920 | for what they're dealing with,

02:30:48.140 | perhaps as a consequence of some of the information

02:30:50.100 | presented today, and maybe help them direct their treatment,

02:30:54.560 | find better treatment, and of course,

02:30:56.900 | apply those treatments for some relief.

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02:33:18.440 | In closing, I'd like to thank you

02:33:19.840 | for this in-depth discussion about the mechanisms

02:33:23.300 | and various treatments for obsessive compulsive disorder

02:33:26.300 | and some of the related disorders.

02:33:28.100 | And as always, thank you for your interest in science.

02:33:31.100 | [upbeat music]

02:33:33.680 | (upbeat music)

The Science & Treatment of Obsessive Compulsive Disorder (OCD) | Huberman Lab Podcast #78

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