Welcome to the huberman Lab podcast, where we discuss science and science based tools for everyday life. I'm Andrew huberman and I'm a professor of neurobiology and Ophthalmology at Stanford school of medicine.
Today, we are talking about
obsessive compulsive disorder or OCD. We are also going to talk about obsessive compulsive personality disorder,
which as you will soon. Learn is distinct from
obsessive-compulsive disorder.
In fact, many people that refer to themselves or others
There's as obsessive or compulsive or quote unquote having OCD or OCD about this or OCD about that. Do not
have clinically diagnosable OCD.
Rather many people have obsessive-compulsive personality disorder. However,
there are many
people in the world that have actual OCD. And for those people, there's a tremendous amount of suffering. In fact, OCD
turns out to be number seven, on the list of
most debilitating. Illnesses, not just psychiatric illness.
Says, but of all illnesses, which is remarkable and somewhat
frightening. The good news is thanks to the fields of
Psychiatry
psychology and Science in general. There are now excellent treatments for OCD. We're going to talk about those treatments today. Those treatments range from behavioral therapies to drug therapies, and brain stimulation and even some of the more
holistic or natural therapies,
as you'll soon learn for certain people, they may want to focus more
on the beach.
Your therapy is whereas for others more on the drug based therapies and
so on and so forth. One, extremely interesting and important thing I learned from this episode is that the particular sequence that behavioral and or drug, and or holistic therapies are,
applied is
extremely important.
In fact, the outcomes of studies often depend on whether or not
people start on drug treatment and then
follow with cognitive behavioral treatment or vice versa. We're going to go into all those details and how they relate to different types of OCD. Because it turns out
There are indeed different types of obsessions and
compulsions and the age of
onset for OCD and so on and so forth, what I can assure you
is by the end of this episode, you will have a much greater understanding
of what OCD is and what it isn't.
And what obsessive compulsive personality disorder is and what it is. Not and you'll have a rich array of different therapy options to explore
in yourself or in others that are suffering from
OCD and if neither you or others that, you know, suffer from OCD
or obsessive.
Also personality disorder,
the information covered in today's episode, we'll also provide insight into how the brain and nervous system translate thought
into action. Generally and also you're going to learn a lot about goal-directed Behavior generally. My
hope is that by the end of the episode, you will both
understand a lot about this disease state that we call OCD. You will have access to information, that will allow you to direct treatments to yourself or others in better ways
and that you will gain greater insight
into how you function. And
How human beings function in
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checkout. Let's talk about OCD or obsessive compulsive disorder.
First of all, as the name suggests OCD
includes thoughts or obsessions and compulsions which are actions,
the obsessions and
compulsions are often linked. In fact, most of the time the obsessions and compulsions are
linked. Such that, the compulsion the behavior is designed to relieve the obsession. However, one of the Hallmark
themes of obsessive compulsive disorder,
Is that the
obsessions are intrusive. People don't want to have them, they don't enjoy having them. They just seem to pop into people's minds and they seem to pop into their mind recurrently, and the compulsions, unlike other sorts of behaviors,
provide brief relief to the obsession,
but then very quickly reinforce or
strengthen the obsession.
This is a very key theme to
realize about obsessive compulsive disorder. So I'm just going to repeat it again.
These two features first the fact that the
Actions are intrusive and recurrent as well as the fact that the compulsions the behaviors provide. If anything only brief relief for the obsessions but in most cases simply serve to make the obsession stronger, are the Hallmark
features of obsessive-compulsive
disorder and turns out to be very important to keep these in mind as we go forward, not just because they define obsessive
compulsive disorder
but they also Define the sorts of treatments that will and will
not work for obsessive compulsive disorder
and then,
Do you understand a little bit about the neural circuitry,
underlying obsessive-compulsive disorder which we'll talk about in a few moments,
then you will clearly understand why, being a quote-unquote, obsessive person or having obsessive-compulsive
personality is not the same as
OCD. In fact, we can leap ahead a little bit
and compare and contrast OCD with obsessive-compulsive personality disorder, along
one very particular set of features again, I'll go into this in more detail later, but it's fair to say that OCD is characterized by these
Current and intrusive obsessions. And as I mentioned before, the fact that there's obsessions get stronger as a function of people performing
certain behaviors so unlike
a niche that you feel and then you scratch it and it feels better OCD is more like an itch that you feel, you scratch it and the itch
intensifies that Contour or that pattern of behaviors. And thoughts interacting
is very different than
obsessive-compulsive personality disorder.
Which mainly involves a sense of delayed gratification that people want and somewhat enjoy.
Joy because it allows them to function better or more in
line with how they would like to show up in the
world. So, again, OCD has mainly to do with obsessions that are intrusive and recurrent whereas obsessive-compulsive personality disorder does not have that intrusive feature to it. People do not mind or in fact, often invite or like the particular patterns of thought that lead them to be
compulsive along certain Dimensions. So
leaving aside,
obsessive-compulsive personality disorder for the
moment. Let's focus a bit more on OCD and Define how it tends to show up in the world.
First of all, OCD is extremely common. In fact, current estimates are that anywhere from two point, five percent to, as high as three or even four
percent of people suffer from
True OCD. That is an astonishingly
High number. Now, the reason the range is so big 2.5% all the way up to three or maybe even four
percent, is that a lot of the features of OCD go unnoticed both in the clinicians office.
And simply because people don't report it and don't talk about it. In fact, it is possible to have recurrent and intrusive obsessions and not engage in the sorts of behaviors that would ever allow people to notice that somebody has OCD that can be because some of the
intrusive thoughts don't actually lead to
overt behaviors like hand washing or checking that other people would notice. It can also be because people learn to disguise or
hide their obsessions and their compulsions out of
shame or fear of looking strange.
Whatever it
might be, such that they have these obsessive and intrusive thoughts, and they do little micro
behaviors. Like, they might tap their fingers on their
Phi, as a way to avoid
at least in their own mind. Something catastrophic happening, that might seem
crazy to you. It might seem bizarre but this is the sort of thing that operates in a lot of people.
And I really want to emphasize this because the
clinical literature that are out there really point to the fact that many
people have OCD full-blown OCD and never report it because
because of the kind of Shame and hiding associated with it.
Another thing to point out is that OCD is extremely debilitating. I mentioned this a few minutes ago, but OCD is currently listed as a number seven. In terms of the most,
debilitating illnesses. Not just mental illnesses or disorders,
but all
types of illnesses, including things like asthma and cancer Etc.
So you can imagine with that standing at number 7,
that it is both
extremely common and extremely
Debilitating. And as a
consequence, it's now realized that
many hours days weeks, months, or even years of work performance or showing up at work of relational interactions really suffer as a
consequence of people having OCD. So this
is a vital problem that the scientific and psychiatric and psychological communities, understand and it's one of the reasons that I'm doing
this podcast. And of course, I received a ton of interest in
OCD because of this incredibly High
incidence of OCD and how debilitating it
it is,
we could go really deep into why it's so debilitating. I don't want to spend too much time on that because I think most of that is pretty obvious, but some of it is not for instance, one of the things that makes OCD so debilitating is, of course, the shame that we talked about before, but it's also the fact that when people are focusing on their obsessions and their compulsions, they're not able to focus on other things.
That's simply the way that the brain works. We're not able to focus on too many things at once. The other thing is that, OCD takes a lot of time out of people's lives
with recurrent in
Rusev thoughts happening at very high frequency or even at moderate frequency. People are spending a lot of time thinking about this stuff and they're thinking about the behaviors. They need to engage in and then engaging in the behaviors. Which as I mentioned before, just served to
strengthen the compulsions. And so they're not actually
doing the other things that make us functional human beings like commuting
to work or doing homework, or doing work or
listening when people are talking or interacting or sports or working out all the things that make for a rich quality life are taken over
by OCD in many cases. So,
So, while that might be
obvious to some, I'm not sure that it's
obvious to everybody just how much time OCD can occupy.
Another thing you'll soon, learn is that sadly a lot of the
obsessions and compulsions in OCD often relate to Taboo topics.
And that's because the general
categories of OCD fall into three different bins,
checking, obsessions and compulsions repetition, obsessions and compulsions and Order
obsessions and
compulsions, the checking ones are somewhat obvious, checking the stove or checking the locks.
Which I think we all tend to do. I'm somebody typically
I'll headed off to the car to, you know, commute to work. And I think I did. I lock the front door and I'll go back once,
but I won't go back twice or 50 times. People with
OCD will often go back, 20 or 30 times before they'll actually allow themselves to drive off, and then it's a real challenge for them to continue to drive off and discard with the idea that they didn't check the stove, or they didn't check the locks, or they didn't check something else, critical
repetition obsessions and compulsions obviously can dovetail with
The the checking ones but those tend to be things like counting off of a certain
number of numbers like 1 2 3 4 5 6 7, 7 6 5 4, 3 2, 1 people will perform that repeatedly repeatedly repeatedly or feel that they have to remember years ago, watching a documentary about the band. The Ramones I most people heard of The Ramones, right, jeans, t-shirts, aviator glasses. Everyone had to change your last name to Ramon. They weren't actually all related to one another. By the way, you had to change your
last name to Ramon, The Ramones had one band member who
Was admittedly and known to others as having OCD. And during that documentary which I forget the name I think it was called
can't remember. Anyway can't remember
hippocampal laps there
but in this documentary, the band members described Joey Ramone as leaving, hotels walking down the stairs to the parking lot, but then having to walk up and down them seven or eight times and sometimes getting out of the van again and walking up and
down them seven or eight times. And I always had to be a
certain number of x given a certain number of stairs. This appears
What crazy but of course we don't want to think of this as crazy. This is somebody who
very likely had full-blown OCD.
Now, that particular example, believe it or not is not all that uncommon, it just so happens that that example, entailed certain compulsions and behaviors that
were overt and that other people could see. And you can imagine how that would prevent somebody from moving about their daily life easily. A lot of people as I mentioned before, have obsessions and compulsions that they hide, and they do these little micro behaviors or they'll just count off in their head.
As opposed to generating some sort of walking up and down stairs or tapping, or things of that sort.
So we have checking we have repetition and then there's order
order, often times is thought of as putting cleanliness or making sure everything is aligned and perfect and
orderly. And oftentimes that is the case but there are other forms of order
that people with OCD can focus on in a obsessive and compulsive way
things like incompleteness the idea that one can't walk away from
Something or stop doing something. Because something is not, right
or complete in that picture, it could be the way that table is set. It could be the way that something's written on a
page. It could be an email again. Now, we're still talking about OCD the disorder. We're not talking about
obsessive-compulsive personality disorder. I'm aware of well I'll just be directed. Several colleagues of mine. It's just remarkable.
The order in their emails. Every email is perfect punctuated. Perfect grammar, perfect. Everything is spaced. Perfect are do they
OCD. Well they might there might
not how would I know unless they disclose
that to me. But they might have obsessive-compulsive personality disorder or they just might be
able to generate a lot of order and they have a lot of discipline around the way they write in the way they present, any communication, with anybody at all.
So if somebody has a OCD that's in the domain of order, it could be incompleteness. And the constant feeling of something, not being completed and a need to complete it. It can also be in terms of symmetry.
That
everything be aligned in symmetric, in some way. This could be seen, perhaps in young kids. This is one example that I read in the
literature of children that need to arrange their stuffed animals in exact
same order every day. And in a
particular order to the
point where, if you were to move the little stuffed frog over next to the stuffed rabbit, that the child would have a anxiety reaction to that and feel literally
compelled driven to fix
that maybe even multiple times over and over again.
We'll talk about OCD and children versus adults in a little
bit and then the other aspect of order which is a little bit less than intuitive is this notion
of discussed,
this idea that something is
contaminated. So we often think about OCD and hand-washing behavior in response to people feeling that something is contaminated a space, a towel etcetera or even simply somebody else's hand and so they're unwilling to shake somebody's hand.
You can imagine how these different bins of obsessions and compulsions checking repetition and Order.
To be extremely debilitating, depending on how severe they are and how many different domains of life they show up in because often times in movies and even the way I'm describing it. Now it sounds as if okay well
somebody has to check the locks but they don't have to also check the stove or somebody has the need to count to seven back and forth up to seven and down to seven, seven times, seven times a day, or something of that sort where they need symmetry in very specific domains of life.
But it turns out that this recurrent and intrusive,
Of obsessions leads people with OCD to have checking repetition and or order compulsions everywhere. So whether or not somebody is at work or in school or trying to engage in sport or trying to engage in relationship or just something simple like walking down the street, the obsessions are so intrusive that they show up. And they compel people to do things in that domain independent of whether or
not, they happen to be one location or another. In other
words, the thought
patterns in the
the behaviors, take over the environment as opposed to the environment driving the thought patterns and behaviors. So, therefore
becomes impossible to ever find a room that's clean enough to find a bed that's made, well enough to find anything that's done. Well, enough to remove
the obsession and I know I've said it multiple times now, but I'm going to say it many times throughout this episode, in a somewhat obsessive, but I believe Justified way that
every time that one engages in the compulsion related,
Obsession. The obsession simply become stronger. So you can imagine what a, what a powerful and debilitating Loop that really is.
So let's drill a little bit deeper into how the obsessions and
compulsions relate to one
another. If we were to draw a
line between the obsessions and compulsions, that line could be described as anxiety. Now, we need to Define what anxiety is and to be
quite honest most of psychology and science. Can't agree on exactly what anxiety is. Typically, the way we think about fear
Is that it's a heightened state of autonomic
arousal. So, increase heart rate, increased breathing sweating
Etc in response to an immediate and present
threat or perceived
threat, whereas anxiety. Generally speaking in the scientific literature relates to the same sorts of
thought, patterns and somatic bodily responses, heart rate, breathing, Etc,
but without a clear and
present danger being in the environment or right there.
So, that's the way that we're going to
talk about anxiety now.
Anxiety is really what binds the
obsessions and compulsions such,
that someone will have an intrusive thought. So, for instance, some will have the
thought that
if they turn left on any street, that, something bad will
happen. Okay? That's an obsession is actually not all that uncommon. Now, how bad and what the specificity of that. Bad thing really is, will vary
some people will think if I turn left something generally, bad will happen. It just makes me
feel anxious. So they always insist on going, right?
Whereas other people will think if I turn left, so and so will die.
Die or I will die or something. Terrible will happen
and I'll get a disease or someone else will get a disease or I'll be cursing myself or somebody else in some very specific way. This is unfortunately quite common in people with OCD so
they have this feeling and the feeling can be generally or specifically related to a particular outcome. But beneath that is a feeling of anxiety,
a quickening of the
heartbeat, a quickening of breathing, a narrowing of ones visual Focus.
I've talked about this before another podcast, the master stress, and other podcast. But
if you haven't heard those, let me just briefly describe it. When we are in a state of increased
so-called autonomic arousal alertness stress, Etc.
Our visual field literally Narrows the
aperture of our visual field, get smaller and that's because of the relationship between the autonomic nervous system and your visual system. So you
start seeing the world through sort of soda,
straw view or through binocular, like view as opposed to seeing the big picture. Why is that important? Well,
it literally
Lee sharpens and narrows your focus toward the very
thing that the obsessions and compulsions are focused on. So the person walking down the street, who seized the opportunity to go, left or
right will only see the
bad decision, their visual field Narrows very tightly along that possibility of taking a left turn. And I know as I describe, this seems totally irrational but I want to emphasize that the person with OCD knows it's irrational. They
might feel crazy because they're having these thoughts. But
No, it makes no sense whatsoever. That
left somehow would be different than right in terms of outcomes in this particular case. And yet, it feels as if it would, in fact, in some cases, it feels as if they went left, they would have a full-blown panic attack.
So, the idea here is that the obsessions and compulsions are bound by anxiety. But then by taking a right hand turn again, in this one particular example, by taking a right hand turn, there's a very brief. I should mention very brief
relief of that.
At anxiety
at the time of the decision to go, right? Not left. And there's an additional
drop in anxiety. While one takes the right-hand turn as opposed to the left-hand turn and then as I alluded to
before there's a reinforcement of the compulsion in other words by going right, it doesn't
create a situation in the brain and psychology of the person that you know what? I'm not anxious anymore left. Would have probably been
okay. It reinforces the
Idea that right made me feel better or turning, right, made me feel better and going left, would have been that much worse. Again, it reinforces the obsession even further.
And again we could swap out, right turns and left turns with something like hand washing, the feeling that something is contaminated and the need
to wash one's hands. Even though one already wash their hands. 20, 30 50 times prior we're actually going to go back to that example a little bit later
when we talk about one particular category of therapies that are
A
effective in many people for OCD, which are the cognitive behavioral and exposure therapies. Because I
think some of you have heard of cognitive behavioral and exposure therapies, but the way they are used to treat OCD is very much different than the way they're used to
treat other sorts of anxiety, disorders and other sorts of disorders, generally.
So it's fair to say that up to 70% of people with OCD. Have some
sort of anxiety or elevated anxiety, either
directly related to the OCD
or indirectly.
A to the OCD and it's really hard to tease those apart
because OCD can create its own
anxiety. As I mentioned before, it can even increase its own anxiety
and there's also an issue of depression
having OCD can be very depressing, right? Especially if some of these OCD thoughts and behaviors, start to really impede people's ability to function in life. It work and school and relationship. They can start feeling less optimistic about life and in fact, some people can become suicidally depressed. That's how bad OCD can be for us.
So,
We have to be careful when saying, that 70% of people with OCD.
Also, have anxiety, or X number of people with OCD are also
depressed. Because we don't know whether or not the depression led, the OCD, or the
other way around or whether or not. They're operating as we say in signs in parallel some of the drug treatments for OCD and depression, and anxiety can t some of that apart. And we'll talk about that.
But I think it's fair to say that what binds the obsessions and compulsions is anxiety, that there is a feeling of it, or I should say an urgent feeling of a need to get rid.
Of the obsession and the person feels as if the only way
they can do that is to engage in a particular compulsive Behavior.
Some people are probably wondering if there's a genetic component to OCD and indeed there is, although the nature of it isn't exactly clear. And oftentimes when people hear that something has a genetic component, they think it's always
directly inherited from a parent and that's not always the case. There can be genes that surface in
siblings or genes that surface in children that are not readily.
Ali apparent, in terms of what we call a phenotypes, you have a genotype, the Gene, and then you have a phenotype, the way it
shows up as a body form, or like eye color or how it shows up in terms of a behavior or behavioral pattern.
Based on twin studies where researchers have examined, identical twins, fraternal twins, even identical twins, that share the same sac in utero, the, what we
call monochorionic. So sitting in the same little
bag during pregnancy or indifferent little bags, you can see different levels
of what's called genetic code.
Gordon's. But if we were to just sort of cut a broad swath through all of the genetic data, it's fair to say that about 40 to 50 percent of OCD cases, are have some genetic component, some mutation or some
inherited aspect that's genetic and that one could point to if they got their genome
mapped. Now while that's interesting I don't think it's terribly useful for most people.
First of all you can't really control your jeans at least at this point in history even though there are things like epigenetic control and people are very excited about Technologies like Chris.
Or modifying the genome
in humans at some point. Most people can't control their genetics. Right. You can't pick who your
parents were as they say.
So just know that there is a genetic component in about
half of people with OCD, but
not always. Now, as is typical for this podcast, I want to focus on some of the neural mechanisms and chemical systems in the
brain and body that generate obsessive compulsive disorder. In fact, if you watch this podcast before, listen to this podcast before, this is always
how I structure.
Things. First we introduce a topic and we explore that
topic in detail and really
Define what it is and what it isn't. And then
it's very important that we focus on what is known and what is not known
about the biological mechanisms that generate whatever that thing happens to be in this case both CD and obsessive-compulsive personality disorder.
Now I want to emphasize that even if you don't have a background in biology, I will make this information accessible to you. And I also want to emphasize that for those of you that are interested in treatments and are anxious
Viciously awaiting the description of things that can help with OCD encourage you if you will to please try and digest some of the material about the underlying mechanisms because understanding even just a little
bit of those biological mechanisms can
really help shed light on why particular drug and behavioral treatments at end other sorts of treatments work and don't work. This is especially important in the case of OCD where it turns out that the order and type of treatment can really vary according to individual.
And that's something really special and important about OCD that
we really can't say, for a number of the other sorts of disorders that we've described on previous podcasts.
So let's take a step back and look at the neural circuitry. What's going on in the brain and body
of people with OCD, why the
intrusive recurrent thoughts.
Why the compulsions? Why is
that whole system Bound by anxiety. And in some ways, in thinking about that, I want you to keep in mind that the brain has two main functions.
The brains main functions are to take care of all the
housekeeping stuff. Make sure digestion Works, make sure the heart beats, make sure you keep breathing no matter what.
Make sure that you can see you can hear, you
can smell etcetera, the basic stuff
and then there's an enormous amount of brain real estate. That's designed to allow you to predict what's going to
happen next. Either in the immediate future and the long-term future
and largely that's done based on your knowledge of the past. Are you also have memory systems and of course you have systems in the brain?
Body that are designed to bind. What's happening
at the housekeeping level, like your heart rate to your anticipation of what's going to happen next. So, if you're thinking about something very fearful, your body will have one type of reaction. If you're thinking about something very pleasant and relaxing, your body will have another type of reaction. So whenever I
hear about the brain-body distinction, I have to just remind everybody that there really is no distinction
between brain and body when you think about it. Through the nervous system, the nervous
system is the brain, the eyes, the spinal cord. But of course, all their connections
with all the organs
The body and the connections of all the organs of the body, with the brain, the spinal cord
etcetera. So, as I described these neural circuits, I don't want you to think of them as just things happening in the head, they are
certainly happening in the head. In fact, the circuits all described most in detail do exist within the confines of your cranial Vault. That's nerd speak for skull. But
those circuits are driving particular predictions and therefore
particular biases towards particular actions in your body, they're creating a state of Readiness, or a state of
Desire to check or desire to count or desire to
avoid etc. Etc.
So what are these circuits? Well, there's been a lot of wonderful research,
exploring the neural circuits underlying obsessive compulsive disorder
and that's mainly been accomplished through a couple of methods. Most of those methods when applied in humans involve getting some look into which brain areas are
active when people are having obsessions. And when people are engaging in compulsions,
now that might
It seemed simple to do. But of course, your
brain is housed inside the cranial Vault, and in order to look inside it, you have to use things like magnetic resonance
imaging, which is just fancy technology for looking at blood flow, which relates to
activation of neurons, nerve cells, or things like pet PE T Imaging, which has nothing to do with the verb pet, and has nothing to do with your house,
pet as everything to do with positron emission, tomography, which is just another way of seeing which brain areas are active. And
in, you can also use pet to figure out what sorts of
Chemicals are
active like dopamine, Etc. Many studies we can
fairly say dozens if not hundreds of
Studies have now identified a particular circuit
or Loop of brain areas that are interconnected and very
active in obsessive compulsive disorder.
That Loop includes the cortex, which is kind of the outer shell of the human brain.
The lumpy stuff as it sometimes appears. If the skull is removed, and it involves an area called the striatum, which is involved in
action, selection, and holding back action. The striatum is involved in what's commonly called go and no go types of behaviors.
So, every type of behavior, like, picking up a pen, or a mug of coffee, involves a
go type function, it involves generating an action
but
Time I resist an action. My nervous system is also doing that using
this brain structure, the striatum which includes among other things. The basal ganglia talked about that before, I'm not trying to overload you with terminology here, but I know some people are interested in terminology,
so you have go behaviors and you have no.
Go resisting of behaviors. Not going toward Behavior,
the cortex, and the striatum are in this intricate back and forth,
talk, it's really Loops of connections. The cortex doesn't tell the striatum what to do. The stream, doesn't tell the
Tex what to do. They're in a crosstalk, like any good relationship. There's a lot of back-and-forth communication.
There's a third element in this cortical
striatal loop as it's called and that's the thalamus.
Now, the thalamus is not a structure. I've talked a lot about before on this
podcast but it's one of my favorite structures to think about and teach about in neuroanatomy which I teach back at Stanford. And I've taught for many years elsewhere,
because the thalamus, is this Incredible Egg like structure in the center of your brain that has different channels through it?
Channels for relaying visual information
or auditory information or touch information
from your environment, up into your cortex and as a consequence making, certain things that are
happening to you and around you apparent
to you, making you aware of them, making you perceive them and suppressing others. So, for instance, right now, if you're hearing me say this, your Thalamus has what are called auditory
nuclei. There's there's collections of neurons that respond to sound waves.
Herbs that are of course, coming in through your ears and
your Thalamus is active, in a way that those particular regions
of your Thalamus are
allowed literally permitted to pass the information coming from your ears through some other steps. But then to your Thalamus, your auditory Thalamus, then up to your
cortex and you can hear what I'm saying. Right now,
at the same time, your Thalamus is surrounded by a kind of a shell, something called the thalamic reticular. Nucleus again, you don't have to remember the names but this the lamech reticular nucleus. Also, sometimes called the
Ticular thalamic nucleus. This is Believe It or Not a subject of debate in size are people that literally hated each other? Probably still hate each other even though one of them's dead for decades because they would argue is thalamic reticular, nucleus together with retention particular, thalamic nucleus. Anyway, these are scientists, they're people, they tend to debate, but the lamech reticular nucleus, as I'm going to call
it serves as a sort of gate as to, which information is allowed to pass through up to your conscious experience. And
which is not and that gating mechanism is strongly regulated.
By the chemical Gaba
Gaba is a neurotransmitter that is inhibitory. As we say, it serves to shut down
or suppress the activity
of other neurons. So, the Philemon particular nucleus is really saying, no
touch information cannot come in right now. You
should not be thinking about the contact of the back
of your legs. With the chair that you're sitting on Andrew, you should be thinking about what you're trying to say and what you're hearing and how your voice sounds and what you see in front of you etcetera,
Whereas if I'm about to get an
injection from a doctor, or I'm in pain, or I'm in pleasure, I'm going to think about
my somatic, sensation at
the level of touch and I'm probably going to think less
about smells in
the remote. Although I might also think about smells in the room or what I'm seeing. And what I'm hearing we
can combine all these different sensory modalities but that the lamech reticular nucleus really allows us to funnel to direct particular categories of sensory experience into our conscious awareness and
suppress other categories of set.
Sensory experience.
In addition, the thalamic reticular, nucleus plays a critical role in which thoughts
are allowed to pass up to our conscious perception, and which ones are
not so much. So that some neuro
scientists, and indeed some neuro philosophers, if you want to call them that have theorized or philosophize that,
the thalamic reticular,
nucleus is actually involved in our Consciousness.
Now, Consciousness is in the
topic that I really want to talk about this episode and it's a very kind of music.
She murky as we say in science, it's Ash muy term because it doesn't really have clear. Definitions, so arguments about it often get lost in the fact that people are arguing about different things,
but when I say Consciousness, what I mean is conscious awareness. So let's zoom out and take a look at the circuit that we've got and that we now know based on neuroimaging studies is
intimately involved in generating obsessions and compulsions in OCD, we have a cortex or neocortex, which is involved in perception. And understanding of what's Happening,
we have the
A demand basal ganglia which are involved in generating behaviors, go and suppressing behaviors. No, go. And we have the thalamus, which collects all of our sensory experience in, parallel hearing touch smell etcetera. Not so much smell through the thalamus, I should mention, but the other sensor senses that is, and then that Thalamus is encased by the thalamic reticular nucleus, which serves as a kind of a guard saying you can pass through and you can pass through. But you you
can't pass through up to conscious understanding.
Standing and perception.
So, that Loop this corticosteroid Edith, the lamech loop corticosteroid ophthalmic Loop is the circuit thought to
underlie
OCD and dysfunction in
that circuit is what's thought to underlie OCD.
Now again, the circuit exists in
all of us and it can operate in healthy ways or can operate in ways that make us feel unhealthy, or even suffer from full-blown OCD. How do we know that this circuit is involved in OCD?
Well, there we can look to some really
interesting studies that
Involved bringing human subjects into the laboratory and generating their
obsessions and compulsions and then Imaging their brain, using any variety of techniques that we talked about before.
What would such an experiment look like? Well, in order to do that, sort of experiment. First of all, you need people who have OCD
and of course, you need control subjects that
don't and you need to be able to reliably
evoke the obsessions and the compulsions.
Now it turns out this is
most easily or I should say most
simply done because it can't be easy for the people with OCD but this is
most straightforward.
That's the word I was looking for
most straightforward when looking at the category of
obsessions and compulsions that relate
to order and cleanliness. So what they do typically is bring subjects
into the laboratory who have a
Obsession about germs and contamination, and a
compulsion to hand wash.
And they give these
people believe it or not, a sweaty towel that contains the sweat and the odor. And the
Liquid, basically, from somebody else's hands. In fact, they'll
sometimes have someone wipe their own
sweat, off the back of their neck and put it on the towel. And then they'll put it in front of the person which as you can imagine. For someone with OCD is incredibly
anxiety-provoking and almost always evokes.
These obsessions about oh this is really, this is really bad. This is really bad. I need to, I need to clean. I need to clean. I need to clean
now. They're doing all this while someone is in a brain scanner or
while they're being image for positron emission, tomography. And
I can also look at the patterns of activation in the brain while the person is doing hand-washing, although sometimes the apparatus I associate with these Imaging studies make it hard to do, a lot of movement, they can do these sorts of studies, they have done, these sorts of studies in many
subjects using different
variations of what I just described and
lo and behold what lights up when I say lights up? What what sorts of brain regions
are more metabolically? Active more, blood flow more neural activity. Well it's this particular cortical striatal.
The lamech
loop, in addition to that, some of the drug treatments that are effective in some and I want to emphasize some individuals at suppressing obsessions and or compulsions such as the
selective serotonin reuptake Inhibitors or ssris, which we'll talk about in a little
bit.
When people take those drugs they see not just a suppression
of the obsession and compulsion but also a
suppression of
these particular neural circuits, they become less
active. Now, I want to emphasize and Telegraph a little bit of what's coming later.
These drugs like ssris, do not work for
everybody with OCD and as many of, you know, they carry other certain problems in side effects for many, but not all individuals.
But nonetheless, what we have now is an observation
that this circuit, the corticosteroid offal
amick Loop is active in OCD. We
have a manipulation that when
people take a drug that at least in those individuals, is effective in
suppressing or eliminating the obsessions and compulsions, there's less
activity in this Loop and thanks to some very good animal model studies that
At least, at this point in time, you really couldn't do in humans, although soon that may change. We now know, in a causal way that the equivalent circuitry may
exist in other animals, such as mice, such as cats, such as monkeys
and that activation of those particular, cortical
striatal thalamic
circuits in. Animal models can indeed evoke OCD in an individual that prior
to that did not have
OCD. So I'm just going to briefly describe one such
Buddy. This is a
now classic study
published in the journal science one of the three Apex journals in 2013.
The first author on this paper is Suzanne, Amari a hmar. I will provide a
link to this in the show notes as a truly Landmark paper done in Renee, hens Lab at Columbia University and the title of the paper is repeated corticosteroid. I'll stimulation. Generates that's the key word here. Generates persistent OCD like Behavior. What they did is they took mice, mice.
Do mouse things, they move around, and they play with toys, they eat, they pee, they mate. They
do various things in their cage, but they also groom humans, groom animals with ferc
room. Well, you hope most people groom some people over groom some people under groom but most people groom they'll comb their hair, they'll
clean etcetera. Those are normal behaviors that humans engage in. I'm not aware that my scone there, but my
adjust their hair. So they'll kind of pet their
hair and they'll do this, or sometimes, even do it to each other. We
used to have mice in the lab. Now we only do human studies but the
The mice will groom themselves and typical what we call
wild-type mice. Not because they're wild, but because they're typical will groom
themselves at a particular frequency, but not to the point where their hair is
falling out. Not constantly. They are grooming some of the time and they're doing other Mouse, things other Mouse X.
So in this particular study, what they did is they used some technology
which actually was discussed on a previous episode of The huberman Lab podcast. This is technology that was developed by a psychiatrist and bioengineering.
The name of Karl deisseroth, one of my colleagues at Stanford school of
medicine. This is technology that allows researchers to use the presentation of light to control neural activity. In particular, brain areas in a
very high fidelity way. You control the activity in the cortex of the striatum where the thumb is when you want and how you want. It's really a beautiful
technology in any event. What they did in this study is or I should say what Susan Amari.
And colleagues did in this study was to
stimulate the corticosteroid.
Striatal circuitry in animals that did not have any
OCD like behavior. And when they did that,
those animals started grooming incessantly to the point where their hair was falling out
or they even, you know, they didn't take the experiments this far, fortunately, but the animals would have a tendency to almost rub themselves raw
in the same way that somebody who has a compulsion to handwash would, sadly people
will hand wash to the point where their hands are actually bleeding and raw. It's really that bad. I know that stuff imagery to imagine and you can't even imagine why someone would self-harm in that way.
But again, that's that incredible anxiety relationship between the compulsion, excuse me, the obsession and compulsion, and the fact that engaging in the compulsion simply strengthens the obsession, and therefore, the anxiety.
So that collection
of studies of data,
fmri pet
scanning in humans. The
treatment with ssris and these experiments where researchers have actively triggered.
These particular circuits in animal models.
That previously
Did not have
too much activity in these circuits, and then they observe
OCD emerging really Point squarely to the fact that the corticosteroid of thalamic
loop is likely to be the basis of OCD.
Now, of course, other circuits could also be involved but the corticosteroid of the lamech
circuit seems to be the main circuit generating OCD like Behavior.
That's a lot of mechanism. Hopefully, it was
described in a way that you can digest and
understand and some of you might be thinking. Well, so what, why does it help me? I mean, I
can't reach
it.
Into my brain and turn off my cortex. I can't reach into my brain and turn off my Thalamus
and indeed on the one hand. That's true. But as you'll next learn when thinking about the various behavioral treatments and drug
treatments and holistic treatments for
OCD, what you'll notice is that each one Taps into a different component of this corticosteroid I-80 thalamic Loop and by understanding that you can start to see why certain treatments might work at one stage of the illness versus others. You will also
So start to understand why obsessive-compulsive personality
disorder
does not have the same sorts of engagements of these neural loops and yet relies on other
aspects of brain and body and
therefore responds, best to other sorts of treatments or in some cases. People with obsessive-compulsive personality disorder are not even seeking treatment as I alluded to. Before the point here is that by understanding the
underlying mechanism, why certain drugs and behavioral treatments work and don't work will become immediately apparent.
And in thinking about that in knowing that you'll be able to make excellent choices. I believe in
terms of what sorts of treatments you pursue. What sorts of treatments you, abandon. And, most
importantly, the order, the
sequence that you pursue and apply those
treatments before we go any further. I'd like to give people a little bit of a
window into what a diagnosis for OCD would look like
give you a sense of the sorts of
questions that a clinician would ask to determine whether or not somebody has OCD or not.
Now, I want to be clear, I'm not going to do this in an exhaustive way. I wouldn't want anyone to self-diagnose, although I'm hoping that by sharing some of this, that some of you might get
insight into whether or not you do have obsessions and compulsions, that might qualify for OCD and perhaps, even to seek out, help
the most commonly used
test of OCD or for OCD. I should say, is called the Yale Brown, obsessive-compulsive scale, and this is scientists love, acronyms as do the military. And it's the, why box? The why
Dash Bo C, s-- Hawaii box.
So, typically someone will go into the clinic either because a family member encourage them to or because they feel
that they're suffering from obsessions and compulsions.
And before the clinician would proceed with any kind of direct questions, they would very clearly Define what obsessions and compulsions
are here. I'm actually reading from the why box.
So, quote, obsessions are unwelcome and distressing ideas, thoughts, images, or impulses, that repeatedly enter your mind. They may seem to occur against your will they may be repugnant to you?
You may recognize them as senseless and they may not fit your personality,
then there are compulsions quote,
compulsions on the other hand, our behaviors our acts that you feel driven to perform, although you may recognize them as senseless or excessive and times, you may try to resist doing them. But this may prove difficult, you may experience anxiety that does not diminish until the behavior is completed.
And, as I mentioned before, in many cases, immediately after the behavior is completed. The anxiety. Doesn't just return it. Indeed can strengthen. Now, there are tremendous number of questions on the wire box. Oh,
I'm just going to highlight a few of the general categories, typically the person will fill out a checklist, so they will designate. Whether or not currently or in the past they have, for instance, aggressive obsessions fear. That
one might harm themselves for your that one might harm others
fear that they'll steal things. If you're, that they will act on unwanted impulses currently or in the past, or
both, that's one
category. The other one are contamination of session. So concern with dirt or germs bothered
by sticky substances or
To do is etc, etc. So a bunch of different
categories that include for instance, sexual obsessions, what are called saving obsessions even moral obsessions right excess concern with right or wrong or morality concerned with sacrilege and blasphemy obsession with need for Symmetry and exactness again. All these questions being answered is either present in the past. We're not present in the past present, currently or not present currently, and then the the tests generally transitions over to
Questions about Target symptoms. They really trying to get people to identify if they have obsessions. What are their exact obsessions? Now this turns out to be really important because as we talked about some of the therapies that really work, I'll just give away a little bit of why they work best in certain cases and why they
don't work as well. In other
cases, it turns out that it becomes very important for the clinician and the patient to not
just identify the obsessions in the compulsions
generally and it kind of a
generic or top Contour way.
To really encourage or even Force, the patient to Define very precisely what the
biggest most catastrophic fear
is what the obsession,
really relates to that
turns out to be very important. In disrupting. This corticosteroid,
offal amick Loop and getting relief from symptoms, one way or the other.
So the Yale Brown obsessive compulsive scale. This why box again is very extensive. It goes on for
dozens of pages actually
and has all these different categories.
Not so much designed to just pinpoint what people obsess
about, or what they feel compelled to do.
But to also try and identify. What is the fear?
That's driving. All this right in the way that
we've set this up, thus far, we've been talking about obsessions and compulsions is kind of existing in a vacuum. You're obsessed about germs and you're compelled to wash your hands. Obsessed about germs compelled to wash your hands or obsessed about
symmetry compelled to put, right, angles on everything, or obsessed about counting in there, for counting Etc,
but
Beneath that is a cognitive component that is not at all a
parent from someone describing their Obsession and from someone describing or displaying their compulsion. The deeper layer
to all that is what is the fear?
Exactly
if one were to not perform the compulsion
meaning, what is the fear? That's driving the obsession.
So that brings us to a very powerful category of treatments
that I
should say, does not work in every
Everybody with OCD but works in many
people with OCD
and really speaks to the underlying neural circuitry that generates OCD and how to interrupt
it. And that is the treatment of cognitive
behavioral therapy and in particular
exposure based cognitive behavioral therapy.
So we're going to talk about cognitive behavioral therapy and exposure therapy now. But right at the outset, I want to distinguish the kinds of cognitive behavioral therapy and
exposure therapies that are done for obsessive compulsive disorder for the sorts of
In behavioral therapies that are done for other types
of mental challenges in
disorders because cognitive behavioral therapy for OCD really has everything to do with.
Identifying the utmost fear,
in some sense we can think of fears, is kind of along a hierarchy, right in the example, earlier of somebody, being afraid to turn left in there for
feeling compelled to turn,
right? You would want to take that person and really understand. What do they fear most about turning left? Now, they might
Not be aware of it, they might not be conscious to
what that really is.
But if you were to probe them in a clinical setting, you would eventually get to an answer that answer could be at first. I don't know. Just it's
just bad. I don't know why it's bad. It makes no sense but it's just bad. I do not want to go left. I don't know why. I don't know why but if you were to push that person a little bit in a
respectful and kind and caring way aimed at their treatment, if you were to push them and say, well what do you mean my bad? If you turn left, you think the world would end? They might say no, the world's not going to end but
You know someone is going to die
suddenly. I know that sounds crazy but somebody's going to die. Suddenly it almost this almost sounds like Superstition talk about superstitions later
but indeed it is somewhat superstitious. So for instance you would say who's gonna die and they'd say, I don't know. And you'd say no really who's gonna die? If you think about this, are you going to die is so-and-so? Going to die and very often. Very often what you find is that people will start to
Reveal the underlying Obsession at a level of detail that both to the clinician and to them can be somewhat astonishing. Even though they've been living with that
detail in their mind for a very long time. Now,
how could somebody start to reveal detail about something that's
existed in their mind for a very long time? But not known about it, right? Not been aware of it. Now, some of you might think, oh, it's repressed or
something. That's not at all. What's happening? If you think about the architecture of OCD typically, people will have an obsession and then the
Age in the compulsion as quickly as they can to relieve that Obsession.
So in many ways, the disease itself. Prevents people from Ever Getting to the bottom of that trough ever getting to the point where they really clearly
articulate to themselves exactly what it is that they fear but
it becomes so essential to articulate exactly what it is that they fear. For a somewhat counterintuitive reason, you might think, oh, the moment they realize exactly what they fear, everything lifts, the circuit turns off, and they just feel better because they
Did it? I wish I could tell you, that's the case, but it turns out it's the opposite. What the clinician is actually trying to do is get people to feel
more anxiety, not
less. What they're trying to get them to do is to Short Circuit, no pun intended to intervene in their own
neural circuit. I should say,
with that relief of anxiety. However, brief brought on by engaging in the compulsion related to the obsession. So whereas typically, someone would feel the obsession with
I don't want to turn left. Go something bad's going to happen, someone is going to die and then they turn,
right? They never get the option or the opportunity to really
explore. What would happen where they to turn left or to not be able to turn
right by forcing them down, the path of inquiry. That leads them to the place, where they very
clearly, identify the fear the anxiety, it raises the anxiety, and them.
And that's actually what the clinician is after
cognitive behavioral therapy.
And exposure therapy in the context of OCD.
Most often involves trying to get
people to tolerate not relieve, their anxiety.
This is extremely important, and I realized there's variation to this, depending on the style of
cognitive behavioral, therapy the style of exposure therapy but
almost across the board. The goal again, is to get people to feel the anxiety that normally they are able to at least partially relieved.
However, briefly by engaging in the
Ocean. So if we think back to that circuit of cortical, striatal thalamic, what's going on here, where
is CBT intervening? What part of the circuit is getting interrupted. Well, as you recall, the cortex is involved in conscious perception, the thalamus and that thalamic reticular, nucleus are involved in the
passage of certain types of
experience up to our conscious perception, and not others. And the striatum is involved in this go/no-go type behavior.
When OCD is really,
Seeing itself in its fullness, people feel anxiety around a
particular thought and they either have a go. For instance, wash hands or a no-go, do not turn. Left type reaction
by having people
progressively in a kind of hierarchical way,
reveal
their precise source of anxiety, their utmost fear. In this context,
what happens is, they feel enormous amounts of
autonomic arousal. Now in the
Of anxiety treatment or other types of treatments. The goal would be to teach people to dampen, to lessen their anxiety, through breathing techniques, or through
visualization
techniques, or through self talk or through
social support. Any of the number of things that are
well known to help people self-regulate their own anxiety. Here, it's the opposite
with they're trying to get the patient to do, is to really feel the anxiety at its maximum, but then do the exact opposite of whatever the normal
component is. So, if normally the compulsion is to wash one's hands, then the idea is to
suppress hand-washing, while being in the experience of the utmost anxiety, or in the
case of not turning left, the person is expected to or would
hopefully be able to
actually turn left. And as you can imagine that would evoke tremendous
anxiety and yet to tolerate that anxiety.
Now, I want to be very clear, this is not the sort of thing you want to do on your own. This is not the sort of thing you want to do for a
friend. This is done by trained licensed psychologist and psychiatrist.
But nonetheless, it really points to the fact that as a anxiety related disorder OCD is
distinct from other types of anxiety and anxiety Related Disorders. Things like PTSD and panic disorder, Etc.
Because the goal again, is to bring the person right up close to the thing that they fear the most, and
then to interrupt the circuit. And now, you should be able to know just intuitively. Because you understand the mechanisms
that the
What you're trying to disrupt is the pattern of information flow
from the thinking, part of the brain, the perception part of the brain, which is the the
cortex to the striatum, right? The striatum has these neurons which are active that essentially are
it sounds a little bit like
a discussion about free will but they're trying to get some the person to generate
a certain behavior of suppress, a certain behavior and as anxiety ramps up it's sort of a hydraulic pressure to do that very thing that they've done for so long and they suffer from so much. We talked about
Draw like pressure in the context of aggression. In the aggression episode, this is very
similar, right? There's a kind of a
now when I say hydraulic pressure it's not actual hydraulic pressure. It's the Confluence of a lot of different systems. It's neurochemical is will soon learn its hormonal its electrical. It's a lot of different things operating in parallel. So we can't point to one chemical or transmitter.
What's happening? Is the person is feeling compelled
to act act, act to relieve the anxiety, and
through a progressive. Type of exposure, right? You don't
throw people in the deep end.
In this kind of therapy right off the bat, you gradually ratchet them toward or move them toward the discussion of exactly what they fear the most and
then eventually move them
toward the interruption of the compulsion as they're feeling this extremely elevated anxiety. Of course within the context of a
supportive clinical setting but in doing that what you are teaching people is that the anxiety can
exist without the need to engage in the
compulsion. Now, some of this might sound to people like oh this is a lot of kind of
fancy psychological.
A science speak around something that's kind of intuitive, but I think for most people, this is not intuitive and for people with OCD the
there's no really other way to put it. The impulse that the compulsion to
avoid anxiety is such a powerful driving force that it should. Now make sense to you as to why being able to tolerate anxiety and really sit with it and do the exact
opposite of what you're normally compelled to do is going to be the path
treatment and indeed CBT has been shown to be enormously effective.
Again for a large number of people with OCD but not all of them and often times it requires that it also be used in concert with certain drug treatments, which we're going to talk about in a moment. Next, let's
talk about some of the really unique features of cognitive behavioral therapy and exposure
therapy in the context of OCD
that you often don't see in the use of CBT.
That is cognitive behavioral therapy for other types of psychiatric challenges and disorders.
The first element is one of
Casing. And I already mentioned this before but this
gradual and Progressive
increase in the anxiety that you're trying to evoke from the patient from the person suffering from OCD.
That's done in the context
of the office or the laboratory Again, by a trained and licensed clinician.
But then the person leaves, right? They leave the office, they leave the, the laboratory, and a very vital component of CBT and
exposure therapy for people with OCD.
Is that they have and
perform. What's called
homework is literally what they call
this might be seen in other sorts of treatments. But for OCD homework is extremely important. Because within the context of a laboratory experiment, or the clinic patients, often feel so much support that they can tolerate those heightened levels
of anxiety and interrupt their compulsions.
Whereas, when they get home, often times, the familiarity of the environment, brings them to a place where all of a
sudden those obsessions and compulsions start, interacting the same way and have a very hard time suppressing the
Why would that be
well in Neuroscience? We have a phrase that's called conditioned Place, preference and conditioned Place avoidance. There's some other phrases to but basically it all has to do with a simple thing which is when you feel something repeatedly in a given environment or sometimes, even once within a given environment, you tend to feel
that same thing again when you return to that, or similar environments, okay? So conditioned Place Blank or condition
place. That is simply fancy nerd.
Speak for the fact that
when you're in a place
When something good happens, you tend to feel good
if you return to that place or a place like it or if something bad happens in a, given a place, you tend to feel bad when you return to that place or a place like it. I think that most Salient example that leaps to mind is in unfortunately, category of bad. But I had some friends years ago, visit San Francisco. There's been an ongoing. It seems like it's been happening forever, but this is really in the last decade of daytime break-ins and nighttime break-ins into cars to steal anything from computers to what seems to be like a box of tissues. And
There are numerous reasons for this, I don't want to get into. It's not the topic of today's podcast, but I will use this opportunity to say if you're visiting anywhere. In the Bay
Area, do not leave anything in your car because the window will get broken
into sometimes in broad
daylight some good friends of mine were visiting the Bay
Area and I texted them and said
hey by the way, when you're headed to dinner guys make sure you bring in
all your luggage and computers at whatever can be inconvenient, that might be they wrote back to late everything got
stolen. So with some years ago now, I think five six years ago, this
happened sad.
Ali, all everything got stolen, most of it could be replaced, but some of it was very sentimental to them.
Every time we talk, every time we consider having a meeting in a particular City, this
comes up. As I don't want, I don't want to be there, I don't like that City anymore etcetera. And of course, San Francisco has some wonderful redeeming features, but it only takes
one bad incident in one location to kind of color the whole
picture dark. So to speak
the brain works that way. The brain generalize is, it's not a very
specific organ, again. It's a
prediction machine. In addition to other things,
So in the case of CBT therapy, the reason there's homework is that when people go home, often times, that's when they
relapse, if you want to call it that back into their obsessions and compulsions. And that
location that condition place is where it becomes most important to challenge
the anxiety. And to deal with the anxiety to not try and suppress the anxiety through compulsions or other means.
And when I say other means, I want to highlight something will come up again a little bit later in the podcast that
Since abuse is very common in people with OCD
because of the anxiety component and also
because of people's feelings that they just can't escape from
the thoughts or behavioral patterns that are so characteristic of OCD. So alcohol, abuse, or cannabis, abuse or other forms of Narcotics. Abuse are very common in OCD later. We'll talk about whether or not cannabis can or cannot help
with OCD. But needless to say, suppressing, anxiety is
exactly the wrong direction.
Action, that one should take if the goal is to ultimately relieve or eliminate the OCD.
So we now have two characteristics of CBT, exposure therapy that are extremely important for
OCD and somewhat unique to the treatment of
OCD. And that's the stair casing up towards the really bad fear. The really severe and specific articulation and understanding and feeling of how bad
things really would be, if someone engage in a particular Behavior or avoided a particular Behavior. Then there's the component of
homework given by the
and for the person to be able to create a broader set of contexts in which they
can deal with the anxiety not engage in the compulsions.
And then a very unique feature of treatment of OCD That You Don't See in many other psychiatric disorders are home. Visits, I find this fascinating. I think that the field of Psychiatry and psychology traditionally doesn't allow
for or
invite home visits but this component of context location and
Being so vital to the treatment and relief of OCD has inspired many
psychiatrists and
psychologists to get permission to do home visits where they actually go visit their patients in their native setting in their home cages, right? They're not mice but in their home home
cages, right? I'm being facetious here but people mice, living cages, at least in the laboratory and humans, generally live in houses or elsewhere.
So they visit them in their home. In order to see how they're interacting and
And the particular locations that evoked the most anxiety in the least anxiety. Some of the, I want to call them crutches, but some of the tools that people are using to confront and deal with the obsessions and compulsions and in particular to try and identify some of the tools and tricks that people are using to try and
avoid that heightened anxiety because
once again and I know I'm repeating myself but I think this
is just so vital and so unique about OCD in the treatment of OCD.
The critical need for the patient to be able to tolerate
Rate, extremely
elevated levels of anxiety, is
so crucial. So if
people are avoiding certain rooms in the house or if people are
avoiding certain foods or certain locations in the kitchen, the clinician can start to
identify that by mere observation. And I
should mention here that patients are not always
aware of how they are interacting with their home
environment. Some of these patterns are so deeply ingrained in people that they don't even realize that they're constantly turning to the left or they don't even realize,
Why's
that they're only washing their hands on one side of the
sink. And so the clinician by visiting the home can start to interrogate a bit in a polite way in a friendly in a supportive way, as to do you ever think about why you
always, you know, flip the faucet to the left or flip the faucet
to the right, Etc. Now, we all do a lot of things that are
habitual. We all do things that are somewhat regular from day-to-day. In fact, I would invite you to ask
yourself. Do you always put your
In the same location. Do you always
kept the toothbrush before? Or after you use it? What? Sorts of things you you wipe the little
threading on the toothpaste or not. I'm somebody, I confess that I have well, I have about 3500 pet peeves, but one of my pet peeves is toothpaste, kind of on the thread of the, the toothpaste. It really bothers me. I don't know why. Almost as much as trying to wipe it off, bothers me, which creates a certain Challenge. And if I talk about this any further, then I think I would qualify for obsessive-compulsive personality disorder, but I have to say, I don't experience.
Ton of anxiety about it. It doesn't govern my life. In fact, I realized that right now,
there are tubes of toothpaste that have toothpaste along the thread everywhere in the world. It
doesn't really bother me. I can still sit here and provide some information about OCD to you. It's not intrusive at least not to my awareness.
So by the home visit, the therapist can really start to explore through direct questioning and can allow the patient
to explore through direct questioning of
themselves. The things that might be conscious of and the things that they might not be conscious of
That would qualify for OCD. So I'd like to just Briefly summarize. The key elements of cognitive behavioral therapy and exposure therapy and how they can be combined with drug treatments that are very effective, much of what I'm going to talk about next relates to the data and indeed the practice of an incredible research scientist and clinician. So, this is Helen Blair Simpson or I should say dr. Helen Blair Simpson because she is indeed an MD medical doctor and a
PhD research scientist at Columbia University School of
Medicine. And one of the world's foremost experts,
if not the expert, I would put her in a category of maybe just one, two, three people who is most knowledgeable about the mechanisms of OCD is actively researching OCD in humans, trying to find new treatments, trying to unveil
new mechanisms and expand on our current understanding and
who also treats OCD quite actively in her own Clinic.
Dr. Simpson gave a beautiful presentation, which she summarize some of the core elements of
CBT and exposure therapy for the treatment of obsessive-compulsive disorders. She describes it. The key procedures are exposures, of course,
done in person. And with the
actual thing that evokes the obsessions and
compulsions. So this could be the sweaty
towel as described earlier or could be any number of different triggers done with the patient in real time.
So in Vivo, as we say and it
could also be things that are imaginal
sitting somebody down in a chair and an office and saying, okay? I want you to imagine the thing that triggers the intrusive thought, or let's just focus on the intrusive thought as it arises, and then to explore and expose the patient to their obsessions and compulsions that way. So, it can be real or can be imaginal. And the goal of course, then is to gradually and progressively increase the level of anxiety. But then, to intervene and so-called ritual.
Tension to prevent the person from engaging in the compulsion
the goals. Again, I'm paraphrasing, here are two
as she states
disconfirm, fears and challenge
the beliefs about the obsessions and compulsions to intervene in the thoughts and the behaviors, and to break the habit of ritualizing and avoiding. Now,
how is this typically done, what are the
nuts and bolts of this procedure?
Typically this is done through to planning sessions with the patient. So, describing to the patient, what will
Happen and when it will happen and how long it will
happen. So they're not just thrown into
this out of the blue and then 15 exposure,
sessions, done, twice a week or more.
So the one thing to really understand about cognitive
behavioral therapy is that it can take some period of time, several or more weeks as many as 10 or 12 weeks. However, as you'll soon, learn many of
the drug treatments that are
effective in treating OCD either alone or in combination with behavioral therapies also can take eight, ten twelve weeks or longer and many of those
Our work at all. So even though 10 to 12 weeks seems like a long period of time, it's actually pretty standard.
If you'd like to see more complete description of the protocols for
cognitive behavioral, therapy and exposure therapy for OCD. I'll provide links to two papers
Kozak and fo fo a
which is published in 1997 which might seem like a long time ago. But nonetheless that the protocols are still very useful. And then the second paper is by that last author fo at all in 2012 and will provide links to both of
those in addition. Dr. Blair
Simpson and others have explored. What are
the best treatments for patients with OCD by
comparing cognitive behavioral therapy alone. Placebo. So essentially no intervention
or something that takes an equivalent amount of time, but is not thought to be effective in
treatment, as well, as selective serotonin reuptake Inhibitors. So, what
is an SSRI? An SSRI
is a drug that prevents the reuptake of
Serotonin at the synapse.
Our synapses there, the little
spaces between neurons where neurons communicate with one,
another by vomiting little bits of
chemical into the space, the
synapse, and then those chemicals either evoke or suppress the electrical activity of the next neuron across the
synapse. And in this case, the neurotransmitter, the chemical that were referring to is
serotonin ssris selective serotonin reuptake
inhibitors. Prevent the
reuptake of the chemical, that's left in this case, the serotonin that's left in the
Apps after that, I called it vomiting to be dramatic, but it's not actually a vomiting, the Extrusion of the
chemical into the synapse. And as a consequence, there's more serotonin around to have more of an effect over time. The net effect being
more serotonergic, transmission more serotonin overall. So not more
serotonin being made more serotonin
being available for use. That's what an SSRI does.
So they compared cognitive behavioral therapy accessorize. They also at the placebo group and they
add cognitive behavioral therapy
Plus
The Selective serotonin reuptake inhibitor. This was a
12-week study done as described before two times a week over the course of 12 weeks. First of all, the most important thing, of course, Placebo did nothing. It did not
relieve, the OCD, to any significant degree, right? How did they know that they gave them the? Why box test that we talked about before the wit, the Yale Brown test with all those questions of which I read a few.
So the OCD severity
that one has to have on the, why box is
Measured in terms of an index that goes from any here, from ate all the way up to 28, that shouldn't mean anything. So it's number eight is kind of meaningless here. It's in terms of an index. That's only only meaningful for the why box,
but if somebody has a threshold of 16 or higher, it means that they still
having somewhat. Debilitating symptoms are very debilitating
symptoms. Placebo did not reduce the obsessions or
compulsions to any significant degree. However and I think quite excitingly cognitive behavioral therapy had a dramatic.
Effect in reducing the obsessions and compulsions such that by four weeks, that score that in this case, range from eight to Twenty Eight
dropped, all the way from 25 down to about 11. So it's a
huge drop in the severity of the symptoms.
Now, what's really interesting is that when you look at the
effects of ssris in the treatment of OCD
symptoms, they had a significant effect in reducing the symptoms of OCD
that showed up.
First at four weeks. And then continued to
eight weeks. In fact, there was a progressive and further reduction in OCD symptoms from the four to eight week period. Again. These are the people just taking the SSRI and then it sort of flattened out a little
bit. Such a by 12 Weeks. There was still a significant reduction in OCD
symptoms for people taking ssris
as compared to Placebo, but the severity of their symptoms that was still much greater
than those receiving cognitive behavioral therapy alone.
So at least in this
this study
and I should tell you what
study it is. This is follow Leibovitz
at all 2005. In the American Journal of Psychiatry will also provide a link to this so you can peruse the data if
you like. But at least in this study cognitive behavioral therapy was
the most effective selective
serotonin reuptake
Inhibitors less effective. So what happens when you combine them while they explore that as well and the
combination of cognitive behavioral therapy
and the ssris
together did not lead to any further decrease in OCD symptoms?
This points to the idea that cognitive behavioral therapy is the most effective treatment. And again when I say
cognitive behavioral therapy, now I'm still referring to cognitive-behavioral / exposure therapy done in the way that I detail before twice, a week for 12 weeks or
more. So, all of the data at least, in this study point to the fact that cognitive behavioral therapy is really effective and the most effective. Does
it alleviate OCD symptoms for
everybody? No. Is it very time-consuming? Yes. Twice a week for,
you know, two sessions or more of 15 minutes
Sometimes in the office. Plus there's homework plus they're can in an ideal case. There's also home visits from the psychiatrist or psychologist. That's a lot of investment, a lot of time and investment to say nothing of the potential Financial investment
now dr. Blair Simpson has given some beautiful talks where she describes these data and also emphasizes. The fact that despite the demonstrated power of cognitive behavioral therapy for the treatment of OCD. Most people are given drug treatment simply because of the availability.
Ability of those drug treatments.
Now, when I say, most people want to emphasize that I'm referring to most people who actually go seek treatment because a really important thing to realize is that most people with
OCD do not actually go seek evidence-based treatment. I want to repeat that most people though,
CD do not seek evidence based treatment which is a tragic
thing. One of the motivations for doing this podcast episode is to try and encourage people who think they may have persistent obsessions and compulsions
to seek treatment, but most people don't
For a variety of reasons we spelled out earlier. Shame, etcetera,
of those that do the first line of attack is typically a prescription
most often an SSRI, although not always just ssris because soon we'll talk about the
somewhat common use
of also prescribing a low dose of a neuroleptic or an anti-psychotic, not always but often.
So the important thing to understand here is that excellent researchers like dr. Simpson
Understand that while there are
treatments that we could say our best or are ideal based on the data that doesn't necessarily mean, that's what's being deployed. Most often in the general public as a
consequence, dr. Simpson and others have explored in a very practical way whether or not it matters. If somebody is
getting SSRI treatment and is experiencing
that
Reduction in OCD symptoms. That as
you may recall is more than what they would experience with Placebo loan. But not as dramatic a reduction in OCD symptoms as they would get with cognitive behavioral therapy.
And as I mentioned before there was this exploration of
combining drug treatment cognitive behavioral therapy from
the outset but they also quite impressively explored. What happens when people who are already taking
ssris initiate, cognitive behavioral therapy.
This is a really wonderful thing that they've done this because
In doing that. First of all, they're acknowledging that there are many people out there who have sought
treatment, and are getting some relief from those ssris, but it perhaps is
not as much relief as they could get and they are actively acknowledging. That many people are getting these drug treatments first. In
fact, most often people are getting these drug treatments first so what
happens when you add in cognitive behavioral therapy? Well the good news is when you add cognitive behavioral therapy
to someone who's already taking ssris, that further improves.
Their symptoms. Now
that's
different than the results that I described before from the same laboratory. In fact that if you combine
cognitive behavioral therapy with ssris, from the outset there's no additional benefit of
SSRI
However, as I just described, if someone is already taking an SSRI, and they're experiencing a reduction in their OCD symptoms
by adding in cognitive behavioral therapy. There is a further reduction
in the symptoms of OCD so
it's very important. So for those of you that
have sought treatment in, you're taking a SSRI or if you're thinking about treatment and your prescribed, an assessor, I the ideal scenario really would be to combine the drug treatment with cognitive behavioral therapy, or in some cases, maybe cognitive behavioral therapy alone, although
To decision that you really have to make with the clothes advice and oversight of license physician. Because, of course, these are prescription drugs. And any time you're going to add or remove a prescription drug or change dosage, you really want to do that in close discussion with and on the advice of your physician, don't you say that to protect me? I said to protect you and because it's just the right thing to do.
So again, cognitive behavioral therapy is extremely powerful drug treatments seem less powerful though. If you're already on a drug treatment, adding cognitive behavioral therapy can
Lee
help. So I've been talking about ssris and described a little bit about how they work at a kind of superficial level of keeping more serotonin in the synapse. So that more serotonin can be in action as opposed to gobbled back up by those neurons. I should just mention what some of the selective serotonin reuptake Inhibitors are so things like Clemente bromine, which is not entirely selective, I should say that. That one in generally falls into a category of less selective so it can impair.
Or I, or can enhance some of the other neurotransmitter, a neuromodulator systems, like epinephrine, etcetera, The Selective serotonin reuptake Inhibitors are least the classic ones are fluoxetine. Prozac fluvoxamine flew Vox paroxetine Sertraline Citalopram etc.
Etc. There about six or classic ssris. Some of them like Citalopram are
used in children and are available in pediatric doses. Some like, Prozac
May or may
not be used in children, the details of which ssris
Etc. Is a very extensive literature and discussion
and I think it's safe to say that which
drugs to use and which dosage and whether or
not to contain it continue. Scuse me the same dosage over time.
Depends a lot on the individual variation that people Express and the responses that they have all of these drugs. In fact, I think we can say all drugs have side
effects. These, the question is how
detrimental. Those side effects are added daily.
Yes, their eyes are well known
to have effects on appetite. In some cases, they abolish appetite in some cases, they just reduce it a little
bit. In some cases, they
increase appetite, he's highly individual.
They can have effects on
libido, for instance, they can reduce sex drive
depend in sometimes in the dose-dependent way. Sometimes in a way that's more
like a step function where people are fine at say 5 or 10 mg, but then they get to
15 milligrams and there's a
cliff for their libido.
That can happen. It really depends. Please don't take those dosages as exact values because this is going to depend on the what they're being used for depression or anxiety or OCD. And it's also going to depend on the drug Etc. I just threw out those numbers as a way to illustrate, what a kind of a step function would look like, it's not gradual. Its immediate at a given dose is what that means.
The other thing is that some of these drugs will have transient effects of side effects, that show up, and then disappear or sadly. People will sometimes take these drugs for awhile and then side effects will surface.
That weren't there previously depending on life factors nutrition Factor so
it's a very complicated landscape overall and that's why it's really important to explore any kind of drug treatment SSRI or otherwise really in close
communication with a psychiatrist who really understands the pharmacokinetics and has a lot of patient history and experience with
them. So what I'm about to tell you next is most certainly going to come as a
big surprise which is
that despite the fact that the selective
serotonin reuptake Inhibitors can be effective in reducing the symptoms of OCD at least somewhat.
And certainly more than Placebo.
There is very little if any evidence that the serotonin system is disrupted in OCD and I have to point out that this is a somewhat consistent theme in the field of Psychiatry that is a given drug can be very effective or even partially effective in reducing symptoms or in changing the overall
landscape of a psychiatric disorder or
illness and yet.
There is very little, if any evidence that that particular system is what's
causal for OCD or anxiety or depression, Etc. This is just
the landscape that we're living in, in terms of our understanding of the brain
and psychiatry in the ways of treating brain disorders.
So as a consequence, there are a huge
number of academic reviews, that clinicians and research scientists
have generated and read and share one of the more I think thorough ones in recent years was published in 2021.
Provide a link to this. This is by an excellent. Truly, excellent researcher. From Yale University School of Medicine, I should say not just a researcher but a clinician scientist again and MD Ph.D. This
is Christopher pittenger and the title of the review is farmer. Go through pharmaco
therapeutic strategies and new Targets in OCD and again we'll provide a link to it
as this is a just gorgeous review describing as I just told you that the serotonin system isn't really disrupted in OCD and
yet Assessor
Guys, can be very
effective. The review goes on to explore. Even what sorts of receptors for serotonin might be
involved. If it's in fact a case that serotonin is a culprit in the creation of OCD symptoms,
talk about the serotonin 2A receptor and the serotonin one, a receptor. Why am I mentioning all that
detail? If in fact it's not clear serotonin is involved. Because I'll just
tell you right now. There is currently a lot of interest in whether or not some of these
Cadillacs in particular, psilocybin can be effective in the treatment of OCD
psilocybin has been shown in various clinical trials in particular, the clinical trials, done at Johns Hopkins School of Medicine by Matthew Johnson and others Matthew
was on the huberman Lab podcast. He's been on the Tim Ferriss podcast, he's been on the Lex Friedman podcast is a world-class researcher on the use of psychedelics
for depression and other psychiatric challenges. And their psilocybin treatment has been seen at least in those trials to be very effective in.
The treatment of
certain kinds of major
depression.
Currently, the exploration of psilocybin for the treatment of OCD has not yielded similar results. Although the studies
are ongoing
again has not yielded similar
Effectiveness, but the studies are ongoing and the
serotonin 2A receptor. And the serotonin one, a receptors are primary targets for the drug psilocybin.
So I figured they were going to be some questions about whether or not psychedelics help with OCD. Thus far, it's
inconclusive, if any of you
have been part of clinical trials or have knowledge or intuition about this,
this relationship or potential relationship, I should say between psilocybin and other psychedelics and OCD. Please put them in the comment section, we love to love to hear from you.
One thing I should point out is that even though serotonin has not been directly implicated in OCD serotonin, and the general systems of
Serotonin, the circuits in the brain, that carry serotonin and depend on
it have been shown to impact cognitive,
flexibility and inflexibility which are kind of Hallmark themes
of OCD. So in
That have their serotonin depleted or in humans that have very low levels of
Serotonin. You can see evidence of cognitive inflexibility challenges in. Task-switching challenges in switching the rules by which one performs a game challenges in any kind of
cognitive domain switching,
and so that does in
directly implicate serotonin in some of the aspects of OCD.
Again, when one starts to explore the different transmitter systems that have been explored in animal models and in humans, it's a vast vast.
Landscape. But serotonergic drugs, do seem to be the most effective drugs in treating OCD. Despite the fact, again, despite the fact that there's no direct evidence that serotonin systems are
the problem in OCD.
If you recall the court ago,
striatal thalamic Loop, that
is so Central to the
etiology, the presence and the patterns of symptoms in OCD.
Of course, serotonin is impacting that
system, serotonin is impacting just about every system in the
brain.
But there's no evidence that tinkering with serotonin levels
specifically in that network is what's leading to the improvements in OCD.
However if people go into an fmri scanner and those people have OCD and they evoke the obsessions and compulsions. You see activity in that corticosteroid otha, lamech Loop treatments like ssris.
That reduce the symptoms of OCD equate to a situation where there is less activity in that Loop.
And I should point out cognitive behavioral
therapy, which we have no reason to believe only Taps into the serotonin system. I think it would be the extreme strategy would be false actually to say that that cognitive behavioral therapy Taps only into the serotonin system, clearly it's going to affect a huge number of circuits and neurochemical systems. Well people do cognitive behavioral therapy and find some relief for OCD. They also show reductions in those corticosteroid otha, lamech Loops.
So, basically, we have a situation where we have a behavioral therapy
that works,
In many people not all
and we have a pretty good understanding of about why it works. It increases anxiety, tolerance, and interference with pattern
execution. Getting people to not engage in the same sorts of behaviors that are detrimental to them.
And we have drug treatments that work at least
to some degree but we don't know how they work or where they work in the
brain. One of the things that really unifies, the behavioral treatments and the drug treatments is that they take some period of time. Some
relief from symptoms seems to show up around for weeks and certainly by
eight weeks for both cognitive behavioral therapy and the
ssris but it's really at the 10 to 12 weeks stage
when someone's been doing these twice a week cognitive-behavioral sessions where they've been taking a SSRI for 10 to 12 weeks
that the really
significant reduction in OCD symptoms starts to really show
up. Now, up until now, I've been talking about the fact that people are getting relief from these treatments, but sadly,
The case of OCD there is a significant population that simply does not respond to
CBT or to accessorize or to their combination, which is why psychiatrist also explore the combination of ssris and neuroleptics or drugs that tap into the so called dopamine system or the glutamate system. These are other neurotransmitters and neuromodulators that impact different circuits in the
brain and just to really remind you what neurotransmitters and
neuromodulators do. Because this is
Important to contextualize all. This
neurotransmitters are typically involved in the
rapid communication between neurons and the two, most common neurotransmitters for that are the neurotransmitter glutamate,
which we say is excitatory. Meaning when it's released into the synapse, that
causes the next neuron to be more active or active
and Gaba, which is a neurotransmitter that is inhibitory meaning when it's released into the synapse. Typically not always, but typically that Gaba is going to
encourage the next neuron to be less electrically active or even silence. Its
The
neuromodulators by contrast, so not neurotransmitters. But neuromodulators like dopamine, serotonin epinephrine and
acetylcholine and others operate a little bit differently. Then tend to act a little bit more. Broadly, they can act within the the synapse, but they can also change the general
patterns of activity in the brain, making certain circuits, more likely to be active in other circuits, less likely to be
active. So, when we say, you know, dopamine does
X, or dopamine does y, or serotonin does exercise.
Or serotonin has why
they don't really do one thing, they change the sort of overall tonality they make
it more likely, or less likely that certain circuits will be active.
You can think of them as kind of activating playlists or
genres of activity in the brain rather than being involved in the specific, communication, or specific songs if you will, in this analogy, or discussions between particular neurons.
So, when we hear that ssris, increase serotonin and reduce the symptoms of OCD or a neuroleptic, reduces the amount of
Dopamine and makes people feel
calmer for instance, where can remove some
stereotype repetitive
motor Behavior, which they can either generate or reduce motor Behavior turns
out. So when I say that, what I'm referring to is the fact that these neuromodulators are turning up the volume on
certain circuits and turning down the volume on other circuits. I say that because
if you are going to explore drug
treatments again with a licensed physician,
if you're
Going to explore drug treatments for
OCD. And in
particular, if you are not getting
results from ssris or you're not getting results from cognitive behavioral therapy or the side effect profiles of the drugs that you're taking for OCD are causing problems that you don't want to
take them. Well, then it's important to understand that any time you take one of these drugs. They're not acting specifically
on the corticosteroid I-80 thalamic circuit. That would be wonderful. That's the future of Psychiatry. But
as now,
When you take a drug, it acts systemically. So it's
impacting serotonin your gut. It's also impacting serotonin and other areas of the brain. Hence, the effects on things like digestion or libido
or any number of different things that
serotonin is involved in. Likewise if you take a neuroleptic like haloperidol or something, that
reduces dopamine transmission. Well then it's going to have some motor
effects because dopamine is involved in the generation of motor sequences and smooth. Limb movement. That's why people with Parkinson's who don't have much dope.
Mean will get a resting Tremor. Have a hard time,
generating smooth movement. And so that the side effects start to make sense given the huge
number of different neural circuits that these different neuromodulators are involved in.
I don't say that to be discouraging, I say that to encourage, patience and careful,
systematic, exploration of different drug treatments for OCD always, again, with the careful and close guidance and oversight of a psychiatrist because psychiatrist really understand which side effect profiles make
Likely that you can or cannot or will never or maybe
someday. We'll be able to take a given drug at a given dose. They are the ones
that really have that knowledge. This is not the sort of thing that you want a cowboy and go try and figure out yourself now. I
also want to acknowledge that there are other forms of drug treatments, we touched on psilocybin briefly but there are other forms of drug treatments that have been explored for OCD earlier. We talked a little bit about cannabis. Why would cannabis be a place
of exploration at all?
Well, first of all, a number of people try and self-medicate for OCD, there is some clinical
evidence. I'm not talking about recreational, use something about clinical evidence that cannabis can reduce anxiety. Now, earlier we were talking about, not reducing anxiety, but learning anxiety, tolerance, in order to deal with and treat OCD in the context of cognitive. Behavioral therapies
that doesn't necessarily rule out cannabis as a
candidate for the treatment of OCD. And in fact, this has
been explored a study from
Dr. Blair Simpson herself looked at this, this was a fairly small scale study. So first
of all, I'll give you the title. And again, we'll provide a link. This is entitled
acute effects of cannabinoids on symptoms of
obsessive-compulsive disorder. Human laboratory study
very briefly. This was 14 adults with OCD, they had prior experience with cannabis, this was randomized. Placebo-controlled the Cannabis was smoked,
they had different
varietals as they're called, they had a placebo. So, this is basically
a condition in which certain
Consumed a cigarette that had zero percent THC, others had seven percent THC, other groups that is or some had point four percent
CBD and THC. So they looked at CBD I know a lot of people out there interested in CBD, is one of the few studies I could find where they explore, different percentages of THC and CBD in these cannabis or marijuana cigarettes. Basically,
the total amount that they consumed. I believe was 800 milligrams.
These again are not suggesting.
Hutchins. These are just simply reporting what's in this study. You can again, I'll provide a link,
they looked at OCD symptoms ratings. They looked at cardiovascular effects, they had a large number of different things that they explored and I should say this study was done in 2020 and it was the first placebo-controlled investigation of cannabis in adults with
obsessive-compulsive disorder. Pretty interesting.
And I'm just reading from their conclusions here. The data suggests that smoke cannabis whether containing primarily THC or CBD,
T. Remember, they looked at different concentrations of
those has little
acute impact, meaning immediate impact on OCD symptoms
and yield smaller reductions and anxiety
compared to Placebo. So they did not see a when I say A positive effect, I mean a meal or differ effect, an effect in reducing symptoms of OCD from Cannabis, or, or CBD. Which, you know, it's unfortunate. It's unfortunate any time a treatment doesn't work, but nonetheless, those are the data. I'm sure they're going to be other studies. I'm sure they're also going to be people in.
In the YouTube comment section saying that cannabis and CBD
helps their OCD symptoms. At least I anticipate there probably
will almost everything I say here or somebody will contradict it with something from their experience, which I encouraged. By
the way, I want to hear about your experience with certain things, even if it's not
from randomized, placebo-controlled studies. I still find it. Very interesting to know what people are doing and what they're experiencing. I think that's one of the better uses of social media. Comment sections is to be able to share some of that not in an advice, giving away or prescriptive way. But simply as
A to share and encourage different types of exploration. There are other sorts of drug treatments that are gaining popularity for OCD, at least in the research realm,
one treatment that is a legal L.
EG Al right sometimes want to say legal sometimes people think I said illegal but that is legal at least by perscription
in the United States is ketamine. The actions of ketamine are somewhat complex. Although we know, for instance, that ketamine acts on the glutamate system, it tends to
disrupt the trends.
Submission or the relationship I should say between glutamate, right? Not glutamine, not the amino acid but glutamate, the neurotransmitter
and the so-called
nmda, the n-methyl-d-aspartate receptor which is a receptor, that's
very special in the nervous system because when glutamate binds to the nmda receptor, it tends to offer the opportunity for that particular synapse to get
stronger. So called neuroplasticity and ketamine is a
essentially, an antagonist.
Although it works through a complicated
Kasim. It tends to block
that binding of glutamate to the nmda receptor of the effectiveness of that
ketamine therapy is now being used quite extensively for the treatment of trauma. And for depression at least to a dissociative State, it's a so called associative analgesic
and their variety of ways in which that happens. We did an episode on depression. We're going to do another entire episode. All about
ketamine.
Describing the networks that ketamine impacts etcetera,
ketamine therapies are being explored for OCD as of now the
To look somewhat promising, but there's still a lot more work
that needs to be done.
My read of the data are that the more extensive clinical trials, have not happened, yet, the smaller studies that have happened. Reveal that some patients do get some relief from ketamine therapy for OCD, but there was nothing overwhelmingly pointing to. The fact
that ketamine is a Magic Bullet for OCD
treatment. So, cannabis CBD, at least now, even though it's one smaller,
Sorry, there's no real evidence that it can
alleviate OCD symptoms. If there are new studies published soon, I'll be sure to update you and if you see those studies please send them to me
ketamine therapy.
The jury is still out psilocybin. The jury is still out, these are early days,
another treatment that's becoming somewhat common or at least, people are commonly excited. About
is transcranial magnetic stimulation. So, this is the use of a magnetic coil. This is completely non-invasive
placed on one portion,
one of the skull and one can direct magnetic energy. Toward particular, areas of the brain to either suppress or nowadays. You can also
activate particular brain regions.
There are some interesting data showing that if TMS is applied to areas of the brain involved in the generation of motor
action. So the so-called motor areas or supplementary motor areas as they're
called, while people think about or
have intrusive thoughts.
We know that the TMS coil can interrupt
The motor behaviors the compulsive
behaviors and at least in a small cohort of studies and a small number of patients within those studies. This has been shown to be
effective. Not just while the coil is on the head of course, but act after the study has been performed of the treatments been
performed in reducing OCD symptoms by disrupting the tendency for
the compulsive Behavior to be so automatic. One of the
key features of obsessive-compulsive disorder is that
You know, especially if it's been around for a
while. The person's been dealing with it for a while, there isn't a pattern in which the person thinks, oh, I have this, you know, contamination fear, or I need symmetry, or I'm kind of obsessed to count to the number seven. And then they pause and they
go and then they do it. No. Typically, there's a very close pairing of the obsession and the compulsion in
time. So that somebody's walking down the street thinking, one, two, three, four, five, six, seven, one of the rising 777 freighter where they're doing
and they're doing this in such rapid.
Session because the obsessions are coming up so
quickly, right? Thoughts can be generated very
quickly and then they're generating, the compulsions of the way to beat down or to try and
suppress that anxiety and then it comes right back up again at even stronger as I described earlier.
So transcranial, magnetic stimulation, seems to intervene in these various fast processes right now. I don't think it's fair to say that TMS is a Magic Bullet either. I think there's a lot of excitement about TMS and in particular, really want to nail this.
Home in particular, there's excitement about the
combination of TMS with drug treatments
or the combination of TMS with cognitive behavioral therapy. And this is a really important Point, not just for sake of discussion about obsessive compulsive disorder. But also depression ADHD schizophrenia any number of
different sites yet psychiatric challenges and disorders.
In most cases are going to respond best to a combination of Behavioral treatment that's ongoing that
occurs in the laboratory and clinical
Setting but also in the home setting where there's homework, maybe even home visits.
Drug treatments. Often not always
are a terrific augment to those
cognitive behavioral therapies or other behavioral therapies and then now we
are living in the age of brain-machine interface you have
companies night like neural link that
I think it's fair to say are going to enter
the brain machine
interface world first through
the treatment of certain syndromes Right Movement. Syndromes or psychiatric syndromes, probably before they start putting electrodes into the brain to stimulate enhanced memory or enhance cognition. Who knows? I don't know.
What they're doing Behind the Walls of neural link, but I have to imagine. In fact, I would wager, maybe not
both arms, but I'll wager. My left arm that the first set of
FDA-approved Technologies to come out of companies, like neural link are going to be those for the treatment of things, like, Parkinson's, and movement, disorders, and cognitive disorders, rather than shall we say, kind of recreational cognitive enhancement or things of that
sort. So transcranial, magnetic stimulation is non-invasive. It doesn't involve going down, but below the skull.
Can have some effect. But most Laboratories that I'm aware of at Stanford and elsewhere are that are exploring
TMS for things like OCD and other types of psychiatric
challenges are using
TMs in combination, with drug therapies, are using in some cases, for instance, laboratory at Stanford hope to get him on the podcast.
Psychiatrist Nolan Williams is exploring TMs in combination with psychedelic therapy is not necessarily the same
time, but nonetheless, combining them are exploring how they impact brain circuitry. So,
If you have OCD, should you run out and get TMS?
Or should you try ketamine therapy? Of course, with a licensed
physician. I think it's too early
to say, yes. I think the answer
is, we need to wait and see. I think cognitive behavioral therapy the ssris.
And some other drug treatments, like neuroleptics combined with ssris. And cognitive behavioral therapy are where the real bulk of the data.
Are I want to make one additional point about cannabis
CBD as it relates to obsessive-compulsive
disorder to me? It's not at all
surprising that can
Abbess CBD, did not improve symptoms of OCD because in my discussion with dr. Paul, Conti a few weeks ago and as you mentioned, dr. Conte is indeed a medical doctor
psychiatrist. We were talking about cannabis and its various uses because it does have some
clinical applications
and he mentioned that one of the main effects of cannabis is to tighten focus and to enhance concentration on and
thoughts about one particular thing
and
Cases that can be clinically beneficial and in other cases that can be clinically detrimental. If you accept the idea that cannabis increases focus and you think
about OCD and the networks involved and you think about the anxiety and the relationship between the session and compulsion.
Well then it shouldn't come as any surprise that cannabis did not improve the symptoms of OCD because if anything it
would increase focus on the obsessions and
compulsions.
Now, that's not what they observe. They did not see an
exacerbation or a worsening of the symptoms of OCD with cannabis least, that's not my read of the data but they did not see an
improvement in OCD symptoms with cannabis or CBD. And to me
that's not surprising. Given that cannabis CBD. Seems to increase
Focus. Next. I'd like to talk about some
of the research on and the
roles of hormones in OCD
because it turns out to be a very interesting relationship there.
But before I do, I want to point out something that I realize that
We should have said earlier which is one of the key things for someone with OCD
to come to understand if they're going to experience any relief of their
symptoms. Whether out there doing drug
treatments, are behavioral treatments or
otherwise is that thoughts are not as bad as actions, right? Thoughts are not as bad as actions. One of the
rules that people with OCD seem to adopt for themselves
is that thoughts are really truly the
equivalent of actions. So they'll have
an intrusive thought and
we haven't spent too much time on this today, but earlier,
I touched on the fact
that some of the intrusive thoughts that people have in OCD are really
disturbing, they can be really gross or at least gross to that person. They can invoke
imagery that is, you know,
toxic or infectious or is
highly sexualized in a way that is disturbing to them. Can be very taboo. This is not uncommon when you start talking to people with OCD and you start pulling on the thread
again, this would be
Psychiatrist who was trained to ask the right questions and gain the comfort and
Trust of a patient. They start to reveal that these. These thoughts are really intrusive and kind of disturbing, which is why they
feel so compelled to try and suppress them with
behaviors. One of the powerful elements of treatment for OCD is to really support the patient, and make them realize that thoughts are just thoughts, and that everyone has disturbing thoughts. And that, oftentimes those disturbing thoughts Arise at the most inconvenient.
And sometimes what seems like the most in appropriate circumstances and this relates to a whole
larger discussion that we could have about what our thoughts and why do they surface?
And how come when you stand at the edge of a bridge?
Even if you do not want to jump off, you think about jumping off
and you know, this has to do with the fact that your nervous system as a prediction machine is often times testing possibilities and sometimes that testing goes way off into the Netherlands of
the thought patterns and
You know, patterns that we all have inside of
us. The big difference
between a thought and an action is that, of course, the nervous system is one case not translating those patterns of thinking into motor sequences
that nerdy way of saying, thoughts, aren't actions, believe it or not, can be helpful for people if they really think about that and use it as an opportunity to
realize that, first of all, they're not crazy.
They're not
thinking and feeling this stuff
because there,
R, bad or evil. And of course, sometimes this can cross over
with other other elements of life where we place moral judgment on people for certain behaviors. I think that's part of a healthy Society. Of course, that's why we have laws and punishments and, and rewards for that matter for certain types of behaviors.
But this idea that thoughts are not as bad as actions. And
thoughts can be tolerated and the anxiety around. Thoughts can be tolerated in
overtime can diminish. That's a very powerful Hallmark
theme of the treatment of OCD so I'd be remiss if I didn't mention it. Thoughts are not
Actions, actions can harm us. They can harm other people. They can soak up enormous amounts of time.
Thoughts can so soak up enormous amounts of time? They can be very troubling, they can be very detrimental. We of course want to be sensitive to
that. But when it really comes down to
it, the first step in treatment for OCD, is this realization where the approach to the realization. That thoughts are not as bad as actions.
So what about hormones in OCD? Well, this has been explored.
Albeit not as extensively as I would have liked to find but when I went into the literature I found one particularly interesting, study entitled neuro steroid levels in
patients with obsessive-compulsive disorder Force, author are Bay and as always we'll provide a link to the study.
The objective of this study was to explore Serum with in blood neuro steroid levels in people with OCD why? Well, because of the relationship between OCD and
anxiety. And the fact that in
stress-related disorders such as anxiety and depression, the hormones have been extensively explored but
not so much in OCD at least until this study.
So they compared to serum levels of a number of different hormones progesterone.
Pregnenolone DHEA, cortisol and testosterone.
This was done in 30.
Patients with OCD and 30 healthy controls. So it's not a huge study but it's enough to draw some some pretty nice conclusions. These subjects were 18 to 49 years
old and the
controls were age and sex matched healthy volunteers. Again, no OCD.
What was the basic take away from the study? The basic take away from the study was that in females with OCD there was evidence for significantly elevated cortisol and DHEA now that's interesting because cortisol is
Well, known to be associated with the stress system, although every day should mention.
We all male or
female. Everybody experiences an increase in
cortisol shortly after Awakening, that's a healthy increase in cortisol. Late shifted mean late late in the day, Peaks and cortisol,
or a shift in that cortisol Peak to later in the day is a known
correlate of depression, and anxiety disorders.
So the fact that cortisol is elevated and DHEA
are
Dated in female patients with OCD suggest that
the court is all, it is either reflective of or
causal for the increase in anxiety. We don't know the direction of that
effect. Now, in male patients with OCD, there was evidence for increased
cortisol. Again, not surprising given the role of anxiety and cortisol, or I should say, given the role of cortisol in anxiety, and the increasing anxiety seen
in OCD. But they're also significant reductions in testosterone, which
You should also not surprise us because cortisol and testosterone more or less compete in some fashion
for their own production. Both are derived from the molecule cholesterol, and there are certain biochemical Pathways that can either direct that cholesterol molecule toward cortisol synthesis or testosterone synthesis, but not both. So they compete. So when cortisol goes up in general, not always. But in general, to stas tirone, goes down and vice versa. If you want to learn more about the relationship between cortisol and testosterone and they're even
Some tools to try and optimize those ratios in both males. And females can find that in our episode on optimizing testosterone and estrogen, that's a huberman lab.com. Now, I would
say the most interesting aspect of this study is not that
DHEA and cortisol are elevated and females with OCD or that cortisol in testosterone have this opposite effect. Cortisol up and testosterone down in males with OCD,
but rather the relationship
between all of those DHEA, cortisol and testosterone,
In terms of Gabba Gabba. Again being this inhibitory neurotransmitter that tends to quiet certain neuronal Pathways. It's does different things at different synapses but in general the more Gaba that's present the more inhibition that's present and therefore the more suppression of neural activity and DHEA is known to be a potent
antagonist of the Gaba system.
Okay so here we have elevated DHEA
In females. And I should also mention that testosterone is also known to
tap into the Gaba system
typically. When testosterone is elevated Gaba transmission
at least is slightly elevated.
So here we have a situation in which the pattern of hormones in females and males with OCD Arch are different from those in people without OCD such that Gaba. Transmission is altered and the net
effect would be an overall reduction.
In in Gaba
now Gaba as an inhibitory, neurotransmitter and broadly, speaking is associated with lower levels of anxiety, and it tends to create
balance within various neural circuits.
Now, that's a very broad statement, but we know for instance, in epilepsy that Gaba levels are reduced and therefore you get
runaway excitation of certain circuits in the brain. And therefore seizures, either petit mal, many, seizures, or grand mal massive seizures or even drop seizures, where people completely collapse to the floor.
Teacher, you may have seen this before. I certainly have, it's very dramatic and it actually is quite debilitating for people because obviously they don't know when these seizures are coming on most often and then they, you know, they can fall into a stove or while driving etcetera.
So the situation with OCD is one in which for whatever reason we don't
know the direction of affect
certain hormones are elevated in females and certain hormones are elevated in males and those hormones differ
between males and
females. And yet,
They both funnel into a
system where gabaergic or Gaba Transmission in the brain is
reduced because of this ability
for those particular hormones to be antagonists to Gaba. And as a consequence,
there's likely to be overall levels of increased
excitation and certain networks in the brain. And
that brings us back to this
corticosteroid, Adel to lamech
Loop. This repetitive Loop that seems to
reinforce or we can say
reinforces Obsession leads to anxiety.
It leads to
compulsion leads to transient relief of anxiety. But then increase in anxiety, increased Obsession,
anxiety, compulsion, anxiety, compulsion, anxiety, compulsion, and so on, and so forth. So
I have not found studies that have explored adjusting
testosterone levels through exoticness Administration, cream, or injection or otherwise or that have focused on
reducing DHEA and females. If anyone is aware of such studies, please put them in the comments section on.
YouTube
or send them to mice. We have a contact site on the website at huberman labs.com, but the comment section on YouTube would be
best. But because we know that
hormones impact neuromodulators and neurotransmitters. As I just described and
that those neuromodulators and neurotransmitters play, an intimate role in the generation and the treatment of things like OCD. It stands to reason that manipulations of those hormone
systems. However, subtle or dramatic might want to highlight might prove useful
in adjusting the symptoms of OCD. And
Hope that this is an area that researchers are going to pursue in the very near future because
many of the treatments
for reducing DHEA or increasing testosterone or reducing cortisol, have already made it through FDA approval, they're out there, they're readily prescribed, many of them are already in generic form, which means that the patents have already elapsed on the first versions of those drugs. So when they're available as generic drugs, very often, they're available at significantly lower cost, right? There's a whole discussion to be had there about
Patent laws and and prescription drugs. But because these drugs are largely available in
prescription yet, generic form, I think there's a great opportunity to explore how hormones. Not
just cortisol testosterone and DHA, but the whore, huge category of hormones, might impact the symptoms of OCD.
Especially since many of the symptoms of OCD show
up right around the time of puberty. We haven't talked a lot about
childhood OCD because we're going to do an
entire series on childhood psychiatric disorders. And
Oranges. But many children develop OCD
early as young as, you know, three or four, believe it or not, or even six or seven and ten and in adolescence and
certainly around puberty and in young adulthood, it is rare, although it does
happen that people will develop OCD very late in life around 40 or older just kind of
spontaneously. Most often when you look at their clinical history, you find that either
they were hiding it or is being
suppressed in some way, or if it does spontaneously show up late in life, like
The mid 30s or in 41's 40s? Typically, there's a traumatic brain
injury. Could be due to stroke or physical injury to the head or something of that sort.
Nonetheless, there is a interesting
correlation between the onset of puberty and certain forms of OCD there certain forms of, or I should say there's certain aspects of menopause
that can relate to OCD. You can find all these things in the literature,
all this to say that hormones impact neurotransmitters in her modulators, which clearly impact the kinds of circuits that are involved in
CD. And it makes sense that and I would hope that there would be an exploration of how these hormones impact OCD in the not-too-distant future. Now
there is an extensive literature, exploring how
testosterone therapy both in males and
females can be effective in some cases in the treatment of anxiety Related Disorders. But
not at least a, my knowledge and OCD in particular. So this whole area of the use of testosterone and estrogen therapies DHEA, cortisol suppression
Or maybe even enhancement for the treatment of OCD is essentially a big black box that very soon. I believe will be
lit. I realized that a number of listeners of this podcast are
probably interested in the
non-typical
OR holistic treatments for OCD
dr. Blair Simpsons lab has at least one study exploring. The role of mindfulness meditation for the treatment of OCD there. The data are little bit.
Complicated. And I should mention that good things are happening, at least in the United
States, probably elsewhere as well, but
good things are happening in terms of the
exploration of things like meditation and other,
let's call them non-traditional or
holistic forms of treatment for psychiatric disorders because of the division of complementary Health, that's now been launched by the National Institutes of Health. So whereas before people would think about meditation or Yoga Nidra or even
G b, d, supplementation for that
matter. As kind of Fringe maybe or kind of whoo or non-traditional at the very least, the National Institutes of Health. In the United States, has now devoted an entire division,
entire
Institute, purely for the exploration
of things, like breathing practices, meditation, Etc. So, there's a
cancer institute. There's a hearing and deafness institute, there's a Vision
Institute. And now there's this complimentary Health Institute, which I
think is a wonderful addition to the
more traditional
Aspects of medicine. I think no
possible useful treatment should be
overlooked or unresearched in my opinion,
provided that can be done safely. And as I mentioned, dr. Blair Simpsons lab is looked at the role of mindfulness meditation in the treatment of OCD. Now, we should all keep in mind, no, pun intended. That most of the data on mindfulness meditation shows that it increases the ability to focus. Now, this brings us back to a kind of repeating theme today.
Day, which is that increased Focus may not be the
best thing for somebody with OCD.
Because it might increase. Focus on the obsession and or compulsion,
turns out that mindfulness meditation can be useful in the treatment of OCD. But mainly by way of how it impacts the
focus on and the ability to engage in cognitive behavioral therapies. So it's very unlikely at least by my read of the data to be a direct effect of meditation on relieving the symptoms, rather, it
seems that meditation is increasing focus on things like cognitive.
Real therapy homework and to not focus on other things and therefore,
indirectly improving the symptoms of
OCD. Now, somewhat surprisingly, at least to me, there have also been a fairly large number of studies exploring, how nutraceuticals as they're sometimes called supplements that are available over-the-counter can impact the treatment of obsessive-compulsive
disorder. Now, there's such an
extensive number of different compounds and supplements that fall under the
category of nutraceuticals and that have been explored in the treatment
of OCD that I'd like to point you to
To a review that is entitled. Nutraceuticals in the treatment of obsessive-compulsive disorder are a review. Scuse me of mechanistic and clinical evidence. This was published in 2011. So it's over 10 years old.
And so by now, I
have to imagine that there are an enormous number of additional substances that could be explored but they're just one or two here that I want to focus on here. In this review, they described effects of 5-HTP and tryptophan. So things are in the serotonin pathway which
Makes sense given what we know about the ssris that people would explore how different supplements. That increase serotonergic transmission might impact OCD. What you find is that they do have significant
effects in improving, or reducing the symptoms of OCD in somewhat similar way to some of the ssris. But you, of course have to be careful anything that's going to tap into given neurochemical system. To the same degree,
may very likely have the same sorts of side effects that a prescription drug would.
Good one, compound that I like to focus on in a little more depth however, because it's exciting and interesting to me
is inositol
and also tells a compound that we are
going to talk about in several future podcast. Because well, first of all,
it seems that it can have impressive
effects on reducing anxiety. It also can a pretty impressive effects in improving
fertility, and particularly in women
with polycystic ovarian
syndrome. And here, I'm referring
specifically to
myo-inositol, because it comes in several forms and it
Appear. That, 900 milligrams of inositol can improve sleep, and can reduce anxiety.
Perhaps, when taken at that dosage or higher dosages, I will just confess first of all, I don't have OCD. Although, I will also confess that when I was a child, I had a transient tick, I've talked about this on the podcast before
it was a grunting tick. So when I was about
six or seven, I'm recall a trip to Washington
DC with my family, where I was feeling a
strong desire or need, even as I
recall.
To Grunt in order to clear something in my
throat but I didn't have anything in my throat. It was, I didn't have a cold or any post nasal drip. It was really just the feeling that I needed to do that to release some sort of tension. And I remember my dad at the time, telling me don't do that, you know, don't do that. It's not not good to grunt or something like that. I think he saw that it was, It was kind of compulsive behavior. And so I would actually hide in the back seat of the rental car and do it or I'd hide in my room.
Fortunately, for me, it was transient, I think about
six months or a year later disappeared, although I did notice
Actually an ex-girlfriend of mine point out that when I get very tired and I've been working very long hours. Sometimes that grunting tick will reappear.
What does that mean? Do I have
tourettes? I don't know, maybe it was never diagnosed with Tourette's. Do I have OCD? Maybe I certainly could be accused of having obsessive-compulsive personality disorder which we'll talk
about still in a few minutes. But the point here is that many children, transiently expressed ticks
or low-level Tourette's or OCD and again, transiently and it
Ears over time. So inositol has been explored in a bunch of different contexts including for ticks and no, CD
Etc, going back to
to inositol and its current use or I should say my current use. I've been taking 900 milligrams of inositol, as an addition to my existing
tool kit for
Sleep, which I've talked about many times on this podcast and other podcast, consists of magnesium, three and eight apigenin. And theanine, if you want to know more about that kit, you can go to our
Neural network newsletter huberman. Lab.com, the toolkit for sleep is there. You don't even have to sign up for the newsletter, but I'll give you a flavor of the sorts of things that are in the newsletter. In any case,
I've been experimenting a bit with taking 900 milligrams of
myo-inositol, either alone, or in combination with that sleep kid and I must say the sleep I've been getting on and off. So tall is extremely deep. And does seem to lead to enhanced levels of focus and alertness during the day and perhaps you're noticing that because I'm talking more quickly on this podcast than previous podcast. No, I'm just kidding. I don't think the two things.
Relate in any kind of causal way.
The point here is that inositol is known to be pretty effective in reducing anxiety. But when taking it very high dosages, can it do the same at low dosages? We don't know. I would consider 900 milligrams a low dose. Most of this
given the fact
that most of the studies of
inositol have explored very high dosages. Like you've been 10 or 12 grams per day, which I
must say it seems exceedingly
high and they do report that some of the subjects in those.
Experiments actually stopped taking the inositol because of gastric discomfort or gastric distress as its
called. So I've reported my results with
sleep in a kind of anecdotal way they certainly aren't peer-reviewed studies that I described about my own experience
in anecdotal way. But nonetheless it's been explored that you know, things like
glycine which is another, which is an amino acid which also acts as an
inhibitory neurotransmitter in the brain. Taking it very high dosages, 60 grams per day.
That is a absolutely
Nourishing Lehigh amount of glycine. I would not recommend taking that much glycine unless you're part of a study where they tell you to and, you know, it's safe,
18, mg, 18 G. Scuse me of inositol. These are very, very high dosages used in these studies. Nonetheless, there's some interesting data about an office, it's all leading to some Elite.
Alleviation of OCD
symptoms or partial alleviation of OCD symptoms in as little as two
weeks after initiating the
Protocol. So, I think there's a great future for these nutriceuticals meaning. I think more systematic exploration in
particular, lower dosages in the context of
OCD treatment. And as we saw before, for the ssris and other prescription drug treatments. I think there really needs to be an exploration of these nutriceuticals
in combination with behavioral therapies. And who knows maybe with brain machine interface? Like transcranial magnetic stimulation as well.
Now, way back at the beginning of the episode, I alluded to the fact that OCD is one thing, obsessive-compulsive.
To disorder, and it's truly a disorder and it's truly debilitating, and it's extremely
common. And then there's this other thing called, obsessive-compulsive personality disorder, which is distinct from, that does not
have the intrusive component. So people
don't feel overwhelmed or
overtaken by these
thoughts. Rather they find that the obsessions can sometimes serve them or they even welcomed them. I think many of us know, people like this, I, perhaps even could be accused, or who knows, maybe have been accused of
Having an obsessive compulsive personality at times.
Why do I draw this distinction? Well, first of all, we've come to a point in human history, I think in large part because of social media, but also in large part because there are a number of discussions being held about mental health that have brought
terms like trauma, depression OCD
Etc into the common vernacular so that people will say oh you're so OCD or
someone will say I was traumatized by that.
I was traumatized by this,
we should be very careful, right? I'm certainly not the word police but we should be very careful in the use of certain types of language especially language that has
real psychiatric and psychological definitions
because it can really draw us off course, in
providing relief for some of these syndromes, for instance,
the word trauma is thrown around left
and right. Nowadays, I was traumatized by this or that cause trauma or you're giving me
trauma.
Listen, I realize that many people
are traumatized by certain events including things that are said to them. I absolutely knowledge that. Hence, our episodes on trauma and Trauma, treatment. Several of them. In fact, dr. Conte dr. David Spiegel. And then dedicated solo episodes with just me blabbing about trauma and Trauma treatment.
But as dr. Conte. So appropriately pointed out trauma, is really something that
changes our neural.
Tree and therefore, our thoughts. And our behaviors in a very persistent way that is detrimental
to us. Not every bad event
is traumatizing, not everything that we dislike or even that we hate or
that feels terrible to us, is traumatizing for something to reach the level of trauma. It really needs to change our neural
circuitry, and therefore, our thoughts, and our behaviors in a persistent way. That is maladaptive for
us. Similarly, just calling someone obsessive is one thing saying that someone has OCD or assuming one
has OCD.
Simply because they have a personality or a phenotype. As we say where they need things in perfect order, like I find myself correcting these pens, making sure that the Caps are
fainting facing in the same direction. For instance, right now, that is not the same as OCD. If, for instance, I can tolerate these pens being at
different orientation or even the throw the cap on the floor or something. It doesn't create a lot of anxiety for me. I
confess agree. It's a little bit in the moment then I can forget about it and move on. That's one of the key distinction between
obsessive-compulsive personality disorder.
And obsessive-compulsive
disorder in its strictest
form. Now, once one hears that OCD is different than
obsessive-compulsive personality
disorder because of this difference in how intrusive thoughts are or not. Then that's useful, but it really doesn't tell us anything about what is
happening mechanistically in one situation or another.
Fortunately, there are beautiful data again
from dr. Blair Simpsons, lab and you can tell based on the number of studies that I've referred to from her laboratory though. She's
Truly one of The Luminaries in this field that there really are some fundamental wiring differences and behavioral differences
and psychological differences between people who have obsessive-compulsive disorder and those who have obsessive-compulsive personality disorder.
This is a study first author, Pinto point-0 entitled capacity to delay, reward differentiates obsessive compulsive disorder and obsessive-compulsive personality disorder and the methods in this study were to take 25
people.
OCD and 25 people with
obsessive-compulsive personality disorder and 25
people who have both because it is possible to have both and that's important to point out
and 25 so called healthy controls, people that don't have obsessive-compulsive personality disorder or obsessive compulsive disorder. They take clinical assessments and then they took a number of tests that probed their ability to defer
gratification. Something called in the laboratory we call it delayed
discounting so their ability to
Defer gratification through a task where they can either accept reward right away or accept reward later. Some of you may have heard of the to marshmallow
task. This is a based on a study, that was performed years ago on young children at Stanford and elsewhere, where they take young children into a room. They offer them. A
marshmallow kids, like marshmallows, generally, and you say, you can eat the marshmallow right now, or you can wait some period of time, and if you are able to wait and not eat the
marshmallow, you can have two
Bellows and in general children, want to marshmallows more than they want one
marshmallow. So really what you're probing is their
ability to access delayed gratification
and they're very entertaining.
Even truly amusing videos of this on the internet. So if you just do two marshmallow task video and you go into YouTube, what you'll
find is that the children will use all sorts of
strategies to delay gratification.
Some of the kids will cover the marshmallow. Others will
talk to the marshmallow.
I'd say I know you're not that delicious. You look delicious. But no, you're not delicious. They'll
engage with the Marshal and all sorts of cute ways. They'll turn around and
trying to, you know, avoidance which actually
speaks to a whole
category of behaviors that people with OCD. Also use, I'm not saying these kids that OCD but avoidance behaviors are very much
a component of OCD people. Really
trying to avoid the thing that evokes the
the obsession. Well, some kids are able to delay gratification some aren't and it's debatable as to whether or not the kids that are
able to delay gratification.
Station go on to have more successful lives are not initially, that was the conclusion of those studies. There's still a lot of debate about it. Will bring an expert on to give us the final conclusion on this because there is one and it's very interesting and not intuitive. Nonetheless adults
are also faced with decisions every day all day as to whether or not,
they can delay gratification
and this study
used a not a to marshmallow
task but a game that involves rewards where people could delay in order to get greater rewards later. What is the conclusion?
Illusion. Well, first of all, obsessive-compulsive and obsessive-compulsive personality disorder subjects, both showed impairments in their psychosocial, functioning and
quality of life. They had compulsive Behavior.
So these are people that are suffering in their life because their
compulsions are really strong.
So it's not just being really nitpicky or really orderly in
one case and having full-blown
OCD and the other both sets of
subjects are challenged in life because they're having relationship issues or job-related.
Choose etcetera because they are that compulsive.
However, the individuals with obsessive compulsive personality disorder, they discounted, the value of delayed
gratification significantly less than those with obsessive compulsive disorder. What do I mean? They are
both impairing disorders that are
marked by compulsive behaviors here. I'm
paraphrasing. But they can be differentiated by the presence of obsessions in OCD. So, obsessions in OCD people with OCD are
Absolutely fixated on
certain ideas and those ideas are intrusive. Again that's the Hallmark
theme and by an excessive capacity to delay
reward in obsessive-compulsive personality disorder.
That is people who have obsessive-compulsive personality disorder are really
good at delaying gratification so they are
able to concentrate very intensely and perform very intensely in ways that allow them to instill order such that they can delay reward. Now you can see
Why this Contour of symptoms meaning that the people with OCD are experienced intrusive thoughts. Whereas the people with obsessive-compulsive personality disorder
show, an enhanced ability to defer gratification,
you could see how that would lead to very different
outcomes. People with obsessive-compulsive personality disorder, can actually leverage that personality disorder to perform better in
Certain domains of life not all domains of life. Because remember, again, these people are
in this study and they're showing up as experiencing
challenges in life because of their obsessive compulsive. Personality disorder,
nonetheless, people that obsessive-compulsive personality
disorder. You can imagine would be
very good at say architecture or anything that involves installing a ton of order.
Maybe sushi chef for instance. Maybe a chef in general. I know chefs that just kind of throw things around like the like the chef on The Muppets and
using like throw things.
Everywhere and still produce, amazing food. And then there's some people that are incredibly exacting, they're just incredibly
precise. I think that movie, what is it hero Dreams of Sushi? That movie is incredible. Certainly not saying he has obsessive-compulsive personality
disorder but I think it's fair to say that he is obsessive
or extremely meticulous and orderly about everything from start to finish. You can imagine a huge array of different occupations and life Endeavors were this would be beneficial science being one of them where data collection and Analysis is it
Exceedingly important that one be precise or mathematics or physics
or engineering. Anything, we're Precision has a payoff and gaining Precision takes time and delay of immediate gratification,
you can imagine that obsessive-compulsive personality disorder would synergize well with those sorts of activities and
professions where as obsessive compulsive disorder is really intrusive. It's preventing
functionality in many different domains of life.
So the key takeaway here,
Is
that when we use the words, obsessive-compulsive or we
call someone obsessive-compulsive,
or we are trying to evaluate whether or not we are obsessive compulsive. It's very important that we highlight that obsessive compulsive disorder is very intrusive, it involves intrusive thoughts and it interrupts with normal functioning life whereas obsessive-compulsive
personality disorder. While it can interrupt normal functioning in
life, it also can be productive.
It can enhance functioning in life.
Not just in work, but perhaps it home.
As well, if you are somebody and you have family members that really Place enormous value on having a beautiful and highly organized home. Well then it could lend itself well to that it's going to be a matter of degrees. Of course, none of these things is an absolute.
It's going to be on a Continuum, but I
think it is fair to say that
obsessive compulsive disorder, whether or not in mild, moderate, or severe form
is
impairing normal functioning, whereas obsessive-compulsive personality
disorder. There's a range of
expressions of that, some of which can be adaptive some of which
Can be maladaptive. And again, it's all going to depend on context
before we conclude. I do want to touch on something that I think a lot of people experience and that's superstitions.
Superstitions are fascinating and there's some fascinating research on superstitions.
One particular
study that I'm a big fan of is the work of been. So levski at Harvard, he studies motor sequences and motor learning. And he has beautiful data on how people learn. For instance, a tennis swing and
The
patterns that they engage in early on and then the patterns of
swinging that they swinging the racket that is that they engage in later as they acquire more skill. And basically, the takeaway is that the amount of error or variation from swing to swing
is dramatically
reduced as they acquire skill.
That's all
fine and good. And there's some beautiful mechanistic data that he and others have discovered to support how that comes
to be. But they also explore animal models. In particular rats, pressing sequences of buttons and levers to obtain a reward, Believe It or Not, rats are pretty
smart. I've seen this with my own eyes, you can teach a rat to press a lever, for a pellet of
food. Rats can also learn to press levers in a particular sequence.
In order to gain a piece of food
and they can actually learn to press an enormous number of levers, in very particular
sequences, in order to obtain pallets of food, you
can also give them little buttons to press,
or even a paddle to, or I should say a pedal. Scuse me to
stomp on with their foot in order to obtain a pedal of food. Basically, rats can learn exactly what they need to do
in order to obtain a piece of food, especially if they're made a little bit hungry. First
Ben, says lab.
As published beautiful data showing that as animals and humans, come to learn a particular motor sequence, very often they will introduce motor patterns in that sequence
that are irrelevant to the outcome and yet that persist.
If you've ever watched a game of baseball, you've seen this before, oftentimes the picture up on the mound will
Bring the ball to their chin, they'll look over their shoulder. The look back, over the other shoulder and then they will, of course,
real back and pitch the ball. But if you
watch closely, oftentimes there are components in the motor sequence which are completely unrelated to the pitch. They're not looking necessarily to see if someone stealing a base. They're not necessarily looking down at home plate where the batter is. They're also doing things like touching the
back of the rear before they bring the ball to their chin or adjusting their
And if you watch individual pictures, what you'll find is that they'll do the same sequence of completely irrelevant motor patterns
before each and every single
pitch similarly rats that have been trained to for instance, hit two levers and step on a pedal with their left hind foot. And then Tap a button up above that is the red button will do that to gain a piece of food but sometimes they'll also introduced a pattern into that motor sequence where they will shake their tail a little
Lil Bit or they'll turn their head a little bit or they'll move their ears a little bit Etc. Motor patterns that have nothing to do with obtaining
the particular outcome in
mind. In other words, you could
eliminate certain components of the motor sequence and it would not matter. The rat would still get the pellet. The picture would still be able to pitch.
And yet that again introduced because somehow because they were performed again, and again, prior to successful
trials,
The rat or the human baseball. Pitcher comes to believe
in some way that it was
involved in generating, the outcome, hence Superstition, right? I confess, I have a
few superstitions. I
occasionally will knock on wood. I'll say something that I want
to happen, and I'll say, oh, knock on wood, and I'll just do it
and occasionally, I'll challenge myself in the, I don't want to know, don't knock on wood, and you don't do that, you know. No one. I don't think anyone wants to be superstitious, I certainly don't. And so every once in a while I'll
just challenged it and I
I won't actually knock on wood. I'm admitting this to you to kind of
guess normalize some of this. Some people have superstitions that border on or even become compulsions. They really come to believe that if they don't knock on wood,
that something terrible is going to happen, maybe something in particular, or
in the case of the baseball pitcher, they come to believe that if they don't touch their
right ear before they real back on the
pitch,
That the pitch won't be any good or that they're going to lose the game? Well, I
don't know what their thought process is now. I also don't know what the rat is thinking, but the rat is
clearly doing something or thinking something is related
to the final outcome.
I don't know of any studies where they've intervened with the particular Superstition like
behaviors of the Rat to see whether or not the rat somehow, doesn't continue to do the motor sequence to get the pellet. We don't know they're rats, I don't speak rat. Most people don't or if you speak to a rat.
If it's weeks back, it's not an
English anyway. The point is that superstitions are beliefs that we on an individual scale. Come to believe are linked to the probability of an outcome. When in fact we know we
actually know in our rational minds. They have no real relationship to the outcome.
Superstitions can become full-blown. Compulsions and obsessions.
When we repeat them, often enough that they
become automatic and I think this
is what we observe most of the time when we see a picture touching their
ear. Or, for instance, in tennis,
you see this a lot, you'll see
someone they'll slap their shoes off. And I see this little like slap that their undersides of their
souls. They may tell themselves that this is,
I don't know, maybe moving out some of the dust or something. In the bottoms of their souls, that gives them more traction and they want that to be ready for the server or something like
that. And maybe there's some truth to that. But here, what we're referring to
Our behaviors. That really have no rational relationship to the outcome. And yet we perform in a compulsive
way.
People with OCD. Yes, tend to have more
superstitions people with more
superstitions. Yes. Tend to have a
tendency towards OCD and I should mention obsessive-compulsive personality disorder.
If you think way
back to the first part of this episode, when I was just describing, what the brain does, right? What does
your brain do housekeeping functions to keep you alive, and
it's a prediction machine.
Your neural circuits, you have an enormous amount of
biological investment of Real Estate.
Early cells and chemicals that are there to try and make your world
predictable and to
try and give you control or at least the sense of control over that world. And that's a normal process. Low-level superstitions moderate superstitions, represent a kind of a healthy range, I would say of behaviors that are aimed at generating
predictability that don't disrupt normal function of obsessive-compulsive personality disorder.
Divide is not too severe would I think represent the next level along that
Continuum and then obsessive compulsive disorder as I pointed out earlier is really a case of Highly debilitating. Highly intrusive really overtake of neural circuitry
over our thoughts and behaviors that
requires very dedicated, very persistent and very effective treatments, in order
to stop those obsessions and compulsions, and the anxiety that links them
somewhat counter-intuitively.
Teaching people to tolerate that level of increased anxiety and interrupt those patterns. Unfortunately, as we described earlier such treatments exist cognitive behavioral therapy drug treatments like ssris all though, also drug treatments that tap
into the glutamate system and into perhaps
also the dopamine system, the so-called neuroleptics and then as we
described
there's now an extensive
exploration of things like ketamine psilocybin. Cannabis the initial studies. Don't
Seemed to hold much promise for
cannabis and CBD in the treatment of OCD, but who knows? Maybe more studies will come along, that will change that
story. And then, of course, brain machine interface,
like transcranial magnetic stimulation. And then just to remind you what I already told you
before.
Combinations of Behavioral and drug treatments and brain machine interface. I think it's really where the future lies.
Fortunately, good treatments exist. We cannot say that any one individual treatment works for everybody. There are
Fairly large percentages of people that won't respond to one set of treatments or another and therefore one has to try different
ones and then there are the so-called
supplementation based or more holistic therapies.
Today I've tried to cover each and all of these in a fairly
substantial amount of detail. I realize, this is a fairly long episode that is intentional much like our episode on ADHD. On attention deficit hyperactivity
disorder. I received an enormous number of
requests to talk about OCD.
And my decision to make this a very long and
detailed episode about OCD really doesn't stem. From any desire to subject you to
too much information or to avoid the opportunity to just list. Things off. What I've tried to provide is an opportunity to really drill deep into the neural circuitry and an understanding of where OCD comes from, how a CD is different from things
like the personality disorders that I described.
And also to give you a sense of how the individual behavioral and
Ugh
treatments work and perhaps don't work, so that you can really make the best informed choices again. Highlighting the fact that OCD is an extremely common, extremely common, and yet extremely debilitating
condition and one that I hope that if any of you have or that, you know, people that have it,
that you'll both gain sympathy and understanding for what they're dealing with perhaps as a consequence of some of the information
presented today and maybe help them
direct their treatment, find better treatment and of course, apply those
Treatments for some
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obsessive compulsive disorder and some of the related
Orders and as always, thank you for your interest in science.
