All right, all right, well, welcome everyone to this second part of the series of psychiatric and SUD comorbidities. So today we're going to talk about obsessive compulsive disorder, one of my favorite disorders, don't tell the other ones, but I happen to really like treating SUD. So yeah, so we're going to, I'm going to just go over the same as last time, this is the intro slides, which I'll be saying every time. So we're going to talk about today, what is OCD so you can understand it. Talk about the evidence-based psychotherapy for OCD, which is called exposure and response prevention, which is abbreviated as EXRP or ERP, some people say. And then we'll talk about the medication, which is, we'll talk about SSRIs mostly, and then I can talk a little bit about other, if people want to know about like the medical thinking around OCD, we can talk about that. But I want to spend most of my time talking about the first two because, make sure I focus on understanding the disorder and the treatment, because it actually is like a change in how you usually think about things, and you'll see that, I don't know how much people know about it, I'm going to maybe call on people to see what people think. But we will, hopefully by the end, you'll all know if someone's getting good therapy for OCD, you'll be able to tell, and you'll also be able to be part of the solution rather than the problem, because OCD, it's very tricky, you'll see, to know when you're helping and when you're actually making it worse, so we'll get to that. All right, so here's a background case, just to give you a case example, a patient with a history of OCD and substance use disorder, living in a sober living, and they're worried about contamination fears, which is like, I chose that because it's a very typical OCD, it's the easiest one maybe to treat in some ways, because it's very concrete. Contamination fears, meaning that people are, someone's very afraid of either being dirty or getting sick. There's different reasons why people are afraid of contamination, but it often will manifest in avoiding touching things, repeated hand-washing, and it can be extremely debilitating. The people that have this in the extreme really are, can be like as severe as any severe mental illness when they have very bad OCD. So in this case, the person started experiencing OCD symptoms when they were in early adolescence. At age 13, he developed ritualistic checking behavior, particularly around household appliances and door locks. So that's another example of how OCD manifests. Sometimes people check that the lock is locked multiple times, they have to do it a certain number of times sometimes. Appliances, sometimes people are worried about fires, so they'll actually unplug all the devices in the house when they go to bed, and then they also recheck because they're afraid they didn't unplug it, and then it can become very debilitating again. And then in high school, there's intrusiveness about simple contamination. So you can see actually from my case that in OCD, the fear, the obsessions, which is the field we'll talk about that, they often change. It's not always one thing, and you have to be kind of cognizant of that. Sometimes you deal with one, and then another one pops up. So it's important to attack the disease on a global level, which we'll talk about. So despite this, he was, this is also pretty typical, he was academically successful, completed a computer science degree. This is actually very typical. People will suffer with OCD for many years without getting any help because they're able to work around it, they build their lives around it. And often people are able to be quite successful, but it can lead to real serious problems, and at a certain point it doesn't work anymore. So his obsessive tendencies initially served him well in programming, where he was very attentive to details. However, his symptoms intensified during his mid-20s while he was working at a high-pressure tech company. So again, another takeaway from this case example is OCD is a chronic illness. It's probably neurological in nature. It's not about how your mother treated you or trauma. It's probably much more, maybe you were exposed to a certain bacteria or virus as a kid, and your brain just has a propensity to get locked into certain patterns. But we know that the chronic illness gets worse in times of stress. So in a very stressful environment, it could get to a point where it's really debilitating. In terms of substance use, this is actually also pretty typical, but not, the comorbidity between substance and OCD certainly exists, but it's not quite as much as certain other disorders because a portion of the OCD population is very unwilling to let go of control, and therefore they don't use substances. Sometimes there's also an obsession about rule following, but not always. Oftentimes people do develop a substance abuse disorder along with OCD. So in this case, the person began using marijuana at age 19, but then he started using more, and this is interesting, important to pay attention to. So in this case, he's saying that I'm using it pretty much every day to quiet my mind from intrusive thoughts and reduce anxiety. So the person was using the marijuana and alcohol eventually to actually self-medicate for the OCD, which he wasn't being treated for. And so he started using alcohol socially, but then he started drinking more to numb the anxiety caused by the OCD. And before entering treatment last month, he was drinking six to eight standard drinks a day with occasional binge episodes of 12-plus drinks. So alcohol use disorder, clearly, and also probably a cannabis use disorder as well. And in the context, it's actually, this is pretty more typical. There's different reasons people use alcohol and drugs. In this case, it's pretty clear that there was a sort of direct correlation between OCD leading to this desire to do something to deal with this, the debilitating thoughts. So that's the background. Any comments on the background before I talk about OCD? Okay. So let's talk about the disorder and how we think about it. And it's an interesting disorder because you can actually hear from the name really what the disorder is. But I don't know. People often don't fully understand it, even though everyone says, oh, I'm OCD about this or I have OCD. It's not what typical people say. It's actually a very clear problem. So the obsessive-compulsive disorder, two parts, right, obsessions and compulsions. So what are the obsessions? The obsessions are these intrusive, unwanted thoughts. So it's pretty important that it's different than a person who their personality is very clean or they're very a certain way. That's not, that wouldn't be criteria necessarily for OCD, because this person, the thought is unwanted. I mean, they know this isn't logical. They might be clean, but they know that it's illogical for me to wash my hands 20 times a day. That person usually has insight into that. There could also be cases where it's much more subtle. It doesn't have to be cleaning things. It could also be cases where a person gets an unpleasant image that keeps coming to their mind or a fear that something will happen. Like, for example, I'll give you some examples that I've seen. For religious people, it could be that I'm doing something wrong, like I have some Orthodox Jewish patients that they're afraid they're going to worship idols. So they get this obsessive fear that they're going to start believing in idols. So then that becomes an obsession. It doesn't go away. Sometimes people are afraid that they're a pedophile or that they are going to hurt someone. There's a lot of fears of hurting other people. That's pretty common. And then that leads to obsessions around any sharp objects, being around people, being around kids if you're afraid of pedophilia. So then it can be difficult. Some inexperienced treatment providers might hear that and say, oh, you need treatment as a sex... And then really it's OCD, it has nothing to do with that, as a sex offender to avoid that. But actually they have OCD. Same thing with suicide. Sometimes people get intrusive thoughts around suicide. They're afraid they're going to commit suicide and they get obsessed around that, but they really have no real suicidal ideation. Again, those people might end up in the hospital if someone doesn't really catch what's really happening. And so those are all examples. There actually really could be an unlimited amount of examples. Those are some of the common ones. Other ones, the common ones I'll just let you know about that I've seen quite a bit are counting compulsions, which are also tricky because they're hard to see, symmetry compulsions I've seen a little bit less. Another common one is fear of harm and driving, that people are afraid that they hurt someone when they're driving and they'll circle again and again. That you'll see actually pretty frequently. I think if you see someone with OCD, you can ask them that, has that ever happened to you? Even if you're sitting on a drive, so you can avoid that one. So that's the first part. That's the obsessions. Now I've mentioned a lot of times how people react, but the way the two things interact with each other is what drives this disorder. It has to be obsessions. And then the reaction to the obsession is a compulsion, it's an action which the person takes to neutralize or respond to that obsessive thought. So if you just have obsessions without any action, you don't really have OCD. There has to be some sort of action and response. Now the action the person takes doesn't have to be something you can see. It could be called a mental compulsion, where let's say a person is afraid they're going to harm other people, they're afraid they're going to stab someone. So every time they get that intrusive thought, what if you stab someone? What if you do that? So the person responds by saying, I would never do that, I'm a good person, in their mind. They say that to themselves. I'm a good person, I would never stab someone. And this is pretty typical. That's a compulsion, even though it's not something you can tell and you can see. But there's a mental behavior, right? In psychology, psychiatry, there's an acknowledgment at this point that people can have actions that they take. There can also be mental actions. Sometimes things happen in our minds that we don't control, they just happen to us. But there are also things that we actually actively do in our brains, like think to ourselves something. So in that case, the person is actively thinking something as a reaction to this fear, and then that becomes a compulsion. And then it's the cycle between the two of those things that drives the disorder. It's not one or the other. And it can become quite debilitating. I'll show you my graphs that I show people when I talk about how it becomes debilitating in a few minutes. Any questions so far? Just a quick question. I mean, they're like infinite, but is this sort of just a one way thing from obsession to compulsion? Or does the compulsion begin to feed into the obsession as well and create this sort of cycle? The goal of the person has when they take the compulsion is to neutralize the obsession. But we'll get to why it actually ends up feeding the obsession, because the way the disorder works is that because the compulsion isn't a total fix for the problem, so then they end up having the obsession again, and then that drives another compulsion. There's a small, let's say, you could think of it as like addictive behavior in this case. I don't think it's, it's on the same spectrum, but not the same as an addictive behavior where every time the person does a compulsion, they get some relief from their obsession. So there's some, you could say there's some dopamine probably reaction in the brain at that point that reinforces that behavior. So then you end up in a cycle where the thoughts are going to keep coming back, and you're going to keep having these behaviors. So they feed off of each other. But so that's how they feed off each other. But the obsessions are what drive the compulsions, and the compulsions are reinforcing themselves. So. That makes sense. May I ask one other question, and sorry for putting the cart before the horse here, but is there a way to determine, because I think to some extent, many people have unwanted or intrusive thoughts that wouldn't rise to the level of obsession. Is there a sort of diagnostic, or are there diagnostic criteria for determining this is an obsession or this is kind of more standard? Well, I think it would, I think I could look at the, you can look at the diagnostic criteria, but to sort of say, well, this is where the line is. But I would say, if I were trying to determine that, when I ask someone, I say like, yeah, I was thinking, you know, I get a thought that maybe I'm going to hurt someone. You know, I get angry at someone, I get that thought for a second, but then I just move on. That's probably not OCD, right? OCD, if you talk to someone about it, it's very cyclical and repetitive in nature. There is this clear behavior, there's this clear intrusive thought and response that happens again and again. So that's usually how I would differentiate, and actually, when you talk to people about OCD, you can explain like, look, everyone has some intrusive thoughts, right? Yeah, sure, you're right. You're absolutely right about that, and we all get thoughts that we don't like. But for people with OCD, that thought is so intolerable or unacceptable that they actually take an action to react to that, and then that ends up driving the problem. We'll get to that as I talk about the treatment a little bit more, but that's how kind of I explain it. It's not the intrusive thought necessarily, like an example, like with pedophilia, which is a very hard one to talk about with people, right? But someone's afraid they're going to do something inappropriate, right? So I would say to the person, you know, maybe a lot of people might have like a fleeting thought, but then they just forget about it, and they ignore it. They're not going to fixate on it and keep reacting to it the same way you are. So in some ways, it's not just the intrusive thought that's the disorder, it's the fact the way you're reacting to it, and then it keeps, in some ways, that makes it continue to come back. So there is a spectrum in terms of when we get intrusive thoughts, what we do with them, it's like there's a spectrum of like, you know, maybe sometimes someone will misremember if they lock the door and they'll check again. If you checked one extra time, so you don't have OCD, right, maybe it's a little annoying, but if you check and it has a significant impact on your life, it causes a decrease in functioning or distress, that's when it becomes, rises to the level of OCD, make sense? Anyone getting this? It's more subtle maybe than schizophrenia, I'd say, but not always, right? Sometimes you really see it and it's pretty bad. All right, so it's about 2 to 3% of the population, so it's a pretty common disorder. So it's like, schizophrenia we said was about 1%, so this is about two or three times more prevalent than schizophrenia, right? So this is a more common disease. That means that if you have 100 people, three of them will have, right, three of them will probably have OCD. So pretty common and probably people, I would say, in general in the field don't under-recognize it unless it's a very common form, people sometimes miss it. Now it's, we've talked about this a bit, but it's distinct from normal worries or habits, right? Typically it's more than an hour a day that people are spending on it, right? And then it causes distress and interferes with functions. That's actually what you asked, so I'll answer that one. So just an overview of the treatment of the disorder. So we have medications, SSRIs, which we'll talk about a little bit and how they work a little later. Those are the first-line treatment. They're pretty well-tolerated. You sometimes use other medicines along with them, right, like antipsychotics, benzodiazepines. And then difficult cases you treat with clomipramine, which we could talk about later if people want to discuss it more. Now the really important part of this is the talk therapy. In other diseases, sometimes medication works really completely by itself, but in my experience, it's my belief that there is an important element of OCD where oftentimes you have to give people at least a little bit of talk therapy so they understand about the OCD and they can understand how it works in order to help the medication to work. And again, exposure and response prevention is the gold standard, and there's other approaches which are more mindful in this space, like acceptance and commitment therapy, which are useful as well. If people want to hear about that, ACT therapy, I can talk about that a bit as we get into some of the cases. Now actually, before I get into the therapy, does Anyone have a case where they want to like discuss? We had this case that someone had OCD and they kept asking for reassurance. Reassurance is another compulsion where they keep asking you for something. So maybe someone was asking you for a lot of reassurance. Anyone have an example where they wanted to talk about someone they were talking to with OCD? Yeah. I worked a case a few months ago which was like with someone who was like chronically and disabled from their OCD. It's like at that level where you say, oh it doesn't really equate to psychosis. It's like it was absolutely like debilitating. What was the obsessions and the compulsions? The obsession was on slips of paper mostly and objects. And so papers either being lost like from the person or being tracked in to the house on the person. It's like receipts, trash. So the individual had to be checked multiple times every single day when they entered or exited a room or the house by family. What were they afraid of? They were afraid of the receipts? Losing things. Yeah. Or gaining things essentially. Yeah. What was the fear? The fear was that they would get a receipt? The fear was losing an object. And there was like a core trauma attached to that. And this was like 15 years later. They lost some like important receipt and now they were very worried they were going to lose the receipts? Yeah. Also like running over people, right? Like did I hit someone? Did I hit someone? Also like the paranoia that's attached to it. Like tracking on the phone, not able to use Google Maps, needing to like write down or like be directed directions. So like it really... How long in the Google Maps? What was that one? It was just I think like the amount of fear that was like held in the individual started to sort of spread, right? And so like the amount of like isolation led to like paranoia. Paranoia led to those types of behaviors. Why wouldn't they want to use the Google Maps? That doesn't sound like OCD. What about the Google Maps was OCD? Like what was the obsession with the Google Maps? The obsession, the same thing as like locking doors. Like someone could come in, right? Someone could like track my location. Somebody will follow me. It's actually very difficult to... That's not necessarily OCD. It doesn't sound like OCD. It's very difficult to sometimes differentiate between OCD and psychosis. I mean they were OCD primary like without a shadow of doubt. But then they had OCD and paranoia and schizophrenia. But not using Google Maps doesn't sound like OCD. It sounds like schizophrenia. Because there's no repetitive nature in that. Unless they... And like the need for assurance from like mother and partner to like establish the course and the direction was all ritualistic. Yeah. And it was around, that was around like fear of a certain outcome. I mean also like the dangers of the perceived dangers of driving, right? And like hitting someone and running over. And that one is like of all the examples you gave of those, that's the clearest one that's like pretty clearly OCD. Well the checking was really the... So every single like threshold in the house like the individual would have to like raise their shirt and show their pockets to make sure that there was no item attached to them. And if they had something they once stole, is it because they once stole something or something? Why were they so worried about having something attached to them? Because they lost something. Yeah. All right. Well that one I'm not sure about. We can talk about that one. I would need to talk about the patient more. But let's talk about the driving one because it's a little, that one's a little bit more straight, clear-cut. The fear there is what? Like what's the core fear? Running over a child. Which is harm. Like it's unacceptable to harm someone. Like I would never, we all agree it would be horrible. Like we all would be, like it would all be catastrophic for any of us if we accidentally killed a child, right? That would be terrible. So that's a pretty typical one. So what do we do with that? Like how do you talk to someone about that? How would we treat someone like that? So let's see what I have here written. Here's sort of the, here's the theory and then we'll talk about it in practice. Like if I were talking to this patient, how I would talk to them about it. Just so you can get a sense. There's two parts of exposure and response prevention therapy. One is that we gradually expose the person to the thing that they're afraid of. So in this case, you have to gradually expose the person to the possibility of killing a child, which is pretty hard, right? You don't want to have them actually do it, but you have to like, which is why it's tricky. And sometimes this work is hard. Obviously you don't want to even get them close to that, but you do have to get them exposed to the idea of the problem, which is very counterintuitive. Like usually in therapy, we want people to feel less stress. We want to calm them down. We want to reassure them. But in this case, you have to do the opposite. You have to expose them to the thing they're afraid of. And then you can't allow the person to do compulsions. So let's say, this is how things can go wrong. This is, they're called the response prevention. I'll just, this is like pretty, maybe a little advanced jump ahead, but just so you understand what that means, the second part, response prevention. When you have, let's say you have this person drive and you tell them you can't circle back, it's not allowed. Don't circle back at all, even when you think you might've hit someone. So, okay. So you stop the person from doing the compulsion and now they're driving and they're afraid that they hit someone. So sometimes that person will find other ways to get out of the exposure. Like they're not going to experience the exposure. So they might tell themselves, well, my therapist told me that this is okay. I probably didn't do anything. Right? So they're neutralizing the obsession. They're neutralizing the fear. So part of the treatment is really trying to like help them sit with the anxiety without neutralizing the fear. So that's the, that's the full picture of EXRP. People who are like a little bit inexperienced or something like, well, as long as they don't actually circle, then I did an exposure. But that doesn't work. Those people often will do other things to try to neutralize the anxiety and then you end up not getting a good treatment outcome. So we'll talk about like maybe a little more of the details as we move along. We usually create a hierarchy of things to do. Like you start with the easier things and then you move to things that the person is, that are more difficult and more distressing. So you might have the person like look at a picture of a car crash involving a child as like a start, let's say, or even like say the word like crash or, you know, motor vehicle accident. That itself might be like anxiety provoking for the person. And then that would be like the first level, like something you start very low. Then you might have the person drive around the block. Then you might have them drive past the school. So you're moving to things that are a little bit harder for the person as you, as you work through. And then the whole time making sure they're actually doing it and not neutralizing what you're doing in their mind. So that's exposure response prevention therapy. And is it highly effective? 58% of patients experience significant symptom reduction. I would say it's probably even higher if you do it right. I mean, when I, and I'll say in some, so I'll give you some research evidence. Next, next thing I have is to explain how to do it. But the research evidence shows that if you randomize people to either get exposure response prevention or SSRIs, they work about the same. But in my experience, if you don't do any exposure response prevention, a lot of people, the SSRIs won't help. Because what happens is they override the medication by doing more and more compulsions. And like they act more and more compulsively to control what they're afraid of. And so they never really, they could be on these high doses of medication, and they're on three or four medications. Until we get to the core of the problem and like realize that they have to stop this reinforcing behavior, the medicine doesn't really work. So I'm a real strong believer that even if you don't do the full blown EXRP, you still have to like give a person a little bit of background. And so they understand the disease a little bit. And that's why it's, it's actually somewhat important that the person goes to people that know what they're doing with therapy and with treatment, because you'll get some inexperienced or poorly trained psychiatrists and therapists, they'll be like, well, every time you get that thought, just think it's not real or that would never happen. Or come count down from 10. And that will calm you down. Or take a deep breath and that will calm you down or tell yourself it's going to be okay. All these things are the therapist actually making the disease worse, because they're providing like ways to do the compulsions, right? You're giving all these like compulsive behaviors to the person to do. And then those people end up getting more and more severe sometimes. And they're really, if you come to treatment, like with someone who knows what they're doing, and a lot of stress, and you can really like it's very difficult. So I have a question. Um, so we had a client who had, I guess, severe OCD, and, and they weren't treated. Finally, they were treated with exposure therapy. And it made a lot of difference. But the symptoms were, this person could not sit in certain chairs in the facility. I mean, there were certain chairs that for them to sit there, they have two refrigerators in the kitchen, and they could only go to one of them. And so my question is how long I know, they moved out and they started working with someone that must have been terrific in terms of exposure therapy. And, and I saw this client at like a year later, and it seems to have made a real difference. How long does it take? Um, it depends on the person. But, you know, I would say there is a process of sort of getting an idea of what it is, what is like a EXRP. So that's usually like the first couple weeks, and then they're starting to actually implement it, and then moving through it. So I think it depends on how severe the OCD was, sometimes how like motivated and sophisticated the person is sometimes. So, but I would say it can take at least four to eight weeks, I would say, until someone's like really having improvement. But you could see benefits really early on. I mean, as soon as the person changes their mindset, stop doing the compulsions, if they're really like, sometimes it's a straightforward case, people can get a really quick response. The trials were 12-week trials. I don't remember like in the trials, like when they started seeing the improvement in the scolvars. I think it was relatively early. I think it was like two weeks. But, but, you know, in the beginning of the therapy, it's really just explaining what the disease is, and like getting the idea, the idea of it. But for some people, it takes a really long time. I mean, for some people, they're not sure. I'm going to talk a little bit about where things go wrong. But, but it could, it could certainly take quite a while, especially if it's a severe case. And sometimes it's called morbidity. Other questions? Yeah, if I if I may, I'll be back on camera in a second. Sorry about that. How do you ensure that somebody is not engaging in compulsive behaviors or another sort of like new way of mitigating the obsession? Especially if you It's not you, it's them, right? You have to train them. That's, that's the thing. So that's a good question. And it's, it's really a lot of the work is around getting the person to really get it and be motivated to do it. So and actually, you can ensure it. So let me tell you something. This I was it's a great point. I wanted to say this anyway. So it's good. It's a good leader to this next point. Now, I'm gonna explain this graph in the middle in a minute. But well, yeah, so one of the things well, let me explain the graph and maybe that will help you help you understand that I'll get to this point you're making. So when I talk to somebody about OCD, this is something I learned from the OCD, the guy who runs the OCD center and Zucker Hillside Hospital. His name is Anthony Pinto. He's an OCD OCD expert. He's a great guy. So my head, okay, so I'm going to draw this graph. So he showed me this, and I show it to all my patients. And feel free to steal it and, and do it with people as well. So I talked to people about how OCD works and how the treatment works. It's nice, because people really get a sense of everything about this disease. So this is this is what you start with. So you say, look, for most people, when they do something new and scary, let's say, I don't know, first time you went to a new job going to a new school, I was talking about a case like I was scared of roller coasters as a kid. And I, the first time I went on the roller coaster, I kind of went over this. So I went over this curve, right, where you're anxious, you're anxious, but then you know, maybe you get used to it a little bit. If you stay on a lot enough times or long enough, then eventually you get a little less nervous. Okay, maybe the second time you come back to the theme park, or the second time you go to work, you know, it's a little bit less scary, and you get used to it. Or, you know, actually, we talked, we talked about rock climbing, rock climbing, and then the first time you're scared of heights, eventually, you're a little less scared, then you're a little less scared. Then eventually, when you go rock climbing, you don't even think about how high up you are, you know, it's like, it's not even there, right? So that's, that's how anxiety is supposed to work, right? So that when you, when you, when you, when you, when you start out, it, it's pretty scary to do something, if you let, if you let time pass by itself, then you end up having the anxiety go away, and then the second time you approach the problem, it'll be easier, and then eventually, it's not there at all, the anxiety is completely gone, right? The people, people that are like, for Alex Honnold, like Alex Honnold, I think, did I bring up with you last time? When he was, you know, I don't think he gets that nervous when he's rock climbing, even though he's like, for any of us that we had been up on a wall without a rope, we lose our minds, right? So, so, you know, if you do something enough times, you get used to it, you're not scared, and everyone gets that, right? So I start with that, and I say, look, how does OCD work? Like, why is that not happening for you? Why are you still so nervous? So what happens is, as you start having the thing making you nervous, you start going up that worry hill, you start getting more nervous, then before you have a chance to get used to it, you do something, you do a compulsion, and that brings you back to the start of the, so you're not nervous for a minute, but then that problem is still there, and you haven't gotten used to it, so then it comes back, and then you have to do another compulsion, and then maybe you're going to be doing more and more, because you don't want to feel uncomfortable, and you end up trapped in this little corner of your life, where you're just actively doing compulsion, and you get stuck there. It's a good, I think, like, it's a good visualization of how the process is, not exactly, it doesn't give you everything, but people get that idea of getting trapped, because you keep acting, instead of letting yourself go over the worry hill, right? And so that, that is the first stage, so once people get that, so everyone get that? Make sense to everyone? So then I say, like, look, the treatment for this problem is actually to let yourself be nervous, so you have to let yourself go over this hill, and you can't do anything to make it stop, you just have to let the anxiety be there, and so you're going to have to, and then this is, and so that's, that's one piece of how I talk to people about it, and so that's one piece, so I say, look, you're going to have to let yourself feel nervous, and then some people get it, some people are still don't want to want to sort of jump into it, so then this is what I talk to them to help motivate people, I say, look, this is a question that a lot of the OCD experts ask their patients when they're starting treatment, they say, look, your brain is telling you that something in your life is completely unacceptable, like, the idea that you would run a kid over is, needs to be, like, if you, if I would, if someone would ask you, like, on the street, is it okay that there's a small chance that you're going to kill someone on the street, what would you answer? No, that's not, like, that, that's unacceptable, I can't, I can't have a chance that I would do something like that, so then your brain is saying, okay, so this is completely unacceptable, so then it's going to the extreme to say that this has to be not, not a 0.001% chance, it's got to be a 0% chance, there cannot be any chance, so if there can't be any chance, then you, then you're going to just keep doing all these actions to try to be sure. The problem with that approach is that, that's your OCD, trying to be sure about that one thing, because there's a million other things in your life that you accept, but there is some risk, like, you know, every time we walk down the streets, something horrible can happen to us. You know, we could all get some sort of weird brain tumor and become serial killers. Like that, there's always, there's a small chance that something horrible will happen to everyone. Your OCD is trying to like fixate your brain on one bad outcome to say like, this is completely unacceptable. So I wanna offer you a choice at the beginning of treatment and these are the two options. So one option is that you can hold onto the desire that it's gonna be 100% certain. You're gonna be sure, you're gonna try to make it as sure as possible that you don't hurt anyone in your car. So you won't drive, you're gonna drive, you're gonna check behind you a million times, you can always be checking. That's one option. And you're gonna have the 100% certainty. The other option, and that's letting the OCD win. The other option is you're gonna accept that, look, even though I really don't want that to happen, there's always a chance that something bad will happen. I can't be 100% sure. You can't have full certainty in life. And so you have to make that choice in treatment. Like do you want to hold onto the desire of full certainty and like sort of let the OCD be in charge? And you're gonna go like, I need to be certain. I'm like, I'm not letting go of that. Or are you gonna say like, look, I can't let OCD rule my life. And the reality is I'm never gonna be certain anyway. So I'm gonna actually do these exposures. I'm gonna like accept that I might, there might be some chance of the bad thing happening. Does that make sense to everyone? There's a lot more that we can talk about it. But there's actually another piece that you can bring in that if you're doing, I'm teaching you guys all to be OCD therapists. And a lot of people don't know this stuff. So this is good. You guys are all like more advanced than OCD. Another piece you can bring in, which the OCD experts talk about is the irony of OCD. And that is that you actually will bring upon yourself the feared outcome by giving into the OCD. Like demanding complete certainty will actually bring the problem upon yourself. So like, let's say a simple example of someone who's afraid that your boyfriend or girlfriend is gonna cheat on you, right? Your romantic partner is gonna cheat on you. So by being so afraid that that's gonna happen, you become such a bad partner that you end up bringing that problem on you, right? Like they either abandon you, because they're like, you're always asking me that I cheat. Like, what's wrong with you, right? Or they'll be like, I was so frustrated with you. I ended up going off and like cheating, right? So like that's, and that's actually true of almost every example you can think of. Like with driving, like they're afraid they're gonna hit someone. They keep looking behind themselves so many times, they end up having an accident, right? And they're circling so much, they end up driving so long, they end up having an accident. So in each example, you can actually see that the OCD itself might, but because of this desire for complete certainty, you end up losing, you end up actually having a worse outcome. So these are all ways that you try to motivate the person to do exposure. But like you said, how can you be sure? You can't be sure. You can, you always have to offer the person a choice. And it always has to be from the person's, like it always has to be the person's decision if they wanna do it or not. So hopefully they'll tell you like, look, you know, you're right. I can't live with OCD. I gotta accept this chance that this bad thing will happen. And I'm gonna just have to go through the process of like going through that. That's when things go well. And lots of patients are able to do that. There's really hard patients or they're treatment resistant are often the ones who are like, I really can't. I can't accept a chance that I might kill someone. Like that's just not acceptable to me. Or that, you know, I can't accept that I, like someone very religious, I can't accept that I would like do something horrible against God. That's just not acceptable to me. So that's really hard to treat. Those are hard cases. We can talk about those, you know, later maybe, but this is the basics of EXRP. Does everyone kind of get it, get the questions? Yeah, go ahead. Yeah, it's fascinating. I'm wondering, you know, I think about like as a sort of more minor example, this seems like the cycle of procrastination. People start to think about getting to a project and then they get scared and then back away. Is there relatability there? And is it useful to, I mean, everyone has skills they eventually kind of master become functional with. You can relate skills that this individual has already accomplished and taken through the process of learning that and then kind of applying that to the present concerns and then, you know, fostering getting higher up that hill until you eventually go over the top. And is it ever like curable? I mean, if people really do face their challenges and fears, do you get to a point where they're essentially cured? So two answers to you. The first one about procrastination is, the procrastination is different. And in some ways it's harder to treat than OCD. OCD, the person knows that this is really uncomfortable and difficult. And so generally, and again, this is where it's, you know, this is why people become clinicians. It's, you know, you talk to a lot of people, you sort of get a sense of when it's one and when it's something else, but, you know, you, with EXRP, oh, hey, oh, sorry. I'm in someone else's office and now they're here. I have to move. I might have to move offices. You may have to pause the lecture for a minute. But what was I saying? Oh yeah, so with procrastination, it's a little different than OCD. So it's, you have to treat it differently. You have to be more motivational. And the second question you asked was, do people ever get cured? So the answer is, it is a chronic illness. So I wouldn't say that you get cured of OCD. I wouldn't ever be able to tell someone that. All right, guys, let's take like a break and then I'm going to switch offices. No, you guys, it's going to be a while. You should go on and use your computer. What is this called? I'm just giving a lecture for a little bit. Oh, you're giving a lecture. Can you switch? Yeah, I'll switch, no problem. Yeah, it's going to go for a while anyway. So, but I'm going to log back in in like hopefully like three minutes, okay? Going back, probably need a break anyway for a two-hour lecture. So as I'm bringing up the slides, any other questions on what we've said so far? Yes, I do have a question. Can you hear me? I was saying it's a chronic illness. Last thing we talked about is it's a chronic illness. Can you hear me by the way? Let me make sure. Can you hear us? I can't hear you. But is there any other question? Can you hear me? There may be a question. There's multiple questions. Okay, can somebody say something? Yes, you can. Say something, hello. Now I can hear you. Okay, hold on. Okay, Dr. Shulman, may I ask a question? Sure, let me just try to get my audio louder because it's a little quiet. Hey, go ahead. So you brought up the irony of OCD, which that kind of conundrum makes perfect sense to me. The question I have is the reaction to it and the way that somebody can bring that up in the most constructive way possible, because I could imagine an instance in which you say, hey, look, what you're doing is actually really self-destructive. Like you're circling back all the time, and it makes you so much more likely to do the thing. And my imagination is that could take the anxiety hill that you were showing and make it like 10 times deeper. So is there a way to do that more constructively? And just like how do people generally react to that? I wouldn't bring in the irony of OCD until you really need to. Because people should be motivated. If OCD is an illness that people have insight for, so basically they should understand that this is not rational. And so they should get that this is really causing trouble. So they shouldn't need to have to go that far to say like, you're actually gonna bring this upon yourself. I would say in rare instances, you would have to bring that in. You know, I don't know if you should be doing it or a therapist should be doing it, but it really comes along with a long conversation. Like, look, you really seem to be struggling with this. And you're not willing to accept that chance that the bad thing will happen. You know, honestly, the bad thing could happen anyway. In fact, it might be more likely because of what you're doing. Like, what do you think about that? You know, that kind of way. You know, be very compassionate. And I wouldn't say to like, you gotta do this or you're destroying yourself, which is true. It's horrible, but you don't wanna say it that way. So, you know, I think it's just one piece to bring in. In a much, it has to be someone you really know well, and it should really be part of a much longer and larger conversation. I'm just kind of giving you, yeah, I'm not officially all like licensed therapists after this lecture. You're not deputizing us? I'm not deputizing you all as licensed. I'm just kind of giving you a sense of what it is, but you do have to pace it. Like, there has to be pacing in this. Like, you can't, I'm giving you it all in one hour, but this should be going over like a long period of time. You start with that graph, right? You start with the graph, you start with the experience. You check in with the person, does this make sense to you? Do you get that you're gonna have to feel uncomfortable and you're gonna have to accept that like, it's a bad thing. Even though it's very low chance, it might happen. That's just the reality. Most people will be like, yeah, I get it. I'm gonna try to work on it. And it's really then about like just being a coach and like encouraging them, reminding them. That's usually what happens. And it's really just about like, really being like on their side. Like, yeah, you're doing great. You know, you were able to like, you know, not wash your hands all day today. Like, that's awesome. Like, you should, let's have a party. Like, let's have some cake, like to celebrate that. Right, like that's the kind of thing that you would, the way you'd be thinking about it. Yeah. Sure, something I found helpful for that like beginning part that Simon was talking about, like how to get the crack in the door kind of, is like for that first part of the graph, it's really hard sometimes to get people to engage in exposure therapy, right? They'll be like, no, I'm gonna stick to my thing, which I know that I do, which I know works for me. Like, I have to do it. So what I did is like, I spent a lot of time asking the client like how it felt after they finished the ritual. And honestly, it felt like shit. Yeah, I felt better for a minute and I felt even worse. That's right, I mean, and that's right. And that's how the disease works, right? So they should get that, absolutely. That's right, and that's a great way to, but they kind of know that. I mean, everyone's sort of all realized like it's not working. If it was working, then they wouldn't be coming to you, right, but it is a really horrible illness because they're always trying to find a way out. And there's no, like the way out is very counterintuitive because it's like, I thought the way out was to like be sure that this, like to be safe, but the way out is actually to like make yourself less safe and accept that. So that's why I said earlier that this is tricky illness because it's kind of counterintuitive to the way you usually think about when you're giving like therapy or you're like supporting someone. You're like, you're gonna be okay. Like, you wanna reassure people. You wanna say like, hey, you know, it's all right. Like, you're gonna make it through this. Like, the bad thing isn't gonna happen. Like, you can do it. You know, whereas here it's like, yeah, you know, actually the treatment is to accept that that bad thing could happen, which is like, people can get very upset when they hear that but that's the reality. Like, it's also like, okay, I don't want it to happen, but like, we can all have horrible things happen to us and like, we all kind of have to live with that. So yeah. Peter, you have a question? Yeah, so you were saying that some people when presented with this therapy, you know, they go along with it, they do it. It's helpful. Could you talk about how helpful it could be with or without medication? Like, can it make the OCD like, much more manageable? Because I can understand if they're really resistant to it and they don't engage. It could be a whole, you know, not very effective, but how effective can it be? Which, the OCD exposure? Yeah. Well, you can pretty much get to the point where OCD is in remission, right? I mean, if you really, if you really, like, there are people I've treated that have had pretty bad OCD, where after a long, long time of doing exposure work, they come off medication and they're really like, yeah, whenever they get those intrusive thoughts, which are like, what if? They're like, yeah, what if? Like, it could happen. Like, I got to accept, like, I'll live with that. And then it never really gets to the point where the OCD ramps up and it really is active in their life. This is why it's like, when people act, is it ever cured? It's not cured, but it does go into remission in that the people will get intrusive thoughts occasionally. Like, it will happen. Like, they get a thought like, oh, what if I hit someone when they're driving? But they're able to react to it in, like, a better way. They're able to say, like, oh, there's my OCD, or they're like, yeah, it's true. Like, I got to live with, like, the possibility of hitting someone. I can't let my OCD run in my life. And then they're able to go back to, like, basically, you know, like, functioning. Like, it's just like when you have, like, high blood pressure or diabetes, like, and you, like, deal with it without diet and exercise. Like, if you kind of let your guard down and you let things slip, then you end up getting the problem coming back. So it's kind of similar with OCD. It's a chronic illness. It can be managed. People can be very functional with it, but it's just there. It's just the way the person's brain works. So that's kind of how it is. Yeah, Matthew, you have a question? Yeah, I'm curious about if there's any crossover between OCD and magical thinking. Magical thinking, meaning, meaning what? Like, for example? Well, it's like a way, you know, children try to, like, control reality. Like, they don't step on a crack thing, you know? There isn't a manifestation of OCD that's more like that. It's a little bit less rational. Where, yeah, but again, like, that could sometimes sort of veer into the psychotic realm, I would say, but, and then you, so then it becomes more tricky, but you could have that, like, yeah, I was afraid that if I do a certain thing, something bad will happen somewhere else. That happens. That is a kind of OCD. I guess I'm asking, like, does one lead to the other? Can magical thinking lead to OCD? Or is OCD, that was really interesting. You were talking about how it's like kind of trauma-based in origin. I think it's, I was saying it's not trauma, I think it's medical. I think it's biological. Like genetic. It's probably genetic. There's definitely a genetic side. All psychiatric illnesses have a genetic component. And then there's probably a sort of autoimmune response to, like, disease side, maybe. And then also maybe else, you know, there may be a learning element where a person learns that, like, they should try to control anxiety as opposed to, like, and sometimes life circumstances don't allow a person to develop as much OCD in a certain area. Like they just have, there's just some people, and some people that are a little less privileged, they just don't have a choice. They have to, like, deal with certain things and they can't work around the problem. So it depends, but I don't, I would say- Nature or aspect. I said something earlier about how if something traumatic happens, it kind of alters the development and foster that. Usually it's, I was saying, like, probably, and I'm not sure about this, this is theoretical stuff. It's probably brain insult. Like getting, there's a childhood, I was bringing it up, there's a childhood disorder called PANDAS, which is post-STREP. It's post-audiomune neurodegenerative, I forget what it stands for, but, and then after-STREP, which is basically people, someone develops, like, a pretty severe OCD after getting a STREP infection. So we know that sometimes, like, there's a biological, a very strong biological component to some of the OCD symptoms. We don't fully understand how these disorders happen. And as I said, there's a interplay between, like, biological stress, emotional stress, and genetic predisposition that probably leads to the problem. So that's what I would say in terms of the way that the illness develops. Yeah. All right. Good. Everyone, any other questions before we move on? Nope, not. I will go back to my slides. I have to make sure we find the right one, and I have to share them, share the slides. Yeah. Green. Okay, everyone see my slides, the correct ones, I think, right side, okay. So this is what we're up to. So all right, so let's just let's see if we can get through the rest. So these are all and I talked about a lot of this, but these are all ways you can talk to someone who's coming to you asking for reassurance, like saying like, I can't use that fridge. You can't force the person to use the dirty fridge, like you, but you can talk to them if they're working with their therapist about how like, look, these are I can get this is really scary and really is really hard. It creates this false system where there isn't any, let's see if we can fight that by like not giving into it, right and see, you know, this little one, but you should definitely be very empathetic and I think validating of the experience, but also saying like, we want to fight this instead of like saying like, okay, you feel really bad, let's give into this. That's when you make things worse, right? The goal isn't to eliminate anxiety completely, but you have to learn to tolerate it, we can work together, build your confidence and handle any discomfort. When you feel the urge to wash, try telling yourself this is my OCD talking, not actually not actual danger, I can sit with this anxiety, and it will decrease on its own, right? So there you have to be a little careful because if sometimes people say it's my OCD, it's not going to happen, which is a compulsion. Whenever the person is telling themselves the bad thing isn't going to happen, it's a compulsion. But if they say, yeah, that's my OCD worrying about that, I have to accept that I might get sick, but I'm just gonna have to live with that, then it's not a compulsion. So it's, it's tricky. What would you, what would happen if we delay the hand washing by five minutes? Let's see, let's see if it goes, let's see if this anxiety goes away by itself. I know this is difficult, I respect your courage in facing these fears, each time you resist a compulsion, you're strengthening your ability to manage OCD. This is all language you can say to like, really be like a coach, like, imagine you're encouraging someone who's learning how to like, I don't know, do track and field, you know, got to run a little faster next time, got to make it like, it's the same idea, really pushing the person to like, break the pattern that they're in, it's just like exercising, really. Dr. Shulman, this is one of those points that says by five minutes, would somebody as a general, in general, would they see a decrease in about five minutes of the anxiety caused by the obsessive thoughts? But part of, this is why we talked about like a graded, like you do things in a graded way. So like, sometimes you start by saying like, all right, when you feel an urge to wash, tell yourself, I'm going to stop, I'm not going to do it for five minutes. Then after that, I'll let you do it. Like, that's okay in our treatment, like, that's the level we're at now. But just push it off. It's much better than the person going like immediately washing. And then eventually, actually, with people that have contamination fears, actually, the real sort of like accepted approach in the field is like no hand washing all day long, no matter what, like, forget it. No, you go to the bathroom, you touch something dirty, forget it, just, you're gonna have to live with that. It's pretty extreme. One of the rules we say in treatment is nothing that the therapist wouldn't be willing to do. So like, look, I've had cases where I go out with my patients and like touch a dirty garbage can. I touch the toilet with them, like, I'm like, I'm going to do anything, I won't ask you to do anything I wouldn't do. Like, if I had to, but I not wash my hands for a day, yeah, I mean, I want to go hiking, I go camping, like, you bring some hand sanitizer, what if I forgot my hand sanitizer, like, I wouldn't stop my hiking trip, just because I don't have hand sanitizer, right? Like, I would, I would stay camping. So like, I look like I'm willing to do that, right? So if you'd be willing to do it in like a difficult circumstance, then like, you can ask the patient to do it. So that would be the, like, the way we would do it in the extreme. But like, when we start, yeah, sometimes it's five minutes, and they might not, they might still be anxious the whole time, they might go and wash their hands, but that's a win. It's a big win over like going doing it immediately, because then maybe next week, you'll go to 10 minutes, and then you'll go to 20 minutes, and then you'll go to a half an hour, and then you'll go to an hour, and then you'll go to the whole day, right? Like that, that's what that's, that's what we're going for here. So, so, you know, I think the best situation, and this is important for you guys, is that that, and I come across this in many different contexts, but like, you want to be working with a really good therapist, but the support people are really important, like you being a support people around the person, and being like using OCD, friendly language, like doing the same things in the right way, or they look for reassurance, being a coach, it makes a big difference. When people around the person are like not getting it, they can, they can kind of ruin what the therapist is trying to do, so that's why I think the goal here, that like, I wouldn't say that you should try to do this all on your own, but like if you can get people into the right, like into the right therapy, then like, or even like reading the right books, like just getting that right idea, then you can help them work on this. Does that make sense? Yes, absolutely. Yeah, so any other questions before we move to, we're going to move to medication now, and we're going to talk about SSRIs for a few minutes, and obviously SSRIs are used for all different things, so it'll be kind of talk about SSRIs in general, but good. All right, we're going to go to the medication side, and I don't see anyone raising their hand, but I guess, can I see everyone? Oh, goodness. Yeah, okay, so SSRIs, Selective Serotonin Reuptake Inhibitors, anyone know what the first one was, the first SSRI was? So it was developed in the 80s, the first one was Prozac, fluoxetine, made by Pfizer I believe, and it was actually a real game changer in psychiatry, I'll give you the history, I don't have slides on it like I had last time, but I can give you a little bit of the history of antidepressants treatments. So the early ones were called MAOIs, which work by inhibitors, MAOI inhibitors, they work by like stopping a certain breakdown process in the brain, and they were like really dangerous, if you ate certain foods with them, then they would cause like a hypertensive crisis, you would have like a real serious problem. People still use them occasionally, but they're almost never used anymore. Then came this new medicine called tricyclics, which were developed in the 70s, and some examples are like, you may see someone on like nortriptyline, amitriptyline, Pamilor, this is like a brand name, clomipramine, which is something I mentioned for OCD, which is considered like, like the gold, like for someone who doesn't respond to regular treatment, you put them on that. Those worked pretty well, but they were pretty dangerous in overdose, and they caused some cardiac side effects, so you'd have to check the person's heart more, and there was like a fear of that, they were more sedating, they were more anticholinergic, people would get really dry mouth, they'd get constipated, so you have a lot more side effects. Along comes Pfizer, and they developed this new drug called Prozac, which is very selective in how it works in the brain, so the reason it's called a selective serotonin reuptake inhibitor, what happened there, is that it's specific in that it acts more, instead of, so let me just give you a little background in neuroscience. You may know this, you may not, but I'll just give you a quick overview. So this, let me get my laser pointer, so this picture, this cartoon is supposed to show you two brain cells talking to each other, so this is one brain cell here, this is the other brain cell here. Now when brain cells talk to each other, while a message is traveling through the cell, it's traveling electrically, right? But then at the end of the cell, it travels between the cells chemically, it's a neurotransmitter, it's a chemical that one cell releases, and the other cell picks up, okay? So we talk about dopamine, dopamine is one of those, but the other one that we're talking about now is serotonin, which is important for anxiety, depression, allows the brain to be a little bit more plastic, like maybe change the way it's thinking, important for those things. So you have a situation where the brain is creating this molecule, the cell creates the molecule serotonin, right? It releases the molecule when the pathway, when the circuit is being triggered, so then it releases it to the next cell to say keep going, like activate, right, the next cell down, and the next cell picks it up. Now what usually happens was, because the brain doesn't want to have to keep having to create these molecules again and again, so then after the second cell picks it up, it lets it go back into the synaptic cleft, this is called, the space between the brain cells, and then it gets reuptaked, right? This top cell that let it out actually takes it back up. So what the reuptake inhibitors do is they make the, they make the, they prevent the cell from bringing this back into the earlier, the first cell, they keep it from going back in for longer, so then it ends up staying here and activating the second cell a little bit more, right? So you end up getting more activation of the serotonergic pathway through this, through this process, everyone get that? And patients may ask you about this, it's important to like be able to have a basic understanding, because I think it really helps people get like, I don't really like it when people say like you have a chemical imbalance and you need this serotonergic drug to help you because of serotonin, it's like a vitamin, like it's not like that, it's not how it works, it's, I think this is a more sophisticated way to explain it to people, so you tell them like, look, your brain cells are talking to each other by putting these molecules out into, and then it allows them to, the next, the next cell to pick that up. So what this drug does is it actually keeps that molecule out between the cells longer, and then that makes that serotonin circuit act, like fire more, so it gets that serotonin action in the brain more active, so it allows the brain to maybe be more plastic, allow you to make more changes, I think really that sort of comes to the edge of the science, where what exactly is it doing, and to like come to our experience, we don't really know, but people usually are satisfied with that explanation, you kind of know what it's actually doing, you can explain it in normal terms, so that's how SSRIs work, and yeah, so that's basically, that's basically that, any questions on that, the neuroscience part of the lecture? That, we'll move on. Okay, so I just said this all, but you, the first one, so you know that, so I'm not going to go over that, but the second bullet is some of the common ones, just so you know the names, if it comes up, the probably the most common three are Prozac, fluoxetine, sertraline, which is Zoloft, and Lexapro, which is escitalopram. Now, the other two, if you see someone on them, you might want to wonder about their psychiatrist, so the other two, Paxil, paroxetine is also an SSRI, but it doesn't necessarily work better than the others, it's a little more sedating, maybe because it's a little more side effect, and if you skip a day of Paxil, you get this really unpleasant discontinuation syndrome, so most psychiatrists try not to use it very much, because people miss their drugs sometimes. That sometimes happens with sertraline and Lexapro, but the worst is Paxil. And then Stilexa, citalopram, we don't really like to use it anymore, because the breakdown product of citalopram, if you notice the name, citalopram, which one sounds like that? Escitalopram, right? So Lexapro is actually just a breakdown product of Cilexa, and it seems to work just as well, but have less side effects, so why would you ever use citalopram? So you rarely see the last two, and then actually there was, you want to hear more history, there was actually a controversy about Paxil. One of the things that the pharmaceutical industry got in trouble about was Paxil was approved for children to be used in kids, and it turned out that there were some trials that they ran that showed that it might cause more suicidal ideation in kids, and actually wasn't very safe, and they buried the trials, they didn't publish them, and then so the FDA ended up actually pulling the approval for Paxil for kids. So one of the reasons we have, and maybe other people know about this, but we have a website that every trial anyone ever runs, they have to register their trial, it's called clinicaltrial.gov, so if you're ever curious about a drug, you can always look it up on that website, and that was partially developed because of Paxil, so some interesting history. So those are the common SSRIs, Prozac, Sertraline, Zoloft, and Lexapro, those are the most three, those are the ones you probably will hear the most. There's others which I didn't mention here, but if people have questions about like the differences between each one, we can talk about them, but I'm not going to go into that unless you want to hear about it. So one thing that people should realize just when, if patients are on them for a few days and they're not getting better, you don't really get the full effects till two to four weeks, but you usually get some improvement after like a week, so if people say like nothing happened at all, it's probably not a great sign, and then you might end up getting more benefits even later, so you have to be careful with timing, you have to tell people like look, give it a chance, you know, if you're not feeling fully better after two weeks, just give it a little longer, you might get more benefit as time passes. We talked a little about how it's being tolerated, so they're generally... Sorry, Dr. Schiffelman, I think there's a question in the room, sorry to interrupt. Yeah, my question is, these drugs, you're talking about the effectiveness and the weeks, you know, two, four weeks, six, eight weeks, what do they do for the OCD? Do they just kind of make the obsessions like a little lesser, or like do they just... Yeah, so good question, so the obsessions might come less frequently, and it might be easier for the person to resist them, and it may quiet them down completely. If a person has a really mild case, or I would say mild, person has a very treatment, what's the term, I guess it's treatment reactive, you know, they're not treatment resistant, so when you give the person the SSRI, it may make the intrusive thoughts go away, and they might not even, like, they're like, I don't have those anymore, they went away completely, but usually, also like oftentimes you'll hear like, yeah, I still get them a little, but it doesn't really bother me as much, and I kind of ignore them, and I have less of like an urge to act on them and do these compulsions, so that's usually what you hear in terms of response, that they're less frequent, they don't come as often, and when they do come, I don't really, it doesn't bother me as much, so that's how OCD people respond to... Also, what, you said SSRIs are used to treat a lot of different things, what's the other topic? Yeah, so I don't know, do I have that on the next slide? Do I have that? No, I don't have it, I'll tell you, so the treatment, the SSRIs are approved for almost everything in psychiatry besides bipolar and schizophrenia, so if you have a disorder, you name it, it's probably approved for, SSRIs are probably approved to treat it, like some examples, so major depression is the one that everyone, all the drug companies want to go for because it's the most common, right, so it's approved for major depression, all these drugs are approved for major depression, every single one, generalized anxiety disorder, so anxiety, which is, maybe they work even a little better for anxiety, although you need a little higher dose, so like even if someone doesn't have OCD, but if they're really worried and they're just worrying all the time and it's really tough for them, then an SSRI can be helpful, panic disorder, if a person is afraid to go out because they're in panic attacks, SSRIs are approved for, I'm not sure if they're all approved, I know Zoloft is approved, PTSD, so post-traumatic stress disorder, SSRIs are the first-line treatment, again, you know, they help with like the anxiety and like overthinking thoughts, PTSD is another lecture, which again, if you want a lecture, I can, we can go through every disorder and do a lecture like this, they'll get shorter and shorter, I think as you know more about this stuff, but that's another, it's another disorder that SSRIs are the first-line treatment for, so those are the major ones, depression, generalized anxiety disorder, OCD, panic disorder, and PTSD, and probably others we use them for, but those are, I think, the ones that have the indications. Because I, we have a client that takes Zoloft, but they also have bipolar and he said it wasn't approved for that, I'm sure they have something else, but I guess I was just curious about that. It is not, it is not approved for bipolar, and using an SSRI in bipolar is more of a question, should you do it or should you not? Now, if they have OCD, in theory, they should respond to that, if they have OCD and bipolar, right, then you, you, in theory, could maybe use an SSRI in that case. I would say that in those cases, I sometimes use SSRIs, but it wouldn't treat the depression. If someone's, like, still depressed and they have bipolar, it would not be helpful, and they probably should not be using an SSRI for that reason. Okay, thank you. But that's the psychiatrist's decision to decide on, but you should just know, like, when we look at the studies and, like, the meta-analysis, adding an SSRI to, like, the mood stabilizers doesn't really help with bipolar depression, it's pretty clear. Also, maybe I'm mistaking the different clients in my head, maybe I'm mixing this all up, I'm sorry. No, you're probably not, but there's also a question, is the person really, does the person really have bipolar, or is that just what someone said? So that, that, that's always a question in psychiatry, like, did you get the diagnosis right? OCD you generally get right, there are cases when you can mix it up with like a psychotic illness or OCD, obsessive compulsive personality disorder, hoarding, there's different things, but usually you get it right, but like with bipolar, it's very hard. I think there's a lot of question, like where the line between bipolar and depression and like other disorders is, so. So that's, yeah, that's what the indications are for SSRIs. Any other questions on these? I think Joe has a question. Yeah. Joe, go ahead. Yeah, so I don't know if you already went over this, but how would SSRIs interact with like schizophrenia? So it's a good question. They're not indicated. They're not approved for schizophrenia. A lot of people, it's different than bipolar in that I've seen, and I think it's pretty common that people who are stable on an antipsychotic, they might also have anxiety or depression and you might use an SSRI in that case. I don't think that that's, definitely not approved, but I would say that it's pretty typical. Is it the right thing to do? I don't know, I'd say, but it often happens and I've done it many times and I would say, you often will see someone with schizophrenia on let's say Lexapro 10 and Abilify 10 or 20 and sometimes they're doing well and it seems like that's working. It's not like with bipolar depression where it really doesn't seem to have any benefits. So as far as I know, but I'd have to dig into the literature more. I mean, should we just talk about this client that we're all sort of talking about? Is there a patient that you guys are thinking of? Oh, I thought we were talking about Ben, interesting. Oh, well, yeah, that's why I was confused because I thought that Victor took Zoloft, but maybe he doesn't. That is Ben, right, okay. Yeah, if you want to, let me just finish the lecture and we can talk about the case if you guys want to talk about a particular case more. So last slide, so just an overview, they're better tolerated as I mentioned, but let's just go through the side effects just to talk to people about them. So somebody who starts an SSRI, they might get nauseous, they might get headaches, they might have some trouble sleeping. Trouble sleeping actually could last a little longer and you may need to change SSRIs, but like with the nausea and the headaches, sometimes if you get the person, you have to decide how bad it is, but sometimes it goes away after a week or two. And so it's worth just like muscling through it because then you get the benefit of the medicine. But there is like an adjustment period in the beginning that sometimes people don't feel right. And that's something that's worth warning them about and also maybe telling them to wait it out because it might be worth it because it's not gonna last forever. The sexual dysfunction usually does not go away. That means anything from I have no sex drive to I can't ejaculate or I can't get an erection for a man. So that can be a big deal for people and it's a big problem. It's a pretty common side effect. I think it's one in three people get that. And sometimes, I think some studies it's even more. So there's some effect on sexual dysfunction. Sexual dysfunction. Now, the increased anxiety thing, I'd say that's more with younger people, with kids. You sometimes get like an activation. People that maybe have bipolar and they really are misdiagnosed. There are people that really have a bad reaction to esterserize. So if you hear that, you should believe it. It's not like no one has a bad reaction. And you have to be careful. If someone had a bad reaction, you don't wanna tell them to keep increasing the dose. You should say like, okay, let's stop this and try something else. Another, actually one that I didn't write here, but we probably should mention is that for people under age 25, there's a warning, which is from the FDA, black box warning, which means that like, we have to tell people as a psychiatrist or it's considered malpractice. There's suicidal ideation. So some people that are younger, when they start an esterserize, they start getting these intrusive suicidal thoughts for some reason. It's kind of scary because you're treating depression, right? So all of a sudden now, this person's getting suicidal thoughts. That's not good. But it's there. And RFK kind of wants to get rid of SSRIs for kids. The SSRIs for younger patients are a little trickier, but usually once you get to 18, 20, a lot of people do respond really well for them and it's fine. And I've used them for people with OCD that are like younger and they do fine. So it's, but you just have to be a little more cognizant of being like looking out for that suicidal ideation. The suicidal ideation for younger people usually starts early on in the treatments, like the first couple of weeks. So if it's been a month or two and they haven't gotten it, it's probably not gonna happen. You don't have to worry about it as much. So, okay, discontinuation, important to people should talk about. You guys, this is good to be aware of because you can't prescribe, but people may be stopping while you're talking to them and you should just, people should be aware that there is a discontinuation syndrome. It's not, these are not addictive medicines. You can't, if you take them, you don't get high, or there's no like immediate psychoactive effect. Like I said, the changes happen over like a week or two or three, like you don't get that immediate high, but they are, there is like something like, which seems like tolerance, right? The body gets used to the SSRIs and when you stop them suddenly, you get an unpleasant reaction in many people, not everyone, but many people, and people will complain about this and they're nervous about SSRIs for this reason. Some of the symptoms of that are dizziness, irritability, sensory disturbances, feeling like you have the flu. And for some people, it's really unpleasant and there's lots of online forums blaming SSRIs for ruining their lives. People blame them for ruining their lives because they have this really bad syndrome that doesn't go away. You know, I don't know if I've seen that. I think, I think, but you always warn people for most of the SSRIs, you have to slowly taper them off. So if someone's on like a high dose of sertraline, there's a lot, like you don't tell, you can't, they should really not skip a dose a day. If they skip a day, they might get a headache, they might get, they might feel like they have the flu. They take their medicine the next morning, they'll feel better and they can ask their doctor if they should take it late. You can double up, but you just start it again and that makes you feel better. So that's the discontinuation, they call it serotonin, I think they call it serotonin SSRI discontinuation syndrome. So it's a discontinuation syndrome that people get, which is good to know about. And for OCD, since it was a lecture about OCDs, people should know that for some people, you need high doses of SSRIs above and beyond what you usually use for like treating depression or general anxiety. You need a very strong serotonergic load, so people will go to the highest dose, or maybe even above the highest approved dose for SSRIs, for OCD, because that's what we have the evidence that it works. I have a question. A little bit longer, yeah, go ahead. When you were describing how SSRIs work, with that diagram of the serotonin moving and all that stuff, how does the dose change that process? And is there a maximum dose that is like healthy for a human? And is there a maximum dose of just like physically or like possible? Like, how does that work? So the more, I'm not a neuroscientist, so I'm not an expert, but I'd say the more you have, the more the effects will be to a certain threshold, and then you'll end up no longer having a benefit. At higher doses, the SSRIs start acting on other receptors. They act more, they can, at very high doses, you might get more of a dopamine effect. They might work on other things. Some of the, so let's talk about what you asked about the high, so first of all, they're very safe in overdose. So you don't really have many case reports of people dying from SSRI overdose. When you take too much SSRI, you can get certain, you can have bad things happen, obviously. People that have too much of this medicine over a long period, they get something called serotonin syndrome, which, yeah, it's, I don't want to go through all the details of the syndrome, but it's quite unpleasant. It can involve like shaking and feel like you have the flu and feeling very irritable and uncomfortable. So you would, that wouldn't be from a single dose, but like chronically taking too much SSRI can cause that, and higher doses above the FDA maximum have more side effects. So I think, and I, yeah, does that answer your question? Like if you go to 200, if you go above the 200 milligrams that Zoloft is approved for, let's say you need to go to 300 or 400 for OCD, which I've done sometimes, there's more likelihood that the person's going to start getting headaches, they're going to maybe be more irritable, maybe there's more chance of weight gain. So there's different side effects that you might be getting. Right. I guess I was just curious that what SSRI does is it prevents the serotonin from going back to that original cell. So like how does a low dose, like it just does less for less of the serotonin? Yeah, I think there's a certain, well, this is a neuroscience question, but in all these medicines you can get, there's, and I'm not an expert in this, but you can get a certain percent occupancy. Like there's a certain effect of the percentage of the cells in the brain that are going to be affected. Oh, okay, gotcha. And so the more you have, the more likely that you're going to get up to 100%. And then once you go beyond that, maybe there's, it starts affecting other receptors and then maybe other things that are going on. The brain, yeah. Yeah, thank you. I'm curious, thanks. Yeah, no problem. Other questions? Other thoughts? Good? Okay. So yeah, do you guys want to talk about that one case or do you want to just end? Is this the last one of these that you'll be doing on like medications, as far as we know? I don't know. I work for the ORN. Because I had a question about another medication. I'm happy to do as many lectures as the ORN wants me to do. So, you know, if you request more lectures, we can do more lectures. I don't know if you keep, you know. Yeah, it's fine. I don't know, Katie. Yeah, this is the last scheduled one, but we can always discuss more, just like we've had this request open for a while. So there's always more to do if you guys are interested. That would be terrific, yeah. Right. Yeah, we're recording, Katie, we're recording these for posterity. You still recording these type of questions? Yeah, I'm still recording. Yeah, so if we record them, then maybe we can put them on the repository and maybe others can use them. So there'll be a benefit for beyond just the one group. So I'm happy to give more lectures in the future, so. Hey, Abraham, did you want to discuss that person? Do you have a question? I see that someone had one. Relevant, what? I don't know how relevant it is necessarily. Oh, okay, then nevermind. I don't want to discuss that in this setting. Cool, cool, yeah, copy that. Yeah. All right, sweet. Yeah, I had a question about, I guess you could say comorbidity or just like how the overlap between like eating disorders or like more specifically something like body dysmorphia, where it's a blur between OCD. Great question. Yeah, there's definitely an overlap and there's a lot of related disorders to OCD, which I didn't talk about. Illness anxiety disorders used to be called hypochondriasis, it's sort of like related to OCD. People are afraid they're going to have, let's say cancer, and they're like checking all day long, do I have cancer? Body dysmorphia is also related, harder to treat than OCD, but some of the treatment is might be related. Body dysmorphia is really hard to treat, but person maybe thinks their nose doesn't look right, their stomach doesn't look right. They might get repeated surgeries and some of the treatment may overlap with OCD and that they're, and there's a lot of checking, like some with body dysmorphia might be like feeling their stomach, like, you know, I'm feeling now, I'm like, ah, I gotta work out more, right? So like, but they might be doing that all day long, like it's very repetitive. And some of the treatments are related to the OCD treatments like you might have a situation where you put yourself without your shirt online, like a picture, like there's a Facebook group, I think, of like the room for like people to like do exposures where you like, you know, you try to like allow yourself to face the fear of like, it's okay, like my body is overweight, but I'm okay with that. Like, I'm gonna let people see that, or my body is what it is. It's not exactly the same. I'm not an expert in body dysmorphia and it is very hard, it's harder to treat than OCD in that it's not always like so clear to the person that it's not rational. There might be less insight, but it's certainly related. It's a good point. And this is body dysmorphia, there's also anorexia, which is sometimes related. There's a lot of comorbidity between OCD and these disorders as well. So that's a great question. And I don't know the exact number, but they're certainly connected. They're more connected than let's say other psychiatric disorders and OCD. The other big comorbidity with OCD is obsessive compulsive personality disorder, which is its own unique problem. And I don't think I want to get into it. It's actually very tricky to recognize and treat, but it's obviously related to OCD and there's a lot of comorbidity in that. Awesome, thank you. And I just kind of want to follow up with like, do you ever see like these like substance use disorder in itself is like very like obsessive, you know what I mean? Yes, very true. No, it's definitely feels like there's sometimes like a parallel brain process, yes. Or like, do you see, because I mean, I attend like 12 step meetings, like I think a lot of us do, like as like people, you know, like put down like drugs and alcohol and then like they put down like cigarettes or like sugar or whatever. And then like, they're like, it seems like they've like developed OCD. This isn't like super common, but I've known people that like, it has like- People that I think you might, well, they might develop OCD, they might have OCD that they were masking with their enjoyment. Yeah, excuse me, that's more what I meant. That's possible, but also they might develop, but you might be right, they also might develop more, it's like, just because something is compulsive doesn't mean it's OCD. Like if someone is obsessively exercising all day long, let's say, that is not OCD, but it's still unhealthy. It's like a more behavioral addiction, right? Like, or, you know, or someone who's, I don't know, there's all different behaviors people have. It's a very interesting question. I don't know the answer and I've been curious about it from a science perspective, but we, you know, we have a challenge because the different branches of the government that study these things, unfortunately are separate. There's the NIMH, which studies mental health, and then there's the NIDA, which studies drugs, and there's the NIAAAA, which studies alcohol. So they don't always talk to each other and like think like we should do something to like do like how these things are connected. So as far as I know, there isn't a lot of work on this, but it is a very, it's a really good question. And I have thought about that myself and thought about like, how can we study that? Like, is there a relationship with a treat, but the treatments for one don't really work for the treatment, but the treatments for one don't really work for the other, like SSRIs don't treat and they've been tried for like cocaine, they don't work, right? Like the medicines that work for OCD don't work for addiction for whatever reason. So, and there isn't an addiction that like anxiety obsession side as much. So there's certainly overlap, but there's also differences. And so how did they like, you know, we don't know. So, but it's a good question. It's a good point. I don't see a lot of the overlap existing in like the cycle of fear and control essentially. And like, I mean, I know that that's not really clinical or exacting, but I think that us on our like sort of day-to-day and behavioral end see the fears come up and then see like the efforts to control, try to mask those. That's a great point. You're right. And that's like the first step, right? Like letting go of control. So for definitely there's like an overlap on that level on that high level of like global. So, yeah, I mean, we don't, I don't think we fully understand these things, but yes, you're right. Awesome. All right. Any last questions before we all go off? Everyone did the survey for Katie? Oh, no. It's in the chat, but. Okay, I'll go now. Everybody do the survey now, if you have it. Thanks, Ned. Thank you very much. Thank you all. Here, I'm going to stop the recording.

psychiatric comorbidities

substance use disorder

obsessive-compulsive disorder

intrusive thoughts

repetitive behaviors

exposure and response prevention

pharmacotherapy

psychotherapy

selective serotonin reuptake inhibitors

serotonin levels

therapeutic approaches

medication management

comorbid conditions