Ep.73: Understanding OCD with Dr. Brady Bradshaw MD and Dr. Robyn Cohen, PhD

Episode Transcript
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Colette Fehr (00:03):
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wait list. Now let's dive in.
Welcome back to insights fromthe couch. Everyone. We have a
great episode today on OCD andeverything you need to know, not
the OCD Everyone claims theyhave when they don't and they

(00:50):
just want to clean their roomthe real deal. We're going to be
unpacking it all we have. DrBrady Bradshaw, our friend who's
joined us many times and is oneof our favorite guests, and Dr
Robin Cohen, who is aneuropsychologist, is that the
correct way to say it? Robin?

(01:11):
Yes, that's right. Okay, great.
So can you guys, first of all,welcome. We're so excited to
have you. I have a millionquestions pinging already.
Thanks for being here. And canyou just start out by tell us a
little bit about you so ouraudience knows that you guys
are, you know how you guys aredialed into this work?

Brady Bradshaw, M.D. (01:31):
Yeah, I can go first. I'm a child and
adolescent and adultpsychiatrist. I'm a physician. I
do diagnostic evaluations, aswell as prescribing medications.
I also do psychotherapy,psychodynamic psychotherapy,
with patients, and I have aprivate practice in Orlando, in
Baldwin Park,

right across the street from me, actually, and we
never see each other, which isso bizarre. And we live around
the corner from each other, andwe don't see each other there,
either, too busy, too busy.

Unknown (02:05):
I know. I know.

And Robin, how about you?

Dr. Robyn Cohen, PhD (02:09):
So I am actually a developmental
neuropsychologist, so I seechildren, adolescents and young
adults. Currently, I doevaluations and private practice
in Winter Park. But prior tothat, I ran the neuropsychology,
pediatric Neuropsychologydepartment at Arnold Palmer

(02:29):
hospital. And prior to that, Idid do treatment, actually
specific and researchspecifically with OCD.

Wow, wow. So let's start off. I mean, just what
Colette was talking about,people so flippantly refer to
their OCD, like, Oh, my God, Ilike, I am so OCD, I got to
clean my room, or I need thingsjust a certain way, like that is
not it, right? I mean, can weget, like, a real working

(02:59):
definition of what is OCD?

Basically, when you have clinical levels of
obsessive compulsive disorder,it's comprised of obsessions,
which are really severe,intrusive thoughts that cause
extreme distress, and then thecompulsions come in as behaviors
that you do to try to relievethe distress of those obsessive

(03:25):
thoughts, and that causessignificant life impairment in
terms of taking hours per day,and can interfere with your
relationships, with your workingand it's a pretty broad range of
severity that you can have, butyour your urges to kind of get
things the way you want them andorder them, you know, is not

(03:48):
really what we consider aclinical obsessive compulsive
disorder, yeah, how

did that become a thing that everybody says?
Everyone thinks

I was just going to add, you know, there's
that the prevalence is reallynot very high. So OCD, the
prevalence is like one to 2% ofthe population. So it's really
not very common, exactly as it'stalked about. I mean, ADHD is
more common. General Anxietydisorders are more common. I

(04:20):
think the part that we relate tois the intrusive thoughts,
which, you know, Robin and Iwere talking about this, are not
abnormal. You know, everyone canhave an intrusive thought of, oh
my god, what if I crash intothis car, or what if I, you
know, or I need to clean thiscloset. So we all can have an
experience of like an intrusivethought. But it's the intensity

(04:44):
and the repetitiveness that itjust like keeps staying in the
mind and causing a lot ofdistress. These patients are in
a lot of inner turmoil. It'susually very what we call ego
dystonic so it really feels verybad for them to think. Those
things. When we think about,like, you know, the colloquial
or just like, casual use of OCD,it's like, oh, did I turn my

(05:07):
curling iron off? Like, let mego check I'm so OCD like,
that's, that's not OCD like, wemight go and check our curling
iron, you know, make sure it'sunplugged. And then when we do
that behavior, our brain says,Okay, done. Check. It's, it's,
it's not plugged in. Butsomebody with OCD doesn't have

(05:28):
that inhibition, they don't havethat stop sign, and so they,
they keep going on that loopover and over. They're not
reassured by the checking.

Yeah, I had a client who the intrusive thought
was that this person had runsomeone over, and she couldn't
stop thinking that she had runsomebody over, and there was not
really an incident or anythingthat had even happened to
suggest that it just was athought that perpetuated and

(06:01):
recycled and recycled, and noamount of checking or
reassurance actually quelledthat thought, yeah, yeah.

To that point like there are a bunch of subtypes. I
mean, I don't think peopleunderstand how many different
subtypes of OCD there are. But,I mean, we're talking with that.
You're talking about Colette islike a harm OCD, like, fear of
causing harm, but there'scontamination. There's like a
just symmetry, a just right.
OCD, like, what other? What is?

(06:32):
What falls under the umbrella ofall the different clinical
subtypes of OCD

there are, there's various ones. When you
look at kind of like clusterstudies, and they, when they in
research and subtype it out,contamination definitely, is
probably the most prevalent,followed by harm, which usually
goes along the harm obsessionsusually go along with checking
as a compulsion. There's thesymmetry. There seems to be kind

(07:01):
of like a pure obsessionalsubtype, where you don't see as
much compulsions, but maybethey're more like mental
compulsions. So they arecompulsions, you just can't see
them behaviorally, but they'rehappening inside their head to
neutralize the obsessions andthen hoarding is also related to

(07:22):
OCD as well, right?

And hoarding can be the OCD type and a non OCD
type,

right? I do, yes, I do think there can be
an OCD type and a non hoardingOCD type. The the OCD is the
that fear of discarding things,and so that's part of the
compulsive hoarding. But I thinkhoarding as a symptom can show
up in different disorders.

So when you mentioned this, when it doesn't
have a compulsive behavioralcomponent, so I've had clients
like that where it's really theintrusive, the repetitive,
intrusive thoughts, and thenthere isn't, they don't do a
behavior. But you're saying thatthat can actually there is a
compulsion. It's just mental Socan you give an example of what

(08:09):
that might

look like?
So I can actually give anexample from actually my son,
who has OCD and he had mentalcompulsion, so he would get an
intrusive thought that somethingbad was going to happen to me,
that I was going to get killedor die. And so he in his head,
then had to say things in acertain order in his head,
nobody saw him saying this inorder to protect me. And it got

(08:32):
so significant that, you know,he really wasn't able to pay
attention in class or, you know,because this would take up so
much of his time before he gottreatment for it. So that is
kind of just one example of howit can manifest. But there's
many ways it could, it couldmanifest.

Okay, I had a patient one time that
would have an intrusive thoughtof like throwing her baby off of
the balcony of her stairs, andso she would do a mental
compulsion of a prayer everytime that thought would come
into her mind. And again, it'sso ego, just like this is just
like Robin's example with herson, or this patient with her
baby. It feels so bad becauseit's so different from what they

(09:15):
normally would feel, you know,like she didn't want to harm her
baby. You know, this was like avery terrible feeling for her.
And so the prayer, it's oftenlike prayers or like counting
sometimes can be a mentalcompulsion. And I also wanted to
say that there are some peoplewho just have obsessions that
don't have mental compulsionstoo, but I think the numbers

(09:36):
Robin correct me if I'm wrong,like 90% of people will have
both obsessions and compulsions,either mental or behavioral.

Okay, most people and is it true that, because I
don't know where I got this andif it's really clinically
accurate, but that OCD is sortof on an anxiety continuum, like
a more extreme end, because Ihave a lot of intrusive
thoughts. It's, I don't thinkthat I have OCD and unless maybe

(10:03):
I do, and I just don't know, butdefinitely I don't have, like,
the compulsion behavior part,but I will get horrible thoughts
about, like, let's say I'mtaking a knife out of the
drawer. I'll think about how Icould, like, stab myself with
it, and I'm like, Oh, I mean,I'm not wanting to stab myself
with it. And I think thedifference is that thought then

(10:26):
goes away. I don't continue tothink about the fact that I
could stab myself with theknife, but I get a lot of
horrific worst case, how youcould die. What could happen?
You know, I'm close to an edge.
I could hurl myself off like mybrain will think of that. So is
there, Is there truth to that,that that's just like OCD is an
extreme form of anxiety, or whatdifferentiates this from

(10:51):
anxiety, if anything, other thanthe intrusive thought compulsive
behavior aspect, right?

I mean, it used to be considered, it used
to be under the umbrella ofanxiety disorders. They've since
pulled it out, realizing thatthere's an OT OCD type of
spectrum and disorders that aremore neurologically related to
that. Yeah, so, but it did usedto fall, and anxiety is a huge
part. I think that too, whenyou're experiencing clinical OCD

(11:24):
and you get those intrusivethoughts, not only do they feel
bad, they cause such extremeanxiety, whereas when we're
going through our dayexperiencing intrusive thoughts
just like that, we all havedifferent frequencies of that
experience, but we're notgetting that debilitating fear
coming with it, oh my God, andthen trying to find some sort of

(11:49):
relief to that fear that'sassociated with it.

Unknown (11:53):
Gotcha, yeah,

let me tell you guys about the type of client
I'm seeing, because I see a lotof anxiety disorders, and I see
a lot of that intersectionalitybetween ADHD, ASD, all the
things right, and OCD. And so Ihave like, maybe four of these
types of clients I'll justdescribe here, who are, like,

(12:15):
really bright women, reallycreative. Some of them are very
high functioning. Most of themhave, like, really struggle with
intrusive thinking, a lot ofintrusive thoughts. And they
talk about it in terms of, like,their themes are always
changing. A lot of it's aroundgood person, like moral
scrupulosity, not always becauseof religious trauma or anything,

(12:37):
just because it's like, a lot offeelings of guilt. There's also
a lot of like, fear of they'regoing to find out they're gay,
they're going to find outthey're actually transgender.
They're going to find outsomething that is going to make
them basically unlovable. Andevery time, and they want
relationships very badly, andwhen they get into

(12:57):
relationships, of course, all ofthis ramps and their themes are
always dancing around, andthey're also very like,
typically, a lot of them meetthe criteria for ADHD, and many
of them will have, like, a bodybased, like picking disorder,
or, like, hair pulling. I'mseeing this constant. Am I the

(13:17):
only one do you have? You hadclients like this,

oh, yeah, yeah, absolutely.

So, yeah, this is related to OCD. What you're
describing,

like, what's the main thing? Is it all of these
things kind of dancing together,or is it OCD this? I don't know.
How do you conceptualize that? Ithink

there's a high comorbidity with OCD, which
I think is one connection I'mmaking to what you're
describing. And so we see, youknow, a higher rate of and
people who have tick disorder,we see higher rates of OCD. And
then, like trichotillomania,like pulling hair or like skin
picking, those types of things,we see higher comorbidity with

(14:01):
OCD, but some of what, and thenADHD, or autism spectrum. You
know, with ADHD, people withADHD have higher rates of
intrusive thoughts as well. Soit's like, really impulsive.
Their brains are going reallyfast. And then it's like, what's
something super scary that couldhappen right now, while I'm
pulling the knife out, right,that thrill of that, you know,

(14:23):
so there is high comorbidity.
And I think the other thing thatI was hearing Laura and that,
like, you know, patient examplethat you gave, is possibly like
OCPD as well, which is a, youknow, we would want to
differentiate from OCPD is moreof like a personality, what we
call a personality disorder, ortraits, where there's like, high

(14:45):
perfectionism, guilt feelings,high conscientiousness, detail
oriented, afraid of makingmistakes, and it tends to be
like more. Invasive and chronic,then, you know, big intense
flares of anxiety and OCDsymptoms. So the intensity, I

(15:06):
think, is different, and theclinical picture is different,
but OCPD is more like of achronic, you know,
developmentally, you might hearit over years of time and more
of like, that, intenseperfectionism,

yeah, oh, yeah. I don't know why. I've just, like,
associate that with more withmen. Maybe I'm like, just see it
in men more. Maybe that's my own

body, and I have talked about that a lot. I mean,
I think OCPD is so little knowneven among therapists, you know,
you know, you touch on it fortwo seconds in the DSM in our
pathology class. And I think alot of times with OCPD, people
don't come to therapy unlesstheir relationship is suffering.

(15:54):
I see a lot of it in my office,because there are maybe one of
the partners has OCPD and theycan struggle relationally
because of the rigidity and allof that. Yeah, so it's, and
it's, it's confusing, becauseit's obsessive compulsive
personality disorder, but it'sreally nothing like the mood

(16:15):
disorder

the anxiety disorder, yeah, yeah.

It's poorly named. Unfortunately, I
think it's even slightly moreprevalent than OCD. Yeah, OCPD
is more prevalent. That'sfascinating, but I'm not going
to see it like you said, becausethose people are probably only
seeking treatment when they'rein a couples or family type, you

(16:39):
know, therapeutic. They're notseeking it for themselves,

because a lot of those qualities are really great
in terms of thriving at work. Iknow I'm not saying anyone who's
a workaholic has OCPD, but I dothink that those things can go
hand in hand, and unless thepartner is saying, you know
this, and this is a problem. Ithink rigidity is always

(17:03):
difficult, especially onrelationships, so that's where
it can interfere. But at work,it's like, this works great,
right?

I'll just OCPD is like ego syntonic, right? It's
like they think they're great.
It's working for them, like thepeople who come in to therapy
for, like, intrusive thinkingand and like, they're disturbed,
but they're in and what they'rereally almost shopping for and
like, this goes to treatment,which we can talk about in a
minute, is almost likereassurance. Yes, um, they're

(17:32):
really shopping for reassurance,which is why we can treat this
really wrong if, like, if peopleare improperly trained, this

can go poorly.
Yeah, and I've had so manyclients in the past when I used
to work with a lot ofindividuals who were just never
diagnosed, and it was veryclearly OCD and they were
misdiagnosed forever. Is thattypical that it's hard to get an
accurate diagnosis for a lot ofthese people?

I think so. What do you think? Brady, I
do.

I do hear that from my patients. I think
there's a lot of reasons thatthat might be the case. I mean,
one is that people often have alot of guilt and shame around
their symptoms, because theintrusive thoughts can be really
terrible, and ego dystonic. Sothey might be afraid of being
labeled as like a sexualpredator or deviant or like that

(18:28):
they're a bad mother. If theyfeel that way, you know, like
there's so much shame around itthat they can be sometimes
reluctant to disclose, even to aprofessional, what they're
experiencing. So I do hear thatthat they either are reluctant
to disclose or they get, like,mislabeled for those like
intrusive

thoughts. Okay, so before we get into treatment,
let's talk about if someone'slistening and they're wondering
if they have OCD. I mean,obviously we're defining here
the intrusive thoughts and thecompulsive the compulsion, the
drive to do certain behaviors toreduce the anxiety or relieve
the anxiety around thosethoughts. What might someone

(19:09):
look for and think about if thiscould be a factor in their life?

Well, I think it depends on time spent.
That might be one thing I wouldlook for. Okay, so if you're
spending a lot of your timegoing back and checking the door
to make sure it's locked, andmaybe now you're late for work,
like that would be a good signthat this is impairing to the

(19:35):
point that it's really becominga problem. So time, I think, is
one thing that I really lookfor, time and then intensity or
level of distress. So is thissomething that you're quickly
like, oh, did I lock the door?
Let me check. Did I lock it?
Check again. Okay, I'm good. Oris it like, there's hours of
going back and checking andthinking about it, and I'm

(19:57):
distracted at work because I'mthinking, Did I lock. My door at
home?

Yeah, no, the distraction and the
attention. Because a lot oftimes people think, Oh, well, I
just can't pay attention. Youknow, it's ADHD. I've got a
deficit. But really it's thatthey're attending to these
intrusive thoughts andmonitoring for them, sometimes
even. And so it's, you know,it's something important when

(20:22):
somebody comes in withattentional issues to definitely
look at and roll out.

And I think because the fear sometimes
is irrational, and they're ableto identify that, that's another
reason that they can be sort oflike reluctant to disclose,
like, you know, I've even hadphysicians with like health
obsessions, and they know, youknow logically, that it's not
rational, and they will stillright. They know it's

(20:50):
irrational, but they can't itfeels stronger than their
rationality,

right? And then the conundrum is that the
compulsion and the behavioractually perpetuates the whole
thing and keeps it going. So,and I want to get into the
treatment thing, but can yougive us a little explanation of
what's happening in the brainwith this? Because it really,
there really is a difference,right? I mean, I think, and I

(21:17):
don't know if this is right, butwhat I learned a million years
ago was it's almost like a gearshift getting stuck, like you
can't quite shift into anothergear. And maybe that's not quite
accurate, but what's happeningfor people with this? Because,
like you said, they know thatit's not necessarily, maybe on
some level, you know,consciously, I didn't run
anybody over. I locked the door,but you still can't help but

(21:41):
have that thought and the needto check,

yeah, I think that's a great metaphor. I
mean, you know, it's, it's,there's a, there's a lock
almost, that happens and a loop,and you can't get out of it. And
there's brain structures thatlook different, just on regular
neuro imaging. They're onfunctional neuroimaging, you can
see differences functionally inthe brains of people suffering
from OCD versus normal controls.
So yeah, there's, there's a lotof biological mechanisms that

(22:09):
are happening. And then aftertreatment, as the symptoms remit
and treatment is successful,when they go back into a brain
scan, their brains look likemore of the normal controls. You
don't see those brain Yeah,activations that you did when
they were suffering. So it's,it's a really fascinating

(22:30):
disorder to study from that kindof neurological pinpoint.

That's fascinating. It's funny, like
what I've heard, and the theseclients really do suffer. I
mean, it is so agonizing to bebattling thoughts all the time.
And my clients will say it feelslike a flock of birds are
attacking me, like, and theyjust aren't able to, like, find

(22:58):
the forest for the trees like,it's just, it's so overwhelming
coming in on them, and yeah, Ijust, I have such compassion for
what it's like to do. And it'sthese thinking structures are so
tricky, and it always seems toattack people, like on the level
of their values, like, the morethey care about something, the

(23:19):
more the intrusive thinking willattack them, and it's very
tricky. So it's always shapeshifting. And I just can't say
enough about how much compassionI have for how much work it is
to live with something likethis, and you can't see it. So
it's hard for anybody. It's hardfor the person to have self

(23:39):
compassion, because it's like,is this thing real, or am I just
crazy?

Yeah, yeah. And I think it's hard for people to
when I see the partners andtherapy, you know, often there's
just so much frustration withit, how it also interferes with
the partner's life. Then,because we were two hours late,
because we had to drive back 25miles to check the stove again

(24:06):
when we had already checked thestove 10 times, a frustration, a
difficulty relating to it.
Because if this is not somethingyour brain's doing to you, I
love that flock of birdsanalogy. You know, if you're not
being attacked by a flock ofbirds, it's hard to know what it
feels like to try to movethrough daily life being
attacked by a flock of birds. SoI think it is really important,

(24:30):
if somebody has OCD in yourlife, to understand what's
happening, so that you can havesome compassion for it, and also
that partners don'tinadvertently collude with the
whole mechanism that perpetuatesand exacerbates the OCD, right?
We don't want everybody enablingit so that it gets worse. So

(24:51):
let's talk about what becausethere is hope for this to be
better. I've seen it a milliontimes. I know. We all have,
right? How different it can be.
I did not know that it changedhow the brain shows up on these
scans, which is fascinating tohear. So you know, all I know of

(25:13):
is ERP. My understanding isthat's the gold standard,
exposure response prevention. Isthat? So what works? Do we need
meds? Does it just depend on theperson? Tell us what's the best
practice for treating?

OCD, yeah.
ERP is still recognized as avery helpful treatment as part
of cognitive behavioral therapy.
CBT, so depending on theseverity which most of the
people that I'm I see, you know,when they're walking in to see a
psychiatrist, the severity ispretty high, it's pretty
intense, and so usually it's acombination of medication and

(25:52):
therapy. The therapy, CBT withERP, is hard work for these
folks, you know, like exposureresponse prevention is you're
telling me not to do this thingthat like feels like it I have
to do it, and I have and itsoothes my terrible anxiety and
distress. So it's not easy totolerate this type of therapy,

(26:14):
and so often medication isneeded to help and SSRIs,
serotonin, antidepressants arethe sort of gold standard
Medicaid, gold standardmedication that we use to treat
OCD like a Zoloft, Zoloft orProzac. All of the SSRIs have
good data for OCD.
Chlamypramine, which is atricyclic antidepressant, also

(26:38):
has good data for OCD, butbecause of side effect profiles,
we usually go with SSRIs first,and patients with OCD tend to
need higher than the upper limitof the normal doses of those
medicines. So Prozac forsomebody with anti with
depression or anxiety, might wemight do 20 or 40, but I've had

(27:01):
patients with OCD on 100milligrams of pro sex. So you
sometimes really have to crankthe dose up on the medication.
But I really want those patientsalso to be in therapy and
getting you really need

both, right? That makes sense. And in fact, Brady,
I think we have shared patientswhere I did not know. One of the
common things I see is thatpeople are getting psychotropic
meds from their familypractitioner or internist, and
let's say OCD is happening.
They're getting like, a low doseof Zoloft and saying, Oh, well,
it didn't work for me, right?

(27:41):
And I had no idea until, I thinkI had sent somebody to you,
Brady, that that that was even athing that was done, or why that
was needed, and that that can beeffective. So if this is a
factor for somebody listening,it, my opinion, at least, is
that it really is worth it tosee a psychiatrist,

yeah, and a therapist who knows how to do
CBT with ERP. I don't knowRobin, if you want to speak more
to that, but you, Laura, yousort of alluded to supportive
therapy that's just colludingwith OCD is sometimes more
hurtful than helpful. So yeah,

and it's not easy. It's not easy. It's
not an easy therapy to deliver.
It's not an easy therapy toreceive. It's not, you know, not
everyone responds to it, but youknow, it does have good
effectiveness for a good portionof patients that are especially
motivated, patients, speakingfrom someone who's done it with
children, adolescents, it'sreally important to get family

(28:41):
to be educated and how tosupport at home, because doing
the sessions really won't helpthat much without the carryover
into their day to dayenvironment. And also, too your
sessions have to be veryflexible, because it's not
something that can neatly fitinto, like a 45 minute session.

(29:03):
If you're doing this therapy,you need to have the
flexibility. Some therapysessions might need to be a
couple of hours, because endinga session in the middle of doing
an exposure when that anxietyhas not decreased, could cause
more harm than than benefit. Soit's just, it's it can be very

(29:25):
life changing and effective, butit really needs to be with
somebody who has a lot ofexperience in delivering that,
that type of therapy

you are so right, because there are so many
therapists who have absolutelyno idea about any of this stuff.
There's so many things to focuson and specialize in, that if
this is not something you'vedrilled down on, you know, you
just might not even know whatwould help. So can you guys just
give a little explanation?
Because we're talking about ERPand CBT. And we said the full

(29:58):
names exposure, responseprevention, cognitive behavioral
therapy, but our listenersmostly don't know what those
things are. So can we just givea little like definition of that
kind of therapy?

Sure, absolutely. So the exposure part
of exposure and responseprevention is eliciting the
obsession, or the intrusivethought that's causing distress.
So you elicit that in thesession, and then that creates a
an urge to do the compulsion toneutralize that obsession. And

(30:34):
so the therapy is basicallystopping, you know, the
compulsion, having that anxietyof that obsession, just keep
going and keep going, becauseeventually it has to decrease on
its own. Without the compulsion,you cannot stay in a
physiologically aroused anxiousstate when there is no direct

(30:57):
threat to you for an extendedperiod of time. And some people
could experience that decreasein anxiety in a few minutes, but
some might take hours, buteventually you just literally
cannot physiologically sustainthat. And every time that
anxiety goes down without thecompulsion is like a step in the

(31:19):
right direction,

Unknown (31:21):
learning, yeah, yeah,

exactly.
Rewiring,

rewiring and learning that you don't need the
compulsion in order to reduceyour anxiety, that you can
actually ride the wave of thefeeling, get to the other side
without doing the thing. Andthat's what starts to help your
brain change and know that youdon't need those behaviors

Exactly.
And Robin, I think this is true,but it's usually done in a
gradual way, so that you're notflooding the patient's system.
So it's not like if they have acontamination fear, you're
having them eat food out of thetrash, like it's not that fast,
but you do

eventually have to get to that point. So
you make the hierarchy of whatwould be the least fearful thing
and then what would be the mostfearful thing. But when you're
doing the protocol, you reallyneed to get almost, like, above
and beyond. So like, I've hadkids that had to, like, touch
toilet seats in public bathroomsand touch their face. You know,

(32:26):
contamination, like taking afrench fry and like putting it
on the McDonald's table and theneating it. So, you know, you do
things that even we would not donormally, but you do need to
take it that far to help, like,with with remission, it just
seems to be the most effectivewhen you go to that that extreme
with it. But you would never dothat until you've already had so

(32:48):
much success with so many otherthings, right? So yeah,

I also like act therapy, which is Acceptance and
Commitment, especially with mymy clients that have a lot of,
like, thinking, intrusivethought based OCD, it's really
the tolerance of uncertainty,right, like and and the fact
that we can't know for certainif the relationship they're in
is ever going to work out. Wedon't know for certain if

(33:16):
they'll fall in love with amember of the same sex, and,
like, beginning to tolerateuncertainty and to build the
life worth living anyway, likewe're always, we're always
toggling back between like thelife worth living, because that
builds the willingness to do thework, right? You know? And I

(33:37):
love that model, the ACT model,which is a behavioral based
model as well for helping OCDclients, especially my thinking,
intrusive thinking based ones. Ithink the exposure for
contamination and just right andall that stuff has to be there.
And sometimes exposure for thesethinking things has to happen
too in a structured way. But Inotice how shape shifty it is

(34:00):
that as soon as you know you yousees on one they just come up
with a new theme, yes, andunderlying it all is just like
that. You can never be certainabout life on any level. And can
you tolerate that?

I think the fears this may not always be
true, but a lot of the patientsI see with OCD, the fears that
they have are so fantasticallybad that to accept it would be
intolerable, like throwing yourbaby or running over a person
you know, like it's I think thatspeaks to the intensity of OCD,

(34:41):
and then maybe that's why it gotseparated out of the anxiety
disorders, because it starts tokind of even cross into, like,
magical thinking, or like itgets almost bizarre in the fear,
right? And they know that.
That's why it's not psychotic.
They know it's not real, yeah,but it is really a. Um, with
stressing,

yeah, yeah. And that was what I found
fascinating about that ERPtraining was the hierarchy part
of, you know, Laura. We rememberthat with Laura Myers, yeah,
where she talked about, like,the scale of 100 and starting
with targets that are, say,like, I had a client who's
afraid to drive over bridges. Soyou don't start with, I don't

(35:22):
know, I don't know what's thescariest bridge or anything out
there, but like a really highbridge that has no guard rail
and you're on the edge, youknow, you might go over a bridge
that's low where you can stay inthe center, and even that was
intolerable to this client. Butit is amazing how, just without
OCD. Exposure to things thatscare you is the thing that

(35:46):
builds confidence, that changesit. So it makes sense that this
would work, but also why it's sodifficult. Somebody's really got
to be willing to do the thingand do the thing repeatedly, and
it's very hard to do somethingthat you feel afraid of, it
feels counter intuitive, or tonot do something that brings you

(36:08):
relief. But what seems to bewhat you guys are suggesting,
and what I've seen in my limitedtherapeutic experience with
this, is that this is somethingthat really can change. There's
a lot of hope. There's a lot offreedom from this, right?

Brady Bradshaw, M.D (36:25):
Absolutely.
Oh,

yeah, and the going from living in such
distress to the freedom thatwithin, and it's ironic, right?
Because there there's a lot ofcontrol with OC, you're trying
to control a lot, but when youlet go and you do this
treatment, or you take and youtake medicine, then the relief

(36:47):
on the other end is so lifechanging. And I'm sure you know
all disorders, obviously, whenthere's treatment and there's
relief, there's a big differencein life change. But for some
reason, OCD really sticks out assomething that you really can
just completely change thetrajectory of your life with
that treatment.

Yeah, which is amazing. Another thing
I just wanted to mention that Ibecause I do think it's really
helpful and hopeful. And Robin,you and I have talked about this
before, but, and I think this ispart of a CBT technique, which
is to name the OCD as somethingapart from the person. Yeah, I
feel like that is specificallyhelpful for OCD patients,

(37:29):
because it I don't know that itjust like creates some space,
maybe there's some release ofcontrol there, and I think it
normalizes and maybe reducessome of the shame and guilt that
they feel. So I don't want tothrow my baby my OCD is tricking
my brain and making me thinkthat. But I don't want to do
that. It's not mine. It's myOCD,

yes, and then at the end, you go from the
this perspective change of thatwas controlling me, and now I'm
controlling that. Yes, that'snot separate.

Yeah, you're leading your OCD part. Yeah,
yeah. And, you know, it's likewhat Brady was saying about how
scary some of these things are.
They are really scary. And Ithink it's it speaks to that
when you you have to have areally well trained therapist,
you have to have a lot of trustwith your therapist, and the
therapist has to be like, reallyand very often very creative.

(38:24):
You're coming up with, like,interventions that are very
offbeat, often, like, I waslistening to a guy who had this
fear that he was going to killhimself. But he was like, it
was, it was an ego, dystonicfear. He did not really want to
kill himself. He just thought hewas going to take a knife and
carry to take a knife and killhimself. And literally, the
treatment was he had to sit forlike an hour a day with a knife

(38:46):
to his throat. Like he built upa certain amount of time. But
can you imagine, as a therapist,how much trust you'd have to
have in your therapist to beginto sit with like a knife to your
throat eventually, the upshot ofthis is he eventually got bored.
You know, he was just like,Okay, I guess I don't want to
kill me. I like, he wasn'tafraid of it anymore. But like,
these irreverent treatments,yeah, are scary.

And as a Thera prior therapist who did
this work, we were always inconstant consultation with other
therapists who also do this workto because when you get
creative, you want to bouncethese ideas off other people
and, oh, yeah, no, I've donethat before. Or no, this is this
could go wrong with that. So itis very important, from the
therapist's perspective, toalways have somebody that's also

(39:33):
doing the work to be able towork through some any new
situations that are going tocome your way.

Okay, so I want to ask too about relationship OCD,
right? Is this a real thing?
Like, what is it really? BecauseI had a client come in and say,
like, I am diagnosed withrelationship OCD, and I had to
really, like, look it up and doa deep dive into it. And. I'm
still not sure how clinicallyaccurate this is. So where do

(40:02):
you guys fall along those lines?

I've never, I have not heard of that.
I'm interpreting it as ananxious attachment, maybe like
an attachment. I would probablyuse that lens. It's not a DSM
diagnosis, right?

I have a client who would cop to that, and what
she describes is something whereit's like, she'll get into a
relationship, and very quickly,she's looking for evidence that
she shouldn't be with thisperson and that that she's like,
am I attracted to him? Do Istill like him? Should I break
up with him? Are we compatible?
If we're not compatible in thisand it just keeps proliferating.

That was similar to the guy that I saw, but it
sounds like it's one of thoseinternet diagnoses, you know,
like,

could significant be a significant OCD
in that person, and that's justthe manifestation their
intrusive thoughts are taking.
So almost maybe like another,like a subtype, but not its own
distinct diagnosis.

Yeah, right, I guess I wondered if it was a
real subtype. But maybe anythingcan be. I mean, you could be
preoccupied with anything,

yeah, I would think it would fall, that
would fall under a subtype of,like a checking kind of thing.

Okay, yeah, yeah.
What

about health anxiety? Like, can health
anxiety get quite have an OCDcomponent? Is that under the
same OCD umbrella? I mean, Iknow, like it can be like in its
own category, but I feel likeOCD and health anxiety can dance
quite a bit.

Yeah, I think that would go under the
subtype of, like, a fear ofharm, you know. So they, like,
are really afraid thatsomething's wrong with them, or
that there could be somethingharming them. And so that leads
to the compulsive checking, andlike, either checking your body,
or, like, multiple doctor'sappointments, I've definitely
seen a health anxiety OCD, that

for sure, yeah, or I'll have people who are
constantly looking things upevery day. They're sure they
have something new every day.

And now we have, like, chat GPT to really feel
that, which is like, it's veryconcerning, because you can talk
to chat GPT all day long, and itwill reassure you endlessly,
right?

One, you've seen the stuff about how chat GPT has
also helped people take theirown life. I know this is
terrifying. Yeah, technologycreates new problems.

How do we support people? If you're in a
relationship somebody listeningis in a relationship with
somebody who is suffering withOCD, or you're a parent and you
suspect your child is dealingwith OC cd, symptoms like, how
is the best way to supportbesides like medical
intervention and getting apsychiatrist on board and
treatment just parenting orloving or supporting a person

(42:59):
with OCD, what are some of thebest practices? Well, I mean,

obviously getting the professional support
is number one. And then thatprofessional will be able to
support the caretaker in termsof, you know, giving specific
kind of strategies for thatspecific situation. But, but in
general, keeping a framework ofthis is not who this person is.

(43:28):
This is a disease that thisperson is suffering from and
trying to find the best way tostraddle being supportive
without constantly giving in toyou know, like you said earlier,
going back 25 miles to check thestove, even though you've
already checked it, you know,being able to be comfortable

(43:49):
with, you know, we're not doingthat, you know, I'm thinking
from a parent perspective,obviously, because that's what I
primarily deal with. But I don'tknow, Brady, do you have any
adult kind of examples? Yeah.

I mean, it does take a lot of compassion. I
think if you're if we'rethinking about a partner
example, because sometimes yourpartner might be doing behaviors
that you can see are really theOCD and not your partner, like
you're saying Robin, it feelslike it's different from who
that person is. And so sometimesI think it can be hard to be

(44:24):
patient with that, because itdoes consume hours that maybe
then they're not available tothe partner, to the other
partner, but to be compassionateand know that it's not as simple
as saying, like, you know, wecan't vacuum for two hours
tonight. Like, we're not gonna,you know, like, you can suggest
and encourage and support, butthey may not feel like they can
help themselves, and that's whyyou do have to often have a

(44:48):
medical piece involved, wherethey're getting therapy, they're
getting medication to supportthat, because the partner
telling the person not to do thebehavior that's not really out.
Very effective or compassionate.
You can encourage like, Hey, doyou think do we need to drive
back? Like, maybe this is yourOCD, like, maybe we could just
go, keep going, but they may notbe able to, and so being able to

(45:11):
accept that and that they are ina lot of distress, I think, is
important. I can also just makea comment about the family.
Thing is that okay? Can I? Yeah,I think for a family, if a child
is suffering, or a teen withOCD, for the parents and the
family to be thoughtful aboutinitiating therapy also and

(45:34):
making sure that it is a goodfit before starting ERP, because
I have seen where the parentscan't tolerate the hierarchy of
exposure and will swoop in andpull the child, and that is
really reinforcing the OCD, sotry to be thoughtful at the
beginning, so that you're notcommitting to something that

(45:56):
you're going to have to swoop inand pull out and make sure that
as a parent, you can toleratethe plan before you start

it. When I was treating children and
adolescents, I really maybeolder adolescents, I would do
some sessions individually, butI always included the parent,
because without the buy in fromthe parent and the motivation
from the parent, it's just notgoing to work, and it's just as
important for them to learn thisas it is for the child to learn
it too. So, you know, I wouldsay it's a pretty big red flag

(46:27):
if you have somebody that's justlike, oh, you know, I'm just
going to work with your kid, andthis is what we're going to do,
and I'll see you when we're donewith our session.

That's such good advice. Good point. Yeah, yeah.
So, okay, really like a takeawayhere that we're all saying is
this can be so hard to sufferwith, and there can be so much
shame attached, and when it'shappening to you, it's so
overwhelming, and it probablyfeels like you're the only one
you're not. But really take thestep to get help, because help

(46:59):
is so possible. It's out therefind a good doctor and a good
therapist who have worked withpatients and clients that have
OCD, so you're going to get theright treatment. And it's
amazing how different it can be.
On the other side, there isfreedom from this, so it's
exciting to have something thatactually can change and be

(47:21):
helped when you know some of thestuff we're challenged with is
so seems so fixed and immovable.
So as we wrap up here, can youguys let our listeners know how
they can find

you? Yeah, we're well, we're both in
Orlando, and my website isBaldwin Park, med, M, E, d.com,

and I'm in the Winter Park area, and my
website is the neuro code.com

Wonderful, wonderful. And if you guys are
not in this area or in Florida,you know Google and look for
look in Psychology Today. Youknow, ask around if you have a
therapist. Really, find somebodywho knows what they're doing
with this, because it's its ownthing, and you want somebody who
has additional training for thisspecific thing, absolutely.

(48:16):
Yeah. Thank you so much forbeing here. Really, I learned a
lot, and I know our listenerswill have too. And to all of you
listening, thanks so much fortuning into another episode of
insights from the couch. We hopeyou got some insights from our
couch today, and we'll see younext week. You.

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