Recognizing OCD and Comprehensive Treatment

Margaret: [00:00:00] The Buddhist metaphor of like the thought would be the first arrow that is shot at you. And then all the rest of the pain is coming from the second through 100th arrows, which is in this example, the mom going throughout the rest of her day. And then when she's holding her baby, scanning her body of like, do I wanna throw this baby?

Is that thought gonna come back? Be patient. Welcome back guys, to how to be Patient. The show? No, I'm not gonna make an OCD joke. Preston, how are you doing today? 

Preston: I'm welcome. 

Margaret: You're back. 

Preston: You know 

Margaret: you're here. 

Preston: I'm good. Uh, it's like my first week back, uh, I guess second week back, like really getting into the swing of things.

So we're filming this in, um, January, 2026 and my birthday is in two days, so that's exciting. Your 

Margaret: birthday's in two days. How old will 

you 

Margaret: be? 

Preston: Yeah, I'll be 29. The big two, nine, you know, 

Margaret: diva. 

Preston: Yeah. I mean at this point I'm just celebrating every day. I'm past the 27 club, you know, like, sorry, Jimi Hendrix, but, 

Margaret: oh, 

Preston: I'm [00:01:00] leaving you behind.

Margaret: I never even thought of that. But then after you get to be 30 flirty and thriving. 

Preston: Yeah, it's, it's an in between age, I guess. So, like and flirty. Yeah. What about you? How are you doing? 

Margaret: I'm good. I have really been liking consult, psychiatry, and peds. And it's busy, but it's like so fun. Fun's the wrong word.

It's like so interesting 'cause the complexity of the patience is so high and impedes. One of the like hard things, but also like things that make you think really deeply is that because of good ethics, there's a la paucity PA paucity of evidence for approaches. So like in the adult literature for like catatonia, right?

[music]: Yeah. 

Margaret: There is pretty clear guidance. In peds, we are kind of trying to work from the adult literature, but it's like, is this the same thing as in like an A 7-year-old? I [00:02:00] don't know, like the whole reason you would get catatonia in a 7-year-old is so different and like the developmental component is so interesting.

So anyway, not to nerd out on that, but like I've really liked it and I liked CL and adult and so I kind of forgot that I liked CL and then got to it and I was like, this is fun. And it's fun to talk to the pediatricians and collaborate. That 

Preston: is, yeah, that is really interesting that the uncharted territory of, I guess, child psychiatry in general.

And, and we make so many assumptions about kids just being little adults, I think implicit we don't 

Margaret: do that. We don't make those assumptions. 

Preston: Sorry, Margaret doesn't, I think like there can be, um, I guess like general medical assumptions sometimes when you're applying things like psychiatry, neurology specifically, um, but you, you know, you know, like you're not myelinated in the same way yet and your brains dysfunctioning differently, at least from like a bio biological level.

I'm like, we make these mistakes and Margaret's like, we do not 

Margaret: Well, I'm just, I, that was like a knee jerk reaction. [00:03:00] 'cause in peds they like beat that out of you metaphorically when they're like, like literally, I remember my first lecture at WashU for med school in Peds and it was like. What are kids, not little adults.

I was like, mm-hmm. Like we, my friend who's a pediatrician, we like, make a joke and I'm like, well, you know what they say adults are just big kids. So I'm applying these things. 

Preston: Yeah. Every, everyone's, everyone's a peds patient at the end of the day. 

Margaret: At the end of the day. 

Preston: It makes me think of those, those medieval painters that never learned how to draw a child's proportion.

Do you ever like, look at the 1300? I've not seen this. No. Neighbors. Oh yeah. It'll be like baby Jesus in like, um, Mary's lap, but it's just like a full grown man. 

Margaret: You're like, Hey, '

Preston: cause, because that the monk who drew that has like never seen a child. 

Margaret: I'm, I'm not gonna talk about the, um, um, there's a reason it's painted like that.

But that's all I'll say. Speaking of things happen in childhood, OCD child. 

Preston: Oh. [00:04:00] 

Margaret: So that was my not smooth se segue. Mm-hmm. But this episode is highly requested, uh, multiple seasons in a row for us to do. OCD episode, multiple OCD episodes. Um, and I just have happened to been interested and experienced personally when I was a kid OCD and then worked in an OCD residential here, out here in Boston.

And so today, listeners, we are doing the OCD episode. Preston, how do you feel about OCD? 

Preston: Oh, I, I, I like it just as much as every other disorder. I, I actually, it's 

Margaret: not my fan 

Preston: if, if you're a DH ADHD or anxiety listening. I love all the disorders equally. I don't have favorites. 

Margaret: How do you, what's your experience working with like populations with OCD generalized like.

Clinical sentiment. Is there any like challenges or interesting things that you think about when you think about treating people with OCD from your experience thus 

Preston: far? Um, yeah, so I guess there's a couple [00:05:00] things I've noticed about OCD. Um, and one thing that's been like compelling to me actually is to think about it like along the spectrum of all anxiety disorders, I guess.

So, and, and I kind of explained that to some of my patients that maybe have like some OCD traits without necessarily going into like. OCD disorder. And they're like, well, how can I have all these anxiety traits? But then I, like, I have like the occasional intrusive thought, but like a lot of my behaviors aren't around these intrusive thoughts.

So like, like I put them, organize 'em on a continuum. That's been helpful to me. Um, one thing I've found with OCD patients that gets missed a lot and especially like, um, when I had less experience, is really inquiring about the intrusive thoughts. I think a lot of people, when they picture OCD in the media.

Their mind goes to the compulsions, but the, and the compulsions being, it's like kind of ritualistic behaviors that you see where people are observable washing their hands a ton, or they're like, I have to, you know, count something seven times, or I have to like straighten all these things. Like that's what they [00:06:00] picture, but that's driven by this like obsession or intrusive thought, which can be hard to ask about.

And that's been kind of challenging for me to ask about. I usually general, generally just ask about unwanted thoughts that they experience and then just kind of try to follow the conversation there. So I guess those are kinda the general sentiments I have about it. 

Margaret: Mm-hmm. 

Preston: I think it's been interesting diagnosing it, treating it has been very difficult and I, I honestly have been treating it somewhat with pharmacology and haven't had a chance or really try to treat it from the perspective of a psychotherapist.

And I think I'd be a little intimidated by that challenge, but, but I think it'd be good for me. What 

Margaret: do you think has made it challenging about like treating, like so far, what's been, I guess, challenging to treat or like, has made it hard for you as a person acting more in the prescribing role? Um,

Preston: I guess because, so. People don't respond to [00:07:00] medicines, um, as easily as they would to something like anxiety. So you end up having to crank up to higher doses, which also exposes people to more side effects. Mm-hmm. So, for example, like peroxetine can be pretty effective for OCD, uh, has a, a pretty tight binding, uh, profile for the, the cert receptor, which is possibly.

Why it's, uh, more effective for anxiety disorders, but also tine is pretty, anticholinergic can be pretty sedating. So people may feel like, yeah, like by the time we cranked up the dose to like, here, it made my symptoms a little bit better, but now I'm having all these side effects. Darn. You know, it's like, it feels a lot more like threading a needle, uh, where you have less leeway than with some of the other, um, disorders I can prescribe for.

Margaret: Yeah, no, I think that's a good point. It's something that we'll get to in treatment, which is that. Generally speaking, people with OCD need the higher end of the [00:08:00] range for these medications. Um, and for something like tine that can especially be a problem for some of the other more kind of classically prescribed.

Although Perine is FDA approved for OCD, um, there's less of this issue of. There's always gonna be the issue of the side effect burden as you go up, but there's less of it than compared to peroxetine, like against all other SSRIs. And then the other issue with it that we'll get to is thinking about prescribing and understanding people's responses and understanding the OCD response to being on the lookout for side effects, whereas maybe someone without OCD might experience like very mild, like upset stomach or nausea 10 minutes after they take the medicine.

Then kind of just like stop noticing it and not fixate on it. Like there's a question in the prescribing of how OCD might actually impinge or make side effects more noticeable or bothersome. Mm-hmm. And then prevent you from ever getting to these higher doses that actually [00:09:00] are the things that help more often for ocd, which I think is just like an interesting, like this, like the psychodynamic of.

Prescribing is like how the illness interacts with it. 

Preston: Yeah. Psychodynamics, psychopharmacology, I think is like the fancy term for that. We had a lecture on it the other day, but we didn't talk about OCD, which is really interesting. Yeah, it's It's like, it's like an extra layer. The disorder itself complicates the response to the treatment.

Margaret: Yeah. Which some might say is every psychiatric illness, but I think with OCD it can be particularly interesting. So as our listeners know, this is not up to date. The podcast and so I'm actually not gonna go through like the D diagnosis. That's not update up 

Preston: to date the podcast. 

Margaret: I, yeah, I mean, does UpToDate have a podcast?

Probably. I dunno. We have many colleagues in this space. Who, if you want, I listen in Preston's episodes that are more epidemiologically based, that are much, you know, I will include in the show notes the a PA [00:10:00] guidelines in terms of the current standard of care for OCD treatment as well as the child ACAP guidelines.

Um, and so if you want a comprehensive document talking about epidemiology, I can also, if you DM me for book chapters, I can give you book chapters. But all of that is to say I wanna make this very clinical and I wanna make this very concrete and kind of generate ideas for people who are treating or listening to this and like primary care doctors with OCD or with patients with OCD, et cetera.

So the first thing I wanna say is, outside of anything else, let's start with how do we evaluate for OCD? Um, and we are gonna get to that right after our first break. Be right back, 

Preston: be right back.

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Margaret: So in 2026, my goal is to open a very small private practice as a post-grad psychiatrist.

And one of the tools that has helping me do it is Simple practice. Preston, have you heard of Simple Practice? 

Preston: Yeah, I have heard of Simple Practice. Actually. I use it as a patient, well I guess my therapist [00:12:00] technically uses Simple Practice 

Margaret: and is it in fact simple? 

Preston: It is very simple. It's, it's convenient.

Um. I would recommend. 

Margaret: Yeah, well, from from the therapist side, simple Practice is an all-in-one EHR that is HIPAA compliant, high trust certified, and it is built specifically for therapists. So it brings scheduling, billing, insurance, and client communication. Into one place so that you are not juggling multiple systems just to run your practice.

Or if you're Preston's therapist to see him, 

Preston: I, I mean, I'm enough to handle as is. She doesn't need to worry about other complicated things. 

Margaret: And if you're just starting out or growing your practice, there's also credentialing service that takes the headache out of insurance enrollment, which honestly can be a huge lift and something that I was a little scared of.

Preston: So if you're ready to start the business side of your practice, now is the perfect time to try simple practice, do it with us. Well, I guess me in the future. And Margaret now. So start with a seven day free trial, then get 50% off your first three months. Just go to simple practice.com to clean the offer.

That's simple practice.com.[00:13:00] 

Margaret: Okay, so someone walks into your office, they've been. They have been referred from their primary care doctor. They're like, they've been kind of anxious, kind of depressed. They didn't respond to 125 of sertraline and started getting really bad nausea whenever they would take it. So they're sending it to you, psychiatry, uh, to figure out what's going on.

You do an evaluation and what are things that you think about when someone's coming in for primarily pretty high anxiety? There's always like a little like maybe depression sprinkled in in these referrals, so 

Preston: mm-hmm. 

Margaret: What is the differential you're kind of thinking through? 

Preston: Yeah, it's like I'm high-end anxious, and then when you kind of ask them about anhedonia, they're like, yeah, I don't wanna do anything because I just feel nothing about anxiety all the time.

Like that, that type of like archetype. Okay. Um, so I try to think about the, obviously the medical stuff first. So I'm, I, if I don't have any of. [00:14:00] Those labs, like they're just coming in cold. I'm like, okay, does this person's thyroid out of control? And they're experiencing anxiety from that, like, like the obvious, like, can't misses, like, come on man.

Like, you know, a little bit of like, propanolol would've fixed this. Um, or, or however you would attempt the thyroid workup. Um, and then, um, substances. So if this person's like withdrawing from substances or they have like some sort of chronic substance use and then. Outside of those things, when we started getting into the anxiety disorders, I started to wondering about a couple different things.

So first be, um, obviously generalized anxiety disorder, social anxiety disorder, and, and then like different ineffective like coping strategies that can manifest into personality disorders, trauma related disorders. So PTSD or complex PTSD can manifest as a lot of like anxiety disorders on the front end.

And then I still actually, um. Think about severe mental illness too. [00:15:00] I've been burned by this a couple times where I've had patients that are experiencing hypomanic episodes or manic episodes. Yep. And the only language they had to describe their manic symptoms was that they're anxious. 

[music]: Yep. 

Preston: Like, like I've had a patient who's said, you know, like, oh, I'm so anxious and, and the anxiety just makes you wanna accomplish all these things.

And the anxiety makes me wanna stay up, and the anxiety makes me wanna do that. I'm like, you're describing the symptoms of a manic episode and you're just calling like. Do you feel fear? And he is like, no, I feel great. I just, I just feel anxious, like I gotta do stuff. Yeah. And I'm like, that's, we're using different language here.

I understand now. So like you can't, especially in these like initial evaluations, you can't always like take the language at, at a face value, I guess. And then obviously, um, OCD falls under that spectrum of anxiety disorders. Mm-hmm. 

Margaret: Yeah. No, I totally agree with you. I think that was a really good differential of all the things that, you know, we are.

Looking for anytime we do a comprehensive eval with [00:16:00] psych as psychiatrist, but especially when it come, this presentation, which is maybe one of the most common presentations that we get, um, the things we're thinking about and how anxiety, similar to some of the things we've talked about from like a neuropsychologically functioning perspective or kind of a neuro circuitry perspective.

Anxiety, or what looks and sounds like anxiety is not like. One set of like serotonergic receptors going on and off in some tiny part of your brain, like anxiety can be manifested from a lot of different sort of quote unquote malfunctions or errors. And so getting clinical and kind of descriptive, which is what we have for diagnosis and treatment right now in psychiatry via the DSM, as well as thinking of like how does this show up in different ways and what kind of words do people use similar to like.

If you do the like MDQ, which is like the screen or the like symptom checklist for bipolar disorder, take any of your super anxious patients through that and they're gonna [00:17:00] start screening a little bit for bipolar and it becomes a more complicated question. Um, so yeah, I think that's a great differential.

I think the other thing I think about, which I didn't ask you is the differential and then the one, the comorbidities or the friends that flock together with anxiety and OCD. So the comorbid, the complicating comorbidity. That won't be ruled out on differential, but there is something that in ped psych we can sometimes call our version of the unhappy triad, which is OCD ticks or Tourettes and A DHD.

Oh. So thinking about comorbidities as well as your differential because it's not all ackman's razor. 

Preston: Sure. You, it was funny was when you were describing that triad, I was about to say OCD and eating disorders. That's where that's where my mind went. Yeah. 

Margaret: Or like less common but common in anorexia. Yeah.

Um, and I'm trying to think of a couple other things. So yeah, I just think comorbidity, 'cause that can be [00:18:00] a huge one. 'cause there are people, like you can be bipolar with comorbid OCD. Um, so there's our umbrella of like, what's the one thing this could be? And we kind of try and parse that out first. And then we reopen the umbrella and say, and also is anything complicating the picture of what we expect.

So you walk in, you, let's, let's presume they have an excellent PP as all PCPs are, and I say that as the child of a pcp. Uh, they've done the like general like workup for anxiety. Like their thyroid's normal, their regular labs we look at are normal. They've been seeing the sun, they vitamin D, da da da, da.

They're eating enough regularly and without difficulties or body image concerns. So we're not worried about eating disorder right now. Um, what. One of the things that we would go into next, or that I try to go into, because I think one of the biggest components of OCD over the term of the treatment diagnosis, evaluation treatment is going to be the psychoeducation component of like people often, so the onset of OCD is early, right?

It's [00:19:00] childhood is when a lot of anxiety disorders come on. So it can be. Teenage years, but it can also be like at 6, 7, 8. 

Preston: Is there, I guess immi, um, maybe I should know this, but you know how A DHD has like a young, like an age floor that you could diagnose below. Does that apply to OCD as well? 

Margaret: I don't think so.

Like I think I've seen kids that are diagnosed at like four. 

Preston: Wow. Yeah. 

Margaret: I mean, and technically a DHD you can diagnose at like age three or two, so. Maybe, but like, that's like kind of the unknown in child psych where it's like, can a 4-year-old have bipolar? Um, that, and like some people argue heavily. Yes.

Some people argue heavily. No. So, but yes, but childhood onset. Okay, so 

Preston: more of a gray area question. Gotcha. 

Margaret: Yeah. Um, and so the reason that I bring up the childhood onset besides for clinical pictures is someone has lived with OCD for their whole life, and OCD is relatively pretty genetic. Um, they might have been raised by someone with high anxiety and OC or OCD.

This like alarm bell has been ringing [00:20:00] their entire life and therefore they don't hear it in the same way. 

Preston: Like anymore, like an I see a nurse with alarm fatigue. 

Margaret: Yes. 

Preston: Yeah. So I picture it 

Margaret: and it's like, you hear how I can't hear you? Whatcha talking about? Whatcha talking about? You hear that? No. Yeah. Yeah.

So like in terms of thinking about from like the child perspective, it's like a kid comes up. Let's say a, a parent and their child both have like pretty severe anxiety. One has GAD and the kid has OCD. Mm-hmm. The kid starts to experience OCD when they're like 8, 7, 8, let's say. Um, and then when they talk to this parent about it, the parent is also struggles with uncertainty in terms of anxiety functioning.

And the way that they cope with that is they respond by trying to force certainty and have a lot of like plans or something. And so then the kid is taught that this. Is the way you deal with it, which may or may not be a coping mechanism that makes their OCD better or in this case worse. Um, so I just say [00:21:00] that to say that like throughout the course of working with people with OCD, um, both in outpatient, in my like specialized clinic the last couple years in kids and adults in PA postpartum and in the residential setting, one of the biggest things that is the continual work is helping them figure out what's them and what's OCD.

Does that make sense? 

Preston: Yeah. Because OCD has essentially been carving their identity and a lot of these maybe traits they probably think of as their personality has been them just learning how to cope with this unwarranted distress. Well, 

Margaret: and it's like, listen to your intuition or listen, like what does your gut say?

And it's like their gut says something is wrong all the time. So like. How do you know what you believe in or feel if that alarm bell is just always on? Right? It's really hard to hear a whisper when the alarm bell is screaming. 

Preston: What?[00:22:00] 

That was me. That was me trying to hear over the alarm bell. 

Margaret: So in terms of like evaluation of OCD symptoms in particular, how do you ask about, so you mentioned intrusive thoughts. Maybe we should do this as a role play. 

Preston: I usually just start with, do you have a history of OCD? 

Margaret: Uh, let's do a role play. Okay.

Okay. Let's start now. You be the doctor. I'll be the person with OCD and listeners. I was di, I was diagnosed with GAD and childhood, but I'm pretty sure it was OCD. So I am going to answer, not from my own life experience, but from the felt sense of my life experience with 

Preston: Okay. 

Margaret: Really started those you when I was younger.

Preston: Okay, 

Margaret: gotcha. 

Preston: Hey, 

Margaret: doc, 

Preston: well, um, yeah. Welcome to the clinic. Have a have a seat wherever you'd like. Pick whatever chair you want. 

Margaret: Okay. 

Preston: Just three chairs. You can pick whichever one. Okay. So what brings you into psychiatry today? 

Margaret: I'm just worried all the time and like I'm getting like, so [00:23:00] tired from worrying all the time.

Preston: Hmm. So you can't remember a time when you haven't been worried? 

Margaret: I mean like there are times I'm like having a good time like at school or with my friends, but like, it just feels like, it's like the background noise of my life. Mm. 

Preston: Okay. I see. Can, and this may be about everything, but can you help me understand what this worry is directed towards?

Margaret: What isn't it directed? I mean, I feel like the biggest thing is like. My, like sister got in a car accident last, like a year ago, and I, for six months, like couldn't think about anything besides like, her getting in the car accident and if something had happened. And so like, whenever I worried about her, I felt like if I didn't text her then like something was gonna happen and she would get annoyed with me.

But she also like, knows that's me, so it's fine. But like, like it was like, I couldn't, not, like I thought she was, I felt like she was gonna die if I didn't do it. 

Preston: So, [00:24:00] so during this time it was all directed on the thought of your sister dying? 

Margaret: Yeah, but it's also been like, like my, I like will take a test and I like, I'm so like fixated on it that like I'll like have been doing well in the class and understood it and feel like I did well in the test.

But after I leave it, I just am like running over the test over and over and I like have to check my test like two full times in addition to checking it while I go. Because I just feel like I'm like missing something and I'm gonna like fail and I like feel so panicky. 

Preston: Mm-hmm. I see. 

Margaret: And it's like not, it's like the whole, like four days after, it's not even when I'm taking the test.

Preston: Gotcha. So these, these panicky thoughts, they stick with you and, and they, they drive you to do things to make you feel better. Would that be a way to describe it? 

Margaret: Yeah, but sometimes it's like they, I don't like do something that like other people can see. Like sometimes it'll be like, oh, I feel like I hurt someone's feelings.

[00:25:00] Like I need to like think of 10 ways. Like, or if someone like makes me mad, I'll be like, I shouldn't have felt mad at them. That's bad. I need to think of like 10 things I like about them. So like. It's not always something people can see, but it's like things like that too that kind of just happen, like in my mind, like I don't know if that sounds 

Preston: crazy.

And so, yeah, that, that makes sense. So sometimes it's an action, but sometimes it's another thought to counteract that initial thought. That initial negative thought. Yeah. 

Margaret: Yeah. 

Preston: Do you feel like these thoughts, like are they helpful to you or, or is it frustrating to have to go through these. 

Margaret: I feel like it depends.

Like I don't, I don't know when I'm like thinking and it's me and it's like something's wrong and I need to figure it out and it's like my brain's helping me and versus like my like friend didn't text me back for a couple hours or something and it's like my brain's like, oh, here's all the ways things that could mean about how she like hates you or feels this way or this happened to her.

So it's like, it's hard for me to say 'cause it feels like reality [00:26:00] is like mixed in with it. And then it's like. I mean, I feel like in some ways it helps me 'cause it's like I don't miss details on things like school or like at work and my like job on the weekends. Mm-hmm. 

Preston: I see. If you get to a point where you're able to calm your mind, if, if ever do you find that an anxious thought immediately replaces it or there are new worries just gonna pop in no matter what.

Margaret: Yeah, 

Preston: I see. Sometimes when people are experiencing the emotions around worry, they, they can feel it in their body. Has that ever happened to you? 

Margaret: I feel like I'm like never breathing. 

Preston: Mm. 

Margaret: Deeply. Like I feel like I only ever breathe. So like right here and then someone will be like, like, I'll be like at a yoga class and I'll be like, oh, breathe into your belly.

And it's like, oh, this, like, I've been breathing like almost. Every day, day. And [00:27:00] then sometimes I get headaches kind of like in between my eyebrows when I'm like really stressed. And then like when I go through like, like when I go through a breakup, I like can't eat for like four days after it. 

Preston: I see this, this takes a big toll on you.

Margaret: Yeah. 

Preston: So I guess how I would picture it is you kind of have this almost like baseline level of worry that's that's constant. Like this alarm bell. Does it ever? Reach this peak where it gets to the point where all you can do is just handle the, the anxiety or the worry, almost like an attack. 

Margaret: Mm-hmm. I don't feel like it gets there, but I feel like there are some days where it feels like all I did that day was worry.

[music]: Mm-hmm. 

Margaret: It doesn't feel like I get to the point where I'm like, hyperventilating or like need to like sit down or pass out or anything, or like feel like I'm gonna cry. It's more just like this. There are some days where it feels like I'm just worrying about the [00:28:00] same thing for hours. Even if I'm doing things, I'm like not really there mentally.

Preston: Mm-hmm. I see. And I know these, this worry can be related to the death of others, how people might feel about you, how you may be doing on your test. So it seems like there's no specific theme to these things, it's just these unwanted thoughts. Okay. 

Margaret: Good job. That was really good. Oh, thank 

Preston: you. 

Margaret: How did you feel about it?

Preston: Yeah, I felt, I felt pretty good. I was, I was trying to just like follow the thought as best as I could. And so one thing that I was, I was trying hard to do is like, respond with reflections and then it was kinda giving you the, the, the chance to either say no or yes and kind of clear away the rubble as to what's going on in your mind.

So like. At the beginning when you said like, I feel like I'm always worrying. I tried. This is a, something I've been trying to do more actually in clinic is I'll like, just flip it to [00:29:00] the opposite. Like, you can't remember a time when you haven't been worrying. 

[music]: Mm-hmm. 

Preston: And then that, even if I'm totally wrong with that statement, it's uh, which I, which I probably am, it still gives both of us more information as to like where you are.

Margaret: Yeah. No, I thought it was really good. 

Preston: Oh, thank you. I, I find it like, it's, it's like hard to ask these questions about like saying like, do you have obsessions? Do you have compulsions? Yeah, I know, like, it, it's really like, it's a challenging interview in itself. 

Margaret: Yeah. And it's like also like one of the things is like, do you have secrets?

You're really afraid someone's gonna find out, but probably aren't that big of a deal. Like how are actually I have asked it that way. Like once I knew someone in therapy and I was like, here's how I'm gonna say, and you don't have to tell me what the secret is, but do you sometimes feel like you have a secret that if people find out.

For some reason the world's gonna blow up, even though logically you don't think that's actually true. Mm-hmm. And the reason I ask it that way, and why I paused you at the point you were at was because it was leading beautifully into what I do send to people or their parents. Or go through [00:30:00] with them in the second evaluation session, which is less for clinical necessarily diagnosis and is more for helping me understand the lay of the land of their OCD, which is the Yale Brown Obsession Compulsion Scale syndrome symptoms checklist scale thing.

Preston: The Y Box. The Y 

Margaret: box. Yeah, 

Preston: the Y box. 

Margaret: Which I feel like can be super helpful for people just to understand like. Here's every like to broaden, like everyone knows like, oh, OCD isn't just like needing to have your bathroom be clean or something like, but I think to actually give them like, here are the things that, they're so common that they're in these hundred things are so common in OCD that they have their own subcategory.

Um, and so we are going to take a very quick break and then I want us to talk through some of the stuff on Y Box because I think it can be really helpful. To have some examples for people of all these different areas of what OCD can look like, including pure O or obsessional, [00:31:00] um, or more like ruminative, OCD subject, 

Preston: pure o.

I'm sorry, I've never heard that before. 

Margaret: Don't, we'll be right back after this break. 

Preston: Okay.

Margaret: So we're gonna talk the Y box. So one of the things Preston was really good about asking was, or that you sort of asked, and I kind of directed you in my answer as well. It was, uh, 

Preston: I'll take it, I'll take the credit. 

Margaret: Asking, you were asking about panic attacks, which is good to ask people with OCD 'cause they can definitely get them.

And the way I responded was purposely to help us talk about the Y box, which is hours per day on obsessions or compulsions that people spend. Hmm. And so that's like one of the metrics that we're treating towards in OCD is not. Almost in any form of the treatment, which we'll talk about in a little bit, it is not aiming at getting OCD to be zero and cured.

Right? It's similar to other anxiety disorders, but I think especially with OCD is helping people figure out the places it shows up, and then helping them have a set [00:32:00] of skills or ways of real responding to their OCD voice or brain that sets them up to. More efficiently play whack-a-mole so they can like be chilling the rest of the time.

Because the, as you were asking about the OCD will move to different topics over a lifespan. Some people will have more, like one more than one or stick with one for a long, long time. Um, I think one of the underappreciated parts about OCD as well is like, you know, when we talk about, we'll talk about like medical PTSD.

Preston: Mm-hmm. 

Margaret: So like something happens in a hospital or illness and that. Thing gives them like trauma or flashbacks or like kind of hyper arousal. I think, I wonder if one of the parts of OCD beyond the like kind of hyper aroused nervous system in general and like attention to anxiety related stimuli is like kids with OCD, the way they're responded to and the frustration that people can [00:33:00] have with them, or the fear people can have with not understanding what OCD is, can kind of be like a secondary.

Tructure that can make it so that interacting with their OCD in a better way is even harder. Like they can get parents who are like freaking out every time they're freaking out. Or doctors who are like, why doesn't my meds work on you? Or like misdiagnosing them as like something else. And so I just think there's a lot, we think we understand OCD, but I think there's so much to it that people don't understand.

That creates a kind of shame beyond just the OCD itself. So. What all of that is to say. When we're treating OCD, we're looking at many, many areas. There's an initial screen about time spent performing compulsions. Um, how much does like, obsessive, obsessive thoughts get in the way of your day-to-day life and function distress resistance, or trying to.

How much time do you spend trying to like, not think about the pink elephant [00:34:00] to use that one example everyone uses. Um, and then compulsive behaviors, how much they get in way with your life, and then your sense of your degree of control or ability to respond to your compulsive behaviors. So that is the kind of, um, scale screener.

And then the thing I wanted to talk about was the symptom checklist. So. Preston, are you looking at it right 

Preston: now? This is, this is interesting. So I got this pulled up right here. 

Margaret: Yeah. 

Preston: Like, I think you're right, how specific they are. 

Margaret: Mm-hmm. 

Preston: So like, even, even looking at here, um, miscellaneous, uh, obsessions, like an obsession with, um, superstitious fears or, or like a random color having a specific significance.

Margaret: Mm-hmm. 

Preston: And then yeah, obviously like ritualized handwashing, which I think is like the, the classic one in the media. 

Margaret: Mm-hmm. 

Preston: But then, but then there's like excessive con concern with [00:35:00] environmental contaminants, like asbestos and radiation. Mm-hmm. Like, it's that, like asbestos. Is that common that, that it gets a shout out on the white box and I imagine, I imagine it probably shifts culturally.

I'm sure for a generation, and that's probably still lingering as asbestos has been a lead character in their obsessions. 

Margaret: Yeah. I think like one of the things about this, if you look at them is like there are, there is a cultural component, not just to the specificity or the time of like these ones that we're talking about, but the way that, if you think about what we're gonna talk about, which is like the exposure and response prevention treatment, then.

The treatment is often being like, it's okay if this, you know, urge or thought or intrusive thought or whatever is present and we just like live with it and it's okay. If you look at some of these. Most of these are like threatening to your social belonging and thus they cause shame, at least in the way we've thought about things for the last couple hundred years.

So there's [00:36:00] aggressive obsessions, right? So it's very unsettling for people with OCD to have a thought. Like one of the common ones, super common ones in postpartum anxiety is like, I'm tired and I was holding my baby and they were crying and I'm so tired that I thought about, like, the thought in my mind came of like, I could just drop my baby.

And PE everyone basically, many, many people have that thought and they never do anything about it. But people with OCD have that thought of aggression, and it's so disturbing to them and says to them, they fear so much about who they are as like a mother or a parent, that it gets stuck and then it becomes bigger because they're like, oh my gosh, did I really think that was, I really, did I wanna throw my baby?

Am I a bad mother? Am I gonna abuse my child? Like that is how the OCD goes. But then you look at the others and it's like. Like sexual obsessions. Um, cleanliness is a place of shame for a lot of people. And so it's interesting how the culture interacts with the, what the OCD sticks onto. 

Preston: So it's like [00:37:00] the, the thought pops into their head.

Mm-hmm. And it's an undesirable thought, you should drop your baby. Or I could just drop my baby right now and then 

[music]: mm-hmm. 

Preston: That person immediately almost says like, if my mind created it, my brain. Brought forward this thought then therefore it must be a part of me somehow. Somehow my character is producing this.

Okay, I see. And not everyone has, like, some people occasionally have those thoughts every now and then, maybe easier for 'em to push away. But if that thought's coming multiple times a minute for your entire life, that would be exhausting guess to say the least. 

Margaret: It's like not even the thought that's coming, it's the like response to the thought or what we talk about in like act is the Buddhist metaphor of like the thought would be the first arrow that is shot at you, and then all the rest of the pain is coming from the second through 100th arrows, which is in this example.

The mom going throughout the rest of her day. And then when she's holding her [00:38:00] baby, scanning her body of like, do I wanna throw this baby? Is that thought gonna come back? I'm such a bad, bad, blah, blah, blah, blah, blah, blah, blah. And that's one example. But like, I mean my, my OCD of choice, especially when I was younger, was scrupulosity religious obsessions.

What's up? Um, and you know, that one was a fun existential one, so it can really be in any life area. Um, but I think that some of these ones that are so common are so common because they're things that were kind of like hush hush or they're very inner experiences, and so there's less opportunity for them to be like normalized.

Preston: I see. Yeah. And, and you would never wanna share with someone that maybe had a sexual thought about a child or something. 

Margaret: Right. Exactly. 

Preston: To, to the point where it's, and that's so common that it's even like listed specifically on the. Why 

Margaret: box? Yeah. Many people with OCD have some sort of fear of being like [00:39:00] sexually wrong in some way.

Basically, 

Preston: you know, when, I don't know how this qualifies. Maybe I'm oversharing here. When I was at the academy, um, I would have these intrusive thoughts about being disrespectful to like the authority in the military. So it like made me nervous and I like wouldn't want to interact with the brass, I guess.

[music]: Mm-hmm. 

Preston: So like for example, they'd be like, oh, this three star General's coming to sit at your cadet table at lunch. And like, I would just continuously have this thought that like, you should flip them off right now. Like, imagine how, how socially terrible that would be for you to just like, degrade this person or like show extremities to the, or like prof rip off profanities or something.

So it was, it was always interesting. Like I liked to do academic stuff, but I, I never wanted to venture into like the cadet leadership roles where I'd be hanging around generals or colonels a lot because I would always have these, like, this thought would pop in my head that like, you should, you should do something That would be like the quote [00:40:00] of a social suicide right now to this person.

Margaret: Yeah, no, but like, right. And there was a, and a level of it that even if you had a history of like not doing those things. The feeling of it being so strong or like being like, this could happen and what if I can't control it? I think that also gets to like, I'm looking at the bottom ones that say miscellaneous obsessions and one of those fear of saying things, certain things, fear of not saying just the right thing, fear of losing things, intrusive thoughts.

And this brings us into our triad. Think about someone with A DHD coming into your office who has a diagnosis of a DH, ADHD since childhood. 

[music]: Mm-hmm. 

Margaret: And they say those things. What do you do with that? 

Preston: Yeah, I, I guess honestly, without seeing that specifically on the Y box now, I probably would've attributed it similarly to just fears that have been learned from their A DHD.

Margaret: Yeah, yeah. And like, you know, is it OCD? Like, depending on the, how common it is, who knows. I think [00:41:00] also if we, if we zoom out to kind of a neuro circuitry approach, like anxiety is also an attentional difficulty. Like anxiety is a different part of the brain and a different kind of prefrontal, disinhibition, disconnection, whatever.

It's actually, well, I guess it's increasing the inhibition, but you know what I mean. It's like your attention and the ability to modulate your response to stimuli, both internally and externally is kind of funky. Like the response is like not what we would call neurotypical and. Whether there's like, you know, environment or Yeah.

Still holding your attention captive. Yeah. So, which I think is interesting in terms of that, it's like something similar sort of with like ticks or Tourettes, um. A couple other just ones for Met worth mentioning is that there is like a hoarding slash collecting compulsion part of this. So thinking about that when you're seeing people with OCD of like [00:42:00] asking about their home environment, um, not that they, everyone with OCD has that, some, obviously people with OCD have very clean environments, but just knowing, like when we think about function with OCD, asking about like self-care, hygiene in home.

Asking about school work and then asking about like how does it show up in like relationships or interpersonally, because I think this can also be easy. There's cases that I think can be easy to mi mix up with like social anxiety components that might be more of like an OCD an. Um, anything else you notice on here I want, or sorry, wanna say?

Preston: Yeah. Yeah. One, I guess one interesting thing I noticed, like look at the hoarding and saving obsessions. So it says right here, distinguished from hobbies and concern with objects of monetary or sentimental value. And as you mentioned, like maybe some of the OCD has a very clean home, but they can also have like cluttered homes for different reasons.

Um, and so. One thing I, I was talking about with an attending was about how like [00:43:00] differentiating between OCD and hoarding, um, in patients. And one thing that's like fascinating and I guess where you go is you ask the patient how they feel about the item that's in their house. So most hoarders or patients with hoarding disorder.

Will kind of feel like they like everything and they kind of wanna hold onto it because like, what if I might need it later? And like, you know, I don't, I don't wanna get rid of this just yet, but the patient with OCD may say like, I hate this clutter. I want to get rid of it, but because I'm so worried about throwing a bill out that I didn't pay, I have to recheck and check my mail seven or eight times.

In each envelope before I can throw it out. And that's so exhausting to me that I let the mail pile up. But now it's like mail has covered my, completely covered my entire like living room and my couches and stuff, and I hate it there and I wanna get rid of it, but I can't because I have to go through these steps and it's just feels like torture, 

Margaret: right?

Preston: So you walk into the house, it looks the same at first, but then 

Margaret: mm-hmm. [00:44:00] 

Preston: Then you just immediately just go to like how they feel about the objects. I just found that fascinating. 

Margaret: Yeah. It's like as a coping mechanism, you can end up with like such. A similar picture on the outside, but how you get there is so different.

Like, I mean similar, like if you think about like substance use or eating disorders, it's like every story behind how that became the way of dealing with something, um, is different. But so you know, why box, I don't necessarily recommend people go and look at it and try and self diagnose, but it is something that I think can be really helpful if you're like a primary care doctor.

Listening to this and thinking about like your patients that are on that damn wait list for psychiatrists, um, that can be a helpful thing just to explore. And then I wanted to talk a little bit about treatments, um, from the medication standpoint. So Preston, you mentioned Paxil off the top of your head, what are the other things that you think are FDA approved for OCD in?

Preston: Okay, 

Margaret: [00:45:00] adults. 

Preston: It's funny, like I, I, I love and hate these questions because I'm like, oh, yay. Chance to show off my knowledge. But then like, there's this like, part of me that aggresses to like getting pimped. So like I can go, 

Margaret: I feel like I 

Preston: thought No, no, I like it. No, I wanna go. I'm just, I'm just, I'm just sharing.

Um, so I would say, uh, Serline, fluoxetine and Clomipramine, I think mm-hmm. Are coming to mind. That's being a tca. 

Margaret: Mm-hmm. 

Preston: I don't, I'm not sure if there's any other SSRIs off the top of my head that are approved, and I'm not sure if any of the SNRIs are approved. 

Margaret: Yeah, so we have Luvox. So Fluvoxamine. 

Preston: Hmm.

Margaret: And then Citalopram and e. Citalopram. 

Preston: Oh, 

Margaret: Lexapro. And then for peds, basically it's all of those are approved. And then Paxil is one that's only for adults, I will say on the pediatric side. Some of them [00:46:00] are like age at 10 plus like clmi. I think CLMI is later on. Some of them are age like six plus. So it kind of depends um, for that.

But that's just the ones that are FDA approved. So I would say being FDA approved in psychiatry for an indication is not everything, but it's also not nothing. So I feel like sometimes people will kind of go rogue on like medication too. And I. Don't know that that's indicated unless you have like a really good reason.

Do you know what I mean? Like I feel like sometimes we'll be like, oh, well search Lane didn't work, so I'm gonna like do CAPTA or something. 

Preston: No. Whatever I feel like doing. Yeah. 

Margaret: Yeah. It's like, okay, maybe let's try another FDA approved agent while they're here waiting for us. 

Preston: Yeah. What would, I mean, everyone's partial to their own like agents within the realm of, of like an FDA approval treatment.

What do you, which ones do you like the most? 

Margaret: I think it depends if I'm treating like reproductive age or like prenatal, pregnant or [00:47:00] postpartum and they're breastfeeding, I tend to go with sertraline just because it's one of the best studied ones. Mm-hmm. Um, if it's someone who is very, very scared of weight gain, then I'm avoiding Paxil or has any cardiac conditions.

I'm also avoiding Paxil. Um, if they are someone who forgets to take their medicine and has comorbid A DHD, I'm thinking Prozac, uh, and if they're someone who. Has any heart condition again as well. I would think away from citalopram in terms of QTC prolongation. Clomipramine, I will use, and I feel like most of my attendings, like at the OCD Institute, they'll like, they'll go to Clarine probably faster than people who aren't being thoughtful and kind of going like they think more people should use Clomipramine.

I still, it would probably be my like third line choice, but I would try like an S like some with like a little bit different specificity within like the SSRI. NI cla. Wait. Yeah. But so I feel like for me, it's like, let's say it's a person who's not [00:48:00] pregnant, there's no contraindications. Usually I start with Lexapro, with fluoxetine or sertraline.

If those don't work, then I go to Louw Box. If that doesn't work, then I go Topamine. If that doesn't work, I circle the horses and I question if this is OCD and I'm not missing bipolar. And then I continue from there and I get, you know, think about adjuncts, think about other things you can think about.

Interventional, like TMS, um, was something that was common for the level of OCD we were at. Um, but I think when you think about something like Lexapro, you need to go to high doses on these and you can't really on citalopram and ecetra. Of the QTC issue. And then you don't wanna have the conversation with an OCD patient of, like, this might cause your heart to have a really dangerous rhythm.

Like it's, you can't avoid it because Lexapro like the top dose is 20. Some people push to 25 or 30, but it's just, I, I tend to stay away from it unless you have someone who's like complex like liver or kidney person who needs minimal interactions. 

Preston: Mm-hmm. [00:49:00] Whereas Erline, you can crank 'em up to 200 Fluoxetine, you come up to 80.

What's the max dose of, uh, Luvox you've had a patient on? 

Margaret: Oh, I don't know the top off the top of my head. I don't think I've got 80. That might be not right. 

Preston: Mm-hmm. I think I underutilized fluvoxamine. 

Margaret: It's, it's pretty decent. I mean, it's, it's a good episode. Know there's always, there's always the case of like, it's a newer ish one.

It's not super new anymore, but there's some thought that it's like slightly different from like a. Sero urgent norepinephrine profile. I think that might make it sometimes more beneficial. Um, and then I think clomipramine, like, right, like we're using a different mechanism, can work differently. So it's just the thing I look out for in Clomipramine is like, I don't put someone who is, I'm worried their suicidal ideation is not just intrusive suicidal thoughts, um, just in terms of like overdose risk and things like that.

Um. Those are the medications. I [00:50:00] also think thinking about RNs and OCD, if they have comorbid panic or just like knowing they have a safety blanket a little bit is helpful, especially when they're going through exposure and response prevention. So I tend to go with like, again, depending on comorbidities.

In kids. I think like a clonidine can be useful. I think that, um, hydroxyzine, you know, is one we all use all the time. I tend to stay away from benzos because benzos can interfere with learning, which can interfere with the efficacy of like exposure and response prevention because you're not actually consolidating in the same way.

Mm-hmm. Um, but I'm not against them all together. 

Preston: Yeah. Like, like benzos are really good at anesthetizing the anxiety, but then make it hard to interact with anything else. 

Margaret: Well, I mean there's been studies on like doing exposure and response and like some trauma work on benzos and it like provi prevents like the learning.

So basically like your exposure work Interesting is just like, it's like not a hun. Right? It's never a hundred percent one way or the other. Yeah. But like [00:51:00] we tend to avoid it because it's like, so this one in particular, like we also, like when we do, which we'll talk about in one moment on our Patreon section on exposure and response prevention.

We tend to avoid as needed meds as much as possible when you're in an intensive OCD treatment setting because it's, it's part of the issue is like the avoidance of the stimuli. So like using a med to avoid the stimuli is not, is counterproductive when you're in the acute setting in particular. 

Preston: Sure, that makes sense.

Margaret: Any other meds you think about or things you think about when, like, looking at this list of medications for OCD? 

Preston: I guess maybe, maybe propanolol was, is just a thought. Oh, yeah. Yeah. So, and I know it may not be the best PRN, um, for chasing anxiety, but like, maybe if your OCD is related to a specific scenario 

[music]: mm-hmm.

Preston: Like, you know, call someone or test [00:52:00] anxiety like you, you could, you could offer it then, like that could be an option. Mm-hmm. 

Margaret: Yeah. No, definitely. Especially also like there can be like comorbid performance anxiety. 

Preston: In 

Margaret: terms 

Preston: of 

Margaret: that, 

Preston: probably probably stemming from From their OCD. That makes sense. 

Margaret: Probably.

Preston: Yeah. 

Margaret: They're like, I'm gonna be punished for this after this by myself. Me is gonna punish me. You can catch the next part of this on Patreon. 

Preston: It's patreon.com/happy Patient Pod. Thank you all so much for listening. How's the show? We want to hear what you think. We want to hear your formed thoughts. We want to hear your intrusive thoughts.

If it's a thought that thought, we don't, we don't want to hear all your intrusive thoughts and you don't feel need to feel compelled to tell us. But we do want to hear the thoughts that you want share, and you can do that by reaching out to out to us at How to be patient pod.com. We also have our How to Be Patient Instagram, or you can find me at it's preso or Margaret at badar every day.

Margaret: You can find us in the Spotify comments every Monday afternoon [00:53:00] after releases 

Preston: of episodes. I'm looking lurking in the Spotify comments. A special, special shout out to someone on Apple Podcasts who left a wonderful review. They said, I'm already a big fan of the podcast, but the recent episode on the history of Lithium was just chef's Kiss.

More history episodes, please. So we'll, we'll happily incorporate more history and her story of, of the world. Thanks again for listening. We're your hosts, Preston Roche. Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Duncan. Will Flannery, Kristin Flannery, Aron Korney, Rob Goldman and Shanti Brook.

Our editor and engineer is Jason Portizo. Shout out to Jason. Thanks for letting us. You along these wild goose chases. You're a great sponsor. We don't make it easy of the Yeah, no, we don't. But Jason makes it look easy. And that's the important part. Our music is Bio Benz V. To learn more about our program, disclaimer and ethics policy submission verification, and licensing terms, and our HIPAA release terms, go to how a patient pod.com or reach [00:54:00] out to us at how to be patient@humancontent.com with any questions or concerns.

How to be patient is a human content production,

[music]: how to be patient.

Preston: Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the [00:55:00] background.