The Overlap Between OCD and Anxiety Explained

Summary

Podcast Summary: Get to Know OCD

Episode: The Overlap Between OCD and Anxiety Explained

Host: Dr. Patrick McGrath (NOCD Chief Clinical Officer)
Guest: Shauna Pachette, LPC (NOCD Clinical Operational Manager and Clinical Lead for Anxiety Disorder Treatment)
Date: November 13, 2025

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Main Theme & Purpose

This episode focuses on the significant overlap between Obsessive Compulsive Disorder (OCD) and anxiety disorders. Dr. Patrick McGrath and Shauna Pachette explore how anxiety sensitivity plays into both conditions, discuss various anxiety disorders commonly co-occurring with OCD, and delve into treatment strategies—especially the use of interoceptive exposures. The conversation aims to demystify why tackling anxiety head-on (rather than avoiding it) is essential for progress, offering practical examples and addressing therapeutic misconceptions.

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Key Discussion Points & Insights

1. Comorbidity of OCD and Anxiety Disorders

• OCD often co-occurs with other conditions, especially anxiety and mood disorders.
• Common comorbid anxiety disorders:
  • Generalized Anxiety Disorder (GAD): Persistent, widespread worry. ("Lots of worries about lots of things, lots of the time." – Shauna, 07:03)
  • Social Anxiety Disorder: Fear of being judged or criticized.
  • Illness Anxiety Disorder: Worry about having (or getting) a serious illness; often overlaps with health OCD.
  • Specific Phobias & Agoraphobia: Focused fears (e.g., elevators, crowded spaces).
  • Panic Disorder: Focus on fear of panic attacks and their sensations.

2. Understanding Anxiety Sensitivity

• Definition: Anxiety sensitivity is the tendency to misinterpret physical symptoms of anxiety as dangerous or catastrophic.
• This misattribution leads to a feedback loop: noticing bodily sensations → assigning negative meaning → increased anxiety → intensified sensations.
• Examples include “my heart is racing; therefore, I must be having a heart attack,” fueling more anxiety.

“It’s this misattribution or mislabeling of a physical sensation as being dangerous, as being something unwanted or scary or, you know, a sign of catastrophe. And so then I must get out of that feeling or do something about it.”
— Shauna Pachette [10:24]

3. Interoceptive Exposures: Treatment Approach

• Interoceptive exposures are exercises designed to induce the physical sensations associated with anxiety in a controlled, safe way to help reduce fear of those sensations.

  Examples (11:39 – 12:49):

  • Jumping jacks or running to increase heart rate
  • Breathing through a straw or holding breath
  • Spinning in a chair to induce dizziness
  • Purposeful hyperventilation

• Goal: Build confidence that one can handle uncomfortable sensations without escaping or using “safety behaviors” (like deep breathing or medication) to make them go away.

“The goal...is to break this down one symptom at a time and to really learn that I can handle that symptom, that I don’t need to be afraid of that.” — Patrick McGrath [13:04]

4. Shifting from Avoidance to Acceptance

• Both clinicians and clients must shift from avoidance/distraction strategies to “leaning in” and accepting discomfort.
• Many therapy modalities wrongly teach escape as the solution; the real progress comes from allowing discomfort and realizing it’s tolerable.

“We can’t get rid of uncomfortable feelings in our life. That’s just the way of it. There’s always gonna be uncomfortable physical sensations. There’s always gonna be uncomfortable emotions. Fighting it makes it worse.”
— Shauna Pachette [16:12]

5. Therapist and Client Challenges

• Many therapists (and clients) initially find it counterintuitive to invite discomfort.
• Therapists must trust clients’ resilience and avoid “rescuing” them from unpleasant feelings (17:27).
• Clients often hold out hope that anxiety can be eradicated—acceptance comes when they see that all emotions are part of life, not just the ones they label as “good.”

6. Somatic OCD: When the Body Becomes the Focus

• OCD can latch onto normal bodily functions (e.g., blinking, breathing), turning them into obsessive concerns.
• Interoceptive and behavioral exposures help clients break the link between attention to these sensations and catastrophic interpretations.

“[With somatic OCD] if I were to have us right now focus on our blinking...suddenly I’m very aware of my eyelids and my contacts in my eyes, and I’m like, wait, do I blink too much? How am I blinking? What does it mean?”
— Shauna Pachette [26:21]

7. Common Pitfalls & Motivating Change

• People often get “stuck” hoping anxiety will disappear rather than accepting it as normal.
• Safety behaviors and constant searching for the “why” behind obsessions keep people trapped.
• Education and gradual exposure are crucial; reassurance that discomfort is safe and manageable helps motivate clients.

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Notable Quotes & Memorable Moments

• “Uncomfortable doesn’t mean dangerous.” — Patrick McGrath [33:33]
• “OCD is so creative. Right. It can find anything to be a trigger. Somatic OCD is this worry about the physical, like the workings of your body and the different sensations within your body.” — Shauna Pachette [25:24]
• “Life’s uncomfortable and so we are learning to get comfortable with the discomfort. And your world becomes a whole lot bigger once you do that.” — Shauna Pachette [33:51]
• “Fighting it makes it worse.” — Shauna Pachette [16:15]
• “OCD has an amazing capacity to be convincing to people that just around the corner is the answer...But in all our years, I have never once met a person who satisfied OCD.” — Patrick McGrath [35:21]
• “Sensations and emotions are just that…They can all be here. I think that’s part of what makes life life.” — Shauna Pachette [40:26]

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Timestamps for Key Segments

• [05:08] Comorbidity: Intro to anxiety disorders comorbid with OCD
• [06:53] Breakdown of Anxiety Disorders: GAD, Social Anxiety, Health Anxiety, Specific Phobias, Agoraphobia, Panic
• [09:31] Defining Anxiety Sensitivity
• [11:23] Introduction to Interoceptive Exposures
• [13:04] Purpose and Impact of Interoceptives
• [15:21] Distinguishing Learning to Cope vs. Avoidance
• [16:47] Therapist Adaptation to Exposure-Based Models
• [18:39] Shifting from Fighting to Accepting Emotions
• [25:24] Somatic OCD Explained
• [28:01] Customizing ERP for Somatic Symptoms
• [31:59] Overcoming Hesitation to Exposure Work
• [33:33] Key Insight: Discomfort ≠ Danger
• [34:00] Common Traps: Hoping for Anxiety-Free Life
• [36:12] OCD’s Endless Cycle
• [38:35] The “Scooby Doo” Metaphor for OCD’s Tricks
• [40:26] Closing Wisdom: Embracing All Feelings

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Closing Thoughts

The episode delivers a hopeful, practical message: While OCD and anxiety are challenging, meaningful change happens by facing—not fleeing—uncomfortable sensations and emotions. Interoceptive exposure is a powerful tool for building confidence, reducing fear, and reclaiming life. Acceptance, rather than avoidance or constant analysis, opens the door to long-term relief.

Final Advice:

“Sensations and emotions are just that... They can all be here. I think that’s part of what makes life life.”
— Shauna Pachette [40:26]

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Transcript

[Shauna Pachette]

With OCD, there is a high rate of comorbidity for anxiety disorders. It's the learning to handle those different feelings and gaining confidence in that area. We can't get rid of uncomfortable feelings in our life. That's just the way of it. There's always going to be uncomfortable physical sensations, there's always going to be uncomfortable emotions. Fighting it makes it worse. Life's uncomfortable and so we are learning to get comfortable with the discomfort. And your world becomes a whole lot bigger once you do that.

[Patrick McGrath]

You've probably heard of ocd, but you don't know that OCD isn't really just about cleaning an organization. It's actually debilitating. It's a condition that causes intrusive, persistent and really sticky feelings and thoughts that can see ease on any topic from romantic relationships to illness to spirituality and really anything that matters to you. This can really cause significant anxiety and guilt and shame and discomfort and can make it hard to function in day to day life. If this sounds familiar, know that you're not alone. In fact, 1 in 40 people in the US suffer from obsessive Compulsive Disorder, but help is available. I'm a licensed clinical psychologist with 25 years of OCD treatment experience. So I know that these scary symptoms can be overwhelming. But I also know that they can be managed with the right type of treatment. I lead a team of top tier clinical experts at NOCD who are trained in the effective treatment for Obsessive Compulsive Disorder. NOCD is an online platform offering specialized, accessible and convenient OCD treatment. My team and I have helped people take back their lives from OCD through evidence based therapies that are covered by insurance. To learn more about OCD and to start effective treatment, head to nocd.com that's nocd.com youm deserve to live the life you want to live and not the life that OCD wants you to live. And don't forget to subscribe to our YouTube channel so you can stay up to date on our latest podcasts and webinars. Now, onto today's episode.

[Shauna Pachette]

Hi everyone.

[Patrick McGrath]

Welcome to another episode of the get to Know OCD podcast. I'm excited today to have one of my colleagues, Shala Pachette on and we are going to discuss all things anxiety disorders and treatment for things like panic and somatic ocd. What is the anxiety sensitivity experience? What's an interoceptive exposure? Lots to go over, but before we get into that, Shauna, why don't you introduce yourself to everybody and tell them A little bit about you and your role here at nocd.

[Shauna Pachette]

Hi. Great, thank you. So I'm Shauna Pachette. I am a licensed professional counselor in the states of Wisconsin, Oregon and California. And at nocd, I am the clinical operational manager for a team as well as the clinical lead for anxiety disorder treatment. Outside of here, I have a small private practice and consultation business as well as I am an international OCD foundation faculty member.

[Patrick McGrath]

Fantastic. Well, let's get into it. You have been in this field for how long and how did you get started?

[Shauna Pachette]

I've been in the field for 10 years officially, but specializing in OCD and anxiety disorders for nine of those 10 years. So I found my niche pretty early on and fell in love with the work and haven't looked back.

[Patrick McGrath]

And how did you find that niche? How or how did it find you?

[Shauna Pachette]

I think it found me, actually. Yes. So started not sure exactly what specialty I wanted to go into. And then I was working on moving back to Wisconsin and got offered a role at Rogers and started working with kids and adolescents at the residential level of care. And they all had very significant OCD and anxiety disorders as well as other obsessive compulsive related conditions. And, um, I didn't know much about it at the time and then realized that this was very quickly exactly what I wanted to do and where I needed to be was working in the OCD world.

[Patrick McGrath]

Fantastic. And that put you a specialty obviously then in that anxiety and OCD for you that you have stuck with ever since.

[Shauna Pachette]

Yeah, stayed with it and have continued to grow in that space.

[Patrick McGrath]

Awesome. Since you do anxiety lead here and we talk about the fact that OCD usually doesn't show up alone. It brings friends like mood conditions, anxiety disorders, things of that nature. Today I wanted to focus with you on the anxiety disorder specifically. So let's talk a little bit about anxiety disorders, what they are, this idea of anxiety sensitivity and that experience and then ways that we would go about treating anxiety disorders and anxiety disorders that show up along with obsessive compulsive disorders.

[Shauna Pachette]

Yeah, absolutely. I'm so excited to get into that topic because I think that's something I really do care about for many, many reasons. But I think our comor, our com. Morbid disorders definitely need a lot of attention. So with ocd, there is a high, like you said, high rate of comorbidity for anxiety disorders, mood disorders, as well as other obsessive compulsive related disorders like hoarding, body focus, repetitive behaviors, tics. But we're going to not talk about those today. We'll. We'll stay in that anxiety disorder sphere. So one more. I'm sorry, go ahead.

[Patrick McGrath]

And I just say, and for us, just for everybody, if sometimes we. I throw out a technical term. And so I'll say comorbid just means not uncommonly connected with something that we would see. So again, OCD and depression have very strong ties to each other. So comorbid just means that more. Now that I say that a lot. Morbid sounds really morbid, actually. Now that I say that. Yeah. But. But it just means. Yeah, yeah, Often, often co occurring.

[Shauna Pachette]

I call it like coexisting.

[Patrick McGrath]

Coexisting. Yeah, yeah, we could say that too. However we want to say, say it. That that's.

[Shauna Pachette]

Yeah. Co occurring or coexisting sound a little.

[Patrick McGrath]

Yeah, co. Morbid. Yeah. Co terrible or something like that.

[Shauna Pachette]

Right? Yeah. So high, high chance that if you have ocd, you don't just have ocd. Right. It doesn't always operate on its own. And so we see a lot of those other conditions come along too, for the ride.

[Patrick McGrath]

Yeah. Now, so let's talk about that more specifically for anxiety disorders, then fill us in a little bit on those co occurrences that happen.

[Shauna Pachette]

Yeah. So higher rates of having an anxiety disorder along with ocd. Some of those common anxiety disorders are things like generalized anxiety disorder, which is lots of worries, but lots of things, lots of the time. It's kind of how I sum that one up.

[Patrick McGrath]

Lots of lots and lots of.

[Shauna Pachette]

Lots of. Lots of. Lots of. Right. It's general, it's all over. And then we have social anxiety disorder in which someone's kind of core fear, biggest kind of central worry here is that they're going to be judged, evaluated or criticized. Then we have illness anxiety disorders. This one really tends to have a lot of overlap with OCD as well. So illness anxiety disorder is this worry that there is something wrong with me and I don't know what it is necessarily. And then health OCD can present very similarly to this. You can get into some more nuances of that later. You would like. And then specific phobia. So that's just a very specific fear. Is a way to kind of teach the difference. Just a fear of this one thing. So for example, needles, dogs, open water, anything.

[Patrick McGrath]

Elevators.

[Shauna Pachette]

Elevators. Right. Then we have agoraphobia, which is a fear of three out of five different things. So it could be open, wide open spaces, enclosed spaces, public transportation, being away from home and being in a crowded space.

[Patrick McGrath]

Yeah. Standing in line.

[Shauna Pachette]

Being standing in line.

[Patrick McGrath]

Something like that. Yeah.

[Shauna Pachette]

So three out of those five to be agoraphobia. And like, I missed some anxiety disorders. What am I missing here, Patrick?

[Patrick McGrath]

Well, our panic. Right. Just the fear of what if I were to have a panic attack? Or. Or the panic. The sensations of panic, which is going to lead into our interoceptive exposure Talk.

[Shauna Pachette]

Forgot one of the most most important.

[Patrick McGrath]

Ones, the most basic one. That's all right.

[Shauna Pachette]

It's almost like we're here to talk about panic stuff. Maybe.

[Patrick McGrath]

Maybe. I don't know. Yeah, yeah. Joking aside, panic is a really serious condition because there's so many people who were, when they're having a panic attack, think they're dying, that they need to go to the emergency room, something terrible is happening, and would like quick fix medications like benzodiazepines as a way to calm them down. And emergency rooms are getting less and less likely to give those things out to people because they can be abused. And so our goal is to help people learn how to live with these panic sensations and symptoms. So why don't you talk a little bit about that and how we go about doing.

[Shauna Pachette]

Yeah, so that, that's a great segue into talking about anxiety sensitivity. So anxiety sensitivity is seen with so many different diagnoses. So I think it can be really helpful to just kind of picture or think of anxiety sensitivity as this overarching thing that can occur in which people are sensitive to the experience of anxiety. Right. Let's use the words that are being used there. So someone has a physical sensation, perhaps, you know, my heart starts to go a little bit faster. Then what happens is that physical sensation is followed up by attached meaning, oh, that must be bad. My heart rate shouldn't be going faster. Then people get anxious and I'm nervous because I don't want to have a heart attack. Then that increases the physical sensation of the heart. Heart rate increasing. Right. Because anxiety can often be a racing heart. And so then it creates this cycle in which these physical sensations feel the anxious feelings and they just go back and forth. So it builds upon itself and that's how we get things like panic or somatic OCD presentations or illness anxiety. It's this misattribution or mislabeling of a physical sensation as being dangerous, as being something unwanted or scary or, you know, a sign of catastrophe. And so then I must get out of that feeling or do something about it. And so that's when people use things like you just said, like benzos. Right. I'm gonna have a fast acting benzodiazepine which is going to help me reduce that feeling of anxiety and get out of that. Get out of there quickly, or I'm going to take some deep breaths and really calm myself down, because that feeling is bad. So what we do is we then treat it with enterocleptives in which we try to break that cycle of anxiety sensitivity.

[Patrick McGrath]

So an interoceptive is an exposure to some kind of physical sensation that somebody experiences during panic. So can you give us some examples of what that might look like?

[Shauna Pachette]

Absolutely. So with your clinician, you should be trying to find very specifically what your feelings are of anxiety or what those feelings are that tend to trigger that panic. And then they want to recreate these little doses of that physical sensation. It can be kind of seen as like a test run for anxiety, perhaps. So if I have, for example, the heart racing, I would try to find ways to get my client to increase their heart rate. So that might be doing things like 60 seconds of jumping jacks.

[Patrick McGrath]

Okay.

[Shauna Pachette]

That's going to get your heart rate going up. It may be going up and down stairs. It could be things like even like breathing through a straw. So really restricting how much air you're getting can then increase kind of that physical labor that's going on in your body can increase your heart rate as a result.

[Patrick McGrath]

Okay. And we might do things with breathing, right? So we might hold our breath or we might hyperventilate. People can do spinning, where they will spin in a chair to get dizzy. Because some people have the fear of, what if I feel dizzy or discombobulated in some way?

[Shauna Pachette]

What if this dizziness means I'm losing my mind or there's something medically wrong? Or we could have people spinning a chair and create that feeling of nausea. If someone has a fear of throwing up, even.

[Patrick McGrath]

Yeah. And the goal of all of this is not that we want someone having a panic attack. I think sometimes people hear this and they think they're trying to make me have a panic attack. That is. That is not at all the goal. Actually, it is to break this down one symptom at a time and to really learn that I can handle that symptom, that I don't need to be afraid of that. So as people do this, what have you heard from folks? What do they. What do they say about this experience?

[Shauna Pachette]

Yeah, I think most people are scared before they start off with interoceptives or like this, like you said. What do you mean? You're trying to make me have a panic attack, or you want me to have these really Uncomfortable physical sensations. And then as they go through it, there's such a. An increase in confidence in their ability to handle just different fluctuations within their body. Right. Our bodies are doing all sorts of weird stuff all the time. All the time. Right. We can't attach a meaning to every little thing that we feel. And so most of the time, bodies are just being bodies. They're just doing what they do, and there's no catastrophic reason for that. So people then gain confidence in their ability to even just have these random sensations occur. So I have a client who I worked with recently who one of his big worries is, what if, you know, what if I lose my sense of self? And so physical sensations can trigger that. You know, what if this dizziness means that I'm developing a brain tumor, which means I'm going to lose my sense of self? What if my heart racing means I'm going to have a heart attack or a stroke, which means I'm then going to lose some of my physical functioning. So we did interoceptives, and he recently had a cold. You know, cold people get them all the time. He felt those different feelings of, oh, it's kind of hard to breathe. No, I don't like that. Oh, there's a feeling in my throat. And instead of being triggered by those feelings like he normally would, he was able to say, yeah, you know, maybe. Maybe this is my worst fear coming true, or maybe it's a common cold and I should just wait it out. Uh, so being able to have that confidence in himself to. To feel those different sensations, even though it wasn't directly what we're working on, just having a fluctuation was a big step for him to just feel different and be okay with it.

[Patrick McGrath]

That's pretty cool. Yeah. I think it surprises people sometimes when we say these things that this helps people to feel better. But the opposite treatment, which many people go through for panic, is diaphragmatic breathing, progressive muscle relaxation. And every time you feel any kind of discomfort, do those things. And then people get to spending hours and hours and hours of a day doing those things instead of learning that you can actually just handle some uncomfortable physical sensations without having to do all of this stuff that you've been taught by therapists who don't really specialize in anxiety disorders who are trying to help you get rid of these things instead of learn how to handle them.

[Shauna Pachette]

Yeah, yeah, exactly. It's about learning to handle those different feelings and gaining confidence in that area. And I think so often people do. Yeah, they have lots of Worries about what could possibly be going on there. And so try to keep the feelings away versus allowing them to be present. And like, well, we can't get rid of uncomfortable feelings in our life. That's just the way of it. Right. There's always gonna be uncomfortable physical sensations. There's always gonna be uncomfortable emotions. Fighting it makes it worse.

[Patrick McGrath]

Yeah. When you're teaching therapists about this, it's got to be kind of a switch, right? I mean, because many therapists who come in to either what you do here at nocd, what you do through iocdf, have been taught the basics of diaphragmatic breathing, muscle relaxation, you know, stick your hand in a bucket of ice, those. Those types of things, all to distract yourself. What's their reaction when you start talking about having people live with their discomfort instead of trying to do something to make it go away?

[Shauna Pachette]

Yeah, I've gotten a variety of reactions from people. Some people are excited to try something different because, you know, maybe they've worked with panic before. I'm like, yeah, I mean, like, it kind of helps things for a while, but I feel like it doesn't really keep it away. Other people are think I'm downright cruel to suggest this, but I think this is such a good opportunity for us to have less as therapists, to put faith into our clients as well. Our clients are tougher than, you know, sometimes people give them credit for.

[Patrick McGrath]

I would agree.

[Shauna Pachette]

Yeah, he works incredibly resilient people. And so it is really uncomfortable, though, for therapists to not jump into that seat saving or that, like, get them out of that feeling mode. It can be really hard. Hard mental adjustment for therapists to switch their mindset on that.

[Patrick McGrath]

There's people who keep bringing up that phrase, though, that I have to fight this. Right. Because this idea that. That I have to win over this. How do you. How do you help people deal with this notion that fighting it can make it worse, actually? How do you get that across?

[Shauna Pachette]

Okay, so how would I help someone come from a place of fighting it to, like, accepting it? I think that's. It's a difficult mental switch. Right. To go from, I need to fight this. I need to get rid of this. Because I do think there is this meaning, or I know there is a meaning attached to emotions and sensations. People often say, no, that's a bad feeling, or that's a good feeling, or that's a bad emotion. That's a good emotion. Right. We have to get rid of all of the bad emotions. And so it goes from. To this place of recognizing that's not realistic. And I think, you know, so often people with OCD have this feeling like, I'm special in a bad way. I'm the only person, like, I wouldn't say that to my mom, that, oh, she's never allowed to feel anxious, but me, I'm never allowed to feel anxious. Right. That special in a bad way mentality that comes along with having ocd. And so they're able to often recognize other people don't have to fight this. They can, you know, be accepting of all their different feelings and sensations. But I, however, need to have this, like, experience where I never feel anxious. Otherwise, you know, maybe I'm a failure or it means I'm not doing well at therapy or whatever that worry might be that comes along with it. And so there's a lot of education that goes into recognizing that emotions are just emotions and we can have all of the emotions. You don't have to fight them. We can accept them. We can kind of ride the wave, let them be there and acknowledge, like, the myriad of emotions that are present at one time too.

[Patrick McGrath]

Yeah. And some people just have categorized certain emotions as bad. Right. That, yeah. That I shouldn't have them. And my fear always in that situation is the once that's happened, that's the ones you're looking out for. And when you're looking for it, you're going to find it. And when you find it, you experience it. And then that proves to you, oh, see, I'm a person who has bad emotions.

[Shauna Pachette]

Yeah. Therefore, I'm a failure or whatever it might be. Right.

[Patrick McGrath]

Yeah. Or I have to do this quick fix things fix thing to make it go away because it shouldn't be there. Do you believe there's any emotion that is just off the table and not allowed to be experienced?

[Shauna Pachette]

I don't think so.

[Patrick McGrath]

I, I, I don't either. But anxiety and OCD sure do. Right?

[Shauna Pachette]

Right. Absolutely.

[Patrick McGrath]

Yeah. And so maybe what we're actually battling isn't that there's a bad emotion, because I don't think there is. I think that there's bad information about emotions that our brain is kind of caught onto and has said we shouldn't be having this, this shouldn't be happening, we shouldn't be experiencing this. And I just kind of call bullshit on that and say, why not? What's, what's wrong with experiencing something? Right.

[Shauna Pachette]

Yeah. In fact, I often talk about how if we don't have anxiety, actually we'll die. Right?

[Patrick McGrath]

Yeah.

[Shauna Pachette]

Anxiety keeps us alive. But with anxiety disorders, or ocd. It's like this faulty. Like, faulty smoke alarm that goes off. Even if you just turn on the oven, the smoke alarm's like, yelling fire at you. We do need that smoke alarm, though, in case there is a fire. Right. So enough anxiety keeps us alive. It's helpful in many ways. It just. The volumes turned up too loud with anxiety disorders and ocd.

[Patrick McGrath]

Right.

[Shauna Pachette]

And then as a result, people don't want any of those feelings.

[Patrick McGrath]

I love the show on npr. Invisibilia. I don't know if you've heard the podcast. The first and second episodes are pretty amazing. The first one goes over a person who has harm OCD and who was afraid, you know, what if he were to harm his wife and stab her and do all these things? And it goes through erp, which is great. And the second one is about an interview with a woman who has no anxiety, no fear. And the reason is she's got a disease that turns your amygdala, when you hit your teenage years, into something that absorbs calcium, which means it turns basically into a rock, and therefore, it doesn't work the way it's supposed to anymore. And in that case, you. You can't have a fear response, and you can't actually interview these people without going through, like, five other people to get them. And when you do, you. You are not allowed to know their name, where they live and anything like this, because these people live a very difficult life. Not like if you're literally walking across the street and the car's coming at you. You have to think about getting out of the way because you don't have a fight, flight, or freeze response to get out of the way. That's potentially really dangerous, right?

[Shauna Pachette]

Very dangerous. Yeah.

[Patrick McGrath]

Yeah. So a lot of people will say to you, and they'll say to me, I just don't want to feel anxious anymore. And I say, that's not the goal. Right.

[Shauna Pachette]

That's not the goal. That's funny you bring that up, because I have never seen that episode, but I've read articles about people like that. And so I'll send that to my. My clients and be like, hey, this is kind of. This is what no anxiety looks like. Right. This is zero for anxiety. Do we think this is realistic?

[Patrick McGrath]

No.

[Shauna Pachette]

Do we want that even if it was? And the answer is no. Like, we want a healthy dose of.

[Patrick McGrath]

Anxiety to keep us alive 100%, absolutely we want that. Yeah. Because you were right, Shauna. We. We don't make it in the world otherwise. Right. It just. It Just doesn't work. So kind of in. In similarities to that. We have, okay, we have the panic symptoms. Sometimes OCD uses panic and it'll say, if you don't do this compulsion, you're going to have a panic attack.

[Shauna Pachette]

Right.

[Patrick McGrath]

So we can use even interoceptive work in ocd, correct?

[Shauna Pachette]

Oh, absolutely. Interoceptive has so many applications. Interoceptive exposures with so many applications in different presentations of ocd. So fear having a panic attack. Right? I have to do these compulsions to keep myself safe from having a panic attack or somatic ocd, right? Am I blinking correctly? Am I breathing correctly? Is there something wrong with my internal systems in some way and having to do compulsions around that? And so someone has a focus on am I breathing correctly? Is there something wrong with my breathing? We might have them purposely make mistakes in their breathing and do some of these interoceptive support play around with the way that, like, breathing feels for them.

[Patrick McGrath]

Well, what a segue into the other thing I wanted to talk about then, which was this idea of somatic ocd. And that hits that, right? This idea of blinking and breathing. So can you tell everyone a little bit about what we mean by somatic OCD and how it focuses on the workings of the body?

[Shauna Pachette]

Yeah, somatic ocd. So OCD is so creative. Right. It can find anything to be a trigger. Somatic OCD is this worry about the physical, like the workings of your body and the different sensations within your body. And so it makes sense that having something like an interoceptive would help break that cycle. So the example I just gave, am I breathing correctly? How do I know if I'm breathing correctly? And then what somebody does is they'll then start to focus on their breathing and then analyze their breathing, and then suddenly their breathing seems really weird. Right? So if I were to have us right now focus on our blinking, how often are we thinking about our blinking? So you know everyone who's listening, go ahead, take 10 seconds and just focus on your blinking. Right? I don't know if that's because I probably should have been counting. No.

[Patrick McGrath]

It's so weird, though, to now think about, like, now, now, Damn it, I'm thinking about my blinking now. Annoying.

[Shauna Pachette]

Suddenly I'm very aware of my eyelids and my contacts in my eyes, and I'm like, wait, do I blink too much? Much? Do I? How am I blinking? What does it mean? So you can see how easily ocd, which hates uncertainty, can latch onto these different inner workings of our body and then attribute some sort of there's got to be something wrong here, or am I doing this right? Or does this mean that there's something medically going on? So it can be about all sorts of stuff that happens, and so intrasoptive exposure can target some of those different sensations.

[Patrick McGrath]

Yeah. And it could even be along the lines of, if I'm doing it right, have I. Have I gotten all the carbon dioxide out of my lungs and so that I can get enough oxygen back in in the next breath? And so should I, you know, really, really try to exhale all that out so I can get all that oxygen? Because then what if I don't get enough oxygen into the next breath? What happens to me and my body and I'm not performing a peak efficiency and all these things, or if I don't blink the right way and there's something in my eye, it could build up, you know, just. There's. There's just not a limit to where OCD will go to.

[Shauna Pachette]

To be creative.

[Patrick McGrath]

Ocd, right? To be that annoying jerk of a disorder that it is. Yeah, yeah. So how do you help people with the somatic ocd? What. What kind of ERP work do you do? Yeah.

[Shauna Pachette]

So, I mean, always, always, always with. With ERP want to make sure it's very individualized to that person's experience. Right. No two hierarchies, no two exposures are gonna be 100% the same. So first of all, wanting to figure out what that person's specific triggers are, and then building the hierarchy and their compulsions and build the hierarchy around there. Definitely making sure to include interoceptive exposures. And I think I will just say candidly, I do see a lot of therapists maybe kind of overlooking the benefits of interoceptives. And so.

[Patrick McGrath]

I agree. I agree.

[Shauna Pachette]

Yes. I always joke it, like, when I lead a consultation, I'm like, there is a good chance I will say interoceptive exposure at some point in this consultation group or in this training, because I think it's so important to integrate it into the work. So if we were to use the example of do, let's do the breathing one, you know, I have to exhale my breath completely in order to make sure I'm working at peak efficiency for breath and getting the right amount of oxygen and all that. What I might have someone do is leave just a little bit of air left at the end, so exhale the way you normally would with the full like, but then stop a second short, two seconds short, whatever it may be, and then having them continue the breath that way. So you want to kind of make mistakes in OCD's rules. We want to defy what it wants interoceptives for that. We can have them breathe through a straw. Right. So you're not getting a peak breath when you are breathing through a straw. You can even play on the sizes of straws too. They're not super fun to do, but it is great learning, great learning opportunities. So you could breathe through straw. You could do over breathing, which is like a forced hyperventilation where it's kind of create some dizziness. You're obviously not getting a solid breath and you're not doing the full exhale that you might want to do for that person who really wants to exhale fully. But then also, you know, there's other types of exposures. We've got in vivo, which are these lived experiences. We've got imaginal, which are more imagined. So things like written content or maybe listening to somebody else breathe, reading about different breathing conditions where someone cannot fully exhale and in vivo would be having them kind of play with those different rules in their day to day things like that. So really depends on the person's individual triggers. But that's just the example based up the one we, we talked through.

[Patrick McGrath]

Sometimes in the blinking, I'll even have people purposely blink weird.

[Shauna Pachette]

Oh yeah.

[Patrick McGrath]

And it, it's funny, when you prescribe the problem, sometimes it becomes hard for someone to do after a while, right?

[Shauna Pachette]

Yes.

[Patrick McGrath]

Then it's just like they get annoyed by it and they go back to blink. They like you're not blinking weird anymore. Isn't that interesting? You know, before when you were blinking the way that you usually do, OCD was saying it was doing wrong. And now when you purposely go do it the way that OCD wants you to do, you get exhausted after about two minutes of doing it and you go back to doing it that way. So maybe OCD's advice isn't quite the best. You know, maybe. Maybe it isn't quite right. Yeah. Have you. Have you found a piece of advice that OCD's given that was. Was worthwhile and publishable at all?

[Shauna Pachette]

Or have. I can't say I have.

[Patrick McGrath]

No, I haven't. I just didn't know if maybe you did. You. You might have found something I missed somewhere along the way.

[Shauna Pachette]

Yeah, I have lots of people that are trying to find that perfect advice from ocd, but turns out most of the time it's pretty misguided, unfortunately.

[Patrick McGrath]

Yeah. So there's people out there watching this who might be scared to Start with interoceptive exposure work or, or dealing with bodily sensations, somatic ocd, panic issues. How do you motivate somebody to take the step into starting to do some of these things?

[Shauna Pachette]

Yeah, I think a really good educational foundation is important. Right. Why are we doing this? And one thing to know too about interoceptives is they're not dangerous. So the actual act itself is not dangerous. I would never ask my clients to do something that is dangerous, that is life threatening. I do often get people to have medical clearance too, when applicable. So I work with a lot of people with chronic health conditions too. So chronic health and ocd. OCD can play off of somebody's chronic health condition. And so in those cases, a lot of times it is very important to get medical clearance before doing interoceptives. But what they find too is by doing these interoceptives, they actually manage their chronic health conditions a little bit better because they don't feel that anxious response to their chronic health symptoms when they occur. So I guess my advice would be, yeah, get really good foundational information, recognize that it's not actually dangerous and that the outcomes are so incredibly worth it. They just, they truly are. I've seen interoceptives make huge changes in people's lives every day. So.

[Patrick McGrath]

So I would agree. I. I've noticed that also that it can do massively great things for people when they learn to face their physical sensations, when they allow themselves to live in their discomfort. And recognize that uncomfortable doesn't mean dangerous.

[Shauna Pachette]

Right.

[Patrick McGrath]

It doesn't mean something terrible or awful is about to happen. It doesn't mean that you're going to die even though OCD takes it to those absolutely worst case scenario kinds of experiences. That is not necessarily the case.

[Shauna Pachette]

Right.

[Patrick McGrath]

Yep.

[Shauna Pachette]

Yeah. Life's uncomfortable. And so we are learning to get comfortable with the discomfort. And life, your world becomes a whole lot bigger once you do that.

[Patrick McGrath]

Yeah. What are some of the things that people will say that that kind of keeps them stuck or how have you noticed people might stay stuck instead of fully engaged in the treatment?

[Shauna Pachette]

I think still kind of going back to our point earlier, still kind of holding onto that hope that like anxiety won't be there. Yeah, right. That there's like rationally they understand. Yeah. Everyone feels anxious, but sometimes I see people still kind of holding onto that. Like what? Oh, I can't let myself feel. I can't let myself fully feel that. Right. I can't fully accept that fact that things are going to be uncomfortable. And so the more you work towards this place of acceptance, I find that that's when that beautiful change really happens, is people saying, yeah, actually all sorts of emotions are welcome here. So I'd say holding onto that, not recognizing almost the safety behavior component of that, that. So safety behavior being something that help or, you know, someone uses in response to an anxious feeling to get rid of that. Those anxious feelings. Sometimes it's almost in preparation for the anxious feeling that they'll use a safety behavior. Now I'm going to prepare for this situation or I'm going to not let myself fully be present so I don't feel that anxiety. And I find that gets people to feel pretty stuck.

[Patrick McGrath]

Yeah. OCD has this. If, if I'll give it one thing, it has an amazing capacity to be convincing to people that just around the corner is the answer.

[Shauna Pachette]

Yeah.

[Patrick McGrath]

Right.

[Shauna Pachette]

There's one more, one more compulsion or one more like. And you're there.

[Patrick McGrath]

Yeah, right. It. The lie is even if you get there, it will say, great, now level two or now level three. And then there's infinite levels. So in, in our careers, which if you're 10 years in my 20s, we're looking at 35 plus years of doing this work together. We have never once met a person who satisfied ocd.

[Shauna Pachette]

No.

[Patrick McGrath]

Right?

[Shauna Pachette]

Not once. Yeah. And people try, right. Like I just give it again, give it this one more compulsion, then it'll be good, then, then OCD will get quiet.

[Patrick McGrath]

The other piece that I think is always interesting to discuss is, is people will say to me, well, why does it have to be this? So why is it my blinking? Why is it my breathing? Why am I having these panic sensations? And I may not have an absolute answer, but, you know, I can usually say it. It must be somehow important to you because as you said at the beginning, people don't have issues with this stuff if they don't care about it. Right. I mean, that would be kind of funny for therapy. If someone came in and said, I've got this issue going up, but I don't, I don't really care about it. I'd be like, well, it's really nice to meet you. Have a, have a great day.

[Shauna Pachette]

Right.

[Patrick McGrath]

It's, it's always there. So we may not know why it's so important. And sometimes people come into treatment and say, but I have to know why.

[Shauna Pachette]

I have to figure it out.

[Patrick McGrath]

Yeah. And we say, well, how about this? Let's work on it. And then afterwards we can try to figure it out. And I make that kind of tongue in cheek offer to people because at the end, nobody ever cares to figure out where it came from by the time they'd gone through the treatment because they're so excited to have their life back there, and they realize, oh, yeah, I didn't need to know where it came from. I just had to know what to do about it. And that was the most important thing of all of it.

[Shauna Pachette]

Yeah. And it's so important to help people know what to do about it, because I think, too, so often when people get stuck in this, like, analyzing spot of, well, I have to figure it out. I have to figure it out. Then what happens is OCD can, like, it can shift. It can shape shift, Right? Okay. You're not caring so much about this now, but you're really caring about analyzing your feelings now, because you are so stuck on analyzing why your OCD was showing up the way that it was. And now that's where OCD is latching on. Right. So I really want to help people understand the anxiety sensitivity. Right. Their reactions to anxiety, their attitudes towards these emotions, but then also just the commonality of OCD and how it's the same thing. It's just showing up a little differently. And I've also I all sorts of metaphors that I use for that. Sometimes. It's like, you know, the Scooby Doo, the, like, there, they reveal the monster at the end, and it's always like, the same guy. Pretty much.

[Patrick McGrath]

Yeah. That cranky old dude. Yeah. Yeah, right. If it wasn't for you meddling kids, yeah. I would have figured this.

[Shauna Pachette]

I would have gotten this thing right every time. And it's like, oh, it's not the. You know, this underwater monster. It's not this big, scary Frankenstein. It's. It's this old guy who's just crabby.

[Patrick McGrath]

Yeah, get off my land. Yeah, right. Yeah. The other thing. Yeah.

[Shauna Pachette]

Well, they try to get your ocd, tries to get your attention by showing up as a different monster, by showing up scary. And then you realize, oh, it's underneath the surface. It's all ocd. And we know what to do with that.

[Patrick McGrath]

I often love the book there. It's Grover from Sesame Street. And the book is. There's a monster at the end of this book. And Grover's begging you not to turn the page because there's a monster at the end of the book. And every page you turn, he's like, ah. And of course, you get to the last page, and there's Grover, and he says, oh, it was me.

[Shauna Pachette]

It was me. I'm the monster.

[Patrick McGrath]

I'M the monster at theater. Okay. Yeah. And that's what it's like. But it's hard to convince people to do this. Right. And so a lot of people are fixing to get ready to do it, and we try to motivate people to go and actually do it instead of just be ready.

[Shauna Pachette]

Yeah. And I think it's so hard, too, because with ocd, going after what you care about, that feels like the one thing someone's not willing to accept uncertainty in. Right. So, like, ask me to do all this other stuff. Sure. But, ooh, when it comes to that topic, I don't. That's the thing I really care about, that I can't. Can't let myself be wrong by doing erp and that can be tough, really tough to speak that first step. So that's why they. Why they say fixing to get ready.

[Patrick McGrath]

Fixing to get ready. Well, Shauna, thank you for being here today and kind of going over some of this with us. Any final words of wisdom you'd like to leave with the audience before we're. We're done for the day?

[Shauna Pachette]

I think kind of the summary is that sensations and emotions are just that. Right. We don't have to let them be anything more than what they are. They can all be here. I think that's part of what makes life life.

[Patrick McGrath]

Yep. Everything gets to swim in the fishbowl with us, right? Yep.

[Shauna Pachette]

Absolutely.

[Patrick McGrath]

Awesome. Well, Shana Pachette, thank you for being here on the get to Know OCD podcast, and we really appreciate it and thank you for the work you're doing with our members and helping to manage our clinicians here at NOCD as well.

[Shauna Pachette]

Thanks for having me.

[Patrick McGrath]

If you're looking for help for OCD related conditions out there, check us [e-mail] that's n o c d dot com. And if you like the get to Know OCD podcast, well, you can subscribe to the NOCD YouTube channel or anywhere where you get your favorite podcast at. Until next time, be better to yourself than your OCD will ever be to you. Thanks for listening. We'll talk to you later.