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Essentials: The Science & Treatment of Obsessive Compulsive Disorder (OCD)
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In this Huberman Lab Essentials episode, I explain the biology and psychology of obsessive-compulsive disorder (OCD).
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Welcome to Huberman Lab Essentials, where we revisit past episodes for the most potent and actionable science based tools for mental health, physical health and performance. I'm Andrew Huberman and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. Today we are talking about Obsessive Compulsive Disorder, or ocd. First of all, as the name suggests, OCD includes thoughts or obsessions and compulsions, which are actions. The obsessions and the compulsions are often linked. In fact, most of the time, the obsessions and the compulsions are linked such that the compulsion, the behavior, is designed to relieve the obsession. However, one of the hallmark themes of obsessive Compulsive disorder is that the obsessions are intrusive. People don't want to have them, they don't enjoy having them. They just seem to pop into people's minds, and they seem to pop into their mind recurrently. And the compulsions, unlike other sorts of behaviors, provide brief relief to the obsession, but then very quickly reinforce or strengthen the obsession. OCD is extremely common. In fact, current estimates are that anywhere from 2.5% to as high as 3 or even 4% of people suffer from true OCD. That is an astonishingly high number. Another thing to point out is that OCD is currently listed as number seven in terms of the most debilitating illnesses. Not just mental illnesses or disorders, but all types of illnesses, including things like asthma and cancer, et cetera. So you can imagine with that standing at number seven, that it is both extremely common and extremely debilitating. And as a consequence, it's now realized that many hours, days, weeks, months or even years of work performance or showing up at work of relational interactions really suffer as a consequence of people having ocd. With recurrent intrusive thoughts happening at very high frequency or even at moderate frequency. People are spending a lot of time thinking about this stuff and they're thinking about the behaviors they need to engage in, and then engaging in the behaviors, which, as I mentioned before, just serve to strengthen the compulsions. And so they're not actually doing, doing the other things that make us functional human beings like commuting to work or doing homework or doing work or listening. When people are talking or interacting or sports or working out, all the things that make for a rich, quality life are taken over by OCD in many cases. Another thing you'll soon learn is that sadly, a lot of the obsessions and compulsions in OCD often relate to taboo topics. And that's because the general categories of OCD fall into three different bins. Checking, obsessions and compulsions, repetition, obsessions and compulsions, and order, obsessions and compulsions. The checking ones are somewhat obvious. Checking the stove or checking the locks. Repetition, obsessions and compulsions obviously can dovetail with the checking ones, but those tend to be things like counting off of a certain number of numbers, like 1, 2, 3, 4, 5, 6, 7, 7, 6, 5, 4, 3, 2, 1. People will perform that repeatedly, repeatedly, repeatedly, or feel that they have to. So we have checking, we have repetition, and then there's order. Order oftentimes is thought of as putting cleanliness, or making sure everything is aligned and perfect and orderly. And oftentimes that is the case. But there are other forms of order that people with OCD can focus on in a obsessive and compulsive way. Things like incompleteness, the idea that one can't walk away from something or stop doing something because something's not right or complete. And in that picture, it could be the way the table is set, it could be the way that something's written on a page, it could be an email. It can also be in terms of symmetry, that everything be aligned and symmetric in some way. This could be seen, perhaps in young kids. This is one example that I read in the literature of children that need to arrange their stuffed animals in exact same order every day and in a particular order, to the point where if you were to move the little stuffed frog over next to the stuffed rabbit, that the child would have a. An anxiety reaction to that and feel literally compelled, driven to fix that, maybe even multiple times, over and over again. And then the other aspect of order, which is a little bit less than intuitive, is this notion of disgust, this idea that something is contaminated. So we often think about OCD and hand washing behavior in response to people feeling that something is contaminated. A space, a towel, et cetera, or even simply somebody else's hand, and so they're unwilling to shake somebody's hand. You can imagine how these different bins of obsessions and compulsions, checking, repetition and order, could be extremely debilitating, depending on how severe they are and how many different domains of life they show up in. And I know I said it multiple times now, but I'm going to say it many times throughout this episode in a somewhat obsessive, but I believe, justified way that every time that one engages in the compulsion related to the obsession, the obsession simply become stronger. As you can imagine, what a. What a powerful and debilitating loop that really is I'd like to take a
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subscription so let's drill a little bit deeper into how the obsessions and compulsions relate to one another.
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If we were to draw a line
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between the obsessions and the compulsions, that line could be described as anxiety. Now we need to define what anxiety is, and to be quite honest, most of psychology and science can't agree on exactly what anxiety is. Typically, the way we think about fear is that it's a heightened state of autonomic arousal, so increased heart rate, increased breathing, sweating, et cetera, in response to an immediate and present threat or perceived threat. Whereas anxiety, generally speaking in the scientific literature, relates to the same sorts of thought patterns and somatic bodily responses, heart rate, breathing, et cetera, but without a clear and present danger being in the environment or right there. So that's the way that we're going to talk about anxiety now. And anxiety is really what binds the obsessions and compulsions such that someone will have an intrusive thought. Some people are probably wondering if there's a genetic component to ocd, and indeed there is, although the nature of it isn't exactly clear. Based on twin studies where researchers have examined identical twins, fraternal twins, even identical twins that share the same sac in utero, the what we call monochorionic. So sitting in the same little bag during pregnancy or in different little bags, you can see different levels of what's called genetic concordance. But if we were to just sort of cut a broad swath through all of the genetic data, it's fair to say that about 40 to 50% of OCD cases have some genetic component, some mutation, or some inherited aspect that's genetic, and that one could point to if they got their genome mapped. Now, while that's interesting, I don't think it's terribly useful for most people. First of all, you can't really control your genes, can't pick who your parents were, as they say. So just know that there is a genetic component in about half of people with ocd, but not always. Now, as is typical for this podcast, I want to focus on some of the neural mechanisms and chemical systems in the brain and body that generate obsessive compulsive disorder. So let's take a step back and look at the neural circuitry. What's going on in the brain and body of people with ocd? Why the intrusive, recurrent thoughts? Many studies, we can fairly say dozens if not hundreds of studies, have now identified a particular circuit or loop of brain areas that are interconnected and very active in obsessive compulsive disorder. That loop includes the cortex, which is kind of the outer shell of the human brain, the lumpy stuff as it sometimes appears if the skull is removed. And it involves an area called the striatum, which is involved in action, selection and holding back action. The cortex and the striatum are in this intricate back and forth talk. It's really loops of connections. There's a third element in this corticostriatal loop, as it's called, and that's the thalamus. Now, the thalamus is not a structure I've talked a lot about before on this podcast, but it's one of my favorite structures to think about and teach about in neuroanatomy, which I teach back at Stanford and have taught for many years elsewhere, because the thalamus is this incredible egg like structure in the center of your brain that has different channels through it. Channels for relaying visual information or, or auditory information or touch information from your environment up into your cortex, and as a consequence, making certain things that are happening to you and around you apparent to you, making you aware of them, making you Perceive them and suppressing others at the same time. Your thalamus is surrounded by a kind of a shell, something called the thalamic reticular nucleus.
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Again, you don't have to remember the
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names, but the thalamic reticular nucleus, as I'm going to call it, it serves as a sort of gate as to which information is allowed to pass through up to your conscious experience and which is not. So let's zoom out and take a look at the circuit that we've got and that we now know, based on neuroimaging studies, is intimately involved in generating obsessions and compulsions in ocd. We have a cortex or neocortex, which is involved in perception and understanding of what's happening. We have the striatum and basal ganglia, which are involved in generating behaviors. Go. And suppressing behaviors. No go. And we have the thalamus, which collects all of our sensory experience in parallel. Hearing, touch, smell, et cetera. Not so much smell through the thalamus, I should mention, but the other sensor senses, that is. And then that thalamus is encased by the thalamic reticular nucleus, which serves as a kind of a guard, saying you can pass through and you can pass through, but you, you. You can't pass through. Up to conscious understanding and perception. That loop, this corticostriatothalamic loop. Corticostriatothalamic loop is the circuit thought to underlie ocd, and dysfunction in that circuit is what's thought to underlie ocd. How do we know that this circuit is involved in ocd? Well, there we can look to some really interesting studies that involve bringing human subjects into the laboratory and generating their obsessions and compulsions and then imaging their brain using any variety of techniques that we talked about before. So what they do typically is bring subjects into the laboratory who have a obsession about germs and contamination and a compulsion to hand wash. And they give these people, believe it or not, a sweaty towel that contains the sweat and the odor and the liquid, basically from somebody else's hands. In fact, they'll sometimes have someone wipe their own sweat off the back of their neck and put it on the towel, and then they'll put it in front of the person, which, as you can imagine for someone with ocd, is incredibly anxiety provoking and almost always evokes these obsessions about, oh, this is really. This is really bad. This is really bad. I need to. I need to clean. I need to clean, I need to clean. Now they're doing all this while someone is in a brain scanner or while they're being imaged for positron emission tomography. And then they can also look at the patterns of activation in the brain while the person is doing hand washing. Although sometimes the apparati associated with these imaging studies make it hard to do
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a lot of movement.
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They can do these sorts of studies. They have done these sorts of studies in many subjects using different variations of what I just described. And lo and behold, what lights up when I say lights up. What. What sorts of brain regions are more metabolically active, more blood flow, more neural activity? Well, it's this particular corticostriatal thalamic loop. In addition to that, some of the drug treatments that are effective in some, and I want to emphasize some individuals at suppressing obsessions and or compulsions, such as the selective serotonin reuptake inhibitors or SSRIs, which we'll talk about in a little bit. When people take those drugs, they see not just a suppression of the obsession and compulsion, but also a suppression of these particular neural circuits. They become less active. Now, I want to emphasize and telegraph a little bit of what's coming later. These drugs like SSRIs do not work for everybody with OCD. And as many of you know, they carry other certain problems and side effects for many, but not all individuals. That collection of studies of data, FMRI PET scanning in humans, the treatment with SSRIs really points squarely to the fact that the corticosteroidothalamic loop is likely to be the basis of ocd. Now, of course, other circuits could also be involved, but the corticosteroidal thalamic circuit seems to be the main circuit generating OCD like behavior. But as you'll next learn, when thinking about the various behavioral treatments and drug treatments and holistic treatments for ocd, what you'll notice is that each one taps into a different component of this corticostriatal thalamic loop. By understanding the underlying mechanism, why certain drugs and behavioral treatments work and don't work will become immediately apparent. And in thinking about that, in knowing that you'll be able to make excellent choices, I believe in terms of what sorts of treatments you pursue, what sorts of treatments you abandon, and most importantly, the order, the sequence that you pursue and apply those treatments, I'd like to
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Before we go any further, I'd like to give people a little bit of a window into what a diagnosis for OCD would look like, Give you a sense of the sorts of questions that a clinician would ask to determine whether or not somebody has ocd or not. The most commonly used test of ocd, or for ocd, I should say, is called the Yale Brown obsessive compulsive scale. And this is, you know, scientists love acronyms, as do the military, and it's the Y box. The why dashbocs. The Y box. Before the clinician would proceed with any kind of direct questions, they would very clearly define what obsessions and compulsions are. And here I'm actually reading from the Y box. So, quote, obsessions are unwelcome and distressing. Ideas, thoughts, images, or impulses that repeatedly enter your mind. They may seem to occur against your will. They may be repugnant to you. You may recognize them as senseless, and they may not fit your personality. Then there are compulsions. Quote, compulsions, on the other hand, are behaviors or acts that you feel driven to perform. Although you may recognize them as senseless or excessive at times, you may try to resist doing them, but this may prove difficult. You May experience anxiety that does not diminish until the behavior is completed. Now, there are a tremendous number of questions on the why box, so I'm just going to highlight a few of the general categories. Typically, the person will fill out a checklist, so they will designate whether or not currently or in the past.
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They.
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They have, for instance, aggressive obsessions, fear that one might harm themselves, fear that one might harm others, fear that they'll steal things, fear that they will act on unwanted impulses currently or in the past or both. That's one category. The other one are contamination obsessions. So concerned with dirt or germs, bothered by sticky substances or residues, et cetera, et cetera. So there are a bunch of different categories that include, for instance, sexual obsessions, what are called saving obsessions, even moral obsessions, right excess, concern with right or wrong, or morality, concerned with sacrilege and blasphemy, obsession with need for symmetry and exactness. Again, all of these questions being answered as either present in the past or not present in the past, present currently, or not present currently. And then the test generally transitions over to questions about target symptoms. They really try and get people to identify if they have obsessions, what are their exact obsessions. Now, this turns out to be really important because, as we talk about, some of the therapies really work. I'll just give away a little bit of why they work best in certain cases and why they don't work as well in other cases. It turns out that it becomes very important for the clinician and the patient to not just identify the obsessions and the compulsions, generally in a kind of a generic or top contour way, but to really encourage or even force the patient to define very precisely what. What the biggest, most catastrophic fear is, what the obsession really relates to. That turns out to be very important in disrupting this corticostriatalthalamic loop and getting relief from symptoms one way or the other. So the Yale Brown Obsessive Compulsive Scale, this Y box, again, is very extensive. It goes on for dozens of pages, actually, and has all these different categories. Not so much designed to just pinpoint what people obsess about or what they feel compelled to do, but to also try and identify what is the fear that's driving all this. Right in the way that we've set this up thus far, we've been talking about obsessions and compulsions is kind of existing in a vacuum. You're obsessed about germs, and you're compelled to wash your hands. Obsessed about germs compelled to wash your hands or obsessed about symmetry, compelled to put right angles on everything, or obsessed about counting and therefore counting, et cetera. The deeper layer to all that is what is the fear exactly, if one were to not perform the compulsion, Meaning what is the fear that's driving the obsession? So that brings us to a very powerful category of treatments that I should say does not work in everybody with ocd, but works in many people with OCD and really speaks to the underlying neural circuitry that generates OCD and how to interrupt it. And that is the treatment of cognitive behavioral therapy and in particular, exposure based cognitive behavioral therapy. Cognitive behavioral therapy and exposure therapy in the context of OCD most often involves trying to get people to tolerate, not relieve, their anxiety. This is extremely important. And I realize there's variation to this depending on the style of cognitive behavioral therapy, the style of exposure therapy, but almost across the board, the goal again is to get people to feel the anxiety that normally they are able to at least partially relieve, however briefly, by engaging in the compulsion. So if we think back to that circuit of corticostriatal thalamic, what's going on here? Where is CBT intervening? Well, as you recall, the cortex is involved in conscious perception. The thalamus and that thalamic reticular nucleus are involved in the passage of certain types of experience up to our conscious perception, not others. And the striatum is involved in this go, no go type behavior. When OCD is really expressing itself in its fullness, people feel an anxiety around a particular thought and they either have a go, for instance, wash hands, or a no go, do not turn left type reaction. By having people progressively, in a kind of hierarchical way, reveal their precise source of anxiety, their utmost fear. In this context, what happens is they feel enormous amounts of autonomic arousal. Now, in the context of anxiety treatment or other types of treatments, the goal would be to teach people to dampen, to lessen their anxiety through breathing techniques, or through visualization techniques, or through self talk, or through social support, any of the number of things that are well known to help people self regulate their own anxiety. Here it's the opposite. What they're trying to get the patient to do is to really feel the anxiety at its maximum, but then do the exact opposite of whatever the normal compulsion is. So if normally the compulsion is to wash one's hands, then the idea is to suppress hand washing while being in the experience of the utmost anxiety. Now, I want to be very clear, this is not the sort of thing you want to do on your own. This is not the sort of thing you want to do for a friend. This is done by trained licensed psychologists and psychiatrists because the goal again is to bring the person right up close to the thing that they fear the most and then to interrupt the circuit. What's happening is the person is feeling compelled to act, act, act to relieve the anxiety and through a progressive type of exposure.
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Right?
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You don't throw people in the deep end in this kind of therapy. Right off the bat, you gradually ratchet them toward or move them toward the discussion of exactly what they fear the most, and then eventually move them toward the interruption of the compulsion as they're feeling this extremely elevated anxiety. Of course, within the context of a supportive clinical setting, but in doing that, what you are teaching people is that the anxiety can exist without the need to engage in the compulsion. So I'd like to just briefly summarize the key elements of cognitive behavioral therapy and exposure therapy and how they can be combined with drug treatments that are very effective. Much of what I'm going to talk about next relates to the data and indeed the practice of an incredible research scientist and clinician. So this is Helen Blair Simpson, or I should say Dr. Helen Blair Simpson, because she is indeed an MD, medical doctor and a PhD research scientist at Columbia University School of Medicine and one of the world's foremost experts. If not the expert, I would put her in a category of maybe just one to three people. Who is most knowledgeable about the mechanisms of ocd, is actively researching OCD in humans, trying to find new treatments, trying to unveil new mechanisms and expand on our current understanding, and who also treats OCD quite actively in her own clinic. She describes that the key procedures are exposures, of course, done in person and with the actual thing that evokes the obsessions and compulsions. And the goal of course then is to gradually and progressively increase the level of anxiety, but then to intervene in so called ritual prevention to prevent the person from engaging in the compulsion. Typically, this is done through two planning sessions with the patient, so describing to the patient what will happen and when it will happen and how long it will happen so they're not just thrown into this out of the blue. And then 15 exposure sessions done twice a week or more. So the one thing to really understand about cognitive behavioral therapy is that it can take some period of time, several or more weeks, as many as 10 or 12 weeks. In addition, Dr. Blair, Simpson and others have explored what are the best treatments for patients with OCD by comparing cognitive Behavioral therapy alone. Placebo. So essentially no intervention, or something that takes an equivalent amount of time but is not thought to be effective in treatment. As well as selective serotonin reuptake inhibitors, placebo did not reduce the obsessions or compulsions to any significant degree. However, cognitive behavioral therapy had a dramatic effect in reducing the obsessions and compulsions, Such that by four weeks, that score that in this case ranged from 8 to 28, dropped all the way from 25 down to about 11. So it's a huge drop in the severity of the symptoms.
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A.comhuberman now what's really interesting is that when you look at the effects of SSRIs in the treatment of OCD symptoms, they had a significant effect in reducing the symptoms of ocd, but the severity of their symptoms was still much greater than those receiving cognitive behavioral therapy alone. So what happens when you combine them? Well, they explored that as well. And the combination of cognitive behavioral therapy and the SSRIs together did not lead to any further decrease in OCD symptoms. This points to the idea that cognitive behavioral therapy is the most effective treatment. And again, when I say cognitive behavioral therapy now, I'm still referring to cognitive behavioral exposure therapy done in the way that I detailed before, twice a week for 12 weeks or more. So for those of you that have sought treatment and you're taking a ssri, or if you're thinking about treatment and you're prescribed an ssri, the ideal scenario really would be to combine the drug treatment with cognitive behavioral therapy, or in some cases, maybe cognitive behavioral therapy alone. Although that's a decision that you really have to make with the close advice and oversight of a licensed physician. Because of course, these are prescription drugs. And anytime you're going to add or remove a prescription drug or change dosage, you really want to do that in close discussion with and on the advice of your physician. I don't just say that to protect me, I say that to protect you and because it's just the right thing to do. So what I'm about to tell you next is most certainly going to come as a big surprise, which is that despite the fact that the selective serotonin reuptake inhibitors can be effective in reducing the symptoms of OCD at least somewhat and certainly more than placebo, there is very little if any evidence that the serotonin system is disrupted in ocd. And I have to point out that this is a somewhat consistent theme in the field of psychiatry. That is, a given drug can be very effective or even partially effective in reducing symptoms or in changing the overall landscape of a psychiatric disorder or illness. And yet there is very little if any evidence that that particular system is what's causal for OCD or anxiety or depression, et cetera. Now, earlier we were talking about not reducing anxiety, but learning anxiety tolerance in order to deal with and treat OCD in the context of cognitive behavioral therapies. That doesn't necessarily rule out cannabis as a candidate for the treatment of ocd, and in fact, this has been explored. A study from Dr. Blair Simpson herself looked at this. This was a fairly small scale study. So first of all, I'll give you the title and again, we'll provide a link. This is entitled Acute Effects of Cannabinoids on Symptoms of Obsessive Compulsive Disorder, A human laboratory study. I'm just reading from their conclusions here. The data suggests that smoked cannabis, whether containing primarily THC or cbd, has little acute impact, meaning immediate impact, on OCD symptoms and yields smaller reductions in anxiety compared to placebo. So they did not see a. When I Say a positive effect, I mean a ameliorative effect, an effect in reducing symptoms of OCD from cannabis or, or cbd. Another treatment that's becoming somewhat common, or at least people are commonly excited about, is transcranial magnetic stimulation. So this is the use of a magnetic coil. This is completely non, invasive, placed on one portion of the skull, and one can direct magnetic energy toward particular areas of the brain to either suppress or nowadays you can also activate particular brain regions. There are some interesting data showing that if TMS is applied to areas of the brain involved in the generation of motor action, so the so called motor areas, or supplementary motor areas as they're called, while people think about or have intrusive thoughts, we know that the TMS coil can interrupt the motor behaviors, the compulsive behaviors, and at least in a small cohort of studies, in a small number of patients within those studies, this has been shown to be effective not just while the coil is on the head, of course, but act after the study has been performed or the treatment's been performed in reducing OCD symptoms by disrupting the tendency for the compulsive behavior to be so automatic. Right now I don't think it's fair to say that TMS is a magic bullet either. I think there's a lot of excitement about tms and in particular I really want to nail this point home. In particular, there's excitement about the combination of TMS with drug treatments or the combination of TMS with cognitive behavioral therapy. I realize that a number of listeners of this podcast are probably interested in the non typical or holistic treatments for OCD. Dr. Blair Simpson's lab has at least one study exploring the role of mindfulness meditation for the treatment of ocd. There the data are a little bit complicated and I should mention that good things are happening at least in the United States, probably elsewhere as well. But good things are happening in terms of the exploration of things like meditation and other, let's call them, non traditional or holistic forms of treatment for psychiatric disorders. Because of the Division of Complementary Health that's now been launched by the National Institutes of Health. So whereas before people would think about meditation or yoga, NIDRA, or even CBD supplementation for that matter, as kind of
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fringe, maybe, or kind of woo or
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non traditional, at the very least, the National Institutes of Health in the United States has now devoted an entire division, right, entire institute, purely for the exploration of things like breathing practices, meditation, et cetera. So there's a cancer institute, there's a hearing and deafness Institute, there's a vision institute, and now there's this complementary health institute, which I think is a wonderful addition to the more traditional aspects of medicine. I think no possible useful treatment should be overlooked or unresearched, in my opinion, provided that can be done safely. Turns out that mindfulness meditation can be useful in the treatment of ocd, but but mainly by way of how it impacts the focus on and the ability to engage in cognitive behavioral therapies. So it's very unlikely, at least by my read of the data, to be a direct effect of meditation on relieving the symptoms. Rather, it seems that meditation is increasing focus on things like cognitive behavioral therapy, homework, and to not focus on other things and therefore indirectly improving the symptoms of ocd. Now, somewhat surprisingly, at least to me, there have also been a fairly large number of studies exploring how nutraceuticals, as they're sometimes called supplements that are available over the counter, can impact the treatment of obsessive compulsive disorder. One compound that I like to focus on is inositol, and here I'm referring specifically to Myo inositol, because it comes in several forms. And it does appear that 900 milligrams of inositol can improve sleep and can reduce anxiety, perhaps when taken at that dosage or higher dosages. So I think there's a great future for these nutraceuticals, meaning, I think, more systematic exploration in particular of lower dosages in the context of, of OCD treatment and as we saw before, for the SSRIs and other prescription drug treatments. I think there really needs to be an exploration of these nutraceuticals in combination with behavioral therapies and who knows, maybe with brain machine interface like transcranial magnetic stimulation as well. What I've tried to provide is an opportunity to really drill deep into the neural circuitry and an understanding of where OCD comes from, and also to give you a sense of how the individual behavioral and drug treatments work and perhaps don't work, so that you can really make the best informed choices. Again highlighting the fact that OCD is an extremely common, extremely common, and yet extremely debilitating condition, and one that I hope that if any of you have or that you know, people that have it, that you'll both gain sympathy and understanding for what they're dealing with, perhaps as a consequence of some of the information presented today, and maybe help them direct their treatment, find better treatment, and of course, apply those treatments for some relief. In closing, I'd like to thank you for this in depth discussion about the mechanisms and various treatments for obsessive compulsive disorder and some of the related disorders. And as always, thank you for your interest in science.