← Ologies with Alie Ward
Ologies with Alie Ward
Obsessive-Compulsive Neurobiology (OCD) with Wayne Goodman
01:19:49
Ruminations and reassurances. Checking and counting. Suffering and stigmas. It’s OCD, babes! OCD is now considered one of the most common psychiatric conditions, afflicting 2% to 3% of the general population, and this episode is among our top-requested topics. So we snagged a top-shelf ologist: psychiatrist, researcher, advocate and OCD Neurobiologist, *the* Dr. Wayne Goodman. We cover myths, misconceptions, diagnosis and treatment options for OCD, as well as advice for loved ones. Also: PANDAS, famous folks who are helping break the silence on it, intrusive thoughts, deep brain stimulation, genetic components, links to Tourette’s Syndrome, finding the right doctor, and the behavioral therapy that is the gold standard for OCD. And surprise! Later this week we’ll have a bonus episode on OCD lived experience with neuroscientist, mental health advocate and OCD-haver, Uma Chatterjee.
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- [00:00]
Alie Ward
Oh, hey, it's the bowl that's chipped, but not chipped enough to throw it away. A.L.I.E. ward this is Ologies. This is OCD. Okay, we asked y' all on Patreon your most desired episodes and this was among the top, which was both a surprise, it was also a delight to me. Also a delight we got the world's most revered expert in OCD to talk to me for an hour. This person invented the scale by which OCD is measured. They've been working in this field for for many, many decades and is pioneering a bunch of new treatment and research for it. They studied at Boston University and Yale School of Medicine. They've also been instrumental in nonprofit work for OCD treatment and research. They're now a professor and the chair at the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College in Houston. And if you have OCD or you know someone who does or might, their life is better because of this absolute OCD icon. And just a content note, of course we talk about some parts of OCD that are distressing to people and that's part of why we're doing this to talk about it. But just a content warning up top that we do touch on self harm and some intrusive thoughts that might be a little disturbing to people. Now, I was nervous as hell to hop on this interview because I know their time is very limited, but we were able to cover so much, including questions from patrons@patreon.com Ologies you also can ask questions before we record. You can join that for less than 25 cents an episode. Also, Ologies merch is available at ologiesmerch.com should you need it. And for no dollars you can support the show just by leaving a review. And I read them all and then I pick freshie to read such as this one this week from Mich R who wrote if you were a kid who went to the Scholastic book fairs looking for non fiction books or fun facts books, this is the podcast for you Mish R. Let's crack into the catalog. Let's get some ocd. But first. Also thanks to sponsors of the show for making it possible to donate to a cause of the ologist choosing introducing the new Dell AI PC powered by the Intel Core Ultra processor. It helps do your busy work for you so you can fast forward through editing images, designing presentations, generating code, debugging code, summarizing meeting notes, finding files, managing your schedule, responding to long emails from some kind of gym, leaving all the time in the world for things that you actually want to do. No offense, Jim. Get a new Dell AI PC starting at $699.99 at Dell.com AI PC how those ahead? Stay ahead.
- [02:28]
Dr. Wayne Goodman
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- [02:59]
Alie Ward
Okay, Is OCD a niche condition? I would have thought so, since people don't talk about it a lot unless it's an offhand punchline or like an excuse for a complicated Starbucks order. But research reveals that OCD is now considered one of the most common psychiatric conditions afflicting 2 to 3% of the general population. I did not know that. And because of the high demand for this episode and because it's so close to my heart, surprise. We have a bonus episode coming out in a few days. We've been cooking up. It's all about lived experience. It's with a lovely neuroscientist researcher, board certified mental health peer specialist and mental health advocate Uma Chatterjee. So yes, an extra episode this week. Enjoy. That's a great conversation. But for now let's take a deep breath. Let's treat our brains to a feast of info on overt versus covert perfectionism, obsessions versus compulsions, neurodivergence and ocd. Pediatric illness induced OCD symptoms, ruminations, checking, counting, reassurance seeking, a few famous folks who are helping break stigmas, medicines on the forefront, some hopeful treatments in the future, Finding a therapist, Deep brain stimulation, genetic components overlap with Tourette syndrome, advice for loved ones and the behavioral therapy that is the gold standard for OCD. With Dr. Psychiatrist, researcher, advocate and OCD neurobiologist, the Dr. Wayne Goodman.
- [04:46]
Dr. Wayne Goodman
I'm Wayne Goodman. He him. I'm a psychiatrist and I work at the Baylor College of Medicine down in Houston, Texas.
- [04:55]
Alie Ward
Really excited to talk to you. We've wanted to do this episode for literally years and everyone we've talked to has said that you are a perfect choice for this. So we're very excited to be speaking to you specifically. Hundreds of papers last I saw on ResearchGate, 36,000 citations to your work. I believe you started in the 80s.
- [05:17]
Dr. Wayne Goodman
Yes, it's hard to believe it was the 1985. So 40 years.
- [05:23]
Alie Ward
40 years. What got you started down this path?
- [05:27]
Dr. Wayne Goodman
So I was at Yale doing my residency and starting a research fellowship, and I came across a patient with ocd. And it was the first patient I had seen with OCD and started reading about it, and I began to realize there wasn't that much known, particularly about the neurobiology or the treatment. So, long story short, wound up launching the OCD program at Yale, and I've been focusing on OCD ever since.
- [05:58]
Alie Ward
Was there something about this patient, Was it the level of suffering or the level of OCD that really hooked you? Were they particularly nice? Were they a patient you liked working with?
- [06:10]
Dr. Wayne Goodman
Well, I like all my patients. But of course, this patient had kind of a classic form of OCD involving contamination concerns and fear that if they didn't wash their hands carefully, they would get somebody else sick, particularly somebody they loved. And they realized that whatever they were doing, whatever they were thinking about was excessive. So that's what really struck me, you know, that this person was driven to the point that she used to have to use bleach on her hands. Her hands were red. Bleach. I mean, it could be caustic cause, not only skin irritation, but actual damage. And she was consumed by these thoughts almost every hour of the waking day. But yet again, she had complete insight into how absurd it was. And that's what struck me, was that paradox between the irrationality of the thoughts, the excessiveness of the behaviors, and totally preserved insight and executive functioning.
- [07:12]
Alie Ward
So this is a classic presentation of ocd, and it's probably what people think of first because it's just easy to explain too. And according to the research, up to 46% of folks with OCD do deal with contamination fears, but the other 54%, the majority, don't struggle with that. And at that time, were there scales to measure this? Was it something that was being treated with medicine? I know the Gail Brown Obsessive Compulsive Scale is something that you pioneered, which among people who know ocd, they're like, whoa, that dude did the actual test. He's OG. So the Yale Brown Obsessive Compulsive Scale, or Ybox as it's known, is a clinician administered 10 item scale with each item rated from 0 for no symptoms to 4 for extreme symptoms. So scores can run 0 to 40. And it was developed in 1989 by a Yale doctor. And this OCD legend named Wayne Goodman, who we are talking to right now. What interventions or what qualitative analyses was it back then?
- [08:19]
Dr. Wayne Goodman
So at the time, there were only case reports that one medication in particular was effective. It was a medication called clomipramine, which is still available. And it was one of the older medications with lots of side effects. And the case report suggested it was the only medication that seemed to work. And there was a theory that the reason it worked is because it had potent effects on the brain's serotonin system. Serotonin is one of the brain's neurotransmitters, or neurochemicals. And my training at Yale really focused on trying to understand not only treatment, but neurobiology. So that led me to want to test a newer generation of medications that were selective for their effects on serotonin. And then I looked around, and back to your question about rating scales. There really weren't any gold standard scales. So I work with my colleagues on developing one.
- [09:19]
Alie Ward
Is that something that a person can administer themselves, or is that really something that you gotta talk through with a doctor who can figure out, you know, very impacted, somewhat impacted? Can people self diagnose ocd?
- [09:32]
Dr. Wayne Goodman
Yes. So the way the Y box, that's the Yale Brown Obsessive Compulsive Scale is administered is it should be by a clinician who has experience in treating ocd. There are forms of the scale that are self rated so that the patient fills them out, but really the diagnosis is left up to the clinician.
- [09:52]
Alie Ward
We hear so often, and I'm wondering how you feel about this when people say I'm so ocd, Like, I love to have my. All my pens in the same spot on my desk. People with ocd, from what I understand, hate that a lot.
- [10:06]
Dr. Wayne Goodman
Yeah, they do.
- [10:07]
Alie Ward
Yeah. How do you feel as a professional and a clinician when you hear people say I'm so ocd?
- [10:14]
Dr. Wayne Goodman
Well, you know, I'm not judgmental. That's one of the things that you need to be as a psychiatrist. But I do point out that that's not the same as OCD.
- [10:23]
Alie Ward
Dr. Goodman says it's healthy and common to have certain preferences or routines. Sure.
- [10:29]
Dr. Wayne Goodman
Meaning being perfectionist, liking things, orderly. Those are good. But it's not a disorder until it takes up a lot of time and by definition would be more than an hour a day. It would be distressing. And for most of the patients I treat and I focus on treatment resistant OCD, I focus on severe OCD. We're talking about patients that can't go sometimes 15 minutes without having an intrusive thought or having to perform a compulsion.
- [11:01]
Alie Ward
We'll define those in a moment. And our surprise bonus episode out later this week with UMA goes into a ton of detail about lived experience.
- [11:09]
Dr. Wayne Goodman
So that's very different from the people who are, you know, have a little bit of OCD in them, like things orderly, and are still able to work and lead a very productive life. People with very severe OCD can be incapacitated, although many of my patients, despite their severe symptoms, figure out ways of still working around them. And a lot of patients. The other thing about patients with OCD is they're really good at camouflaging their symptoms.
- [11:36]
Alie Ward
Now we'll get to kind of outward behavior versus inward. But you mentioned severe versus kind of high functioning or people who can function around it. Well, is it a spectrum like a lot of other conditions?
- [11:53]
Dr. Wayne Goodman
Yeah, yeah. So even on the Y box, the rating scale goes from 0 to 40. And most patients that we treat in an outpatient setting with first line treatments, they have a score around 20, you know, like a midpoint. And those patients can continue to work, go to school, lead a very productive life, but the OCD is kind of gnawing at them and interfering with their ability to be fully functional and fulfilling life.
- [12:23]
Alie Ward
One thing that really surprised me about OCD is that it's not the same as an anxiety disorder. It's not underneath the umbrella of anxiety disorders. Is that correct?
- [12:33]
Dr. Wayne Goodman
That's correct. As of the DSM 5, the Diagnostic Statistical Manual, 5th Edition, that came out in 2013, before that, it was considered an anxiety disorder. And actually, I'm not sure that it was the right decision not to call it an anxiety disorder. It's now listed in the CSM5 manual as in the obsessive, compulsive and related disorders. But anxiety is almost always a component of ocd.
- [13:05]
Alie Ward
Does the anxiety tend to come from trying to control the ocd? Like people who have ADHD might have a lot of anxiety because executive function is difficult for them. Is the anxiety sometimes a byproduct?
- [13:19]
Dr. Wayne Goodman
It comes in various forms, but OCD comes in various flavors. But all patients with OCD by definition, have obsessions and compulsions. And the obsessions are the intrusive thoughts or images, and those by themselves are distressing. Kind of. By definition, an obsession is something that is disturbing.
- [13:41]
Alie Ward
More on these in a sec and in the bonus episode with uma. But these can, again be the fear of getting sick and getting someone else sick. Existential OCD about whether you really exist. There's false memory, OCD perfectionism, OCD relating to order and symmetry and counting that just feel off if incorrect. There's also harm OCD worrying that you might impulsively hurt yourself or others on accident or on purpose. Cause. And a very seldom discussed facet of OCD is pedophilia. Ocd. And this is a distressing worry that you will harm a child. But wait, there's more. There's moral scrupulosity, worrying about if you're a bad person who doesn't know it. There's checking ocd, like with matters of safety, like ovens or curling irons or locks. And there's reassurance seeking ocd. All of these obsessions can run like a ticker tape in your brain, and you would really like them to shut up. How do you do that? Compulsions.
- [14:41]
Dr. Wayne Goodman
And then the compulsions are designed in a way to reduce the anxiety associated with that obsession. But sometimes the compulsions themselves can be so time consuming. So like in the patient I mentioned before, you know, or even painful. I've had patients who took a shower so long that they ran out of hot water and they wind up taking a cold shower until they feel that they're clean enough.
- [15:07]
Alie Ward
You mentioned your. One of your first patients had contamination ocd, but I understand there's a lot of flavors. As you mentioned, there's pure ocd, there's moral scrupulosity, there's checking OCD numbers, there's reassurance seeking. So there's a lot of different ways that the obsessions and compulsions show up. Can you talk a little bit about pure OCD versus contamination versus moral?
- [15:37]
Dr. Wayne Goodman
Well, yeah. So again, going back to the Y box, we have this first part where we do the symptom checklist. And when I worked out with my colleagues, we saw hundreds of patients together and came up with a list of different categories. So different categories of obsessions include contamination. But also, like you mentioned, scrupulosity is a big one. It could be about taboo thoughts about religion or sexuality, unwanted, aggressive thoughts. You know, fear that you would be responsible for harming somebody or harming yourself even though you don't want to. And there's a whole bunch of miscellaneous ones that can occur as well.
- [16:15]
Alie Ward
So in response to those thoughts.
- [16:17]
Dr. Wayne Goodman
And the compulsions are generally designed. Again, design is probably not the right word, but they're functionally connected to the obsessions that try to reduce them. And they're not always in the form of something like washing or contamination that you can observe. They can be if, say, somebody has an intrusive thought of something terrible happening to a loved one, they could recite something in their head, or they can review something in their head, and you can't see that. But we would count that as a compulsion as well.
- [16:50]
Alie Ward
And via the paper Prevalence and Clinical Characteristics of Mental Rituals in Longitudinal Clinical Sample of Obsessive Compulsive Disorder in the journal Depression Anxiety, There are overt and physical compulsions, which you're probably more familiar with, but there are also covert or mental compulsions with no behavioral signs. And those types of compulsions include acts like silently repeating words or phrases or praying or counting or mental checking or thinking of good or safe thoughts to neutralize distressing mental images, among others. Now, that has to be a slim majority, right? That has the COVID kind, right? Nope. So this paper cites research suggesting that as many of 60% of OCD patients present without overt compulsions, meaning the majority of folks with OCD may just be struggling internally with mental compulsions, trying to undo the obsessive thoughts with other thoughts.
- [17:51]
Dr. Wayne Goodman
Now, you mentioned about pure obsessions.
- [17:54]
Alie Ward
Yeah.
- [17:54]
Dr. Wayne Goodman
There was a country star talking about. Did you see this about pure ocd? Oh, okay. I won't mention the name, but you can look it up.
- [18:03]
Alie Ward
Okay. It's Luke Combs, and he's been super public about it. And an article in NBC News reported that Combs hopes to use his platform to support others facing similar struggles. And in a recent interview with 60 Minutes Australia, Luke Combs explained his experience that it's thoughts, essentially, that you don't want to have, and then they cause you stress, and then you're stressed out, and then the stress causes you to have more of the thoughts, and then you. You don't understand why you're having them, and you're trying to get rid of them, but trying to get rid of them makes you have more of them. So what is pure O? Just obsessions.
- [18:37]
Dr. Wayne Goodman
And said that he had the form of pure ocd. It's a controversial entity. Most of us in the field who've seen a lot of OCD can identify mental rituals that patients perform when they have their intrusive thoughts. So I don't think patients pure OC or pure O is actually that common. I think most patients who have really a real case of ocd, and they may not perform overt rituals, but they're probably doing something mentally to try to ameliorate the anxiety associated with their thoughts or their images.
- [19:16]
Alie Ward
Oh, got it. So pure O is just the obsessions is what they're saying without compulsion.
- [19:20]
Dr. Wayne Goodman
Yes, it's just the obsessions. Yeah. And the vast majority of patients with OCD have both.
- [19:27]
Alie Ward
So Goodman is iffy on pure O because again, compulsions to stop the obsessions can be covert or mental and not outwardly behavioral. But usually, yes, the ways that you try to stop the obsessions are compulsions. The O and the C are the buddy comedy that you never asked for.
- [19:46]
Dr. Wayne Goodman
And they seem to be functionally connected.
- [19:49]
Alie Ward
So is it possible that some people might not realize the compulsions that they're even doing, and they might just think, oh, because I'm not doing something physical, then I don't have a compulsion.
- [20:01]
Dr. Wayne Goodman
Right, yeah, they might think they have pure O, which they probably don't.
- [20:05]
Alie Ward
Oh, that's interesting. Okay, I wasn't sure about that. Now, what are some of the more overlooked types of OCD that you feel like the general public doesn't know much about? I feel like the ones I hear about a lot are contamination and checking, making sure that the curling iron's unplugged, that everything's stove is off, that the front door is locked. You have difficulty believing that you've done those things, and so you have to keep checking. But can you elaborate on some of the other, maybe more overlooked ones?
- [20:36]
Dr. Wayne Goodman
Yeah. There's a category we sometimes refer as just so or just right OCD where people have to repeat something. I have a patient recently who was looking at the clock, and she really wasn't looking to see what time it was. She had superstitious concerns about she had to watch the second hand of the clock and see it hit 12, because otherwise she had had this thought that if she doesn't see the 12, something bad is going to happen to her. And the other things that she would do could be really random. She could just repeatedly touch something or repeat something and you wouldn't notice it. And I would ask her, how do you know when it's done? How do you know when you've done enough of these, performed enough of these compulsions? And she would say, until it feels just right. So it's kind of a just right feeling. And people have a hard time articulating that. But that's a common form that's often overlooked.
- [21:36]
Alie Ward
And just full disclosure, I was diagnosed two years ago with ocd. Never realized that I had it. I don't have a super severe case, but I look back and I'm like, I had some stationary that I've had for 20 years, and I was like, if I use the last piece of this stationary, my dad will die. Things That I didn't tell anyone that I even thought because it sounded bonkers. But I was very afraid that if I used that something bad would happen or I have terrible procrastination problems. I'm really avoidant because I'm always afraid of making a mistake, and then it'll lead to my downfall. My career will be over if I make one mistake. And so there's. There's like a certain kind of magical thinking. It feels like.
- [22:18]
Dr. Wayne Goodman
Yeah, that's a good category too. Yeah. Magical thinking.
- [22:22]
Alie Ward
This feeling that you can maybe control the outcome of bad things and avoid them if you do something concrete about it.
- [22:29]
Dr. Wayne Goodman
Yeah. Even though, you know it doesn't make any sense. Right.
- [22:32]
Alie Ward
Yeah. Doesn't make any sense.
- [22:34]
Dr. Wayne Goodman
But you don't want to take a chance.
- [22:35]
Alie Ward
Exactly.
- [22:36]
Dr. Wayne Goodman
Because the stakes are too high.
- [22:37]
Alie Ward
Stakes are high.
- [22:38]
Dr. Wayne Goodman
And the OCD is telling you to do it.
- [22:41]
Alie Ward
Oh, yeah. Or not to do it.
- [22:43]
Dr. Wayne Goodman
Right, Exactly.
- [22:44]
Alie Ward
Because if it landed on you, you could never forgive yourself. But I feel like, you know, when you mentioned the contamination OCD with one of your first patients worried about she would hurt someone else, it feels like the avoidance of a bad outcome can fuel a lot of obsessions and compulsions. Do you find that with a lot of your patients?
- [23:05]
Dr. Wayne Goodman
Yeah, I think that's a universal. So again, we talked about all the kind of different forms of flavors of ocd, but I think most of them have in common that patients with OCD are harm avoidant. They're worried about some outcome. That outcome could be something happening to themselves or their loved ones, failing at work or having their career go up in smoke. And we talk about scrupulosity. It may be something that's most dear to that particular person is the thing that they're going to worry about most.
- [23:37]
Alie Ward
That makes sense. And what about onset? When do you tend to see OCD become apparent enough? Cause I'm sure a lot of people might have this as kids. I mean, don't step on a crack, you'll break your mother's back.
- [23:50]
Dr. Wayne Goodman
I was gonna mention that one. Yeah, that's the classic magical thinking one. But you actually do see it.
- [23:56]
Alie Ward
Just a side note, this superstition has folkloric origins, and it was a common and incredibly racist rhyme originally. And about 5% of adults still avoid cracks in the sidewalk. So let's just retire this one forever. Okay, Good. Love that. I wonder how much that particular rhyme is responsible for patterns. But what do you think the onset might typically be?
- [24:21]
Dr. Wayne Goodman
So about half the cases of OCD have onset in childhood, and then there's another large group in early adulthood. So actually, I see a lot of people who first have onset of OCD after they go off to college.
- [24:35]
Alie Ward
Oh.
- [24:35]
Dr. Wayne Goodman
So around that age range, it's unusual to see onset after age 35.
- [24:42]
Alie Ward
Okay. Have you seen more people seeking treatment after the COVID pandemic hit with. Especially with contamination?
- [24:52]
Dr. Wayne Goodman
You know, it's funny I should know the answer to that because I was on a paper that looked at it. I don't think it's had a huge impact. It's just made it a little bit more confusing. For example, I had a patient who I was treating with very severe OCD during the pandemic, and he used to wear three layers of gloves and a mask. And once the COVID struck, he didn't stand out anymore. Ah, he thought that was really, really helpful in a way that it kind of normalized his appearance. Yeah, but I don't think so. It may have had a temporary impact because, I mean, we were all concerned, but I don't think it really caused that many new cases of O. OCD.
- [25:34]
Alie Ward
And for more on this, you can see the 2023 paper Dr. Goodman co authored titled COVID 19 Related Intrusive Thoughts and Associated Ritualistic Behaviors, which looked at a new thing you could have called CITRB or COVID 19 related intrusive thoughts and Associated Ritualistic Behaviors. But the study, however, concluded that while it's helpful and even critical for providers to see and take into account Covid related distress, it's likely a chicken or the EG situation. That is, if you only noticed obsessive compulsive traits after the COVID pandemic hit, chances are you already had a little bit of OCD before then. Also, there is a very baseline preoccupation with germs that came out of this. The September 2020 study, COVID 19 and OCD Potential Impact of Exposure and Response Prevention Therapy acknowledges right up top that the SARS CoV2 Coronavirus Disease 2019 pandemic is the greatest international health crisis in our modern era. So if you've been on edge about microbes, just about COVID that's just kind of normal. This is a novel virus killing millions of people. And to this day, half of reported COVID deaths in the world are in the United States. The US has half the deaths, and because of truly unhinged politics, half the country or won't wear masks or take a vaccine. So what the fuck? But yeah, there are rational precautions in a pandemic, and then there are OCD behaviors that prevent you from daily functioning and reading through Dr. Goodman's list of published papers, so many of them, it's astonishing. I'm going to be real with you. I started crying at how much work he's done in your research, which, again, you've done so much research. Neurochemistry versus neurobiology. You mentioned serotonin, you mentioned SSRIs as a treatment line or SNRIs. Have we.
- [27:34]
Dr. Wayne Goodman
You know your stuff, by the way. You know, you really do.
- [27:37]
Alie Ward
It's because I'm on one of them. I am. I got. I got put on Lamictal, actually, after I was diagnosed, and it's been. So I have questions about glutamate, of course, too, so. Lamotrigine, brand name Lamictal, was developed for the treatment of certain types of epilepsy because it slows bursts of electrical activity that could cause seizures. But some psychiatrists prescribe lamotrigine off label for depression associated with bipolar and also for things like fibromyalgia, certain types of migraines, panic disorder, binge eating disorder, and, yep, OCD. So the 2015 paper Role of Lamotrigine Augmentation in Treatment Resistant Obsessive Compulsive Disorder, A retrospective case review notes that genetic, behavioral and neuroimaging studies have shown evidence of abnormally high glutamatergic concentration in certain parts of the brains of people with ocd. And adds that resistance to pharmacotherapy is one of the major challenges in the management of ocd. But one avenue for that is glutamatergic modulators like Lamotrigine. So we're gonna link a few other papers on our site, but just something to explore, maybe with your doctor. And also because lamotrigine can cause some severe allergic reactions in some people and it needs to be closely monitored, it can also affect your white blood cell count. So talk to an actual doctor. Because I'm. And Dr. Goodman cannot treat or diagnose you from a podcast, nor can you take a transcript of this podcast to your pharmacist. But, yeah, neurochemistry versus neurobiology. Is it a combination of both?
- [29:13]
Dr. Wayne Goodman
So going through my own career, which we already established, has gone on for a long time. The first half was more neurochemistry, neurobiology, looking, for example, at the role of serotonin. And I published a lot of negative studies looking to try to identify an abnormality in the brain, in the serotonin system. And that's proved elusive, not only for me, but for the whole field. And you mentioned glutamate. That's another neurotransmitter that's been implicated in ocd. And there's some interesting work on that and some medications that are being tried. But at some point, I pivoted more to looking at OCD is a brain circuit disorder instead of a neurochemical disorder. Not that serotonin clearly plays a role in treatment, but it's not clear it plays a role in the origins or pathophysiology of the illness. So I started getting involved more in looking at the brain circuits that mediate the symptoms of ocd.
- [30:12]
Alie Ward
So he's been in the game so long, he's gone deeper into the actual brain and even in 2012, published the study Deep Brain Stimulation for Intractable Psychiatric Exploring treatments for patients who had exhausted other avenues. And by helping these cases, he's also pioneering new understanding in the process.
- [30:31]
Dr. Wayne Goodman
And that's led me to different treatments, more neuromodulation, medical devices instead of drugs. Not. There's still a role for drugs. And. And there's definitely. The thing we haven't touched on and we need to is the role of behavior therapy. If I don't do that, my psychologist colleagues will be very upset with me. Damn right.
- [30:51]
Alie Ward
Okay, so behavioral therapy, the right kind, is huge. We're gonna get into that, especially the gold standard, which is exposure response prevention or ERP therapy, in just a little bit. But I do wanna give you some broad strokes of the neurobiology of and the medication options for OCD. So let's start with SSRIs. SSRI? It stands for selective serotonin reuptake inhibitors, because these medications target serotonin and they prevent it from getting sucked back up into the brain cells. So there's more serot serotonin that stays floating between the nerve cells to relay messages between them. And there are a ton of other SSRIs on the market as well that go by a lot of different names. Now, SNRIs, they're not as selective as SNRI stands for serotonin and norepinephrine reuptake inhibitors, and they work to keep more of both of those neurotransmitters between the cells. So SNRIs can have fewer side effects in some people than SSRIs do. And SNRIs are sometimes pres for anxiety and nerve pain. And lamictal or lamotrigine is neither an SSRI or an snri. It's what's called a phenyltriazine drug and it's used to prevent seizures and types of epilepsy. It's also used as a mood stabilizer which can help with bipolar depression. And it's been shown to modulate those glutamate levels in the brain. We have a whole episode on neurotransmitters. It's called molecular neurobiology with Dr. Brain, aka Dr. Crystal Dilworth, which we'll link in the show notes. But let's put that skull juice to work to learn more about itself. Would you say that the majority of cases can be helped with medication or is it really a crapshoot?
- [32:36]
Dr. Wayne Goodman
Depends who you ask. But you're asking me, so I would say, you know, it's really a lot up to the patient. I mean, if I'm seeing a patient who say I'm first diagnosing them with OCD and they have moderate ocd, not severe ocd, Well, a moderate is still not great. I mean, it still can be quite distressing and impairing. I would outline, you know, you have two options. You can have do the cognitive behavioral therapy, you can do the medications, and I'll give the pros and cons. A lot of patients will do well with one or the other and sometimes you wind up doing a combination of both.
- [33:12]
Alie Ward
Do SNRIs because they work in norepinephrine. Do those tend to help with the anxiety that can be a result of ocd?
- [33:21]
Dr. Wayne Goodman
That's a good theory. I like that theory. But if you really want to be hardcore and you look at randomized controlled trials and peer reviewed publications, the only medications that have been shown effective are the SSRIs. The SNRIs, based upon clinical experience are also effective. And perhaps the neurogenergic effects have some additional benefit, like you said, for anxiety. But I'm not totally convinced.
- [33:47]
Alie Ward
Okay.
- [33:48]
Dr. Wayne Goodman
But I'm even skeptical of my own work. Again, over the years I've tried different medications in our patients, maybe even published a paper case report showing that it worked. But until you subject it to the rigor of a randomized controlled trial and by mean that a blinded study where you randomize patients to either the drug or the placebo, you don't really know the answer.
- [34:14]
Alie Ward
Yeah, and you mentioned that your work involves people who have not been helped by what's typically administered. You do deep brain stimulation. Can you explain what that is?
- [34:27]
Dr. Wayne Goodman
I work with brain surgeons. So the last 20 years I've been working with neurosurgeons and they do the deep brain stimulation or dbs. And that's mostly A treatment for movement disorders like treatment resistant Parkinson's disorder. But we've done studies together showing that it can be very effective in patients with treatment resistant severe ocd.
- [34:52]
Alie Ward
What is happening there? What are you stimulating? I picture there being this OCD rope that you just go in and cauterize, but I don't think that's how that works. What happens?
- [35:05]
Dr. Wayne Goodman
It's a very complicated story and a very controversial one. There's been so called psychosurgery. I hate that term because it's brain surgery. Nobody's operating on your psyche, they're operating on your brain. But before the introduction of deep brain stimulation, some surgeons at different centers both in the US and the UK were doing what's called ablative surgery. Ablative means actually making a lesion a small hole. And the theory behind that was that there's a circuit. So let's identify those connections between those two areas, between the obsessions and the compulsions and cut those connections and create a lesion. So that was the hypothesis. And there have been many case reports and case series showing that some of those patients with severe OCD did very well with very few side effects. Not like the lobotomy error. You know, that's a totally, totally different kind of procedure. So that led to the theory that, that you could use deep brain stimulation, which is not causing a lesion, but is stimulating an area of the brain at a high frequency that still interrupts those pathways. So the idea still behind DBS is somehow it's interrupting the OCD circuit, this reverberating loop that's self reinforcing between obsessions and compulsions. Because that's part of the problem and the basis of the exposure response prevention is you. The more a person performs the compulsions and the more effective those compulsions are in reducing the angst associated with the obsessions, the more that's going to become habitual.
- [36:38]
Alie Ward
Now is that kind of helpful in determining how genetic it is? If you're looking at brain anatomy or I should just ask straight up, but like how much of this is genetic?
- [36:48]
Dr. Wayne Goodman
Yeah, there's definitely a fair contribution of genetics. It's not simple. It's not simple. Medallion genetics, where it seems to be more genetic are in those patients that have both OCD and Tourette syndrome.
- [37:02]
Alie Ward
Oh, right.
- [37:03]
Dr. Wayne Goodman
It seems to be a stronger genetic connection.
- [37:05]
Alie Ward
And the 2014 paper Tourette Syndrome and Obsessive Compulsive Disorder Compulsivity along the continuum in the Journal of Obsessive Compulsive and Related Disorders recaps some previous Research that revealed that genetic family studies have shown higher rates of OCD symptoms or OCD in relatives of individuals with Tourette syndrome. And also research has shown higher rates of tics or Tourette syndrome in first degree relatives of patients with ocd. And the proportion of individuals with Tourette syndrome who also have OCD is up to 63%, rather than the general population rate of 2 to 3%. This study notes that, however, despite the significant genetic overlap between these disorders, Tourette syndrome and OCD do have distinct genetic architectures. And deep brain stimulation has been used to treat conditions like Tourette syndrome, Parkinson's disease, essential tremor, epilepsy, and of course, the reason that we are all here, obsessive compulsive disorder. I'm sorry, how though, does that work?
- [38:10]
Dr. Wayne Goodman
Going back to your question though, about how the DBS works. Yeah, I honestly don't. It's an area that we're studying, but where it's implanted in the brain is the reward circuitry, so the immediate effects. So I do the programming of the device and the surgeon does the implantation. And then after they've recovered from the surgery, which is just overnight, a week later, I can interrogate the device, I can stimulate that area of the brain, and that area of the brain is part of the reward circuitry. And some of the immediate effects when I turn on the stimulation are the person feels happier, they feel more energetic and less anxious. And over time that leads to reduction in ocd.
- [38:50]
Alie Ward
How bad off do you have to be for how long before you get bumped up to the Goodman level? Treatment?
- [39:00]
Dr. Wayne Goodman
Yeah. Yeah. It's not just me. I'm not the only one. But it's not that many of us either. But you have to have OCD for at least five years. Has to be an adult. We won't do it in a kid. A child. And it's gotta be a Y box in the severe to extreme range. And they have to have had multiple medication trials and failed ERP Exposure response prevention.
- [39:22]
Alie Ward
Why does ERP work?
- [39:25]
Dr. Wayne Goodman
Again, let me say ERP is not my specialty. My psychologist colleagues are specialists in that, but it breaks this cycle. We've talked a little bit about OCD as kind of self reinforcing, and the idea is with the surgical ideas, you interrupt that, and I think with erp, you try to interrupt that too.
- [39:42]
Alie Ward
So cognitive behavior therapy is a type of brain retraining and it comes in a lot of forms. One of those is erp, or exposure response prevention, which involves exposing your yourself to the thoughts and confronting them and then the prevention or making a choice not to do a compulsive behavior once the anxiety or obsessions have been triggered, they say so you're like, oh, okay, so just like, don't do the thing. Okay, cool. Thanks. I promise it's not that simple. Of course. And working with a therapist trained in erp, they'll help come up with a plan to take small steps to retrain your brain. And according to the International OCD foundation, yes, it's scary at first, and that's the point. But when you do ERP correctly, the following things happen. They say you will feel an initial increase in anxiety, uncertainty, and obsessional thoughts. You will find that these feelings and thoughts are distressing, but also that they can't hurt you. They're safe and manageable. When you stop fighting the obsessions and the anxiety, these feelings will eventually begin to subside. And this natural drop in anxiety that happens when you stay exposed and you. You prevent the compulsive response is called habituation. So just staying in it and confronting the fact that you're having these obsessive thoughts without doing the compulsive response, you get used to that. So you'll find that your fears are less likely to come true than you thought, and then you'll get better at managing everyday levels of risk and uncertainty. So Dr. Goodman explains the clinician's role.
- [41:18]
Dr. Wayne Goodman
What happens to people that have an obsession is they try to perform a compulsion to reduce the anxiety. So what you want to teach them in a behavior therapy session is don't perform your compulsion. Let's just wait and tell me how much distress you're feeling. Maybe on a scale of 1 to 10, maybe it starts off as an 8, but 40 minutes later, even without performing compulsion, it's maybe down to a four. And you didn't have to perform a compulsion. So you begin to teach the person over time that they shouldn't try to avoid the obsessions. They actually should try to let them come. So often a metaphor is like, don't fight the waves. Ride those waves. The more you try to react to the ocd, the more it's going to take a grip on your life.
- [42:07]
Alie Ward
And we've talked about the compulsions and what those look like, but can you describe how your patients describe the obsessions? How do other people describe them?
- [42:16]
Dr. Wayne Goodman
It really varies, but it's definitely intrusive. It's always disturbing. I mean, we may not have emphasized this enough. When we talk about obsessions and ocd, we're talking about thoughts, images, or unwanted impulses. That are disturbing. On the other side of the coin with compulsions, they're never pleasurable. So we use the word compulsion very loosely. Sometimes like compulsive eating, compulsive gambling, compulsive sexual activity. Now even though all those could be problematic activities, particularly like the gambling gets you in a lot of trouble or some drug use can get you into some trouble, we may use the word compulsive, but we wouldn't say that that has any connection to ocd because at least at some point the gambling was pleasurable, you got some gratification from it, certainly when you won. In ocd, the compulsions are never gratifying. They may reduce tension, they may reduce the anxiety associated with the intrusive thoughts, but in of themselves they're not inherently gratifying.
- [43:25]
Alie Ward
So not like other compulsions, I'm like a less cool compulsion. And Dr. Goodman says that one consistent issue that OCD sufferers have, no matter what the flavor, is harm avoidance. Harm to yourself and others becomes so terrifying that the brain puts too much energy in trying to to avoid it ultimately doing a harm to you and your life. And I wanna talk a little bit about comorbidities and we have questions from listeners who have they know you're coming on and so they submitted em ahead of time. We also donate to a cause of your choice, a related cause and I know there's an OCD walk coming up.
- [44:02]
Dr. Wayne Goodman
Iocdf.
- [44:03]
Alie Ward
Oh okay, great, perfect. We will donate to them and shout them out and put a link for people. Iocdf. No hesitation. I love that. The International OCD foundation is a highly respected and core source for so much support and info for folks who have OCD or know someone who does. Their vision is that everyone impacted by OCD and related disorders has immediate access to effective treatment and support and they provide up to date education and resources, quality professional training and they advance groundbreaking research. And as a leading nonprofit in this space, IOCDF has been around since 1986. It was co founded by a guy named Dr. Wayne Goodman, you may have heard of him. Also he asked that his honorarium for this show also be donated to iocdf.org so thank you to sponsors of the show for making that double donation possible.
- [44:53]
Dr. Wayne Goodman
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Alie Ward
Them.
- [45:06]
Dr. Wayne Goodman
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- [45:40]
Alie Ward
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- [48:08]
Dr. Wayne Goodman
Yeah, that happens a lot. The most common comorbidity is depression.
- [48:13]
Alie Ward
Yeah, bummer.
- [48:15]
Dr. Wayne Goodman
Particularly the more severe, the more treatment resistant, the longer it's lasted. It's very common for, for patients to present with depression, and that's what I teach our residents or trainees is if you have a patient that's presenting with either anxiety, of course too is part of the syndrome. They're presenting with depression. It really behooves you to ask questions. Do you have any behaviors that you feel you have to perform over and over or any rituals that you have to perform in order to reduce your anxiety? Because again, one thing as I mentioned earlier, is patients with OCD by definition have insight into the absurdity of their thoughts and excessiveness of their behaviors. I'll tell you one example. A patient of mine many years ago who came to me was a software engineer, a very logical guy, and he said, doc, you're going to think I'm crazy. I've never told this to anybody, but and this goes back a few years is when you used to go to the mailbox and mail a letter. And he said, I can't mail a letter without wondering if my 5 year old daughter's inside. And I said, doc, you're going to want to lock me up because I know you can't put a five year old in the door, but unless I check before I mail it, I worry something's going to happen to her. So it was kind of a metaphor for something happening to her. So it reached the point where it became very physical that he would have to look inside an envelope, he would have to look at billboards to make sure she wasn't in the billboards. And he actually did very well with treatment, but he was completely logical, kept this as a secret from his family, including his daughter.
- [49:51]
Alie Ward
And I've read of other people who are so afraid that they hit someone on the road and didn't realize it, that have to drive back and check several times. And it's interesting that harm avoidance is something that is so common with so many patients of it. And again, we mentioned that the majority of compulsions can be covert and not related to any outward behavior or rituals. But what's the difference? Difference between strong preferences and compulsions? Patrons Jennifer Lemon Zink, Alicia Henning, Amelia Phillips, Valerie Kirby, Dee Austin Broadwater, Mackenzie King. All of them asked in the words of s first time question asker. How do you disentangle OCD from autism? Are they frequently comorbid when it comes to rituals and things like that? Do you see folks who are autistic who have trouble maybe understanding if it's OCD versus if it's just like a rigidity? That's comfort.
- [50:44]
Dr. Wayne Goodman
It's a great question and it comes up a lot because. Because if you have somebody with autism who may have some limited communication skills, they may have trouble explaining the obsession. So you have to infer them. So if they're doing ritualized hand washing or they're doing repeating, getting in and out of a chair, you can probably infer that they have obsessions, even if you can't really identify them and you wind up treating them in the same way as you would for ocd.
- [51:12]
Alie Ward
And how about for people who are verbal and aware of their own rituals? Is there ever an overlap that gets misdiagnosed where people maybe don't realize they have OCD or don't realize that they have autism, like eating the same meal, say, or sitting in the same spot?
- [51:31]
Dr. Wayne Goodman
It's somebody who's very ritualized. Yeah. Yeah. That isn't necessarily ocd. The other thing I would say is, although you can have a monosymptomatic picture, meaning that maybe just one type of ocd, most patients with OCD check off different boxes. Sometimes when I'm not sure myself, I have more confidence in the diagnosis when I find that over time some of their obsessions and compulsions have changed and that they check off different ones.
- [51:59]
Alie Ward
What about executive function and perfectionism or avoidance? Things like that. People who might have trouble? Yeah, like, for example, me getting set into work or work avoidance students Patrons Matt Sekafian Kuxjember Issa, A perfectionist, but not ocd. Haver and Alex Rose, first time question asker, who asked quite simply, why is perfection OCD such a bitch? Where is the line between perfectionism and ocd?
- [52:30]
Dr. Wayne Goodman
There is another condition, obsessive compulsive personality disorder, that sometimes it's hard to distinguish that from ocd. But that diagnosis implies more Perfectionism and insistence that others kind of follow rules. And generally speaking, people with OCPD don't have a lot of insight. Generally what I found is that it's their family members who say, you really need to see somebody because you're driving me crazy with wanting to do things in your way all the time or in a certain way all the time. So there is some connection, but I think they're distinct most of the time.
- [53:10]
Alie Ward
And other experts note that the core difference lies in the motivation behind perfectionist tendencies. Is it a high standard? Is there a certain goal in mind? OCD related perfectionism, however, may come from a place of extreme anxiety, catastrophizing self criticism and doubt. So one compulsion is avoidance. And a 1994 study titled Procrastination Tendencies among Obsessive Compulsives and Their Relatives did find a correlation between OCD and task avoidance. The author of that study is world renowned procrastination expert Dr. Joseph Ferrari. And if you're like, you should do an episode with him. I did Volitional psychology. We did it. It's linked in the show notes. His big advice is like, just do the thing. He even signed my copy of his book book still procrastinating. The no Regrets Guide to Getting it Done with the scrawl. Just do it now. All caps. At the time I was like, joe, I can't, so fuck me, I guess. And then I learned much later that just do it now was just a little brusque and a less gentle type of exposure response prevention essentially. So until you stop procrastinating, you will not realize that procrastinating and compulsive avoidance is worse than the thing you're afraid to do poorly. And because of a therapist who understood erp, I have since adopted two phrases which are essentially like bite sized takeaways that have helped me more than anything else to tackle my decades long plague of putting off the highest stakes tasks and avoiding them. So I used to know myself as a last minute person. That was just like my vibe. Now when I see an email or a form or a thing I have to write and I avoid it because what if I do it wrong? I tell myself I'm a person who does things at the first minute. So that when a task or email or decision or a draft of something comes up, I decide or I start it that first minute or that first day, do not let it grow mold. So I just say I'm a person who does things at the first minute to have me just jump right into something the other thing that exposure response prevention has taught me to say to myself all the time is worst things first. So what do you dread the most? Do it first. If you don't want to do it, well, it's therapy to get it done. And after a while you say, wow, okay, I did a bunch of things I would have otherwise avoid. They did not kill me, and I did not do such a bad job that my whole life collapsed. So look, I made this episode, and so far I have not died or killed anyone in the process. Hooray. Now, speaking of putting some thoughts into our little meatball brains, what about the thoughts that we don't want around the ones that barge into our lives like a dinosaur made out of a grizzly bear doing jazz hands through the wall like the Kool Aid Man? Well, patron Audrey Keene wrote, can you ask about intrusive thoughts in ocd? I really do not want to drive my car into a tree or touch a hot stove, but in difficult times, my brain has yelled at me to do such things. Honestly relatable and patrons love to learn. 46 Nicole Campbell, Ruby Gordon Moss, Emily Stauffer and nasty garden rat's friend wanted to know about these rude intrusions. Liliana first time crossing Oscar wrote. Sorry for a rather intense question. I know many people with OCD experience intrusive thoughts, and some, like my friend, have especially distressing ones, such as pedophilic intrusive thoughts or fears of cheating or other scary and taboo topics. Could you speak about why OCD often involves such intrusive thoughts, what causes them, whether they're dangerous, and how people can manage? We mentioned intrusive thoughts, and sometimes all thoughts feel intrusive. But can you explain exactly what an intrusive thought feels like or when you know that thought is unwanted, why you can't just kind of swat it away?
- [57:06]
Dr. Wayne Goodman
Well, I can just go by what my patients tell me.
- [57:09]
Alie Ward
Yeah.
- [57:09]
Dr. Wayne Goodman
And the other thing, as long as you're on that point, there are patients with psychotic conditions like schizophrenia may hear voices, right? They may have auditory hallucinations. So they may hear a voice that tells them something or tells them to do something. One of the distinctions we make when we're making a diagnosis of ocd, I'll ask the patient, well, it feels like there's a voice in your head. Is that from your own brain? Or you're actually hearing a voice? And if they have ocd, they say, oh, no, no, I know it's my brain, but it's like part of me is telling me that I need to be careful that something terrible may happen. And until I do something about it, that terrible feeling is going to linger. So I think you're right. When I screen for somebody, I say, do you ever have intrusive thoughts? Do you ever have thoughts that come out of the blue and bother you? Everybody has them. That doesn't distinguish ocd. It's really the combination of having an intrusive thought that's unwanted, unpleasant, and the need to do something about it. It either physically or in terms of a mental ritual.
- [58:13]
Alie Ward
We had a great question from someone named Reyna, who very passionate request. They say, can you talk about the intrusive grippy sock type of ocd? I don't know if you know that term, but grippy sock vacation refers to, like an impatient stay. But this person said that they were having intrusive thoughts, but they didn't seek help because they were afraid of getting hospitalized for saying it out loud. And they said, I think more people need to know the difference between, say, suicidal ideation or intent versus intrusive OCD thoughts of self harm. How do clinicians parse that out? And does that happen a lot where someone is having intrusive thoughts without intent, but it shoots them down, the wrong thing?
- [58:53]
Dr. Wayne Goodman
Yeah, that's a really good question too. So some patients may have an intrusive thought that they may hurt themselves. But what they'll tell me if they have OCD is they really don't want to hurt themselves. They have no plan, they have no intent. It's the last thing I want to do. But they're worried that if they don't do something, perform some ritual, that somehow they're going to hurt themselves. More often people are worried that they're going to hurt someone else rather than themselves. And when suicidality comes up, it's usually because the person is very depressed. They feel demoralized, they feel hopeless. Maybe they feel embarrassed about their symptoms. That's when suicidality comes to fruition.
- [59:38]
Alie Ward
We have an entire episode called suicidology with suicidologist Dr. Dequenzi Mayfren Lazine, which we'll link for you in the show notes.
- [59:47]
Dr. Wayne Goodman
Let me say something about a fear of harming others. That's a very common one. And there the questions come up. Well, say if you're an inexperienced clinician and somebody comes to you and they're afraid they're gonna hurt somebody. I mean, what you find out first, do they ever hurt anybody, you know, intentionally? And who are they afraid of hurting? Are they afraid of hurting Their boss who they hate. I don't know. Well, maybe that's not lcd.
- [60:12]
Alie Ward
I'm well within my rights to kill you right now.
- [60:16]
Dr. Wayne Goodman
But what are they afraid of? They can't babysit for their grandchild anymore because they're afraid they're gonna put their grandchild in the microwave. And they said, that's crazy. But I'm afraid that instead of baking the cake, I'm gonna put my grandchild in the microwave so I can't babysit anymore. That's ocd.
- [60:36]
Alie Ward
When you mention harm others versus self. Mallory Alby wanted to know, is OCD associated with things like skin picking or hair pulling, things like that? Is that under the OCD umbrella?
- [60:46]
Dr. Wayne Goodman
The skin picking and hair pulling? Trichotillomania is under this larger category, larger umbrella of OCD and related disorders. But they're consider from OCD you do see some comorbidity, but they're separate and sometimes require different treatments.
- [61:03]
Alie Ward
What about eating? Deanna Day, Zoe Dunham, Mie Gio Beck. And in Matt Sekafan's words, what's known of the relationship between eating disorders and ocd? Same with disordered eating at all.
- [61:17]
Dr. Wayne Goodman
Yeah. In terms of the relationship between eating disorders and ocd, the one where I see the strongest connection in some patients between anorexia nervosa and ocd. In fact, I've seen some patients over the years who may have started with anorexia nervosa, where the focus has been more on their weight, and then they develop some rituals and other obsessions unrelated to their weight. So I see some connection there. The idea of compulsive eating or bulimia, I don't see a strong connection between that and ocd. That's in my mind, a misuse of the term compulsive.
- [61:57]
Alie Ward
Okay, that's good to know. Some people wanted to know about infections and capi. Berigal asked, how often is the onset of OCD preceded by an illness or infection? And a lot of people wanted to ask about pandas, which is a. I'll put it in aside. Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infections.
- [62:18]
Dr. Wayne Goodman
Or say that three times fast.
- [62:20]
Alie Ward
I cannot. Or pans. Okay, so PANS stands for Pediatric Acute Onset Neuropsychiatric Syndrome. And it's related to pandas. Cute names, horrible conditions. And PANDAS stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. No, I'm not going to say that three times. I Just said it twice. That was hard enough. But according to the National Institute of Mental Health, these conditions affecting kiddos involve autoimmune encephalopathy, or brain inflammation, causing sudden and severe onset of ocd, or restrictive eating disorder in children. And mood, behavior, and sensory and motor function can also be affected. But what doctors suspect triggers this are infections like pandas involve strep or scarlet fever. And in general, pans may be triggered by immune system issues or illness or even environmental factors. And the conditions may start or stop suddenly. And for a while, there was a lot of controversy on whether pans or pandas were even real. And in 2012, Stanford University became the first academic institution to start treating it. Now, patrons including Anastasia Press, Aaron Sorensen, Nicholas Randall, Raina William Russell, they all asked, if PANDAS or pans is the same as OCD, does treatment differ, and what's Dr. Goodman's take on it? And Nicholas Randall echoed. Oh, gosh. The PANDAS question would be so good to hear and ask. But, yeah, a lot of people wanted to know about this. It's something that typically the general population knows very little about, unless you've known someone that has it. But can you talk about that and like sudden onset in kids?
- [64:02]
Dr. Wayne Goodman
Yeah, I've done some research on it. Some of my colleagues are more expert than I am. But it goes back to the reason when, if you have a child and they have a sore throat, the reason you want to make sure it gets treated is you want to make sure it's not beta hemolytic strep, a strep infection. Because with strep, this is unrelated to ocd, but I'll make the connection. The concern there is that some patients, if you fail to treat the strep infection adequately, you can get a complication called Sydenham's chorea, which is autoantibodies directed against the brain. And Sue Swedo, who came up with the idea of pandas many years ago, had identified a subpopulation of patients with OCD where they had a strep infection. And instead of developing what was Choreo Sinam's chorea, which is a certain type of movement disorder, they develop tics or OCD symptoms out of the blue kind of overnight. So it's a very interesting, very fascinating and still controversial entity, but I think it does exist. It's hard to diagnose, and it's been expanded now to consideration. As you mentioned, with pan, not just focus on strep, but maybe other infectious agents cause a autoimmune response. Where the antibodies attack your own brain and instead of producing sinhamskorea, you get ticks or ocd.
- [65:23]
Alie Ward
Is the treatment for that still something serotonin or behavioral therapy or. I've heard immunoglobulin therapy can be helpful for that.
- [65:31]
Dr. Wayne Goodman
Yeah, no, there are some. I'm not as up to date on the literature there, so I'm gonna be a little bit careful about what I say about the latest. A lot of the patients that I see who are adults will raise questions about that they had OCD when they were a child. And could that be related to pandas? It's possible, but if it's say five, 10 years have transpired, I'm probably not going to try an immunotherapy because probably even if there was an insult, an activation of the immune system, that inflammation is long gone. So we generally would treat it OCD kind of independent of whatever we think caused it, including pandas. So it'd be the same treatments of behavior therapy or SSRIs for the most part.
- [66:16]
Alie Ward
So yes, treatment varies depending on the case, but some first line therapies are treating the underlying strep infection, if that's still active and going after the OCD challenges using cognitive behavioral therapy, perhaps also trying SSRIs or according to the 2017 paper, clinical management of Pediatric Acute Onset neuropsychiatric syndrome, part two, use of immunomodulatory therapies. Immune abnormalities in 75 to 80% of patients occur as inflammatory and post infectious autoimmune presentations and that oral or IV corticosteroids may help, but IV immunoglobulins or antibodies are the preferred treatment now for very severe cases. The paper continued. Therapeutic plasma exchange is the first line therapy sometimes combined with immunoglobulins and the high doses of steroids and possibly rituximab, which is an antibody medication used to treat certain autoimmune diseases like rheumatoid arthritis and cancers like non Hodgkin's lymphoma. And on the topic of neuroinflammation triggered by an illness, we have a two part long Covid episode that just went up a few months ago with this amazing doctor, Dr. Wes Ely, that we'll link in the show notes. And we also have an episode on multiple sclerosis coming up very soon. But I'm grateful to say I have some kiddos in my life who have had pandas, went to this exact, exact Stanford Pans Clinic and are doing amazing. So if anyone from that clinic Stanford is listening. Thank you from the bottom of this lady's heart. It's really challenging to find doctors who are looking at different types of treatment for this, but it's heartening to see that it's become more widely known and treated. Now, if you think that your kid is struggling with this, the National Institute of Mental Health recommends that you reach out to the wonderful International OCD foundation or the PANDAS Physicians Network to find a healthcare provider who may be knowledgeable about PANS and pand. We'll link that on our website. And, you know, we talked about a little bit about, like a childhood situation. I know we're throwing around a lot of letters when it comes to complex ptsd. Some folks, Jordan Irons, Kayla Tozier, Will Clark, Alex Minor, Orla Spurr, Reece Perini wanted to know, is ocd, in Reese's words, sometimes trauma induced? Do you see that in any patients? Kayla wanted to know, can childhood trauma lead to ocd?
- [68:33]
Dr. Wayne Goodman
I've seen some cases over the years where I thought that there was a direct connection between a traumatic life event and and the ocd, but it's not all that common in my experience. I remember one patient I treated who was a combat veteran and he had an awful job of. This was in the Vietnam era of doing body counts and it was obviously a very traumatic experience. And he developed OCD after that. And I thought there was definitely a connection.
- [69:02]
Alie Ward
Well, well, well, look at that. A 2024 study titled Exploring the Interplay Between Complex Post Traumatic Stress Disorder and Obsessive Compulsive Disorder. Severe dise. Implications for Clinical Practice, which opens with a banger of a sentence. Traumatic events adversely affect the clinical course of Obsessive Compulsive disorder. And the paper concludes that the coexistence of CPTSD in OCD exacerbates obsessive compulsive symptoms and increases the burden of anxiety. So, yeah, no, you're not imagining that. And here I just have to shout out one of my favorite musicians, Alison Pontier, who not only only has the voice of an angel, you may have heard her eps, Faking My Own Death and Shaking Hands With Elvis the Last Few Years, or her feature on Lord Huron's song I Lied, but also last week released an essay on Substack about her OCD titled Manifesting. But Even Evil what I Couldn't Tell Anyone, and I'll link it on our website, but it opens around age 11. I discovered that if I made deals with God, my stomach wouldn't hurt anymore. At least until the Next time it happened. God isn't big on money or favors. He's mostly interested in meaningless tasks performed in exchange for a few minutes of relief. Now, on Allison's Instagram post about it, the comments flooded in like, ex religious OCD was rise up and religious OCD plus magical thinking. OCD were rude. And I was really moved by her essay and I found it relatable as well. Hell. And Olivia Lester wanted to know if there's a correlation between OCD and Judaism. I was personally raised Catholic, and if there's ever an obsessive and compulsion. Catholicism is like, you will go to hell unless you say this rosary the exact number of times. You know what I mean? They can send you to penance. So do you ever see people with maybe religious backgrounds that are.
- [71:02]
Dr. Wayne Goodman
Oh, yeah, yeah, all the time. And definitely a lot of Catholics, for sure. In fact, some of the earliest, probably some of the earliest descriptions of OCD that correspond to our current definitions go back to the Catholic Church referring to scrupulosity. In fact, I don't know if it still exists, but there was a treatment center in the Midwest for priests who were scrupulous. They were taking the biblical studies too literally. And so one of the things when I. I'm Jewish and I've certainly, I've had Jewish and Catholic and people from all walks of life, all religions who have had ocd, and some of them do involve religious ideation. And what I will ask him is, have you sought out your priest, your rabbi, and have they tried to reassure you that you're over interpreting these concerns? And usually that doesn't work. My experience is that that kind of reassurance doesn't cure the ocd.
- [71:55]
Alie Ward
The priest is like, no, yeah, you do have to do this. That's interesting that Catholic literature is some of the first. But Keegan Newman and Linda English wanted to know about hoarding. Does it ever bother. Bother you when you see shows like. Or hear of shows like Hoarders, where they're like, we're just gonna come in and clean up your house and you're gonna be fine. When it's so much deeper than that, is that under the OCD umbrella again?
- [72:16]
Dr. Wayne Goodman
It's separate again. It's under the same umbrella of OCD and related disorders. Sometimes they're connected. Other times, hoardings is separate. I'll give you an anecdote. A patient this years ago, gotten to the point where she collected her cat litter in bags because she was afraid that the cat would ingest something valuable. And she pointed out that she really didn't own anything valuable, but nevertheless she was worried that something would be thrown out in the trash that was valuable, including in the cat litter. And you can imagine collecting bags of cat litter in your basement. So her husband took advantage of a weekend when she was visiting her sister brought in a dumpster and he and his friends the decide to clear out the house. She came home early and she did a dumpster dive.
- [73:03]
Alie Ward
Oh no.
- [73:04]
Dr. Wayne Goodman
So it did not work. Oh no, that approach doesn't work.
- [73:08]
Alie Ward
Just a fun side note, we have an episode on decluttering called oikology and the expert in it is named Jamie Hord. But simply Marie Kondoing. Your house is not gonna do the full trick. Results on medical trials for hoarding disorder have been a little mostly focused on SSRIs, which have been a little effective. Although SNRI and glutamate modulators or ADHD medications may show some promise, but a ton more research is needed. So for now, the best treatment for hoarding disorder seems to be cognitive behavioral therapy and usually a lot of support from caregivers or loved ones. And hoarding disorder, remember, isn't ocd, although some folks can struggle with both. Now what if some of this OCD info is hitting a little too close to home, but you also don't want to diagnose yourself from a one hour long podcast episode. Do you have any advice for someone who suspects that they might have OCD in terms of how to seek help and how to really recognize the impact that it's having?
- [74:11]
Dr. Wayne Goodman
So I want to put a plug in for the International OCD Foundation. I was a co founder of that organization back in the 80s. You go to their website, they have a lot of great information. They identify different places where you can seek treatment. So I think that's a good starting point.
- [74:29]
Alie Ward
What about for people whose loved ones might have ocd? Anonymous wanted to know about living with someone with ocd, both in ways to help and ways to cope. And Elena Gorilla also wanted to know any tips on coping, how to support but also not enable Too many compulsions.
- [74:47]
Dr. Wayne Goodman
Yeah, you know that's a tough struggle for loved ones. You talk about enabling, you don't want to enable. But also if you have some, you have a loved one who's in distress or you have to make it to a dinner date together and they say, well you got to check. Or they're asking for your reassurance that they did something correctly or that they have to check the locks again or the stove.
- [75:07]
Alie Ward
Or in the case of say Moral scrupulosity, OCD involving ruminations, worrying that you're not a good or moral person or that you're always harming people. Reassurance seeking may come in the form of asking loved ones over and over if you've done anything wrong. Now, with a therapist who doesn't specialize in ocd, you may just run around in circles treatment wise, just asking your therapist for reassurance and getting it, but not getting to the root of the issue or confronting those obsessions and compulsions. And also I said enable, but I meant accommodate. My brain did not do words well.
- [75:42]
Dr. Wayne Goodman
It's easy just to give into it because that's the most parsimonious thing to do. So there's no one, one script. I think if somebody's going for exposure response prevention, it's really important for the family members to participate so that they're not inadvertently accommodating the symptoms, but also not looking like they show feeling. No empathy for the person's feelings. It's easy to say from the outside, just stop it. Yeah, but it isn't for the patient who has ocd.
- [76:13]
Alie Ward
Especially if this stakes are typically so high where you're asking someone to.
- [76:19]
Dr. Wayne Goodman
Or like going to hell.
- [76:21]
Alie Ward
Yeah, going to hell. Or giving someone an illness that could kill them. Just this notion of like if I don't do this correctly, I could kill someone. It's not as easy as just not doing it, you know, and any biggest myths, last questions. Any biggest myths that you want to stand on a soapbox and flim flam you on a bust?
- [76:42]
Dr. Wayne Goodman
Again, this goes back to sometimes, you know, there are family members who are very supportive and understanding and some who feel that the person just doesn't work hard enough to control their behaviors. And that's. If somebody with ocd, it was so easy to just stop it, people would, they wouldn't need treatment. So I think one of the myths is that it's a weakness weakness. The other is I see it really as a brain based disorder. I mean there's just so much evidence that this is the disorder of the brain. And it certainly has manifestations or behavioral, but it's a brain based illness. And even a behavioral therapy is acting to retrain the brain.
- [77:28]
Alie Ward
Again, exposure and response prevention therapy. Huge, huge, huge love, hate doing it. Love that it's helped me so much. What do you feel is the hardest part about your, Your job?
- [77:40]
Dr. Wayne Goodman
The patients who don't get better. Yeah, I mean, and so I've never told the patient that. I can't think of something else that we can do. And so I've always taken that position. I never give up on somebody.
- [77:53]
Alie Ward
What about your favorite? What's the most rewarding doing the deep.
- [77:58]
Dr. Wayne Goodman
Brain stimulation in patients who have had OCD for 20 years and within a few months they're back to living a normal life. It's just incredible.
- [78:08]
Alie Ward
Do you ever cry about it? I'm about to start crying.
- [78:11]
Dr. Wayne Goodman
No, I don't cry.
- [78:12]
Alie Ward
You don't?
- [78:13]
Dr. Wayne Goodman
But in the operating room, it's interesting. So I'm going to get into detail. But we wake up the patients in the operating room to test the stimulation. And sometimes, you know, what we look for is that they feel happy. And when we turn on the stimulation. And we had one patient who in the middle of the operating room says, I feel happy. In fact, we asked her, what does it feel like? It feels like love in my chest for everyone else. And almost everybody, maybe not me, start to tear up in the operating room. And she did very well. She went on to do very, very well.
- [78:47]
Alie Ward
Do you ever lie about crying? For example, right now?
- [78:54]
Dr. Wayne Goodman
I'll cry sometimes in movies. I'm not a big crier.
- [78:56]
Alie Ward
I'm crying about it. I don't even even know this person. Well, the work you're doing so important and it's really such a privilege to talk to you. Anyone who has knowledge of OCD is like, whoa, Wayne Goodman, that's amazing. Including me. So this is really cool.
- [79:13]
Dr. Wayne Goodman
You know your stuff too, Allie. I'm. I'm impressed.
- [79:16]
Alie Ward
Thank you so much for doing this.
- [79:17]
Dr. Wayne Goodman
It's my been my pleasure.
- [79:20]
Alie Ward
So consult an expert about your curiosities. When it comes to getting treated, Please remember that an evaluation is really important. Some conditions look like others and they overlap and treatment can be really different. So find a specialist at the link in the show notes or on our website@alieward.com ologies ocdneurobiology, which we've also linked in the show notes, so you don't have to write that down right now. Now come back in a few days. Should be up this weekend for a bonus episode all about lived experience and more research and tips for loved ones and folks with ocd. As I chat with researcher and OCD haver and mental health athletic advocate Uma Chatterjee, who's amazing. And thank you so, so much to Dr. Wayne Goodman for the decades of tireless work to make this condition better understood and to improve the lives of people who have it, and for founding the International OCD foundation, the charity of choice this week. And we'll link them in the show notes as well. We're Ologies on bluesky and Instagram. I'm Alieward on both. We have weekly kid friendly episodes called Smologies available. Wherever you get podcasts, just look for smologies S M O L O G I swear Free shorter versions. Ologies Merch is available@ologiesmerch.com and to support the show and sending questions for upcoming episodes, you can sign up@patreon.com Ologies Erin Talbert is our Ologies podcast Facebook Admin Big hugs to the whole Campbell clan this week. A whale of a hug to Mike. Aveline Malik makes our professional transcripts. Kelly R. Dwyer does the web page. Noel Dilworth is our scheduling producer. Susan Hale managing directs the whole show. Jake Chaffee is one wonderful editor and lead editor. Up top is Mercedes Maitland of Maitland Audio. Nick Thorburn wrote the theme music and if you stick around to the end of the episode, I tell you a secret. And if you heard the ADHD episodes For a while, my chronic procrastination looked a lot like adhd, and one doctor said it's possible. But a short trial of ADHD meds with me was like trying to coax a terrified Chihuahua out from under a car by injecting it with espresso did not help me. Further evaluation revealed Hands hey bitch. Thinking nonstop that everyone might hate you because you made a minor mistake and procrastinating to the point of panic because you're avoiding something so hard. We have a therapy for that. It's called exposure, and it will suck so hard. But then your brain will say, okay, this is not so bad. It's like a jump from a high dive or a plunge into an ice bath. It is scary. It's not comfortable. It's not as bad as you thought. And then it's much easier to do the next time and you'll be like, holy shit, I did that. So if you're listening to listening to this because you have a loved one going through it, or you were like me, diagnosed with OCD in the last couple years, I hope you get it a little bit more. Let me tell you, there are brighter days ahead. You got this. Also, the second secret is that sometimes I have a hard time not scrolling and I don't get a lot of stuff done. And my friend Simone told me about this thing called a brick. It's like 50 bucks. It's a physical object you use to brick certain apps on your phone phone. You keep it on the fridge or somewhere that's not your hand. If Brick wants to advertise, I love them but here I am just giving it to them for free. But yeah, this thing called a brick has helped me stop scrolling so much when I'm avoiding things. Okay, I hope this episode helped in some way. Stay tuned. We're going to talk to UMA in a couple days. That's a great combo too. Thank you for hearing about all of my mental health issues. I feel like we all have them. I just tell you I about them. Well, I hope it helps. Okay, bye. Bye. Pachydermatology, Homeology Cryptozoology Litology Nanotechnology Meteorology Olfactology Maplology, Serology OCD it's all flared up.
- [83:09]
Dr. Wayne Goodman
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- [83:42]
Alie Ward
The brand brands you love like Birkenstock.
- [83:44]
Dr. Wayne Goodman
Nike, Adidas, New Balance and more. Head to your DSW store or visit dsw.com today.