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Why OCD Is Deeper Than You Think

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Hey everyone, my name is Dr. Aluk

Kenoja. I'm a Harvard trained

psychiatrist and today we're going to

talk about OCD. So, obsessivecompulsive

disorder is characterized by two things.

Obsessions, which are intrusive,

unwanted, and repetitive thoughts, and

compulsions, which are behaviors or

mental reactions, which we engage in to

reduce the anxiety from our obsessions.

Compulsions can be repetitive behaviors.

Things like washing my hands seven times

when I'm afraid I have germs. Or they

can even be mental reactions like

repeating certain thoughts in your head

over and over and over again until that

feeling of anxiety goes away. The

scariest thing about OCD is that you may

have it and never realize it. And even

if you see a mental health professional,

there is a very, very good chance that

you will get misdiagnosed with something

like an anxiety disorder. Let's take a

look at a couple of really quick

statistics. 90% of lifetime respondents

with OCD met the criteria for another

lifetime disorder. 79.2% of cases of OCD

began after comorbid anxiety disorders.

Only a minority of severe cases receive

treatment for OCD. So this diagnosis is

incredibly easy to miss. Why is that?

Because OCD feels like really bad

anxiety. 65% of people with OCD rank as

severely impaired on a disability scale.

So why is that? So let's understand

something, okay? We have two kinds of

psychiatric illnesses. We have the

psychiatric illnesses that we give names

to based on how they feel like major

depressive disorder or generalized

anxiety disorder. And we have other

psychiatric diagnoses like OCD in

schizophrenia that are named based on

what causes them. So I know that sounds

kind of confusing. So let me just

explain. Okay. So if we have something

called a mocardial infarction, this is a

heart attack. This means that there's a

part of my heart that is not receiving

adequate blood supply. Maybe I have a

blocked coronary artery. So there's a

part of my heart that is essentially

suffocating. So myioardial infuction

doesn't describe what it feels like. So

when someone has an MI or heart attack,

you know, it feels like crushing

substeral chest pain. So you feel like

there's an elephant sitting on your

chest. So Mario myioardial inffection is

a good example of a diagnosis that is a

technical diagnosis and what it feels

like to a patient. If we look at the

psychiatric illnesses the they also fall

into those categories. So major

depressive disorder feels like you're

depressed all the time. Generalized

anxiety disorder feels like you're

really anxious. Social anxiety disorder

feels like you're anxious in social

situations. And then we have

obsessivecompulsive disorder, which

based on social media portrayals and

things like that, everyone's like, "Oh

my god, I'm a little I'm so OCD. Oh my

god, I'm so OCD because I have to have

my pens arranged in a particular way."

That's not what OCD feels like. OCD

feels like crippling anxiety. Anxiety

that won't go away no matter what you

do, except for the one thing that

actually makes it go away. So, if you're

someone who has crippling anxiety and

there's one thing that works, you should

seriously consider getting evaluated for

OCD. Like I've said, one of the most

frustrating things about OCD is how

often it gets misdiagnosed. People can

spend years trying to manage anxiety,

depression, or even something else

entirely without realizing that

underneath it all, it might actually be

OCD. And because it's so misunderstood,

it gets missed. Another study showed

something like 50% of people with OCD

get misdiagnosed at first, which means

they don't get the right kind of support

early on. And even when it is diagnosed,

not every therapist is trained in the

specific treatment that is effective for

OCD, like exposure and response

prevention or ERP. But here's the real

challenge. There's a shortage of OCD

specialists out there. That's where our

sponsor, NOCD, comes in. It's a telealth

platform that connects you with licensed

therapists who are trained specifically

in ERP. Our scientific advisory board

spent some time digging into NOCD's

clinical approach and how they handle

things like safety and escalation, and

they were genuinely impressed by the

level of rigor and understanding there.

So, if you're dealing with intrusive

thoughts or you find yourself stuck in

loops of obsessive thinking or

repetitive behaviors, it might be worth

talking to someone who really knows what

to look for. 155 million Americans have

insurance that covers the cost of their

sessions, making it an affordable option

for therapy. They even offer in-app

support when you need help between

sessions, so you're never alone. You can

schedule a free 15-minute call with no

using the link in the description below.

So, what we're going to start with is

someone who is lucky enough to not have

OCD. So, here's you. Let's hope that you

don't have OCD. So what happens is

you're in a particular

situation and the situation creates a

thought. The thought will create an

emotion. So let's say that the situation

is that my partner who I'm in a

long-distance relationship is boarding a

plane and is going to come visit me. So

the situation is a visit and then I have

a thought. I hope that the plane doesn't

crash. I hope they're safe. I hope

everything is okay. And then this

thought leads to anxiety. Now, in a

normal brain, someone without OCD, there

are a couple of different things that

can happen to this anxiety. The first

thing, as I'm sure y'all are aware, is

that we can habituate to it. So, we have

to explain this for a second. Okay?

Anytime we have a negative experience

within our body or our mind, like let's

say I feel hungry, we don't feel hungry

forever, right? We feel hungry for a

little while and then my brain sort of

my body figures out, okay, we're not

going to get food right now, so we're

going to suppress hunger signals for

some amount of time. If you wait an hour

or 2 hours later, the hunger signals

will come back. But our brain and our

body basically suppress negative signals

after a little while. Another really

great example of this is like body odor.

So sometimes you step into a place where

like someone is a little bit smelly or

you step into, you know, a place that's

smelly and then it smells really bad for

the first few seconds and then over time

the badness kind of goes down, right?

It's not that you ever forget the smell,

but that you habituate to it. So you

kind of get used to it. This can be true

of temperature, it can be true of smell,

it can be true of hunger, it can even be

true of anxiety. So if you're lucky

enough to not have OCD, you'll feel

anxious about something and the anxiety

will naturally decrease. The second

thing that we do with anxiety is that we

tend to distract ourselves. So, this one

is my favorite. It's the funnest way to

deal with your anxiety, we can do things

like I've had patients who enjoy when

they're feeling anxious, getting high

and playing video games. We have all

these devices that give us dopamine that

allow us to distract ourselves from our

anxiety. Let's say I have a test on

Friday and today is Monday. So, the test

is in 4 days. So, I think to myself, "Oh

my god, I need to study. I'm anxious

about the test. Instead, I'm going to

just play video games all day." So

Tuesday rolls around and I'm like, "Oh

my god, I still have this test, but I

feel anxious about it. So I'm going to

get high and play video games again." So

I'm going to use certain mechanisms to

regulate my emotions, right? So I'm I

feel bad. I'm going to do something to

make the feelings go away. But then if

I'm lucky, Wednesday rolls around, and

this is really important. Now I've

wasted two days and then I have

something that works, right? I can get

high and play video games. But Wednesday

rolls around and I think to myself, you

know, that's not really a great idea. I

really should study on this test for

this test. And you all may know this

that there are certain days that you do

the wrong thing. But there's a voice

inside you that then inhibits the wrong

thing. So we call this response

inhibition. Right? So what we're going

to do is we are going to stop the

emotional regulation that is unhealthy.

So, we'll distract ourselves for a

little while, maybe we'll spend 15

minutes on our phone, but then

eventually we inhibit that response and

we get back to what we should be doing.

And so, then hopefully what happens is

once I'm inhibiting my response, then I

end up taking appropriate action. So, I

end up basically fixing it. So, this is

the brain of someone who does not have

OCD. We have a situation, we have a

thought, we have an emotion, and we have

three ways that we sort of deal with the

emotion. We habituate to it. we distract

ourselves or regulate that emotion and

then even if we're regulating that

emotion eventually we learn how to stop

regulating that emotion in that way and

we take definitive action to fix our

problem. So how is the brain of someone

with OCD different? So the first thing

that

happens is the

situation. So already we know that one

thing is different. People with OCD have

overestimation of threat. Okay. So,

there's a situation. Someone is boarding

a flight. If I were to ask you, are you

worried that the plane will crash? A

normal person may say, or a person

without OCD may say, yeah, you know, I'm

worried about it. What do you think the

chances are? Oh, I think the chances are

less than 1%. But for someone with OCD,

the chances of a plane crash are 10%.

Or, I know this sounds a little bit

crazy, no pun intended, and not trying

to offend anyone, or the chances may be

100%. If you're someone who has a

thought of a potential danger that feels

like it is going to happen 100% unless

you do something about it, you may have

OCD. So this creates a thought and then

this creates anxiety. So we also know

that there are changes in the amygdala

of people of OCD. This is our fear and

threat center of the brain and it tends

to get ramped up very easily. So we are

overestimating the threat and our

amygdala is hyperactive which means that

we feel an intense intense amount of

anxiety. Remember this anxiety is so bad

that it is severely disabling for 65% of

people. Then we get to another problem.

So remember how we habituate to negative

things like we're you know in a smelly

we step into the restroom smells really

bad but then slowly the smell kind of

goes away and then when we step out we

feel really good but we're not tortured

while we're in the bathroom the whole

time. So we know that in the brains of

OCD people fail to habituate. So whereas

a neurotypical brain may get used to a

bad smell a feeling of of anxiety it'll

kind of tone things down. the brains of

people with OCD, they fail to habituate.

So they don't habituate nearly as

easily. So that function doesn't work.

The other thing is that they have a lot

of difficulty even distracting

themselves. They can try, but there is a

lack of something called cognitive

flexibility in OCD. So what does this

mean? So when I'm worried about

something, let's say I'm worried about

my test on Friday, in order to distract

myself with video games, my brain needs

to stop thinking about the test and

start thinking about video games. Even

this degree of cognitive flexibility is

impaired in OCD. So usually my patients

with OCD will feel like once a thought

gets stuck in their head or a thought

gets stuck really lodged in there, it's

like a pitbull that is bitten onto

something and refuses to let go. So

whereas your friends may be able to

distract themselves pretty easily. They

can forget about it in a way that seems

completely foreign to you. You get stuck

in this almost obsessive degree of

anxiety. So distractions don't really

work as well. And this is also

associated with emotional regulation

deficits. So our capacity to calm

down the amygdala is impaired. Okay? So

it's hard for us to calm ourselves down.

It's hard for us to distract ourselves.

So there's an emotional regulation

deficit. Now, here's the worst part of

the

illness. Remember how we talked about

response inhibition?

So remember that. Okay. So for the first

two days on Monday and Tuesday I'm going

to get high and test it on Friday. It's

not that big of a deal. Whatever I'll

figure out later. Wednesday rolls around

I'm like you know that is not a good

idea. I basically did something for a

couple of days and then I inhibit that

response and start studying. This is the

most critical thing that is impaired in

OCD because once someone with OCD finds

something that

works, they continue to engage in that

behavior no matter the cost. So this is

impaired. Okay? So they'll have some

kind of thought like, "Oh my god, I'm

going to get HIV if I touch anything in

a public restroom." So they feel an

intense intense anxiety. The anxiety is

crippling. It doesn't go away. I try to

distract myself. It doesn't really work.

And then what happens is I wash my

hands. I'm like, "Oh my god, I feel so

anxious. I feel so anxious. So I'm going

to I'm going to wash my hands. I'm going

to wash my hands." And then what happens

when I wash my hands is my anxiety

improves. This is really important to

understand. It is the only thing that

makes my anxiety feel better. Remember

that thought sticks in your mind,

doesn't actually go away. The anxiety is

still there. So I think to myself, okay,

let me wash him again. And then I wash

him again. And now I feel, oh my god, I

feel 75% better. I feel so much better.

Let me make sure. Then I wash him a

third time. Oh my god, that feels so

much better. Now I'm 90% better. Let me

watch him a fourth time, fifth time,

sixth time. So OCD is actually a deficit

of learning. Okay, so there's anxiety

andor uncertainty with goal- directed

behaviors and then a compulsivity with

habitual behaviors. So our brain learns

that this thing is going to work. there

are brain changes as a consequence is a

cause and consequence of OCD. So now

let's talk a little bit about what

obsessions actually look like. So the

one that we've used today is an

obsession with contamination. So this is

incredibly common where people are

germaphobes. They feel like they have to

wash their hands. They can't touch

particular things. They uh maybe need to

shower excessively. I've seen really bad

cases of that. The second obsession

that's really common is danger towards

yourself or others. So, this can look

like the scenario that we talked about

where you're, you know, your your

partner is boarding a plane. You're

afraid that the plane will crash. I've

had patients who will be worried every

time a loved one gets into a car and has

to drive somewhere, they're afraid that

there will be a crash. You know,

there'll be some kind of accident.

People can be what's something that

people are more familiar with are like

concerns about a danger about the house

burning down. So, this is why people

will turn off and on the stove seven

times or people will turn off and on

light switches, but what's going on in

their head? Unless I make sure that the

light is off, maybe there's some kind of

electrical signal that will cause a

spark and my house will burn down. So,

they will have a lot of concerns around

danger. I had a patient who anytime a

loved one was in transit. They would

have to say a prayer in their head. It

was almost like a magical protective

spell where they would say the sequence

of things. This person is leaving this

place. They will be safe and they will

arrive on time or something like that.

They would say some kind of prayer and

they would say that in their head seven

times every time a loved one was getting

into a car or plane or anything like

that. So I I hope y'all can imagine how

debilitating this is because every day

when 5:00 p.m. rolls around and everyone

is leaving work, they have to stop

whatever they are doing and say this

prayer seven times for every person who

they know who they care about. Oh my

god, this person is boarding a flight.

They would set an alarm, repeat the

prayer in their head. So compulsions can

absolutely be in your head. Other forms

of obsessions in involve things like

checking and counting. We've sort of

talked about that a little bit. So what

a lot of people don't realize is that

obsessions can be like really nasty. So

I've had patients who will have

intrusive thoughts about hurting other

people. I've had uh patients who have

intrusive thoughts about sexual acts. So

sometimes obsessions can be sexual in

nature. Um they can also be towards

really inappropriate people. So I've

unfortunately had to work with patients

I mean unfortunate for them that you

know they'll have intrusive sexual

thoughts about their parents and this is

why OCD is like so hard to diagnose

because when someone has really negative

thoughts they feel like a really bad

person. So if you think every day about

having sexual a sexual relationship with

someone that's really inappropriate, you

feel really guilty. You feel like am I

really screwed up? Am I a sociopath? The

number of people with OCD who I've I've

worked with who think that they're like

a sociopath is astronomical. But

remember the nature of OCD is that an

obsession is not that you're like

obsessed with something like, "Oh my

god, I'm so obsessed with this celebrity

or this influencer." That's not what

we're talking about. You didn't want

this. It doesn't say anything about you.

You don't care about it. You don't like

it. Most of the time, what OC what

people with OCD want is they want their

obsessions to go away more than anything

else. So if you have a persistent

intrusive thought that you don't like

and you tend to have some kind of

ritualistic behavior, that's behavior

that you repeat over and over and over

again in response to the thought, that's

really what characterizes OCD. So if you

have OCD, what do you do about it? So

this is where OCD is one of the most

undertreated disorders. Remember, only

30.9% of people with OCD actually

receive OCD specific treatment. A lot of

people will misdiagnose OCD as a severe

anxiety disorder and they actually get

treatment for anxiety. OCD responds

really well to biological treatments.

Now what do I mean by that? So if we

look at psychiatric illness, there are

kind of like two sources of psychiatric

illness. It can come from your brain or

it can come from your mind. Okay? So if

we look at like diseases that come from

let's say from your mind, I mean they

still come from the brain in some way.

But if we look at something like let's

say a mood disorder like major

depressive disorder, only about onethird

of people with major depressive disorder

respond really well with medication.

What we know about major depressive

disorder is that a lot of psychotherapy

can be incredibly effective. You can

treat depression by targeting your

thoughts, changing the way that you

think without necessarily doing anything

to your brain. Right? So we don't have

to take a pill or do electrocomvulsive

therapy or have some kind of surgery for

our brain in order to treat depression.

We can treat it using psychotherapy. Now

this is also true of something like

generalized anxiety disorder or

socialized anxiety disorder. Especially

if we look at these illnesses like

narcissistic personality disorder. There

really no medications that help with

your personality. The personality sort

of exists within your mind. So we can do

psychotherapy to help you with your

mind. There are some psychiatric

illnesses however that I think are a lot

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YouTube Transcript:
Why OCD Is Deeper Than You Think