YouTube Transcript:
Why OCD Is Deeper Than You Think

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
an
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
more in the brain. So the number one
example of this is something like
dementia. So when someone has dementia
and they have Alzheimer's disease and
they have all these like plaques in
their brain when their brain tissue is
kind of deteriorating. I just realized
how terrible this is to talk about in a
video about OCD. I'm not trying to freak
y'all out. But what I mean is that there
are some illnesses where there are
changes in the brain which then affect
the way that we feel and affect the way
that we think. So I think OCD is more in
the brain than it is in the mind. So we
know that there are all these
neuroscientific uh changes that we know
like for example failures of habituation
um inability to distract yourself sort
of repetitive learning habitual learning
towards one thing the compulsion which
is the only thing that relieves your
anxiety but there are a couple of other
indicators for example 40% of OCD is
basically heritable which means that we
know that about 40% of the illness has
to do with your genetics. Some of the
most interesting literature at the
intersection of OCD neurology is that
describing obsessivempulsive symptoms
that are precipitated by streptocockal
infection so-called pediatric autoimmune
neuroscychiatric disorders associated
with streptococcus pandas. So what does
this mean? This means that some children
who get a streptocal infection will have
an autoimmune reaction that will alter
the way that their brain kind of
functions and they will actually develop
OCD. But we just have a lot of data that
suggests that OCD can be related to
things like infections in childhood.
That may be how you develop it. Most
people develop OCD between the ages of
18 and 29, but there are cases that it
kind of gets developed in childhood. And
if you're past 30, the likelihood that
you will develop OCD is really low. The
likelihood that if you're past 30 and
you think you've had anxiety that has
not responded really well to treatment
or therapy hasn't worked great, then
there's a decent chance that you may
have OCD. So, get that re-evaluated. So
first line treatment for OCD tends to be
medication. We have some medications
that tend to work pretty well. About 50%
of people who uh take medication for OCD
will not have a great or sufficient
response. It can be kind of a stubborn
illness. But this is also where I love
it because there are particular modes of
psychotherapy. So my favorite uh thing
to prescribe to patients, I don't do it
very much is something called exposure
and response prevention. So the cool
thing is we have tailored certain kinds
of psychotherapy specifically to OCD and
instead of going to a therapist and
talking about your feelings which there
are absolutely that can work. There are
good papers that suggest that
psychonamic therapy can be very
effective for OCD but I personally like
really like when patients do exposure
and response prevention. So what does
that look like? Remember we had this
diagram. So what exposure and response
prevention does is it trains you to stop
this. You train this in therapy where
you like train your mind. It's like
doing push-ups for your brain and your
mind where when you have a certain
situation, the situation will an
exposure will create a response, right?
So that response can be cognitive, it
can be a thought, it can be emotional,
which is anxiety and then it can be the
response can also have a behavior or a
compulsion. So how do we uncouple and
relearn how to deal with these
situations in a healthy way? Because
remember that OCD is a an illness of
essentially inappropriate learning where
our brain learns that only one thing if
I feel like I'm afraid I have a
contamination on my hands. The only
thing that helps is washing my hands
seven times. So what we actually do in
exposure and response prevention is we
expose oursel to the scary thing but we
do it in a graduated manner where we can
basically handle the degree of thought
or obsession that arises and then we can
stop washing our hands in a very
damaging way. And then the cool thing
about that is once you stop relying on
the compulsion to manage your anxiety,
you can start to develop other ways to
manage your anxiety. And the coolest
thing that I've seen in my patients is
they will start to develop habituation.
And once they stop relying on washing
their hands, their anxiety, they feel
really anxious and then the anxiety
actually habituates and it just goes
away on its own. So there are a lot of
we've shared a we're going to show a
quick treatment algorithm. As y'all can
see, it's long, it's complex, but the
truth of the matter is it works
incredibly well and you can get better
from OCD. But the good news is that if
you get tailored treatment to OCD,
there's a really good chance that you
can get substantially better and you do
not have to live with severely impairing
anxiety anymore. Hey y'all, hope you
enjoyed today's video. We talk about a
bunch of topics like this on the
channel, so be sure to subscribe for
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