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OCD and related disorders DSM 5 explained in plain language: Docs Tracey and Paul cover OCD in adults, OCD vs anxiety, and the symptoms families often miss.
Psychiatry, Education, Insight. Docs Tracey and Paul Discuss it All! Two psychiatrists — Dr. Paul E. Keck Jr., MD and Dr. Tracey Goodman Skale, MD of TMBO (Two Minds, Better than One) — illuminate mental illness, teach signs and symptoms, dispel myths, and advocate timely care and dignity. Nearly 70 years of combined expertise. DISCLAIMER: educational/general discussion only, not personalized medical advice; in crisis call the 988 Suicide & Crisis Lifeline.
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Tracey Skale: You probably have people in your life say,"Oh, you're so OCD," and they throw that term
Tracey Skale: around
Paul Keck: Someone who has a contamination fear might end up taking 20 showers a
Paul Keck: day.
Tracey Skale: What's the gold standard of treatment for obsessive compulsive disorder?
Tracey Skale: [upbeat music]
speaker_2: Welcome to the Two Minds Better Than One podcast, Docs Tracy and Paul Discuss It All.
Paul Keck: Hello, and welcome to Docs Tracy and Paul Discuss It All. Our topic today
Paul Keck: is obsessive compulsive disorder, parentheses OCD, and related disorders.
Paul Keck: Tracy, do you wanna start us off on what an obsession and a compulsion are?
Tracey Skale: Well, Paul, you know I want to point out, though, that when I start off these podcasts, I
Tracey Skale: always introduce you and I say,"This is my husband, Paul," but that's okay. That's okay.
Tracey Skale: We're s- we're starting... I, I'm Tracy and this is Paul, and we are talking about
Tracey Skale: obsessive compulsive disorder and related, related disorders as well. So before we do
Tracey Skale: that, Paul, I would like to talk about the different kinds there are. So
Tracey Skale: obsessive compulsive disorder used to be actually under the category of anxiety disorders,
Tracey Skale: and I think it was, was it 2013?
Paul Keck: Something like that, yeah
Tracey Skale: ... something like that, that the DSM 5, I guess now it's 5TR, text revision,
Tracey Skale: changed it, took it out, um,'cause it used to be under the umbrella of, uh, anxiety
Tracey Skale: disorders. A- and we'll get into it because it's still, there's a lot of anxiety involved
Tracey Skale: with OCD, don't you think?
Paul Keck: Yes
Tracey Skale: But it's, there's, it's such a complex disease state that it has its own category now.
Tracey Skale: But some of the other things under the umbrella of OCD, and well, that will be the main
Tracey Skale: disease state we talk about today, obsessive compulsive disorder, but there's also body
Tracey Skale: dysmorphic disorder, hoarding disorder, trichotillomania, you
Tracey Skale: may know it as hair pulling, excoriation or skin picking, and,
Tracey Skale: um, OCD due to medical conditions, also due to substances. There's that. I don't know how
Tracey Skale: much we'll talk about that t- today, though. And then there's this other s- other
Tracey Skale: specified OCD and related disorders such as excessive nail biting, lip
Tracey Skale: biting, cheek chewing-
Paul Keck: Obsessional jealousy
Tracey Skale: ... obs- obsessional jealousy, and what about the olfactory-
Paul Keck: References
Tracey Skale: ... the olfactory reference disorder. Yeah. So do you wanna talk about, do you wanna start
Tracey Skale: off leading with the definition of OCD?
Paul Keck: Sure. First of all, OCD is common. Uh, affects about, we always try to talk about how
Paul Keck: common these things are.
Tracey Skale: Mm
Paul Keck: Um, affects about 1.2% of a, of the population in our country.
Tracey Skale: Okay
Paul Keck: So about one out of 100 people will be struggling with this at some point in their lives,
Paul Keck: and it can be debilitating. Um, so it's not a trivial problem for a lot of
Paul Keck: people. It's characterized by OC, obsessives, o-
Paul Keck: obsessions and compulsions. Obsessions are defined as recurrent and persistent
Paul Keck: thoughts, urges, or images experienced as intrusive.
Paul Keck: So people don't want to have them
Tracey Skale: You don't want them, yeah, so they're, yes. They, whereas they're intrusive and they don't
Tracey Skale: really make sense to you. They're not reality based, not a delusion. This is a fixed
Tracey Skale: belief that's not true, but say someone with anxiety, they might be obsessing about
Tracey Skale: something, but it might be I'm obsessing about I'm so anxious because I, I can't pay my
Tracey Skale: bill, or I didn't study for this test and I'm not gonna do well. This is something that's
Tracey Skale: unrelated. It's not reality based
Paul Keck: And compulsions, in turn, are rebet- repetitive behaviors or mental acts,
Paul Keck: um, that people do, uh, in response to the obsessions in an, in an
Paul Keck: attempt to neutralize them, get rid of them, suppress them. So
Paul Keck: the, the two go hand-in-hand for most people
Tracey Skale: Mm-hmm, and there's marked, there's anxiety and distress associated with it. You, nobody
Tracey Skale: wants this kind of feeling, and you're right. The r- it's a, it's a false attempt to
Tracey Skale: neutralize. If I d- if I wash my hands all these many times, then
Tracey Skale: I won't be contaminated, but there's ne- it's never enough. W- with obsessive compulsive
Tracey Skale: disorder, and like all the disorders that we talk about, it's only an issue if it
Tracey Skale: adversely affects your life. So this has to cause distress, and it has to be
Tracey Skale: time-consuming. It's not that just you're a little obsessive, you're a little compulsive.
Tracey Skale: You probably have people in your life say,"Oh, you're so OCD," and they throw that term
Tracey Skale: around. And you could be a little on the compulsive side. In some ways, that might be
Tracey Skale: helpful to you in a work setting and being a little bit on the perfectionistic side, but
Tracey Skale: it's requiring at least an hour a day. It's time-consuming, and you don't want it, right?
Paul Keck: Right, so we all have personality traits-
Tracey Skale: Mm-hmm, mm-hmm
Paul Keck: ... characteristics, some of which can be compulsive. This is greatly
Paul Keck: exaggerated-
Tracey Skale: Mm-hmm
Paul Keck: ... it to the point it becomes a disorder causing disability-
Tracey Skale: Distress
Paul Keck: ... dis- distress, interference with da- da- daily function, relationships, things like
Paul Keck: that. So someone who has a con- contamination fear might
Paul Keck: end up taking 20 showers a day.
Tracey Skale: Mm-hmm
Paul Keck: That's an ex- an example, not an extreme example, of what, uh, obsessions
Paul Keck: about con- uh, contamination can drive someone to-
Tracey Skale: Well, I've seen in my practice people obsessively hand washing to the point that their
Tracey Skale: hands are raw and bloody, kinda, and they still, even though they're in pain from that,
Tracey Skale: they s- they can't stop. Um, more about compulsions, you talked about obsessions,
Tracey Skale: uh, very thoroughly, I think. So the compulsions, these repetitive behaviors, it also can
Tracey Skale: be a mental act. You could be mentally trying to stop or extinguish something, and it's,
Tracey Skale: it, it's in response to the obsession or according to these rules, these so-called rules
Tracey Skale: that they made up in their head that they feel like they have to follow Um, it's not
Tracey Skale: necessarily driven by fear, like some of our anxiety disorders are. Um, but it's, there's
Tracey Skale: a lot of shame. It's, it's an attempt to get rid of the shame or the disgust or
Tracey Skale: this generalized discomfort. Unfortunately, it leads to more of all of those things.
Tracey Skale: There's a lot of shame associated with this, um, disease state, particularly when we get
Tracey Skale: into the hoarding disorder. We'll get into that more, but, um, that which the person's
Tracey Skale: trying to extinguish just makes it all that much worse.
speaker_2: Well, and, and relat- So everybody's different.
Tracey Skale: Mm-hmm.
speaker_2: But there are some commonalities about obsessions, and they often involve fears of
speaker_2: contamination-
Tracey Skale: Mm-hmm
speaker_2: ... fears of harm that could be caused-
Tracey Skale: Self or others
speaker_2: ... right, e- to self or others. Um, disgusting thoughts, either of
speaker_2: a violent or sexual nature that come, again, unbidden and
speaker_2: are very disturbing when people have them, and then they'll, of course, go out of their
speaker_2: way to try to neutralize them and get rid of them.
Tracey Skale: Or avoid. So say you have this, I, this, my beloved parents that I love more than anything
Tracey Skale: in the world, I have this sensation or I have this fear that I'm going to stab them to
Tracey Skale: death. So then you can literally see people shudder and turn away from the thoughts, their
Tracey Skale: own thoughts, but they might then go to, to the extreme of avoiding anything that where
Tracey Skale: there's knives around. You know, we hear it wi- with the, um, with the postpartum mother
Tracey Skale: sometime. You know, they love their baby more than anything in the world, and but they
Tracey Skale: have these intrusive thoughts that they're going to, like, throw the baby down the stairs
Tracey Skale: or smother the baby or something, and they're mortified by it, and you can imagine the
Tracey Skale: shame associated with it, but it's definitely a disorder, and it's definitely treatable.
speaker_2: Absolutely.
speaker_2: So what we've outlined are the compulsions are excessive
speaker_2: and often, um, not adequate to neutralize the
speaker_2: obsessions, and so the cycle just keeps repeating itself. Um-
Tracey Skale: There's specifiers, too, so with insight, without insight. So some people are like,"Okay,
Tracey Skale: I know this doesn't make any sense, but I still can't stop doing it," and then there's
Tracey Skale: some people that they still think,"Well, but if I check the stove
Tracey Skale: 37 times before I go out, then the house won't burn down," and they really believe that.
speaker_2: Yeah, as an example of, um, how debilitating OCD can be, I once
speaker_2: knew of a patient who, um, I remember
speaker_2: seeing, not personally, but seeing on a inpatient ward, who
speaker_2: was, looked like he was catatonic. Could, did not move, was
speaker_2: unkempt, long beard, long hair, malodorous, and I thought,"Oh,
speaker_2: this person has catatonic schizophrenia." No.
Tracey Skale: Hmm.
speaker_2: Upon interview, what he said was that he had a fear of harming someone.
Tracey Skale: Hmm.
speaker_2: And so he had to write a note on little note cards of what he had actually
speaker_2: just done, what physical act he did, and that became a hall of mirrors. So he had to
speaker_2: write a note, then he had to write a note about writing a note-
Tracey Skale: Mm
speaker_2: ... then writing a note about writing a note
Tracey Skale: Mm-hmm
speaker_2: ... et cetera, until he realized the only way out of this conundrum was not to move.
Tracey Skale: Wow. Wow, that's so interesting because I wish now, looking back at some of the
Tracey Skale: people that I thought had catatonia, I wish I had looked at it under that lens. That's
Tracey Skale: fascinating because I know there's a particular person I'm thinking about. He would talk
Tracey Skale: about he w- he couldn't get out of the car, and his father would be so frustrated that,
Tracey Skale: "Come on, get out of the car. You're here to see Dr. Scale," or whatever, and he would
Tracey Skale: just freeze getting out of the car. Now, I wonder if there was a part of that. Now, he did
Tracey Skale: have psychosis, but I'm sure there's a comorbid component that you could have both, right?
speaker_2: Yeah, and OCD is frequently comorbid with other psychiatric struggles.
speaker_2: It can occur with schizophrenia, can occur with bipolar disorder.
Tracey Skale: Mm-hmm.
speaker_2: About 25% of people with OCD have bipolar disorder.
Tracey Skale: Really?
speaker_2: Yeah.
Tracey Skale: That's, that's an important statistic.
speaker_2: And it's an interesting clinically dynamic in which
speaker_2: the OCD symptoms tend to be prevalent when someone's depressed but go away
speaker_2: when someone's manic.
Tracey Skale: Well, uh, that makes sense to me, though. Like, they're, so they're ruminating,
Tracey Skale: ruminating, ruminating, ruminating. But then it's distinct. That's one of the differential
Tracey Skale: diagnosis, right, with OCD and depression. The, the d- the person with depression is
Tracey Skale: ruminating about something that happened or maybe didn't happen,
Tracey Skale: but the, it's not an intrusive thought like-
speaker_2: Right
Tracey Skale: ... the person that's ruminating with OCD.
speaker_2: Right.
Tracey Skale: But that makes sense to me. What about, let's talk about OCD and trichotillo- uh, no, not,
Tracey Skale: not a, OCD and Tourette's. That's, both start with T. So
Tracey Skale: about, uh, 30%, you like statistics, but tell me if this statistic sounds right to you.
Tracey Skale: 30% of individuals with OCD have lifetime tic disorder. It's most common in men,
Tracey Skale: right? And 30 to 60% of people with Tourette's, true Tourette's disorder, also have
Tracey Skale: obsessive compulsive disorder. So with classic OCD, the so-called
Tracey Skale: trigger is a cognitive anxiety, a fear, intrusive thoughts. But with Tourette's,
Tracey Skale: it's more of this physical tension, this physical sensory urge, hence
Tracey Skale: the ticking piece.
speaker_2: That has to then be relieved-
Tracey Skale: Has to be relieved
speaker_2: ... by the tic.
Tracey Skale: Right.
speaker_2: Yeah.
Tracey Skale: Right. You can see how they overlap a lot. So with classic OCD goal, so-called goal in
Tracey Skale: quotes, is to avoid some catastrophic outcome. So again, fire. I'm gonna avoid the fire by
Tracey Skale: checking the stove a million times. Um, with Tourette's, it's just like they're,
Tracey Skale: they're just trying to get relief. They're just trying to feel Normal, right?
Tracey Skale: Common behaviors with OCD is the checking and the hand washing. With Tourette's, it's more
Tracey Skale: touching, tapping, symmetrical arranging. You'll see that piece.
speaker_2: Well, the, so the, it, it's telling us something that these two
speaker_2: syndromes are closely related genetically.
Tracey Skale: Mm-hmm.
speaker_2: And it's a little early to get into neurobiology, but there's a lot of
speaker_2: evidence that the caudate and-
Tracey Skale: Putamen
speaker_2: ... putamen are involved in OCD-
Tracey Skale: Mm
speaker_2: ... and Tourette's.
Tracey Skale: Mm-hmm.
speaker_2: And the caudate, the deep part of the brain, directs cognitive goal-oriented
speaker_2: behavior and actions related to that, so you can see how that fits with OCD.
Tracey Skale: Mm-hmm.
speaker_2: And then the putamen directs, uh, voluntary motor activity.
Tracey Skale: That's interesting, yeah.
speaker_2: And there's also a, um, a lot of interest in a- the
speaker_2: autoimmune and infectious etiology of, of OCD in some people.
speaker_2: And one of the interesting things about OCD is in 1918,
speaker_2: in the i- influenza, Spanish flu pandemic-
Tracey Skale: Mm-hmm
speaker_2: ... which killed about 50 million people, survivors often had new
speaker_2: onset OCD.
Tracey Skale: Mm.
speaker_2: And autopsy studies found that the caudate and putamen were damaged
speaker_2: by the influenza.
Tracey Skale: Hmm. See? A- again, the brain, this is why we're psychiatrists, right? The brain is
Tracey Skale: endlessly fascinating. Well, while you're talking about disease states, and th- this
Tracey Skale: reminds me of the whole piece with PANDAS, when we talked about OCD due to other medical
Tracey Skale: conditions, one of the ways you can have another medical condition that can result in OCD
Tracey Skale: is traumatic brain injury. We see that. But also PANDAS. Do you want to talk about what
Tracey Skale: PANDAS is?
speaker_2: Yeah, there's PANS and PANDAS, and for the sake of just keeping things brief, the
speaker_2: idea is post-strep infection-
Tracey Skale: Right
speaker_2: ... or some other post-viral or bacterial infection,
speaker_2: uh, the body generates, uh, either an inflammatory response, which happens with
speaker_2: infections-
Tracey Skale: Autoimmune
speaker_2: ... or an autoimmune response.
Tracey Skale: Yeah. I always think of it more autoimmune. Yeah, that makes sense.
speaker_2: And that autoimmune means your body's developing antibodies to itself.
speaker_2: And one notion is that those infections trigger i-
speaker_2: antibody or our body to generate antibodies to maybe the part of the brain involved-
Tracey Skale: Mm-hmm
speaker_2: ... in obsessive compulsive behavior.
Tracey Skale: So PANDAS in particular, Pediatric Autoimmune Disorder Associated with Streptococcal
Tracey Skale: infection, can lead to rapid onset OCD. And you mentioned inflammation. Inflammation and
Tracey Skale: autoimmune go hand in hand, and I'm, I'm convinced that inflammation is going to be the
Tracey Skale: key to all psychiatric things and many other things. But I've seen this. I know we were,
Tracey Skale: when we were preparing, you were saying,"Oh, PANDAS can be controversial," but I, I have
Tracey Skale: 100% seen it, so no one can tell me it doesn't exist. I've seen it.
speaker_2: So have I.
Tracey Skale: Yeah, yeah. So I don't know why, why is it con- I don't know why it's controversial,
Tracey Skale: 'cause again, I've, I've seen people, more than one, that have had young,
Tracey Skale: you know, teen or preteen strep that developed OCD symptoms and ended up under
Tracey Skale: my care.
speaker_2: Well, the average age of onset of OCD is about 19, but about 25% of people with OCD have
speaker_2: onset before age 14. And s- so, so-called psychiatric
speaker_2: causes of OCD are, tend to be gradual. In other words, it, it emerges slowly and
speaker_2: then becomes obvious and full-blown. You have to suspect
speaker_2: autoimmune and inflammatory causes when it's suddenly, boom, normal
speaker_2: developing child, adolescent, wow, they just-
Tracey Skale: Mm
speaker_2: ... developed OCD.
Tracey Skale: Mm-hmm. What are some other, uh, ways of determining, what about genetics? Do you know
Tracey Skale: any, do you have anything down about genetics there?'Cause I do if you don't.
speaker_2: Proceed.
Tracey Skale: Well, I don't know. Let's see what you have and I have. So first degree relatives, two
Tracey Skale: times higher risk of OCD. Is that what you have too?
speaker_2: Yes.
Tracey Skale: Okay. And then they were talking about some of the prognostic, risk and prognostic
Tracey Skale: factors. So temperament is one thing. Um, people that tend to
Tracey Skale: internalize more might be more prone to having OCD. Have you heard about that?
speaker_2: Makes sense.
Tracey Skale: It makes sense, like s- psychodynamically too. There, there's some environmental things.
Tracey Skale: So you were talking about exposure to, um, flu, Spanish flu, other,
Tracey Skale: [laughs] you know, other flu. Premature births, they were saying some of the... Now, now
Tracey Skale: again, if you have a premature child, don't think that this kid automatically is going to
Tracey Skale: have OCD, but one, they think some of the premature births are associated with it.
Tracey Skale: Maternal tobacco use, uh, tr- traumatic childhood. But again, these are just some things.
Tracey Skale: There's lots of ways you can develop OCD. Um, what about suicidality?'Cause we think,
Tracey Skale: you know, suicide with depression, suicide with bipolar disorder. What about with people
Tracey Skale: with OCD?
speaker_2: Well, first, as we alluded to earlier, a lot of people with OCD have depression or bipolar
speaker_2: disorder and other significant psychiatric problems. Um,
speaker_2: but severe OCD in and of itself, you can imagine how tortured-
Tracey Skale: Mm-hmm
speaker_2: ... someone must be.
Tracey Skale: That's a good word, Paul. People are so tortured.
speaker_2: And there's an elevated risk of suicide-
Tracey Skale: Mm
speaker_2: ... in people with OCD-
Tracey Skale: Mm
speaker_2: ... without treatment.
Tracey Skale: 14, a rough, roughly 14%. Is that what I read?
speaker_2: Yeah, that's exactly what I have.
Tracey Skale: And then, but suicidal ideation, meaning you're thinking about,"Oh, I can't take this
Tracey Skale: anymore. I'd just as soon be dead," 44%.
speaker_2: Right.
Tracey Skale: So a lot of people are thinking about it. So again- We, you know, depression,
Tracey Skale: schizophrenia, bipolar, those are the big ones we talk about, but all of these illnesses,
Tracey Skale: because to be an illness you have to have, it has to be disabling in a way. Uh,
Tracey Skale: people start avoiding life, right? Um, it c- it can lead to
Tracey Skale: people being reclusive, so they avoid situations that might be triggers for them.
Tracey Skale: So they're avoiding restaurants and public restrooms and, you know, p- potential
Tracey Skale: contaminants, so then they stay huddled up inside their own home.
speaker_2: Yeah, that's been true of a lot of people that I've known and been in contact with over
speaker_2: the years who had OCD, that they became homebound.
Tracey Skale: Right.
speaker_2: Which, and this is the pre-Zoom, you know, virtual appointment era. That made it really
speaker_2: challenging because we had to beg them and their family had to beg them to come in-
Tracey Skale: Yeah
speaker_2: ... for care or at least an assessment.
Tracey Skale: Yeah. Well, especially if you have a contaminant component, they're so worried about
Tracey Skale: exposure. So imagine me in my, you know, community mental health setting, which isn't
Tracey Skale: always the cleanest. You know, we, we tried to do what we could. But sitting, uh, so a
Tracey Skale: person with OCD sitting in the waiting room with one of my patients from the so-called
Tracey Skale: homeless team that had, you know, schizophrenia and was malodorous and, you know, we had a
Tracey Skale: situation in Cincinnati there. It was a lot of, um-
speaker_2: Bedbugs
Tracey Skale: ... bedbugs, yeah. So that was a big deal. So you can ima- you can't sit in the waiting
Tracey Skale: room with someone with bedbugs crawling on them when you also have OCD. It was just no
Tracey Skale: way. It was so painful for them.
speaker_2: Do you want to talk a little bit about treatment or-
Tracey Skale: No, I think no. Actually, I would like to wait on that-
speaker_2: Okay
Tracey Skale: ... because [laughs] I would, but that's import- I feel like we should do that more toward
Tracey Skale: the end because that also gives lots of hope associated with it,'cause we have things to
Tracey Skale: do before that. So what's the difference between OCD and normal childhood
Tracey Skale: development things?'Cause, you know, I, I can speak for one of my own children, there was
Tracey Skale: a lot of needing things in s- all kinds of order and I, you know,"I have a blue pencil, a
Tracey Skale: purple pencil and a pink pencil, but I don't have a green pencil. I have to have a green
Tracey Skale: pen," you know, that kind of thing. But she does not, she's a grown woman now, she
Tracey Skale: absolutely has no signs of OCD, but she definitely had, what we, it's a developmentally
Tracey Skale: normative preoccupation and a little bit of ritual. So you can have that, right, without
Tracey Skale: having OCD.
speaker_2: Right, and presumably that was not interfering with her ability to be an, a, a good
speaker_2: student or have friends-
Tracey Skale: Or socialize or any of that stuff
speaker_2: ... right.
Tracey Skale: No, no, no. Mm-mm. So the problem is, so if your child is doing that kind of stuff, do not
Tracey Skale: be particularly concerned. It's, a lot of kids do that. It's only, again, when it, they're
Tracey Skale: so preoccupied with it they stop doing, they're not eating, they're not gonna go to
Tracey Skale: school,"I can't do anything," because n- it becomes a, this gets so excessive and they,
Tracey Skale: um, have distress associated with it. Would you say that's the thing is mostly the
Tracey Skale: distress?
speaker_2: Distress and-
Tracey Skale: Impairment in-
speaker_2: Impairment, yeah
Tracey Skale: ... impairment in functioning.
speaker_2: For kids it's mostly gonna be school.
Tracey Skale: So it's, uh, going back to some of the obsessions again, some of the things that people
Tracey Skale: really, you talked about contamination is a big one, right? That cleaning, cleaning
Tracey Skale: compulsion that goes with that. Symmetry, we see a lot of, um, ordering,
Tracey Skale: keeping things in order. Counting, you'll hear a lot of people counting. I used to have, I
Tracey Skale: had one of those ceilings in my office that had the little tiles, the little tiny tiles in
Tracey Skale: it, and people, you could sometimes see people counting and some- they would, it would, we
Tracey Skale: would not be able to have our conversation because it was interfering with them counting
Tracey Skale: blocks on the, you know. And it sounds so counting doesn't, to the average,"Oh,
Tracey Skale: what's the big deal they have to count?" Well-
speaker_2: But they're doing it for a reason.
Tracey Skale: Right.
speaker_2: They're not just s- the compulsion is based on some obsession.
Tracey Skale: And that they have to do it or, or something horrible's going to happen if I don't do
Tracey Skale: this, you know?
speaker_2: Right.
Tracey Skale: You talked also about these, these intrusive thoughts about, uh, could be violent, it
Tracey Skale: could be sexual. I have had people that said,"Well, I was in c- class and I kept seeing
Tracey Skale: my teacher in a sexual way or my parent in a sexual way and that was disgusting to me, but
Tracey Skale: I couldn't stop. So therefore I couldn't look at the person and then I stopped going to
Tracey Skale: school or I stopped, I closed myself in my room and wouldn't hang out with my parents."
Tracey Skale: There's also some religious preoccupations too. Can you speak to that?
speaker_2: Yeah. Um, so having, um,
speaker_2: an appropriate faith in
speaker_2: a recognized religion or even-
Tracey Skale: Mm-hmm
speaker_2: ... a non-recognized religion, um, is, is, there's nothing wrong with that.
Tracey Skale: Right.
speaker_2: It's, it's, again, a matter of degree. Um, again, I can remember somebody who
speaker_2: felt compelled to read and write in her Bible
speaker_2: every waking hour of the day.
Tracey Skale: Wow.
speaker_2: So 16, 18 hours.
Tracey Skale: Or what would happen? What was her fear? God, she wouldn't get into heaven or one of those
Tracey Skale: religious-
speaker_2: It, it was n- never entirely clear, but something catastrophic, almost apocryphal-
Tracey Skale: Mm-hmm, mm-hmm
speaker_2: ... would happen.
Tracey Skale: So you see how, so there's anxiet- there's secondary anxiety, so even though we've pulled
Tracey Skale: this out of the anxiety component of DSM, there's definitely a lot of anxiety associated
Tracey Skale: with it because if I don't keep writing this down, something horrible's gonna happen. That
Tracey Skale: makes you anxious.
speaker_2: The world might come to an end.
Tracey Skale: Right. And if you ever look at Reddit, people, like, you know, things like that and you
Tracey Skale: hear people talk about O- OCD or an- they'll all say,"I have anxiety associated with my
Tracey Skale: OCD." Ugh. But also what you're saying to me, you can
Tracey Skale: see how that could lead into a delusional piece too. I mean, it's, that's so extreme.
Tracey Skale: The fact that that's unwanted though, that they don't want that and they know that, okay,
Tracey Skale: if the person doesn't think it makes sense, that's a better, better prognostic indicator
Tracey Skale: than if the person's like,"No, I really, really have to do this or the world's really
Tracey Skale: gonna come to an end," that's starting to hinge on psychotic proportions.
speaker_2: And we, we, you and I are both, um, very interested in insight-
Tracey Skale: Mm-hmm
speaker_2: ... and or lack thereof.
Tracey Skale: Mm-hmm.
speaker_2: And there are degrees of lack of insight- In all of the OCD and
speaker_2: related conditions where people just believe they have
speaker_2: to do these things.
Tracey Skale: Yeah.
speaker_2: That's different from a primary psychotic disorder-
Tracey Skale: Right
speaker_2: ... um, in that they don't have any other symptoms of schizophrenia or-
Tracey Skale: Right
speaker_2: ... no disorganized thinking, no hallucinations, things like that.
Tracey Skale: It's all solely related to the obsession or the compulsion.
speaker_2: Right.
Tracey Skale: So do you have to have obsessions and compulsions, or you could have an obsession or a
Tracey Skale: compulsion to have OCD cra- criteria?
speaker_2: You can have, y- you, most people have both.
Tracey Skale: Right.
speaker_2: Some people have just one or the other. Um, pure obsession,
speaker_2: um, driven OCD is actually tougher to treat-
Tracey Skale: Hmm
speaker_2: ... because it's not amenable to exposure response therapy.
Tracey Skale: Which we'll get into.
speaker_2: Yeah.
Tracey Skale: 'Cause that's the gold, that's the gold standard.
speaker_2: I keep trying to.
Tracey Skale: I know. Why? Then we have to go backwards. So if we do treatments, then we have to loop
Tracey Skale: back around to... [laughs] I ha- I have, can you tell I have an order in my head
Tracey Skale: of how I want to do this?
speaker_2: Yes.
Tracey Skale: I do. I do have an order. So, okay, let's talk about, so the big one is obsessional,
Tracey Skale: obsessive compulsive disorder. Let's talk about body dysmorphic disorder,'cause that's
Tracey Skale: hard. I m- is that okay to move on to that?
speaker_2: So you wanna do treatment overall-
Tracey Skale: Yes
speaker_2: ... not disorder-
Tracey Skale: Yes
speaker_2: ... by disorder?
Tracey Skale: Yes.
speaker_2: 'Cause they're different.
Tracey Skale: There's some differences, but there's an overarching one-
speaker_2: Yeah
Tracey Skale: ... which is the one you-
speaker_2: Yeah
Tracey Skale: ... hinted at. So could we talk about, did you cover everything, the big stuff from
Tracey Skale: obsessive compulsive disorder?
speaker_2: Did we?
Tracey Skale: Did we?
speaker_2: I think so. Yes.
Tracey Skale: [laughs] We'll, w- we'll probably circle back, though. We might circle back. Let's talk
Tracey Skale: about body dysmorphic disorder. You can take the lead.
speaker_2: So it's characterized by a preoccupation with one or more
speaker_2: parts of the body that people perceive a- are flawed,
speaker_2: um, but those perceived flaws are not really,
speaker_2: A, perceived by other people-
Tracey Skale: Right
speaker_2: ... or, if they are perceived, they're really kinda minor compared-
Tracey Skale: So it's, they exaggerate it. So you might think you have a bump in, you might have, you
Tracey Skale: might really have a little bump in your nose. But to you, you have the biggest, worst nose
Tracey Skale: anyone's ever seen, and you're totally preoccupied, and you're squeez- pushing your nose,
Tracey Skale: and you're trying to make it smaller and all these things. That's an example. Or, right?
Tracey Skale: Um-
speaker_2: Right. Very first person I came in contact with, with body dysmorphic disorder,
speaker_2: um, ha- it was a, about an 18-year-old young man who
speaker_2: hated his hair.
Tracey Skale: Huh.
speaker_2: And it was bristly, thick, but bristly, and no
speaker_2: matter how he got it cut, he hated it. He always wore caps, but that didn't
speaker_2: really cover his whole hair. He-
Tracey Skale: So as an objective observer, did his hair, was his hair bizarre, or was
Tracey Skale: it-
speaker_2: No
Tracey Skale: ... it was, so it was in norms, societal norms?
speaker_2: Totally.
Tracey Skale: Okay. So it was his issue. Yeah.
speaker_2: And it was, uh, very debilitating. We knew very little
speaker_2: about the treatment of body d- dysmorphic disorder back then. Um, and he became
speaker_2: more and more reclu- reclusive, stopped going to work, because he was so-
Tracey Skale: Ah
speaker_2: ... preoccupied with people looking at his hair.
Tracey Skale: Ah.
Tracey Skale: What ever happened?
speaker_2: Well, a, a colleague of mine, Cathy Phillips, um, became,
speaker_2: uh, she's a world's expert in body dysmorphic disorder-
Tracey Skale: Oh
speaker_2: ... and she took over his care, and has actually done a lot of groundbreaking work in this
speaker_2: area. Um, and all I know is he did better with her than me. [laughs]
Tracey Skale: [laughs] Well, good. And that's right. So, you know, that's a really good point, Paul, uh,
Tracey Skale: in general. So I was treating lots of people with schizophrenia and bipolar disorder,
Tracey Skale: and if someone went to their basic, I call it bread and butter psychiatric provider for
Tracey Skale: their schizophrenia, that wasn't always a great fit, you know? Um, and if you don't see a
Tracey Skale: lot of people with body dysmorphic disorder, but somebody else does, that's their
Tracey Skale: specialty, if there's a chance that that's who you should see, right? Same thing when we
Tracey Skale: get into the eating disorders. I mean, you and I both treated people with eating
Tracey Skale: disorders. It wasn't our specialty, and we knew how to do it. But if it were my kid that
Tracey Skale: had an eating disorder, I would rather have them see an eating disorder specialist than
Tracey Skale: see one of the two of us, you know, right? So speaking of eating disorders, how
Tracey Skale: is, how are, we're gonna talk about that separately, but how is that not a body dysmorphic
Tracey Skale: disorder, someone might ask?'Cause they look at themselves in the mirror, and they see
Tracey Skale: someone that's way overweight, even though they might be grossly underweight.
speaker_2: Well, it's separated from bod- body dysmorphic disorder in that there's a preoccupation
speaker_2: not just with body image, but also eating behavior.
Tracey Skale: Right.
speaker_2: So, and that, those things, whether it's bulimia, binge eating disorder, or anorexia
speaker_2: nervosa, tend to go hand-in-hand.
Tracey Skale: Right. But then, and you, they also obsess, and then they have compulsive behaviors with
Tracey Skale: it. So, uh, there's lots of overlapping in the psychiatric world,
Tracey Skale: which is why I don't get as, as particularly hung up on actual definitive, it has to be
Tracey Skale: this diagnosis,'cause I feel like there's lots of gray matter. But, I mean, diagnoses do
Tracey Skale: help inform what we're going to do treatment wise, right?
speaker_2: Right. It guides treatment.
Tracey Skale: It guides treatment.
speaker_2: Yeah.
Tracey Skale: Right. So-
speaker_2: There's-
Tracey Skale: ... some of the things, oh, go ahead.
speaker_2: Sorry. No, go ahead.
Tracey Skale: Oh, please. [laughs] Like, go ahead.
speaker_2: I was just gonna mention a subcategory of body dysmorphic-
Tracey Skale: What?
speaker_2: ... disorder, um, which is muscle dysmorphia.
Tracey Skale: Oh, yeah. Yeah, yeah. I had somebody with that. That's fascinating, but tell, tell us more
speaker_2: It's more common in men than women-
Tracey Skale: Mm-hmm
speaker_2: ... as you might imagine, and the perception is that you either are
speaker_2: weak of stature or under, don't have a- enough muscle
Tracey Skale: Underdeveloped.
speaker_2: Yeah. And again, it's, it's an exaggeration. It's not based in other
speaker_2: people's perceptions.
Tracey Skale: So what do they do about it?
speaker_2: S-
Tracey Skale: Excessive gym?
speaker_2: They can, but, um-
Tracey Skale: Butt implants? Like, what do they do?
speaker_2: Hopefully get treatment. Um-
Tracey Skale: I- you know what? I, I, I bet a lot of people don't do treatment for that, though.
speaker_2: Yeah, uh-
Tracey Skale: Don't you think they're just excessively at the gym then, trying to work out?
speaker_2: Probably, and probably constantly frustrated by even though they're getting muscle growth
speaker_2: and still not enough.
Tracey Skale: It's not what they, it's not what they want to see.
speaker_2: Yeah.
Tracey Skale: So people with body dysmorphic disorder, um, there's lots of mirror checking, lots
Tracey Skale: of seeking reassurance, um, excessive grooming. There could be skin picking
Tracey Skale: associated with that, which is its own separate ca- category of things, but, um, that's
Tracey Skale: what you see as well, right?
speaker_2: And excessive plastic surgery.
Tracey Skale: Yes. So especially now, yes, and that goes on, and hence shows like Botched and things
Tracey Skale: like that where people just keep getting more and more plastic surgery even though most
Tracey Skale: people around them would, would say,"Mm, too much. Stop," and they don't see it. Just,"I
Tracey Skale: have to get my lips a little bit bigger," the BBL, having, you know, uh... Uh, do, do you
Tracey Skale: know what that is?
speaker_2: No.
Tracey Skale: That's the whole, uh, [laughs] butt implant-
speaker_2: Oof
Tracey Skale: ... thing. So you don't know that from Paul. [laughs] Paul, you have, you obviously have
Tracey Skale: not been watching much reality TV.
speaker_2: [laughs]
Tracey Skale: [laughs] But I, no, I did see that in my practice. I, uh, one person that was particularly
Tracey Skale: sad situation for me. It was a young girl from a poor family
Tracey Skale: financially, and she, all she talked about... So again, I'm adult psychiatrist, but I did
Tracey Skale: see s- people as young as 14. She was 17, and all, all she could talk about is,"When I
Tracey Skale: turn 18, I'm gonna have every plastic surgery you can have. I'm having my nose fixed. I'm
Tracey Skale: getting breast implants. I'm getting butt implants. I'm doing liposuction," da- da- da-
Tracey Skale: da- da. It was like, first of all, never gonna ha- happen, or she was going to go to
Tracey Skale: extremes to get money to make that happen, which was really very sad to see.
Tracey Skale: But you're right, excessive plastic surgery is something we see with body dysmorphic
Tracey Skale: disorder.
speaker_2: Which is its own hazard.
Tracey Skale: Correct.
speaker_2: Yeah.
Tracey Skale: Yes, yes. Do, I wonder if plastic surgeons, do they
Tracey Skale: consult with psychiatrists ever? I've never been asked by a plastic surgeon my opinion.
speaker_2: Neither have I. But just maybe just the two of us. I, I don't know. It's a good
speaker_2: question.
Tracey Skale: I wonder how that works, though. I suppose even if a plastic surgeon said,"I think s-
Tracey Skale: maybe you should see a psychiatrist," they would just go to a different plastic surgeon,
Tracey Skale: right?
speaker_2: Could be.
Tracey Skale: Hm.
Tracey Skale: Let me... Okay, so the whole thing is the preoccupation causes significant distress, so
Tracey Skale: that's across all the OCD, uh, illnesses. Associated features with this are
Tracey Skale: low self-esteem, perfectionism, they're very sensitive, they might have surgery.
Tracey Skale: Typically starts in the teen years. And by the way, let's go back to just OCD in general,
Tracey Skale: more women or men?
speaker_2: Hm.
speaker_2: I think the prevalence rates of OCD are about even,
speaker_2: OCD per se. Some of these other related conditions, like body
speaker_2: dysmorphic disorder, is more common in women.
Tracey Skale: Mm-hmm.
speaker_2: Um, hoarding is more common in women.
Tracey Skale: Hm. You wanna ex- so that leads, do you wanna talk about hoarding? That's next.
speaker_2: Sure.
Tracey Skale: That's next in my organized [laughs] method of doing this.
speaker_2: Before we do, though-
Tracey Skale: What?
speaker_2: Body dysmorphic disorder-
Tracey Skale: Oh
speaker_2: ... and this is true of everything, actually-
Tracey Skale: Right
speaker_2: ... that we're talking about today, is also associated with depression.
Tracey Skale: Yes.
speaker_2: Also associated with an elevated risk of suicide. So again, underscoring the
speaker_2: seriousness of these problems.
Tracey Skale: Right. Well, let's talk about hoarding. So a show that I really liked to watch but you did
Tracey Skale: not, which wa- were the hoarding shows. You would go in the other room and read or
Tracey Skale: something when I was binging on those.
speaker_2: Well, they were cringe-worthy because the... I mean, I think those
speaker_2: shows did a great service to-
Tracey Skale: Well, educate in the public and enlighten and-
speaker_2: Right, in how disastrous hoarding disorder can
speaker_2: be, including from a public health standpoint.
Tracey Skale: Right, right, right. But it's, uh, the part I don't like about those kinds of shows is it
Tracey Skale: feels like it c- it's exploiting people because, you know, in retur- in return for them
Tracey Skale: getting, uh, treatment, free treatment or getting their house cleaned as they were exposed
Tracey Skale: on TV. So I don't like that aspect of it, but I do like that it educated a lot of people,
Tracey Skale: and I had, I had patients come forward and saying they had watched that show and they were
Tracey Skale: able to tell their secret. So there's a tremendous amount of shame associated with
Tracey Skale: hoarding. Ha- have you had patients with hoarding disorders?
speaker_2: You know, not that I know of.
Tracey Skale: Interesting. That's really interesting to me. So again, our practices were very, very
Tracey Skale: different, but you still, like even on that show, it, it wasn't just the so-called, in
Tracey Skale: quotes,"hermit" that, you know, lived out, like h- had his house overtaken by 8,000
Tracey Skale: lawnmowers and cats and all these things. You know, they would, they would show the
Tracey Skale: suburban housewife that looked, the house on the outside looked nice and was married to a
Tracey Skale: wealthy guy, but inside was a disaster and the kids were ashamed and they couldn't bring
Tracey Skale: anyone home because it was floor-to-ceiling, um, unopened boxes or ordering from-
Tracey Skale: QVC or they're ordering and ordering and ordering, and they never took the tags off, but
Tracey Skale: it's, you know, the house was unlivable essentially. So I, um, you could have had that in
Tracey Skale: your practice
speaker_2: The only hint I ever got was when after COVID hit and I was doing Zoom calls-
Tracey Skale: Mm-hmm
speaker_2: ... and seeing people on Zoom in their homes, there were some people that,
speaker_2: whoa, what is going on behind you?
Tracey Skale: It's a lot of stuff.
speaker_2: Yeah.
Tracey Skale: Yeah. Mm. So no, I have definitely had situations like that, and, um,
Tracey Skale: one person in particular was very on the surface high func- as you would call
Tracey Skale: high-functioning, you know. Um, and she had burned through a lot of the private sector,
Tracey Skale: and also she ended up in community mental health because she, um, had no money'cause she'd
Tracey Skale: lost her job, repeated jobs because of her d- her hoarding, which there was a big
Tracey Skale: OCD, other components with that too, collecting. Um, but
Tracey Skale: she looked, she would come into the appointment clean and neat and lovely looking. She had
Tracey Skale: an advanced de- she had a graduate degree, very well-spoken. She would get dates. She was
Tracey Skale: an attractive woman, really smart, and she would get these different boyfriends, which is
Tracey Skale: what she wanted, just to have a relationship, but she could never sustain them. Why?
Tracey Skale: Well, they would go to-
speaker_2: Couldn't bring them home
Tracey Skale: ... they couldn't bring them home, so she would go to their house, their house, their
Tracey Skale: house. Everything would fall apart when they said,"Can we go to your apartment sometime?"
Tracey Skale: No con- she would never have any contact with them again because it was so sh- so much
Tracey Skale: shame. So it was to the point that she couldn't, and this is a particular composite person
Tracey Skale: I'm making up, but she couldn't get, make her way through her apartment. There was, you
Tracey Skale: know, uh, enough to be on tiptoe through all the stuff. And I had a big window in my
Tracey Skale: office, and I could see the main street, and I could see her one time. There was a bus
Tracey Skale: stop, and I could see her walking down, and as she was walking to the appointment, she was
Tracey Skale: picking up stuff off the ground, like a dirty wire, a rock,
Tracey Skale: a piece of paper, and brought them into the office. So we were able to talk about that.
Tracey Skale: But what she would say is,"Oh, I'm gonna make something out of that," or,"This, I could
Tracey Skale: use this for something else, and I'm gonna make a project out of that." And, you know, so
Tracey Skale: it was, it was really debilitating, really tragic because she had so much potential, and
Tracey Skale: she wanted so desperately to have a relationship. Um, therapy, I mean, there's only so
Tracey Skale: much. We tried, and we're gonna get into this, but remind me when we get to the therapy
Tracey Skale: part. We tried every medication you could potentially think of, um,
Tracey Skale: and all kinds of therapy, and as the time of me leaving there, unfortunately she
Tracey Skale: didn't have the breakthrough that she wanted.
speaker_2: Well, hoarding disorder sometimes starts in adolescence-
Tracey Skale: Mm-hmm
speaker_2: ... but the prevalence increases with age. And so it's common to see in
speaker_2: older, middle-aged people and tends to be triggered by a sudden
speaker_2: loss-
Tracey Skale: Mm-hmm
speaker_2: ... loss of a spouse, family member, close friend. Um,
speaker_2: and one notion is that people have lost control of
speaker_2: their lives and are now trying to control their lives by collecting and holding onto
speaker_2: things that remind them of the lost person.
Tracey Skale: That's how it starts, and then it snowballs, and they start collecting this and that. And
Tracey Skale: this, well, this-
speaker_2: Takes on a life of its own
Tracey Skale: ... you know, Joe liked to smoke pipes, so I have all these pipes, and I have
Tracey Skale: all these tobacco cans, but now I have this, this, this and that. That's unrelat-
speaker_2: Right
Tracey Skale: ... we wouldn't see the relationship to that. So the person has distress associated with
Tracey Skale: discarding or parting with items. Uh, you touched on an interesting point too about
Tracey Skale: often after a loss. So when you watch that show, you'll see a lot of people had some kind
Tracey Skale: of loss. So psychodynamically speaking, you're trying to fill that void,
Tracey Skale: and you can't fill it. You just keep, things aren't filling the void, right? Um, it,
Tracey Skale: in real life, it's very different than what you see on the show. So the show, especially
Tracey Skale: when you call it dirty hoarding, which is, sounds offensive, but it means, like, actually
Tracey Skale: there's feces and dirt and bugs and all these kind of things. That's particularly
Tracey Skale: difficult to treat, and trash everywhere. In real life, there is not a therapist that will
Tracey Skale: sit with you all day and the next day and the next day while you throw out one gum
Tracey Skale: wrapper. What happens in real life,'cause I've seen it, the, um,
Tracey Skale: [smacks lips] board of, what's it called? The-
speaker_2: Board of Health
Tracey Skale: ... Board of Health. Yeah, the Board of Health is called by some neighbor, and because,
Tracey Skale: and they should, because there's rats or whatever is happening, and somebody condemns your
Tracey Skale: house. That's what happens, um, which is, it, there's a lot of sadness associated with
Tracey Skale: this. You will often see people, unless they get ongoing treatment for this, even if you
Tracey Skale: clean the hoard and they, you put them in a brand-new, fresh place with nothing in it, it
Tracey Skale: starts filling up again. So unless you do intensive treatment, and there is definitely
Tracey Skale: treatment for it-
speaker_2: Mm-hmm
Tracey Skale: ... and definitely hope for it. Mm, unfortunately, there's a lot of recidivism with it.
Tracey Skale: What do you think is next on my list?
speaker_2: Trichotillomania.
Tracey Skale: You're right. Go ahead. Trichotillomania.
speaker_2: Trichotillomania is compulsive hair pulling.
Tracey Skale: Mm-hmm.
speaker_2: And-
Tracey Skale: Is it just the hair on your head?
speaker_2: It's usually the hair on your head. It's us-
Tracey Skale: But it doesn't have to be
speaker_2: ... doesn't have to be
Tracey Skale: Oh
speaker_2: ... anywhere there's hair, but the most common places are scalp, um,
speaker_2: eyebrow and-
Tracey Skale: Eyelashes
speaker_2: ... eyelashes
Tracey Skale: But people will pick off arm hair, pubic hair. They'll do any kind of hair, anywhere
Tracey Skale: there's hair. Shame associated with it.
speaker_2: And sometimes such severe hair loss that people have
speaker_2: bald patches-
Tracey Skale: Mm
speaker_2: ... or become bald. Uh, you can get eye infections from picking your, uh,
speaker_2: eyelashes, and in extreme cases, pe- People sometimes
speaker_2: chew their hair-
Tracey Skale: Mm-hmm
speaker_2: ... which can cause dental problems, and swallow their hair, which can cause
speaker_2: hairballs.
Tracey Skale: Say the word you wanted to say, though.
speaker_2: Um-
Tracey Skale: Bezoars
speaker_2: ... bezoars.
Tracey Skale: I know you love that word.
speaker_2: Yeah, yeah.
Tracey Skale: Bezoars. [laughs]
speaker_2: Uh-
Tracey Skale: But by the way-
speaker_2: It's called
Tracey Skale: ... I, I know there's lots of people that pull some hair here, and especially if they have
Tracey Skale: a gray hair or something, they chew their hair. That doesn't make you have
Tracey Skale: trichotillomania. It just, again, it's extreme. There's shame associated with it. One of
Tracey Skale: the things that's different about trichotillomania than the other illness, OCD illnesses
Tracey Skale: that we talked about, this, the body-focused repetitive behaviors are not necessarily
Tracey Skale: triggered by obsessions or preoccupations.
speaker_2: Correct.
Tracey Skale: So that make, that's a difference.
speaker_2: They're more like tics.
Tracey Skale: Yeah. It's instead preceded or accompanied by feeling, well, feelings of anxiety or
Tracey Skale: boredom. You talked about the hair chewing, the hair, boredom, and there's often this
Tracey Skale: increased sense of tension that may lead to this feeling of they feel gratified or
Tracey Skale: satisfied. There's some kind of pleasure and relief when they pull the hair. Related to
Tracey Skale: that is also excoriation. Can you talk about that a little bit? The, they go hand in hand.
speaker_2: You know, e- excoriation disorder is really s- compulsive skin picking.
Tracey Skale: Mm-hmm.
speaker_2: And like you said about trichotillomania, it's not necessarily driven by an obsession, but
speaker_2: more a relief of anxiety or tension-
Tracey Skale: Right
speaker_2: ... and can lead to significant skin lesions-
Tracey Skale: Infections
speaker_2: ... sores, infections.
Tracey Skale: Yeah.
speaker_2: Um, again, social embarrassment, always wearing long sleeves-
Tracey Skale: Mm-hmm
speaker_2: ... or trying to cover up the picking.
Tracey Skale: Yeah. Mm-hmm. Good. Thank you. Now, I would like to move on to
Tracey Skale: differential diagnosis, please. So in that, what I have, I, anxiety
Tracey Skale: disorder, but we touched on that. You can maybe talk about it a little bit more, about
Tracey Skale: anxiety versus, a generalized anxiety versus OCD.
speaker_2: I think you touched on it earlier. Generalized anxiety is anxiety about a whole bunch of
speaker_2: different things, and not necessarily a single obsession, and
speaker_2: tends, people tend to feel like they can, their anxiety
speaker_2: thoughts make sense, even if they're too many.
Tracey Skale: Mm-hmm.
speaker_2: Whereas in OCD, the thoughts are intrusive,
speaker_2: unbidden-
Tracey Skale: Mm-hmm
speaker_2: ... disgusting for the f-
Tracey Skale: Yeah
speaker_2: ... in, in many instances.
Tracey Skale: A lot of ways for them, yeah.
speaker_2: Yeah. So that-
Tracey Skale: Well-
speaker_2: ... that's one of the main differentiating features.
Tracey Skale: So one of the reasons why also OCD was taken out of the anxiety, uh, category in DSM
Tracey Skale: is because there's a distinct neurobiology, believed, and you touched on that a little bit
Tracey Skale: also with the caudate and putamen earlier. So with OCD, there's this whole
Tracey Skale: cortico-striatal-thalam- thal-thalamo, they call it, but thalamic,
Tracey Skale: basically, and cortical, again, with executive function. There's that executive function
Tracey Skale: piece. With the anxiety disorder, it's more amygdala and limbic
Tracey Skale: is involved there. So that's partly why they separate it.
speaker_2: Different brain pathways.
Tracey Skale: Right, different pathways, but there's some commonalities of how we treat, though. And
Tracey Skale: then depression, what about depression? M- we said that mood congruent, not intrusive,
Tracey Skale: right? I, I'm gonna let you talk about OCPD,'cause you love to talk about OCPD, so let's
Tracey Skale: t- explain to everyone what that is.
speaker_2: So in the, [sighs] I'll say general cultural,
speaker_2: you know, dialogue, a lot of people who have obsessive compulsive personality disorder
speaker_2: are c- are said to have OCD.
Tracey Skale: Mm-hmm.
speaker_2: It's an unfortunate, um, coincidence of terminology,
speaker_2: but OCPD, obsessive compulsive personality disorder, um, is not
speaker_2: characterized by intrusive thoughts-
Tracey Skale: Mm
speaker_2: ... images, or repetitive behaviors performed in response-
Tracey Skale: Right, or urges, none of that
speaker_2: ... or urges, right. Um, OCPD, uh, like most personality
speaker_2: traits that then can become disorders-
Tracey Skale: Character pathology
speaker_2: You're right.
Tracey Skale: Yeah
speaker_2: ... personality disorders in the vernacular, um, is defined as a enduring
speaker_2: and pervasive maladaptive pattern of excessive perfectionism-
Tracey Skale: Mm-hmm
speaker_2: ... and rigid control, and a preoccupation with orderliness, lack of
speaker_2: flexibility in relationships and things like that, and over-conscientiousness
speaker_2: and excessive scrupuality.
Tracey Skale: That's a hard word to say.
speaker_2: Yeah.
Tracey Skale: Yeah.
speaker_2: And I think I've just butchered it, but-
Tracey Skale: I don't know
speaker_2: [laughs]
Tracey Skale: They're very sc- very precise and s- scrupulous. Yes.
speaker_2: So, so I had a, still have a good friend from medical school who-
Tracey Skale: Won't be your good friend after this when he recognizes himself [laughs]
speaker_2: No, I don't think he has OCPD.
Tracey Skale: Okay.
speaker_2: But he lined up his shirts in his closet according to color.
Tracey Skale: Yeah, a lot of people do that.
speaker_2: Yeah, and then stripes. He was the most organized person I ever saw.
Tracey Skale: That's not a bad thing.
speaker_2: But it wasn't a bad thing.
Tracey Skale: I would like you to do that.
speaker_2: It actually inspired me to do so back then.
Tracey Skale: Yeah, could you-
speaker_2: Um-
Tracey Skale: What will inspire you to do so again? I would love that
speaker_2: My, my closet's in pretty decent shape.
Tracey Skale: Yeah, but not like that. I would love that.
speaker_2: No. So, so that's an example of a OCP trait.
Tracey Skale: Trait, right.
speaker_2: But it was not a disorder.
Tracey Skale: Right, it wasn't disorder at all. I like, so that's the, I love that,'cause you can have
Tracey Skale: some of these traits that are actually advantageous. They're not destructive at all. So-
speaker_2: He always knew where his shirts were
Tracey Skale: That's right, and today, when you tried to throw around OCPD before we started because I
Tracey Skale: asked you to please check the right side of your hair [laughs]
speaker_2: [laughs]
Tracey Skale: That was a good thing. That was helping you look good on camera. There you go. You're
Tracey Skale: welcome. So can we go to other, just to touch before we get to ther- we want to do therapy
Tracey Skale: for sure, but some, just other obsessional jealousy And then olfactory,
Tracey Skale: um, reference syndrome. So that's just, uh, that's very niche here, but it's
Tracey Skale: like the person thinks that they smell or they're emitting some foul odor, and they don't.
Tracey Skale: They don't. Again, that could be to delusional proportions. That's a whole different
Tracey Skale: somatic delusion we've seen in schizophrenia, but this is different. So again, very small.
Tracey Skale: It's not like the big umbrella of OCD. Can I mention just one thing, just'cause it's cool
Tracey Skale: and it's on every single psychology test you ever take and it's on the boards and all
Tracey Skale: that? I'm gonna say KORO. Do you know what that is?
speaker_2: Yeah.
Tracey Skale: So I'm just saying it because it falls under, it's interesting, K-O-R-O. It's a culturally
Tracey Skale: specific illness that's considered to be an OCD thing, but it could also be delusional if
Tracey Skale: it got to delusional proportions. It's culturally specific because it's East or Southeast
Tracey Skale: Asian, typically China or Malaysia, and it's the, um,
Tracey Skale: episodic or sudden and intense anxiety that the sexual organs are going to
Tracey Skale: absorb back into the body, and people get incredibly anxious about that. And, uh, the
Tracey Skale: reason I bring it up, it's a real thing, and it's on every single test, so if we have any
Tracey Skale: students out there, you might see it. It's irrational and all that. Okay. Treatment. Let's
Tracey Skale: do treatment'cause that's, there's hope here. Okay? This is difficult, but there's
Tracey Skale: treatment. What's the gold standard of treatment for obsessive compulsive disorder?
speaker_2: Um, two things. Um, and by the way, running throughout,
speaker_2: um, all of these syndromes is considering SSRIs, serotonin
speaker_2: reuptake inhibitors.
Tracey Skale: Selective serotonin reuptake inhibitor. Yeah.
speaker_2: Um, but ERP or-
Tracey Skale: Exposure and response prevention
speaker_2: ... response, uh, yeah.
Tracey Skale: That's the, that is the gold standard. It's, uh, exposure and response prevention.
speaker_2: Well, both are considered mutually beneficial.
Tracey Skale: Well, I don't think, so I'm gonna tell you from my own personal experience, I don't think,
Tracey Skale: I, I think I have not had good luck with OCD with SSRIs, selective serotonin. So again,
Tracey Skale: the Prozac, Paxil, Zoloft. And then the one specific, the meds spec- specifically that we
Tracey Skale: think of are Luvox or Anafranil. Mm, you said you've had some successes with it. I have
Tracey Skale: not had that many successes with it. I mean, the cases I've had of people that had these
Tracey Skale: ex- extreme situations, and therapy to me is the gold standard for this. Um, and-
speaker_2: Well, it's part of the gold standard.
Tracey Skale: [laughs] I'm gonna, seriously, after this, please look up gold
Tracey Skale: standard treatment for OCD, and you're gonna see exposure and response prevention.
speaker_2: It depends what website you look at.
Tracey Skale: Uh, uh, okay. We're gonna have your good friend Charlie Brady, who's an expert-
speaker_2: Yes
Tracey Skale: ... on this come on, and he'll talk about.
speaker_2: Yes.
Tracey Skale: But exposure and response, talk about that. What is it?
speaker_2: So it's a form of cognitive behavioral therapy, and the idea is you
speaker_2: expose someone to the thing that they're obsessed about and concerned about, for example,
speaker_2: something that they're, uh, concerned might be contaminating, but in small doses.
Tracey Skale: Very small doses.
speaker_2: You basically desensitize them and help them learn that nothing bad's gonna happen.
Tracey Skale: Right, and it's, it's a gradual exposure, much like we do with people with phobias. You
Tracey Skale: know, it crosses over to those anxieties, but it's just gradual. So what would be an
Tracey Skale: example of that? So let's, let's say somebody has a contamination concern. What would they
Tracey Skale: do with that?
speaker_2: Well, you mentioned Charlie Brady, who's one of the great psychologists who is an expert
speaker_2: in OCD.
Tracey Skale: We should have him on sometime, for sure.
speaker_2: We should. And his office was right next door to mine, and I would see him taking,
speaker_2: leading his patients down to the restroom.
Tracey Skale: Uh-huh.
speaker_2: Not to go to the bathroom, but to be exposed to the bathroom.
Tracey Skale: Contaminants.
speaker_2: Right.
Tracey Skale: Those contaminants.
speaker_2: To the contaminants there.
Tracey Skale: Mm-hmm.
speaker_2: In measured amount of time.
Tracey Skale: Right.
speaker_2: Different, touching different things initially.
Tracey Skale: Mm-hmm.
speaker_2: Touching more things. Um, it, it was very effective.
Tracey Skale: So according to what I've read, and I believe fully, [laughs]
Tracey Skale: 80%, they're, 80% experience significant improvement with exposure and response
Tracey Skale: prevention.
speaker_2: I think it's a great treatment.
Tracey Skale: It really is.
speaker_2: Don't misunderstand me. I'm just saying some people need more than that.
Tracey Skale: Some people need more of that, but I think you really need that, though. I personally
Tracey Skale: don't think, uh, a medication alone is gonna do this. I feel like, I think a
Tracey Skale: medication alone probably is not gonna do this, whereas you could potentially do it alone
Tracey Skale: with exposure and response treatment. But putting them together, even better maybe.'Cause
Tracey Skale: like you said, sometimes people have depression or anxiety or something like that
Tracey Skale: associated with it, but it's, it's gradual exposure is, is key there. What are some other
Tracey Skale: things people can do for their, uh, obsessive compulsive disorder?
speaker_2: Okay. Well, transcranial magnetic stimulation is now FDA approved.
Tracey Skale: For OCD?
speaker_2: For OCD.
Tracey Skale: Okay.
speaker_2: Um-
Tracey Skale: Explain that a little bit.
speaker_2: Yeah. It's basically delivering electromagnetic waves in a very specific area of
speaker_2: the brain. Um, does not require anesthesia
speaker_2: and, but does require a lot of time. So it's about a half an hour a day, five days a week
speaker_2: for four to six weeks.
Tracey Skale: Mm-hmm.
speaker_2: Um, in extreme situations, deep brain stimulation, which involves
speaker_2: planting electrodes-
Tracey Skale: Like they do with people with Parkinson's.
speaker_2: Right. And, and some of the, interestingly, some of the similar brain structures as
speaker_2: Parkinson's. And then, um, there's a drug called Tramadol, which is,
speaker_2: um, a narcotic, an opiate drug. Um, and so I'm not s- suggesting that-
Tracey Skale: Yeah
speaker_2: ... cavalierly, but I have seen some real miracles with that medicine. Um-
Tracey Skale: Well, so have I. So as you know, we, um, have been colleagues for years and years and
Tracey Skale: years, and I would sometimes when I would have a particularly challenging situation, I
Tracey Skale: would reach out to you about that, and I'm greatly appreciative of that. And I ha- was
Tracey Skale: working with someone who loves to tell this story actually too, so the, who had a mood
Tracey Skale: disorder, who we got that under incredibly great control. There was no issues with that.
Tracey Skale: But he had severe OCD with intrusive thoughts that were very upsetting to
Tracey Skale: him, sexual and rage and all that. It's very upsetting to him. He was quiet, timid person.
Tracey Skale: And I tried everything, everything I could think of, and I said to you,"I have tried
Tracey Skale: everything." Um, he, by the way, also worked with Charlie Brady. And then you said,"What
Tracey Skale: about Tramadol?" And I said,"Tramadol? I'm not prescribing Tramadol. You know, it's a
Tracey Skale: controlled substance." And you said,"Well, you know, you don't have to, but I have a white
Tracey Skale: paper on it and you might wanna consider it." And so I talked to him about it and his
Tracey Skale: family, and they're like,"Yes, yes, yes, whatever. Please do this." And we did it, and it
Tracey Skale: made all the difference in the world. He was able to graduate. He's a professional. It's
Tracey Skale: li- was life-changing for him. Again, that's-
speaker_2: It's low on the list
Tracey Skale: ... very low on the list. But we wanna end saying that obsessive compulsive disorder and
Tracey Skale: the related disorders can be troubling for sure, but there is absolutely hope
Tracey Skale: associated with this ill- these illnesses, and people can absolutely get better and have
Tracey Skale: fulfilling, rewarding lives. One more plug for exposure and response prevention [laughs]
Tracey Skale: because I do think it's the gold standard for the OCD related illnesses. But definitely
Tracey Skale: don't give up hope if you have these illnesses. Try not to feel shame associated with it.
Tracey Skale: There's a lot of people out there that are experiencing the same things you might be
Tracey Skale: experiencing, and seek treatment for it.
speaker_2: The OCD Foundation has a good website-
Tracey Skale: Mm-hmm
speaker_2: ... and is a good resource-
Tracey Skale: Yes
speaker_2: ... for people across the country.
Tracey Skale: Absolutely. Thank you for bringing that up. That's a good point. Thank you so much for
Tracey Skale: your time today. We look forward to another time with you talking about more things with
Tracey Skale: Docs Tracy and Paul Discuss It All. [outro music]
speaker_2: Thank you.
speaker_2: [outro music]