Eric Storch, PhD, Professor, McIngvale Endowed Chair and Professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College Of Medicine talks about OCD and its treatment options.
Interview conducted by Ivanhoe Broadcast News in January 2019
We were just talking about whether it’s an environmental trigger or a wiring trigger. And how does the behavior manifest? Are they always attached to the fear or can they cross wires.
Eric: Absolutely. OCD is this incredibly heterogeneous condition. It can manifest in a variety of ways. Many times it doesn’t necessarily have rhyme or reason the way it comes about. Now, typically when we see someone present with OCD there’s some sort of kind of logic to their symptoms. People who have fears of contamination or getting sick will engage in washing type rituals or cleaning rituals. People who have fears of something bad happening or harm befalling someone else will engage in checking rituals. If someone that has fears of doing something morally improper or against their religion will engage in rituals that involve prayer. So, we see that linkage. But for each person it can be very different in the way OCD can present. It can vary from person to person with incredible.
Somebody once told me that if someone has OCD they can’t talk themselves out of itIs that true?
Eric: One of the challenges with OCD is that people who have it recognize that what they’re doing doesn’t make sense or is out of character or out of the ordinary. Ordinary logic just doesn’t do the trick and trying to get them through for some people they’re able to really push themselves and receive some benefit from that. But when people are stuck with significant symptoms just trying to argue back or use logic to get out of that cycle often just doesn’t do the trick.
They’re so frustrated with it, so how do you get them out of this cycle? Is always CBT or other methods
Eric: You bring up a great point that OCD is incredibly debilitating disorder. It causes a significant amount of distress not only to the person affected but to the people that love him or her the most. Very often that level of distress the impairment. That’s what’s bringing people in to try to access care. We have a bunch of different treatment options, in particular, to that that worked very, very well for adults and children with OCD. The first is a specific type of psychotherapy that’s called cognitive behavioral therapy with exposure and response prevention. The basic gist to this is it involves facing your fears starting in a covered gradual sense but doing so without engaging a sort of rituals or safety behaviors. This helps many people though. But one of the challenges is that it’s not always available and it’s hard to do. A second type of treatment that works involves antidepressant medications. These have been around for many years and are widely available and have shown good efficacy. What we think about is that for those people who are most severely affected the combination may be that the most aggressive or advantageous approach, but for those that have more mild to moderate symptomology, we might think about engaging in the cognitive behavioral therapy.
How do people then finally get in here to seek the treatment of the things they fear the most on the planet.
Eric: One of the big fears that people have when they’re seeking out intervention is exactly what you said, that there’s going to be this extreme fear which they’re confronted with right away. The fact is that in exposure therapy doesn’t work like that at all. It’s very gradual. The person is in charge of the pace of therapy, and the role of the clinician is really that of kind of encouraging and pushing but pushing at the time. Pushing in a way that’s sensitive to where the individual is affected with OCD might want to go it stated differently. No one’s ever forced to do something they’re not ready to do. Now, all that said there are some people who say that they either don’t want to engage in psychotherapy or they do when they still experience significant symptomology. It’s important for us to think about what other alternative interventions might be available to help people while considering their own preferences for engaging in treatment and in factors like tolerability and side effects.
On average, how soon could someone get past it and how long would it take?
Eric: A typical course of a CBT really is about 12 to 14 sessions for adults and for kids – huge amount of variance. For some people they’d be much, much more. But for some people they need even a fair bit less. We published a paper a couple of years ago where we found that we had about 85 percent of kids do much better when they receive 10 sessions of cognitive behavioral therapy. It really is that specific to the individual, and it also takes into account the variety of factors that many people will present with which could include other problems like depression or other anxiety manifestations that could complicate presentation in the course of treatment.
Is it all anxiety based?
Eric: OCD is a disorder of circuitry in the brain. One of the reasons why it was originally placed within the anxiety disorders in earlier versions of the Diagnostic and Statistical Manual was that that core element of anxiety and fear challenge was is that there are a number of people who didn’t have that. In one example, individuals experienced distress. But it wasn’t fear per say or anxiety. It was more distress if something wasn’t done a certain way because it didn’t feel right. Another example is when people have a response to stimulate the response is characterized by disgust. It’s not about fears, but rather this kind of aversion or disgust reaction because of that, as well several other reasons. OCD was relocated in the fifth version of the Diagnostic and Statistical Manual into this OCD and Related Disorders category. It’s really just recognition that the OCD can present a multitude of ways. Somewhat, you’re really characterized by anxiety and fear others which are more characterized by this element of distress or disgust that still can present in the form of a obsessional symptoms of repetitive rituals.
So those are two separate areas you’re talking about – four and five you said. So the disgust component as compared to just being fearful of not being clean for example and over washing your hands are two entirely separate things. If a person has both of them at the same time then what?
Eric: This is one of the challenges that our field faces. We see what OCD is as it comes out. But the reality is we have what’s operating behind the scenes may be very different as a function of what we’re seeing. Some treatments may work better for people who perhaps have more fear based element versus who have a more disgust based element. What becomes incumbent upon us is to really investigate a multitude of different approaches to treating OCD, so that we have more than one or two tools on our belt.
When people come in I assume they fill out paperwork so you have some idea of what their disorder is but do they ever manifest something completely different that kind of comes out of left field? And are you just doing that by watching them or watching and listening?
Eric: It’s a variety of ways that we try to understand what’s going on. One of them is, of course, listening to the person who’s affected watching them try to understand what’s happening. We try to get multiple perspectives, so that could be a significant other a spouse a parent to someone that really knows this individual. We try to get the individual telling us in multiple ways what’s happening. And ultimately, if you’ve seen a person with OCD seeing that one person whether it’s just their presentation which can vary so dramatically from individual to individual to the fact that this is a human being who has their own wants, their own goals and wishes, at the end of the day we’re really thinking about this individual on how we can most effectively help them.
So that brings me to the next question which is that people who have the disorder and are constantly trying to fix themselves become very frustrated that they can’t fix it. Do you tell them that it’s just a period of time and kind of reconfiguring how they’re approaching that or pass that where they’re actually angry at themselves because they have the disorder.
Eric: I think the first step is not faulting anyone for having this. This is just a condition. We at some point as humans kind of affixed the term disorder to it. But it’s really distress that’s gone awry. What we present is that we’re going to work on developing new ways of dealing with anxiety that are applicable not only to OCD, but really to anything in general. And so that main skill set is developing a way to tolerate distress to learn how to confront it effectively and then learn from those experiences. And that’s really the core of what we’re doing in this form of cognitive behavioral therapy.
And finally, I would assume that there’s some sort of relief from them just by verbalizing that behavior and having you identify it.
Eric: Yeah, I think it is. It’s a very normalizing experience for many to know that what they’re experiencing is there’s a name to it, that others have the same problem. Perhaps most importantly that others have been able to successfully recover from this. I’m a big believer in instilling hope and not false hope because our hope is based on an understanding of the data quite a bit of which we’ve contributed to,is an understanding of the data and helping convey that in a way that a person can take and know that that this is simply a chapter of their life. It may be a very difficult chapter of that life, but with some support whether it be with whether a team of clinicians, as well as, their loved ones that this is something that they can they can make it through.
So if they live in a place that doesn’t have access to someplace like this one in Houston, if somebody out there watching us and listening to this and really wants help. What do you advise them to do? What’s a first step?
Eric: First step is to look at resources that specialize in OCD. One of the things that’s really important is to first recognize that not everyone is gonna be good at this. That’s OK. We really don’t need that. What we need are to train enough people who are situated around and have expertise in OCD. You can recognize it. That specialty clinic I think is a really important first step. From there, it’s figuring out how you can access it. The unfortunate reality is that for many this involves some level of travel, and it is absolutely not an ideal. If my career ends when my career ends, my goal is that that that’s dramatically changed. The positive is that the last 15 years we have seen a dramatic improvement and dissemination of the therapies that we know improve knowledge and so on. What we want folks to do is to have a look at reputable sources try to understand are there clinicians in their area. If there are, who is nearby if there aren’t there? Can they then make an effort to visit a specialty center? Can they talk? That would be one area. Another would be to go to one’s primary care provider and talk them about OCD. Very often, they’re going to be quite knowledgeable and can help guide them in the right direction which could include trying out antidepressant medications trying to access different forms of therapy as well. There are a number of online types of therapy that can be helpful. In addition, whether it be self-guided or reading a book or working on something online and there’s more and more effort to actually have tele psychiatry services offered so that we’re able to address some of those geographic barriers that come into play.
And last question on the medication what kind of a combination of antidepressants or the SSRIs mixed or something else? Or what’s the most effective treatment?
Eric: For antidepressants, there have really been several that have been FDA approved and most frequently studied. Among the SSRIs, we have fluoxetine. And that’s yeah, those three. We have an older one which is a tricyclic antidepressant which has been well studied. There are a number of others that have also been investigated over time but haven’t received that FDA indication although we suspect that they have similar levels of efficacy as well.
I’m done unless I left anything out that you want to address.
Eric: So, medications for OCD in particular target two messengers in the brain. One of them which is really kind of a prominent one that’s believed involved in how OCD manifests is serotonin. Second involves dopamine which has really been implicated in some of these second line medications to help improve a response to accessorize. Some recent information suggests that there might be a third messenger that naturally occurs called glutamate. Glutamate is thought to be involved in aspects like learning kind of nerve health and communication. One of our goals or one the goals within this project and in particular a compound called BHV 4157 is to actually target glutamate by adding on this medication to existing antidepressants that have been widely used and studied for OCD.
Is it related to this gut bacteria?
Eric: It’s not related to gut. What we’re thinking about is that there might be another kind of messenger or another chemical in the brain that we can target and really try to improve the way it’s moderated. The way it is used and thereby have improved response to antidepressants.
END OF INTERVIEW
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