Huberman Backs Exposure CBT as Superior to Drugs for OCD Treatment

Huberman支持暴露认知行为疗法：治疗强迫症效果优于药物 临床数据显示，暴露疗法可在数周内使强迫症严重程度减半，而联用SSRI或大麻并未带来额外益处。 强迫症是一种由皮质-纹状体-丘脑环路过度活跃驱动的严重致残性疾病，患者的强迫行为非但未能缓解引发焦虑的侵入性想法，反而会错误地强化这些想法。临床评估依靠耶鲁-布朗强迫症量表（Y-BOCS）来明确核心恐惧，从而直接指导基于暴露的认知行为疗法（CBT）——这是一种重新训练大脑耐受焦虑的首要临床治疗手段。尽管选择性5-羟色胺再摄取抑制剂（SSRIs）能显著减轻症状，但临床数据显示其缓解程度不及单独采用CBT，而大麻等替代干预手段则未能显示出有意义的获益。 强迫症（OCD）影响全球 2.5% 至 4% 的人口，在所有疾病致残率中位列第七；其核心机制为侵入性思维引发焦虑，促使患者通过强迫行为寻求短暂缓解，但此举反而会进一步强化底层的强迫观念。 (0:00) OCD 在生物学上的驱动核心是过度活跃的皮质-纹状体-丘脑回路（cortico-striatal-thalamic loop），其中丘脑网状核未能有效过滤背景杂讯；此外，双胞胎研究证实约 40% 至 50% 的病例存在遗传因素。 (7:39) 耶鲁-布朗强迫症量表（Y-BOCS）是诊断的关键工具，临床评估的核心不仅是记录表面症状，更在于挖掘出患者如果不执行强迫仪式所害怕面临的最底层“核心恐惧”。 (11:02) 结合仪式预防的暴露疗法（CBT）是首要推荐治疗手段，其机制是引导患者耐受焦虑而非缓解焦虑；临床试验显示单纯接受 CBT 仅需四周便能将 Y-BOCS 评分从 25 分显著降至约 11 分，疗效优于单用 SSRIs 药物，且两者联合未见额外增益。 (20:46) 在补充与替代疗法中，大麻及 CBD 证实对缓解 OCD 几乎无效；经颅磁刺激（TMS）通过靶向运动脑区可干扰自动化强迫行为，而补充肌醇（inositol）则显示出帮助降低基线焦虑与改善睡眠的辅助潜力。 (25:59)

Obsessive-compulsive disorder (OCD) is driven by hyperactive cortico-striatal-thalamic brain circuitry that traps individuals in rigid thought-action loops. Andrew Huberman highlights that structured exposure-based cognitive behavioral therapy (CBT) serves as the primary intervention, demonstrating superior efficacy over medication by systematically building tolerance to core fears. The Compulsive Cycle and Cortico-Striatal-Thalamic Circuitry (7:39) Affecting 2.5% to 4% of the population and ranked globally as the seventh most debilitating medical illness, OCD operates via an intrusive thought that triggers severe anxiety, compelling repetitive actions for temporary relief. This compulsion subsequently reinforces the obsession. Unlike fear, which responds to an immediate physical threat, OCD anxiety generates somatic arousal without an environmental danger. Twin studies demonstrate a 40% to 50% genetic concordance, indicating substantial biological roots. Mechanistically, OCD centers on dysfunction within the cortico-striatal-thalamic loop. In this circuit, the cortex interprets perception, the striatum governs "go" and "no-go" action selection, and the thalamus—regulated by the thalamic reticular nucleus—acts as a sensory gatekeeper. Human neuroimaging demonstrates that when patients encounter obsession triggers, such as sweat-contaminated items, this entire circuit becomes hyperactive. Successful treatment dampens this heightened metabolic activity, confirming the circuit's direct role in sustaining symptoms. Diagnostic Specificity and Uncovering Underlying Core Fears (15:56) Clinical evaluation relies heavily on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which categorizes intrusive symptoms into distinct domains, including contamination, symmetry, checking, repetition, and aggressive or moral obsessions. Dr. Huberman emphasizes that effective clinical intervention requires identifying the patient's catastrophic "core fear" rather than merely cataloging surface symptoms. Clinicians must uncover the exact consequence the patient fears will materialize if they do not execute their compulsion, as isolating this precise trigger is vital for dismantling the underlying feedback loop. Mechanisms and Efficacy of Exposure-Based CBT (17:16) Exposure-based CBT operates on a mechanism distinct from conventional anxiety treatments: rather than teaching patients to dampen arousal through calming techniques, it requires them to experience peak anxiety while strictly blocking compulsive rituals. Supervised by licensed specialists, protocols developed by Dr. Helen Blair Simpson at Columbia University span 10 to 12 weeks, consisting of two planning sessions followed by 15 gradual exposure sessions. Clinical trials show this behavioral protocol produces dramatic outcomes. Within four weeks of CBT alone, average Y-BOCS scores fell from a severe 25 down to approximately 11. While selective serotonin reuptake inhibitors (SSRIs) significantly outperformed placebos, CBT alone resulted in lower remaining symptom severity than SSRIs alone. Furthermore, combining SSRIs with CBT yielded no measurable benefit over CBT administered on its own. Evidence for Pharmacological, Brain-Stimulation, and Adjunctive Therapies (24:12) The clinical efficacy of SSRIs presents a paradox: although SSRIs dampen the cortico-striatal-thalamic circuit and reduce symptoms, Dr. Huberman notes there is little evidence that the serotonin system itself is natively disrupted in OCD. Meanwhile, alternative substances have shown limited utility. A laboratory study by Dr. Simpson evaluating smoked cannabis (both THC- and CBD-dominant) found no acute symptom reduction and observed weaker anxiety relief than a placebo. Other emerging modalities offer targeted support. Transcranial Magnetic Stimulation (TMS) applied to motor and supplementary motor areas can disrupt automated compulsive patterns during active obsessions. Mindfulness meditation does not directly reduce core OCD symptoms, but strengthens focus and adherence to demanding CBT assignments. At the over-the-counter level, clinical evidence suggests myo-inositol at dosages of 900 milligrams or higher can improve sleep quality and reduce baseline anxiety. While exposure-based CBT remains the gold-standard intervention for disrupting the cortico-striatal-thalamic loop, psychiatric medications, TMS, and nutraceuticals provide varying degrees of adjunctive support. A central unresolved question remains why pharmaceuticals like SSRIs consistently alleviate symptoms despite the lack of evidence that serotonin dysfunction causes the underlying pathology.

安德鲁·休伯曼（Andrew Huberman）指出，强迫症（OCD）是一种严重破坏生活功能的神经生物学疾病，其核心机制在于“皮质-纹状体-丘脑回路”的功能紊乱，导致侵入性思维与强迫行为形成以焦虑为纽带的恶性强化循环。临床证据表明，旨在让患者耐受极端焦虑而非缓解焦虑的暴露型认知行为疗法（CBT）是目前最有效的干预手段，其效果显著优于单纯的药物治疗。 病理特征、遗传倾向与皮质-纹状体-丘脑回路 (7:39) 强迫症影响全球约2.5%至4%的人口，在所有全病种医学疾病中致残程度位列第七。该病以侵入性思维（强迫观念）与重复行为（强迫动作）为特征，患者试图通过强迫动作暂时缓解焦虑，却反向强化了侵入性念头。强迫症表征通常分为检查、重复、秩序与对称（伴随强烈的“不完整感”）以及污染恐惧四大类。在生理机制上，恐惧是对现实即刻威胁的自主神经唤起，而焦虑则是在无现实危险的环境中产生完全相同的身体应激反应（如心率加速、出汗）。双胞胎研究表明约40%至50%的病例存在遗传基础，但这一发现对改变个体DNA层面的临床治疗帮助有限。 神经生物学研究证实，强迫症的核心在于“皮质-纹状体-丘脑回路”的异常超速运转。该回路中，大脑皮质负责意识知觉，纹状体负责动作选择（调控“执行”与“抑制”指令），丘脑充当感觉中继站，并由外围的丘脑网状核担任过滤信息进入意识的“守门人”。强迫症患者该回路的过滤机制失效，陷入不受控制的神经反馈。脑功能成像（fMRI和PET）实验显示，当接触带有他人汗液的毛巾等污染诱导物时，患者该回路会显著激活；而当患者对选择性5-羟色胺再摄取抑制剂（SSRIs）产生良好疗效时，该回路的过度活跃则受到抑制。 临床诊断评估与深层灾难性恐惧的识别 (15:56) 临床诊断强迫症主要依赖耶鲁-布朗强迫症量表（Y-BOCS）。该量表明确区分了违背意志的侵入性念头（常表现为无意义、令人反感或与自身性格相悖的冲动）与患者被迫履行的强迫行为，涵盖攻击性、污染、对称精确性、囤积以及宗教道德过度担忧等维度。 休伯曼强调，临床干预的关键在于穿透表层的强迫行为（如反复洗手或特定摆放顺序），迫使患者明确界定其潜在的最核心、最灾难性的恐惧——即“如果不执行这项强迫行为，究竟会发生什么可怕后果”。深挖这一核心恐惧是打破神经回路固化循环、制定针对性暴露治疗的前提。 暴露疗法的神经重塑与CBT对抗SSRIs的数据 (17:16) 暴露型认知行为疗法（CBT）直接干预皮质-纹状体-丘脑回路。与传统焦虑治疗通过呼吸、可视化或放松技巧降低焦虑截然相反，强迫症的暴露治疗要求患者在面对诱发物时体验最高强度的焦虑，同时实施严格的“仪式阻断”（完全禁止执行强迫行为）。休伯曼特别警告，该过程会引发极高的自主神经应激，严禁患者自行尝试或施加于他人，必须由专业临床人员主导。通过循序渐进的暴露，大脑回路被重新训练，使患者习得“焦虑会自然达到峰值并自行消退，无需强迫行为解救”。 哥伦比亚大学海伦·布莱尔·辛普森（Helen Blair Simpson）博士的临床方案包括2次规划阶段与15次暴露阶段（历时约10至12周）。临床试验显示，安慰剂组无改善，而单纯接受CBT治疗的患者在4周内Y-BOCS评分从重度的25分骤降至约11分。相比之下，虽然SSRIs药物疗效显著优于安慰剂，但药物组的残留症状严重度明显高于单纯CBT组；将CBT与SSRIs联合使用并没有在CBT单项疗效之上带来额外增益。此外，精神病学文献显示出一个悖论：尽管SSRIs有效，但几乎没有证据表明强迫症的发病根源在于5-羟色胺系统的功能缺损。 辅助干预评估：大麻、经颅磁刺激、正念与肌醇 (25:59) 针对辅助疗法与新兴干预手段，科学研究给出了差异显著的结论。辛普森团队发表的人体实验室研究表明，吸食富含THC或CBD的医用大麻对缓解强迫症急性症状几乎无效，且在缓解焦虑方面的表现甚至逊于安慰剂。相比之下，经颅磁刺激（TMS）展现出积极前景：在患者出现侵入性思维时，利用磁线圈刺激大脑运动区及辅助运动区，能够打断强迫动作的自动化执行，且磁圈移开后该阻断效应依然能够维持。 在身心互补领域，数据显示正念冥想并不能直接消除强迫症的核心病症，但可增强患者的专注力，辅助其保持纪律以完成高强度的CBT家庭作业。此外，在营养补充剂方面，临床证据显示每日摄入900毫克或更高剂量的肌醇（尤其是清肌醇/myo-inositol）有助于改善患者睡眠并降低基础焦虑水平，具有作为联合干预辅助手段的潜力。 休伯曼总结指出，强迫症具有明确的神经生物学根基，深入理解其回路机制有助于患者和临床医生在行为干预、药物调节与物理调控之间制定策略性治疗路径。由于该病具有极高的致残性和复杂的代偿行为，患者应在专业精神医学监督下审慎开展阶梯式暴露或调整处方药物，避免在缺乏临床引导的情况下盲目进行暴露干预。

[4:30] Andrew Huberman: About 40 to 50% of OCD cases have some genetic component, some mutation or some inherited aspect that's genetic. [9:56] Andrew Huberman: They bring subjects into the laboratory who have an obsession about germs and contamination and a compulsion to hand wash. And they give these people, believe it or not, a sweaty towel that contains the sweat and the odor and the liquid basically from somebody else's hands. [11:02] unwelcome and distressing ideas, thoughts, images, or impulses that repeatedly enter your mind [11:02] behaviors or acts that you feel driven to perform, although you may recognize them as senseless or excessive. [15:56] Andrew Huberman: what is the fear exactly if one were to not perform the compulsion? [17:16] Andrew Huberman: Now in the context of anxiety treatment or other types of treatments, the goal would be to teach people to dampen to lessen their anxiety through breathing techniques or through visualization techniques or through self-talk or through social support... Here, it's the opposite. What they're trying to get the patient to do is to really feel the anxiety at its maximum, but then do the exact opposite of whatever the normal compulsion is. [17:16] Andrew Huberman: not the sort of thing you want to do on your own [24:12] Andrew Huberman: there is very little, if any, evidence that the serotonin system is disrupted in OCD. [24:12] Acute effects of cannabinoids on symptoms of obsessive-compulsive disorder: a human laboratory study. [27:53] Andrew Huberman: I think no possible useful treatment should be overlooked or unresearched in my opinion provided that can be done safely.

[0:00] Welcome to Huberman Lab Essentials, [0:01] [music] where we revisit past episodes [0:04] for the most potent and actionable [0:06] science-based tools for mental health, [0:08] physical health, and performance. [0:11] I'm Andrew Huberman and I'm a professor [0:13] of neurobiology and opthalmology at [0:15] Stanford School of Medicine. Today we [0:18] are talking about obsessivempulsive [0:20] disorder or OCD. First of all, as the [0:22] name suggests, OCD includes thoughts or [0:26] obsessions and compulsions which are [0:28] actions. The obsessions and the [0:30] compulsions are often linked. In fact, [0:32] most of the time the obsessions and the [0:34] compulsions are linked such that the [0:36] compulsion, the behavior is designed to [0:39] relieve the obsession. However, one of [0:42] the hallmark themes of [0:43] obsessivecompulsive disorder is that the [0:45] obsessions are intrusive. People don't [0:48] want to have them. They don't enjoy [0:50] having them. They just seem to pop into [0:52] people's minds and they seem to pop into [0:53] their mind recurrently. And the [0:56] compulsions unlike other sorts of [0:59] behaviors provide brief relief to the [1:02] obsession but then very quickly [1:04] reinforce or strengthen the obsession. [1:07] OCD is extremely common. In fact, [1:11] current estimates are that anywhere from [1:14] 2.5% to as high as three or even 4% of [1:18] people suffer from true OCD. That is an [1:21] astonishingly high number. Another thing [1:23] to point out is that OCD is currently [1:26] listed as number seven in terms of the [1:28] most debilitating illnesses. Not just [1:31] mental illnesses or disorders, but all [1:34] types of illnesses, including things [1:35] like asthma and cancer, etc. So, you can [1:38] imagine with that standing at number [1:41] seven that it is both extremely common [1:44] and extremely debilitating. And as a [1:46] consequence, it's now realized that many [1:49] hours, days, weeks, months, or even [1:51] years of work performance or showing up [1:54] at work of relational interactions [1:57] really suffer as a consequence of people [1:59] having OCD. With recurrent intrusive [2:01] thoughts happening at very high [2:03] frequency or even at moderate frequency, [2:05] people are spending a lot of time [2:06] thinking about this stuff and they're [2:08] thinking about the behaviors they need [2:09] to engage in and then engaging in the [2:11] behaviors which, as I mentioned before, [2:12] just serve to strengthen the [2:13] compulsions. And so they're not actually [2:15] doing the other things that make us [2:17] functional human beings like commuting [2:18] to work or doing homework or doing work [2:21] or listening when people are talking or [2:23] interacting or sports or working out. [2:24] All the things that make for a rich [2:26] quality life are taken over by OCD in [2:29] many cases. Another thing you'll soon [2:31] learn is that sadly a lot of the [2:33] obsessions and compulsions in OCD often [2:36] relate to taboo topics. And that's [2:38] because the general categories of OCD [2:40] fall into three different bins. checking [2:44] obsessions and compulsions, repetition [2:46] obsessions and compulsions, and order [2:49] obsessions and compulsions. The checking [2:50] ones are somewhat obvious, checking the [2:52] stove or checking the locks. Repetition [2:55] obsessions and compulsions obviously can [2:57] dovetail with the the checking ones, but [3:00] those tend to be things like counting [3:01] off of a certain number of numbers like [3:04] 1 2 3 4 5 6 7 6 5 4 3 2 1. People [3:07] perform that repeatedly, repeatedly [3:09] repeatedly or feel that they have to. So [3:12] we have checking, we have repetition, [3:13] and then there's order. Order often [3:16] times is thought of as putting [3:19] cleanliness or making sure everything is [3:21] aligned and perfect and orderly. And [3:24] often times that is the case. But there [3:26] are other forms of order that people [3:27] with OCD can focus on in a obsessive and [3:31] compulsive way. Things like [3:32] incompleteness, the idea that one can't [3:35] walk away from something or stop doing [3:37] something because something's not right [3:39] or complete in that picture. It could be [3:41] the way the table is set. It could be [3:43] the way that something's written on a [3:45] page. It could be an email. It can also [3:47] be in terms of symmetry that everything [3:49] be aligned and symmetric in some way. [3:51] This could be uh seen perhaps in young [3:53] kids. This is one example that I read in [3:55] the literature of children that need to [3:57] arrange their stuffed animals in exact [4:00] same order every day and in a particular [4:02] order uh to the point where if you were [4:05] to move the little stuffed frog over [4:07] next to the stuffed rabbit that the [4:08] child will have a an anxiety reaction to [4:11] that and feel literally compelled driven [4:14] to fix that maybe even multiple times [4:17] over and over again. And then the other [4:19] aspect of order which is a little bit [4:21] less than intuitive is this notion of [4:23] disgust. This idea that something is [4:25] contaminated. So we often think about [4:27] OCD and handwashing behavior in response [4:30] to people feeling that something is [4:32] contaminated, a space, a towel, etc. or [4:35] even simply somebody else's hand and so [4:37] they're unwilling to shake somebody's [4:38] hand. You can imagine how these [4:41] different bins of obsessions and [4:42] compulsions, checking, repetition, and [4:44] order could be extremely debilitating [4:46] depending on how severe they are and how [4:48] many different domains of life they show [4:50] up in. And I know I've said it multiple [4:52] times now, but I'm going to say it many [4:54] times throughout this episode in a [4:56] somewhat obsessive, but I believe [4:58] justified way that every time that one [5:02] engages in the compulsion related to the [5:04] obsession, the obsession simply becomes [5:06] stronger. So you can imagine what a what [5:08] a powerful and debilitating loop that [5:10] really is. So let's drill a little bit [5:12] deeper into how the obsessions and [5:14] compulsions relate to one another. If we [5:16] were to draw a line between the [5:17] obsessions and the compulsions, that [5:19] line could be described as anxiety. Now, [5:23] we need to define what anxiety is. And [5:26] to be quite honest, most of psychology [5:28] and science can't agree on exactly what [5:31] anxiety is. Typically the way we think [5:33] about fear is that it's a heightened [5:35] state of autonomic arousal. So increased [5:37] heart rate, increased breathing, [5:39] sweating etc. in response to an [5:41] immediate and present threat or [5:43] perceived threat. Whereas anxiety [5:45] generally speaking in the scientific [5:47] literature relates to the same sorts of [5:50] thought patterns and somatic bodily [5:53] responses, heart rate, breathing, etc. [5:55] But without a clear and present danger [5:58] being in the environment or right there. [6:01] So that's the way that we're going to [6:02] talk about anxiety. Now, and anxiety is [6:04] really what binds the obsessions and [6:06] compulsions such that someone will have [6:08] an intrusive thought. Some people are [6:10] probably wondering if there's a genetic [6:12] component to OCD. And indeed, there is. [6:15] Although the nature of it isn't exactly [6:17] clear, based on twin studies where [6:20] researchers have examined identical [6:22] twins, fraternal twins, even identical [6:24] twins that share the same sack in [6:26] uterero, the what we call monocorionic, [6:28] so sitting in the same little bag during [6:30] pregnancy or in different little bags, [6:32] you can see different levels of what's [6:34] called genetic concordance. But if we [6:36] were to just sort of cut a cut a broad [6:38] swath through all of the genetic data, [6:40] it's fair to say that about 40 to 50% of [6:43] OCD cases are have some genetic [6:45] component, some mutation or some [6:47] inherited aspect that's genetic and that [6:49] one could point to if they got their [6:50] genome mapped. Now, while that's [6:52] interesting, I don't think it's terribly [6:54] useful for most people. First of all, [6:56] you can't really control your genes. It [6:57] can't pick who your parents were, as [6:59] they say. So, just know that there is a [7:01] genetic component in about half of [7:03] people with OCD, but not always. Now, as [7:06] is typical for this podcast, I want to [7:08] focus on some of the neural mechanisms [7:11] and chemical systems in the brain and [7:12] body that generate obsessivempulsive [7:15] disorder. So, let's take a step back and [7:17] look at the neural circuitry. What's [7:19] going on in the brain and body of people [7:21] with OCD? Why the intrusive recurrent [7:24] thoughts? Many studies, we can fairly [7:27] say dozens, if not hundreds of studies [7:29] have now identified a particular circuit [7:32] or loop of brain areas that are [7:34] interconnected and very active in [7:36] obsessivempulsive disorder. [7:39] That loop includes the cortex which is [7:43] kind of the outer shell of the the human [7:45] brain, the lumpy stuff as it sometimes [7:48] appears if the skull is removed. And it [7:51] involves an area called the stryatum [7:52] which is involved in action selection [7:54] and holding back action. The cortex and [7:56] the strriatam are in this intricate back [7:59] and forth talk. It's really loops of [8:01] connection. There's a third element in [8:03] this cortico strriatal loop as it's [8:06] called and that's the phalamus. Now, the [8:08] thealamus is not a structure I've talked [8:09] a lot about before on this podcast, but [8:11] it's one of my favorite structures to [8:13] think about and teach about in neuro [8:15] anatomy, which I teach uh back at [8:17] Stanford and have taught for many years [8:18] elsewhere. Because the phalamus is this [8:21] incredible egg-like structure in the [8:23] center of your brain that has different [8:25] channels through it. Channels for [8:27] relaying visual information or auditory [8:30] information or touch information from [8:33] your environment up into your cortex and [8:36] as a consequence making certain things [8:38] that are happening to you and around you [8:40] apparent to you, making you aware of [8:42] them, making you perceive them and [8:44] suppressing others. At the same time, [8:47] your phalamus is surrounded by a kind of [8:50] a shell, something called the theamic [8:51] reticular nucleus. Again, you don't have [8:53] to remember the names, but the theamic [8:54] reticular nucleus, as I'm going to call [8:56] it, serves as a sort of gate as to which [9:00] information is allowed to pass through [9:01] up to your conscious experience and [9:03] which is not. So, let's zoom out and [9:06] take a look at the circuit that we've [9:07] got and that we now know based on [9:09] neuroiming studies is intimately [9:12] involved in generating obsessions and [9:13] compulsions in OCD. We have a cortex or [9:16] neoortex which is involved in perception [9:19] and understanding of what's happening. [9:21] We have the strriatam and basil ganglia [9:23] which are involved in generating [9:24] behaviors go and suppressing behaviors [9:27] no go. And we have the phalamus which [9:30] collects all of our sensory experience [9:31] in parallel hearing touch smell etc. Not [9:35] so much smell through the phalamus I [9:36] should mention but the other sensor [9:38] senses that is and then that phalamus is [9:41] encased by the phalamic reticular [9:44] nucleus which serves as a kind of a a [9:46] guard saying you can pass through and [9:47] you can pass through but you you you [9:49] can't pass through up to conscious [9:51] understanding and perception. So that [9:53] loop this corticostriothamic [9:56] loop corticostriolamic loop is the [9:59] circuit thought to underly OCD and [10:02] dysfunction in that circuit is what's [10:04] thought to underly OCD. How do we know [10:07] that this circuit is involved in OCD? [10:09] Well, there we can look to some really [10:11] interesting studies that involve [10:14] bringing human subjects into the [10:15] laboratory and generating their [10:17] obsessions and compulsions and then [10:19] imaging their brain using any variety of [10:21] techniques that we talked about before. [10:23] So, what they do typically is bring [10:24] subjects into the laboratory who have a [10:28] obsession about germs and contamination [10:30] and a compulsion to hand wash. And they [10:33] give these people, believe it or not, a [10:36] sweaty towel that contains the sweat and [10:39] the odor and the liquid basically from [10:43] somebody else's hands. In fact, they'll [10:45] sometimes have someone wipe their own [10:47] sweat off the back of their neck and put [10:49] it on the towel and then they'll put it [10:50] in front of the person, which as you can [10:52] imagine for someone with OCD is [10:54] incredibly anxietyprovoking [10:56] and almost always evokes these [10:58] obsessions about, oh, this is really uh [11:01] this is really bad. This is really bad. [11:03] I need to I need to clean. I need to [11:04] clean. I need to clean. Now, they're [11:05] doing all this while someone is in a [11:07] brain scanner or while they're being [11:09] imaged for posetronom tomography. And [11:11] then they can also look at the patterns [11:12] of activation in the brain while the [11:15] person is doing hand washing. Although [11:17] sometimes the apparati associated with [11:19] these imaging studies make it hard to do [11:20] a lot of movement. They can do these [11:22] sorts of studies. They have done these [11:24] sorts of studies in many subjects using [11:27] different variations of what I just [11:28] described. And lo and behold, what [11:31] lights up? And when I say lights up, [11:32] what what sorts of brain regions are [11:36] more metabolically active, more blood [11:37] flow, more neural activity? Well, it's [11:39] this particular corticostrial phalamic [11:42] loop. In addition to that, some of the [11:45] drug treatments that are effective in [11:47] some, and I want to emphasize some [11:48] individuals at suppressing obsessions [11:51] and/or compulsions, such as the [11:53] selective serotonin reuptake inhibitors [11:55] or SSRIs, which we'll talk about in a [11:57] little bit. When people take those [11:59] drugs, they see not just a suppression [12:01] of the obsession and compulsion, but [12:05] also a suppression of these particular [12:07] neural circuits. They become less [12:09] active. Now, I want to emphasize and [12:11] telegraph a little bit of what's coming [12:13] later. These drugs like SSRIs do not [12:15] work for everybody with OCD. And as many [12:18] of you know, they carry other certain [12:19] problems and side effects for many but [12:21] not all individuals. That collection of [12:25] studies of data, fMRI, PET scanning in [12:28] humans, the treatment with SSRIs really [12:30] points squarely to the fact that the [12:31] cortical stridthalamic loop is likely to [12:34] be the basis of OCD. Now, of course, [12:37] other circuits could also be involved, [12:39] but the cortical stridthalamic circuit [12:42] seems to be the main circuit generating [12:44] OCD- like behavior. But as you'll next [12:47] learn when thinking about the various [12:49] behavioral treatments and drug [12:50] treatments and holistic treatments for [12:52] OCD, what you'll notice is that each one [12:55] taps into a different component of this [12:57] corticostrial theamic loop. By [12:59] understanding the underlying mechanism, [13:01] why certain drugs and behavioral [13:03] treatments work and don't work will [13:05] become immediately apparent. And in [13:07] thinking about that, in knowing that, [13:10] you'll be able to make excellent [13:11] choices, I believe, in terms of what [13:13] sorts of treatments you pursue, what [13:15] sorts of treatments you abandon, and [13:17] most importantly, the order, the [13:19] sequence that you pursue and apply those [13:22] treatments. Before we go any further, [13:23] I'd like to give people a little bit of [13:25] a window into what a diagnosis for OCD [13:28] would look like. give you a sense of the [13:30] sorts of questions that a clinician [13:32] would ask to determine whether or not [13:34] somebody has OCD or not. The most [13:38] commonly used test of OCD or for OCD I [13:42] should say is called the Yale Brown [13:43] obsessivempulsive scale and this is uh [13:46] you know scientists love acronyms as do [13:48] the military and it's the Y box the Y-bs [13:53] the Y box. Before the clinician would [13:55] proceed with any kind of direct [13:57] questions, they would very clearly [13:58] define what obsessions and compulsions [14:00] are. And here I'm actually reading from [14:01] the Ybox. So, quote, "Obsessions are [14:04] unwelcome and distressing ideas, [14:05] thoughts, images, or impulses that [14:07] repeatedly enter your mind. They may [14:08] seem to occur against your will. They [14:10] may be repugnant to you. You may [14:12] recognize them as senseless, and they [14:13] may not fit your personality." [14:16] Then there are compulsions. Quote, [14:17] "Compulsions, on the other hand, are [14:19] behaviors or acts that you feel driven [14:20] to perform, although you may recognize [14:22] them as senseless or excessive. At [14:24] times, you may try to resist doing them, [14:26] but this may prove difficult. You may [14:28] experience anxiety that does not [14:30] diminish until the behavior is [14:31] completed. Now, there are tremendous [14:32] number of questions on the Y box. So, [14:35] I'm just going to highlight a few of the [14:36] general categories. [14:38] Typically, the person will fill out a [14:40] checklist. So they will designate [14:43] whether or not currently or in the past [14:45] they have for instance aggressive [14:48] obsessions. Fear that one might harm [14:50] themselves. Fear that one might harm [14:52] others. Fear that they'll steal things. [14:53] Fear that they will act on unwanted [14:55] impulses currently or in the past or [14:58] both. That's one category. The other one [15:00] are contamination obsessions. So [15:01] concerned with dirt or germs, bothered [15:03] by sticky substances or residues, etc., [15:05] etc. So a bunch of different categories [15:08] that include for instance sexual [15:09] obsessions, what are called saving [15:11] obsessions, even moral obsessions, [15:14] right? Excess concern with right or [15:15] wrong or morality, concerned with [15:17] sacrilege and blasphemy, obsession with [15:20] need for symmetry and exactness. Again, [15:22] all of these questions being answered as [15:24] either present in the past or not [15:25] present in the past, present currently [15:27] or not present currently. And then the [15:29] the test generally [15:32] transitions over to questions about [15:35] target symptoms. They really try and get [15:36] people to identify if they have [15:38] obsessions. What are their exact [15:40] obsessions? Now, this turns out to be [15:41] really important because as we talk [15:43] about some of the therapies that really [15:44] work, I'll just give away a little bit [15:47] of why they work best in certain cases [15:50] and why they don't work as well in other [15:52] cases. It turns out that it becomes very [15:55] important for the clinician and the [15:56] patient to not just identify the [15:59] obsessions and the compulsions generally [16:01] in a kind of a generic or top contour [16:03] way but to really encourage or even [16:06] force the patient to define very [16:09] precisely what the biggest most [16:11] catastrophic fear is. what the obsession [16:14] really relates to that turns out to be [16:16] very important in disrupting this [16:18] corticostrialamic [16:20] loop and getting relief from symptoms [16:22] one way or the other. So the Yale Brown [16:25] obsessivempulsive scale, this Y box [16:27] again is very extensive. It goes on for [16:30] dozens of pages actually and has all [16:32] these different categories. not so much [16:34] designed to just pinpoint what people [16:37] obsess about or what they feel compelled [16:40] to do, but to also try and identify what [16:43] is the fear that's driving all this. [16:45] Right? In the way that we've set this up [16:47] thus far, we've been talking about [16:48] obsessions and compulsions as kind of [16:50] existing in a vacuum. You're obsessed [16:52] about germs and you're compelled to wash [16:54] your hands. Obsessed about germs, [16:56] compelled to wash your hands. Or [16:57] obsessed about symmetry, compelled to [16:58] put right angles on everything. Or [17:00] obsessed about counting and therefore [17:02] counting, etc. The deeper layer to all [17:04] that is what is the fear exactly if one [17:08] were to not perform the compulsion [17:11] meaning what is the fear that's driving [17:13] the obsession. So that brings us to a [17:16] very powerful category of treatments [17:19] that I should say does not work in [17:21] everybody with OCD but works in many [17:24] people with OCD and really speaks to the [17:28] underlying neural circuitry that [17:30] generates OCD and how to interrupt it. [17:32] and that is the treatment of cognitive [17:34] behavioral therapy and in particular [17:37] exposurebased cognitive behavioral [17:39] therapy. Cognitive behavioral therapy [17:41] and exposure therapy in the context of [17:44] OCD most often involves trying to get [17:47] people to tolerate not relieve their [17:50] anxiety. This is extremely important and [17:53] I realize there's variation to this [17:55] depending on the style of cognitive [17:57] behavioral therapy, the style of [17:58] exposure therapy, but almost across the [18:01] board. The goal again is to get people [18:04] to feel the anxiety that normally they [18:07] are able to at least partially relieve [18:09] however briefly by engaging in the [18:11] compulsion. So if we think back to that [18:14] circuit of corticostrial falamic, what's [18:17] going on here? Where is CBT intervening? [18:20] Well, as you recall, the cortex is [18:21] involved in conscious perception. The [18:23] phalamus and that the phalamic reticular [18:25] nucleus are involved in the passage of [18:28] certain types of experience up to our [18:30] conscious perception, not others. And [18:32] the stridum is involved in this go no-go [18:34] type behavior. When OCD is really [18:38] expressing itself in its fullness, [18:41] people feel an anxiety around a [18:42] particular thought and they either have [18:45] a go, for instance, wash hands or a [18:48] no-go, do not turn left type reaction. [18:52] By having people progressively in a kind [18:54] of hierarchical way reveal their precise [18:58] source of anxiety, their utmost fear in [19:00] this context, [19:02] what happens is they feel enormous [19:04] amounts of autonomic arousal. Now in the [19:07] context of anxiety treatment or other [19:09] types of treatments, the goal would be [19:11] to teach people to dampen to lessen [19:13] their anxiety through breathing [19:14] techniques or through visualization [19:17] techniques or through self-t talk or [19:18] through social support. any of the [19:20] number of things that are well known to [19:21] help people self-regulate their own [19:23] anxiety. Here, it's the opposite. What [19:25] they're trying to get the patient to do [19:27] is to really feel the anxiety at its [19:30] maximum, but then do the exact opposite [19:32] of whatever the normal compulsion is. [19:34] So, if normally the compulsion is to [19:36] wash one's hands, then the idea is to [19:38] suppress handashing while being in the [19:40] experience of the utmost anxiety. Now, I [19:42] want to be very clear. This is not the [19:44] sort of thing you want to do on your [19:45] own. This is not the sort of thing you [19:46] want to do for a friend. This is done by [19:48] trained licensed psychologists and [19:51] psychiatrists because the goal again is [19:54] to bring the person right up close to [19:56] the thing that they fear the most and [19:58] then to interrupt the circuit. What's [20:01] happening is the person is feeling [20:02] compelled to act act to relieve the [20:04] anxiety and through a progressive type [20:07] of exposure, right? You don't throw [20:09] people in the deep end in this kind of [20:10] therapy right off the bat. you gradually [20:13] ratchet them toward or move them toward [20:15] the discussion of exactly what they fear [20:17] the most and then eventually move them [20:18] toward the interruption of the [20:20] compulsion as they're feeling this [20:22] extremely elevated anxiety. Of course, [20:24] within the context of a supportive [20:26] clinical setting, but in doing that, [20:28] what you are teaching people is that the [20:31] anxiety can exist without the need to [20:34] engage in the compulsion. So, I'd like [20:35] to just briefly summarize the key [20:37] elements of cognitive behavioral therapy [20:39] and exposure therapy and how they can be [20:42] combined with drug treatments that are [20:44] very effective. Much of what I'm going [20:46] to talk about next relates to the data [20:49] and indeed the practice of an incredible [20:53] research scientist and clinician. So, [20:56] this is Helen Blair Simpson or I should [20:58] say Dr. Dr. Helen Blair Simpson because [21:00] she is indeed an MD medical doctor and a [21:02] PhD research scientist at Columbia [21:04] University School of Medicine and one of [21:08] the world's foremost experts if not the [21:10] expert I would put her in a category of [21:12] maybe just one to three people who is [21:16] most knowledgeable about the mechanisms [21:18] of OCD is actively researching OCD in [21:21] humans trying to find new treatments [21:24] trying to unveil new mechanisms and [21:26] expand on our current understanding. and [21:28] who also treats OCD quite actively in [21:31] her own clinic. She describes that the [21:33] key procedures are exposures of course [21:36] done in person and with the actual thing [21:39] that evokes the obsessions and [21:41] compulsions. And the goal of course then [21:44] is to gradually and progressively [21:46] increase the level of anxiety but then [21:48] to intervene in so-called ritual [21:50] prevention to prevent the person from [21:52] engaging in the compulsion. Typically, [21:54] this is done through two planning [21:56] sessions with the patient. So, [21:59] describing to the patient what will [22:00] happen and when it will happen and how [22:02] long it will happen so that they're not [22:03] just thrown into this out of the blue. [22:06] And then 15 exposure sessions done twice [22:10] a week or more. So, the one thing to [22:12] really understand about cognitive [22:13] behavioral therapy is that it can take [22:14] some period of time, several or more [22:16] weeks, as many as 10 or 12 weeks. In [22:19] addition, Dr. Dr. Blair Simpson and [22:21] others have explored what are the best [22:23] treatments for patients with OCD by [22:26] comparing cognitive behavioral therapy [22:28] alone, placebo, so essentially no [22:31] intervention or something that takes an [22:34] equivalent amount of time but is not [22:36] thought to be effective in treatment as [22:39] well as [22:41] selective serotonin reuptake inhibitors. [22:43] Placebo did not reduce the obsessions or [22:46] compulsions to any significant degree. [22:48] However, cognitive behavioral therapy [22:51] had a dramatic effect in reducing the [22:55] obsessions and compulsions such that by [22:57] four weeks that score that in this case [23:00] ranged from 8 to 28 dropped all the way [23:02] from 25 down to about 11. So there's a [23:06] huge drop in the severity of the [23:08] symptoms. Now what's really interesting [23:10] is that when you look at the effects of [23:12] SSRIs in the treatment of OCD symptoms, [23:16] they had a significant effect in [23:18] reducing the symptoms of OCD, but the [23:22] severity of their symptoms was still [23:23] much greater than those receiving [23:26] cognitive behavioral therapy alone. So [23:28] what happens when you combine them? [23:30] Well, they explored that as well. and [23:31] the combination of cognitive behavioral [23:33] therapy and the SSRIs together did not [23:37] lead to any further decrease in OCD [23:40] symptoms. This points to the idea that [23:42] cognitive behavioral therapy is the most [23:44] effective treatment. And again, when I [23:46] say cognitive behavioral therapy now, [23:47] I'm still referring to cognitive [23:48] behavioral/exposure [23:50] therapy done in the way that I detailed [23:52] before, twice a week for 12 weeks or [23:53] more. So for those of you that have [23:55] sought treatment and you're taking a [23:57] SSRI or if you're thinking about [23:59] treatment and you're prescribed an SSRI, [24:01] the ideal scenario really would be to [24:02] combine the drug treatment with [24:04] cognitive behavioral therapy or in some [24:06] cases maybe cognitive behavioral therapy [24:07] alone. Although that's a decision that [24:08] you really have to make with the close [24:12] advice and oversight of of a licensed uh [24:15] physician because of course these are [24:16] prescription drugs and anytime you're [24:18] going to add or remove a prescription [24:20] drug or change dosage, you really want [24:21] to do that in close discussion with and [24:24] on the advice of your physician. I don't [24:25] just say that to protect me. I say that [24:27] to protect you and because it's just the [24:28] right thing to do. So, what I'm about to [24:30] tell you next is most certainly going to [24:31] come as a big surprise, which is that [24:34] despite the fact that the selective [24:36] serotonin reuptake inhibitors can be [24:38] effective in reducing the symptoms of [24:39] OCD, at least somewhat, and certainly [24:42] more than placebo, there is very little, [24:45] if any, evidence that the serotonin [24:47] system is disrupted in OCD. And I have [24:49] to point out that this is a somewhat [24:52] consistent theme in the field of [24:53] psychiatry. that is a given drug can be [24:57] very effective or even partially [24:58] effective in reducing symptoms or in [25:01] changing the overall landscape of a [25:03] psychiatric disorder or illness and yet [25:07] there is very little if any evidence [25:09] that that particular system is what's [25:11] causal for OCD or anxiety or depression [25:15] etc. Now earlier we were talking about [25:18] not reducing anxiety but learning [25:20] anxiety tolerance in order to deal with [25:23] and treat OCD in the context of [25:25] cognitive behavioral therapies. That [25:28] doesn't necessarily rule out cannabis as [25:29] a candidate for the treatment of OCD. [25:33] And in fact this has been explored. A [25:34] study from Dr. Blair Simpson herself [25:38] looked at this. This was a fairly [25:40] smallcale study. So first of all I'll [25:41] give you the title and again we'll [25:42] provide a link. This is entitled acute [25:44] effects of canabonoids on symptoms of [25:46] obsessivempulsive disorder a human [25:48] laboratory study. I'm just reading from [25:50] their conclusions here. The data [25:51] suggests that smoked cannabis whether [25:52] containing primarily THC or CBD has [25:56] little acute impact meaning immediate [25:58] impact on OCD symptoms [26:00] and yield smaller reductions in anxiety [26:03] compared to placebo. So they did not see [26:05] a a when I say a positive effect I mean [26:08] a um a meerative effect an effect in [26:11] reducing symptoms of OCD from cannabis [26:13] or or CBD. Another treatment that's [26:16] becoming somewhat common or at least [26:18] people are commonly excited about is [26:20] transcranial magnetic stimulation. So [26:22] this is the use of a magnetic coil. This [26:25] is completely non-invasive placed on one [26:28] portion of the skull and one can direct [26:31] magnetic [26:33] energy toward particular areas of the [26:35] brain to either suppress or nowadays you [26:37] can also activate particular brain [26:39] regions. There are some interesting data [26:41] showing that if TMS is applied to areas [26:43] of the brain involved in the generation [26:45] of motor action, so the so-called motor [26:48] areas or supplementary motor areas as [26:50] they're called, while people think about [26:53] or have intrusive thoughts, we know that [26:56] the TMS coil can interrupt the motor [26:59] behaviors, the compulsive behaviors, and [27:02] at least in a small cohort of studies [27:04] and a small number of patients within [27:06] those studies, this has been shown to be [27:09] effective. Not just while the coil is on [27:11] the head, of course, but act after the [27:13] study has been performed or the [27:14] treatment's been performed in reducing [27:17] OCD symptoms by disrupting the tendency [27:20] for the compulsive behavior to be so [27:23] automatic. Right now, I don't think it's [27:26] fair to say that TMS is a magic bullet [27:28] either. I think there's a lot of [27:29] excitement about TMS. And in particular, [27:32] I really want to nail this point home. [27:34] In particular, there's excitement about [27:36] the combination of TMS with drug [27:39] treatments or the combination of TMS [27:42] with cognitive behavioral therapy. I [27:44] realize that a number of listeners of [27:45] this podcast are probably interested in [27:48] the non-typical or holistic treatments [27:51] for OCD. Dr. Blair Simpson's lab has at [27:54] least one study exploring the role of [27:57] mindfulness meditation for the treatment [28:00] of OCD. there the data are a little bit [28:04] um complicated and I should mention that [28:07] good things are happening at least in [28:09] the United States probably elsewhere as [28:11] well but good things are happening in [28:13] terms of the exploration of things like [28:16] meditation and other let's call them [28:18] non-traditional or holistic forms of of [28:20] treatment for psychiatric disorders [28:22] because of the division of complimentary [28:24] health that's now been launched by the [28:26] national institutes of health. So [28:27] whereas before people would think about [28:30] uh meditation or yoga nidra or even CBD [28:34] supplementation for that matter as kind [28:37] of fringe maybe or kind of woo or [28:39] non-traditional at the very least the [28:41] national institutes of health in the [28:43] United States has now devoted an entire [28:45] division right an entire institute [28:48] purely for the exploration of things [28:50] like breathing practices meditation etc. [28:52] So there's a cancer institute, there's a [28:54] hearing and deafness institute, there's [28:55] a vision institute and now there's this [28:58] complimentary health institute which I [28:59] think is a wonderful addition to the [29:02] more traditional aspects of medicine. I [29:05] think uh no possible useful treatment [29:07] should be overlooked or unressearched in [29:10] my opinion provided that can be done [29:11] safely. Turns out that mindfulness [29:13] meditation can be useful in the [29:15] treatment of OCD, but mainly by way of [29:18] how it impacts the focus on and the [29:21] ability to engage in cognitive [29:24] behavioral therapies. So, it's very [29:26] unlikely, at least by my read of the [29:27] data, to be a direct effect of [29:30] meditation on relieving the symptoms. [29:32] Rather, it seems that meditation is [29:33] increasing focus on things like [29:36] cognitive behavioral therapy homework [29:38] and to not focus on other things and [29:40] therefore indirectly improving the [29:42] symptoms of OCD. Now, somewhat [29:44] surprisingly, at least to me, there have [29:45] also been a fairly large number of [29:47] studies exploring how neutrauticals, as [29:50] they're sometimes called, supplements [29:52] that are available over the counter can [29:54] impact the treatment of [29:55] obsessivempulsive disorder. One compound [29:57] that I like to focus on is inositol. And [30:00] here I'm referring specifically to [30:02] myoininoitol because it comes in several [30:04] forms. And it does appear that 900 [30:07] milligrams of inositol can improve sleep [30:10] and can reduce anxiety perhaps when [30:12] taken at that dosage or higher dosages. [30:14] So I think there's a great future for [30:15] these neutrauticals meaning I think more [30:17] systematic exploration in particular of [30:19] lower dosages in the context of of OCD [30:22] treatment and as we saw before for the [30:25] SSRIs and other prescription drug [30:27] treatments. I think there really needs [30:29] to be an exploration of these [30:30] neutrauticals in combination with [30:32] behavioral therapies and who knows maybe [30:34] with brain machine interface like [30:35] cranial magnetic stimulation as well. [30:38] What I've tried to provide is an [30:39] opportunity to really drill deep into [30:41] the neural circuitry and an [30:42] understanding of where OCD comes from [30:44] and also to give you a sense of how the [30:47] individual behavioral and drug [30:49] treatments work and perhaps don't work [30:51] so that you can really make the best [30:52] informed choices. again highlighting the [30:54] fact that OCD is an extremely common [30:58] extremely common and yet extremely [30:59] debilitating condition and one that I [31:02] hope that if any of you have or that you [31:04] know people that have it that you'll [31:05] both gain sympathy and understanding for [31:08] what they're dealing with perhaps as a [31:10] consequence of some of the information [31:11] presented today and maybe help them [31:14] direct their treatment find better [31:16] treatment and of course apply those [31:18] treatments for some relief. In closing, [31:21] I'd like to thank you for this in-depth [31:23] discussion about the mechanisms and [31:25] various treatments for obsessivempulsive [31:28] disorder and some of the related [31:29] disorders. And as always, thank you for [31:32] your interest in science. [31:36] >> [music]