Living With OCD

Roughly 163 million people experience obsessive-compulsive disorder https://www.cdc.gov/children-mental-health/about/obsessive-compulsive-disorder-in-children.html and its associated cycles of obsessions and compulsions. They have unwanted intrusive thoughts, images or urges; they also do certain behaviors to decrease the distress caused by these thoughts. In movies and TV, characters with OCD are often depicted washing their hands or obsessing about symmetry. Dr. Carolyn Rodriguez https://med.stanford.edu/profiles/carolyn-rodriguez says these are often symptoms of OCD, but they're not the only ways it manifests – and there's still a lot of basics we have yet to understand. That's why, in this encore episode, Carolyn looks to include more populations in research and find new ways to treat OCD. If you're interested in potentially participating in Dr. Rodriguez's OCD studies, you can email [email protected] mailto:[email protected] or call 650-723-4095. _ Questions about the brain? Email us at [email protected] mailto:[email protected] – we'd love to hear your ideas for a future episode! Listen to every episode of Short Wave sponsor-free and support our work at NPR by signing up for Short Wave+ at plus.npr.org/shortwave http://plus.npr.org/shortwave. See pcm.adswizz.com https://pcm.adswizz.com for information about our collection and use of personal data for sponsorship and to manage your podcast sponsorship preferences. NPR Privacy Policy https://www.npr.org/about-npr/179878450/privacy-policy

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• 0:23Regina Barber?

  Around 2% of the global population struggles with obsessive-compulsive disorder, or OCD. That's roughly 163 million people who go through cycles of obsessions, these unwanted intrusive thoughts, images, or urges, and compulsions, behaviors to decrease the distress caused by these thoughts. And Dr. Carolyn Rodriguez says the way it's often portrayed in pop culture, like the movie As Good As It Gets starring Jack Nicholson, a character might do things like-

• 0:53Speaker 02

  Very ritualized hand washing.

• 0:59Speaker 02

  Or you might see an individual who needs to have everything symmetrical.

• 1:07Regina Barber?

  Carolyn is a physician at Stanford University studying OCD. She says these things can all be part of OCD, but they're often the only ways we see it manifested in the media. In reality, there's a lot more to it than symmetry and hand washing.

• 1:21Speaker 02

  OCD is also called the doubting disease. So, for example, an individual may be driving down the road and all of a sudden have an intrusive thought that, oh, maybe I ran somebody over. And that thought, as you can imagine, really increases anxiety to the point where then the compulsions kick in. They have to drive back to the site where they were and make sure that there isn't an ambulance there, a police. Or they might go home and check the news to see if there are any reports of somebody who has been run over.

• 1:56Regina Barber?

  Now, she's the director of Stanford's OCD Research Lab, and she says there's still a lot of basics we have yet to understand about the condition. In her time practicing medicine, she's seen many permutations of the condition. She's met a student who has just started college.

• 2:12Speaker 02

  He was stuck with writing and rewriting his homework, trying to make sure that it was perfect. And that led to him not being able to do well in his classes and really, you know, just derailed his life.

• 2:30Regina Barber?

  And Carolyn's also seen people who wore gloves to prevent people from seeing their hands raw and red from washing.

• 2:37Speaker 02

  And that's when it really hits you that this is something that people keep to themselves and are just going on in their day-to-day lives, really profoundly impacted.

• 2:49Regina Barber?

  Carolyn learned about OCD during her med school rotations, and she realized how often people suffering from OCD, and even medical health providers, may not recognize the symptoms.

• 2:59Speaker 02

  When I was in my training, one of the most sobering statistics that I saw was that, on average, there's a 17-year delay between the onset of OCD symptoms and treatment initiation. And it's heartbreaking.

• 3:18Regina Barber?

  So today on the show, the reality of OCD, how it's managed, and how scientists like Carolyn are looking to include more populations in their research and find new ways to treat it. I'm Regina Barber, and you're listening to Short Wave, the science podcast from NPR.

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• 4:49Regina Barber?

  So Carolyn, we're talking about OCD, obsessive compulsive disorder. What's actually happening in the brain of someone who's diagnosed with OCD?

• 4:57Speaker 02

  Although we don't know the exact cause of OCD, there's converging lines of evidence suggesting that it is a circuit gone awry. And so you'll hear people talk about in the field of the orbitofrontal cortex, which is the front part of the brain that's important for generating thoughts, to the striatum, which is a deeper structure within the brain that's important for generating behaviors, and then to the thalamus, which is a relay station, and then back to the orbitofrontal cortex. So this loop or corticostriatal hyperactivity can result and is associated with these kind of OCD behaviors. Then the other piece is,

• 5:41Speaker 02

  you know, the brain chemistry. So the main chemical messengers in the brain, are they making things go awry as well? And we know that a lot of the treatments that we currently have are based on serotonin reuptake inhibitors. And one of the emerging lines of evidence has been, you know, could it be glutamate, the main excitatory chemical messenger in the brain? And so my research is really focused on glutamate.

• 6:13Regina Barber?

  So there's still a lot we like don't know when it comes to OCD. Right now, there are gaps in populations on who we are looking at who have OCD. So like, studies tend to be largely white, they're, you know, largely male, largely young sometimes because we're taking like college students. But you're looking at people within the Latin American community and having Hispanic ancestry. Like, what are you finding?

• 6:36Speaker 02

  Yeah. So I'm a site in an NIH-funded study called the Latino OCD Genomics Study. And sites across the US and Latin America are looking to see if we can collect more samples of individuals with OCD from these backgrounds so that we maybe have a greater representation within genomics studies. And so that study is ongoing. I'm really excited about it. I think one of the things that is difficult in mental health more broadly, but also in Latin American Hispanic countries is stigma.

• 7:15Speaker 02

  And it's just so heartwarming to see a group of scientists and researchers coming together, raising awareness for OCD in Hispanic and Latin American countries. And I'm really hopeful that this will do a lot of good, not only for the genomics and the science, but also in terms of raising awareness of the importance of these issues in their home countries.

• 7:41Regina Barber?

  Yeah, that's very important work. So Carolyn, when should someone seek diagnosis and treatment if they think they might have OCD?

• 7:51Speaker 02

  So individuals with obsessions and compulsions and part of the OCD diagnosis, if they have these obsessions and compulsions for greater than an hour a day for at least a year, then we consider that they may have obsessive compulsive disorder. Also, as part of the diagnosis, it needs to impact and interfere with social or work or other important aspects of functioning.

• 8:19Regina Barber?

  Okay, so when somebody is diagnosed, then you'd mentioned therapy and medication. Can you kind of walk me through these treatments?

• 8:27Speaker 02

  So. When somebody is first diagnosed with OCD, there are two first-line, evidence-based strategies for treatment. One of these is cognitive behavioral therapy with exposure and response prevention, or for shorthand, I'll use ERP. So with ERP, what you're trying to do is try and unlink the connection that individuals have with an obsession that causes anxiety and the need to do a repetitive behavior to decrease the anxiety. Because you can imagine, if you have an obsessive thought, then you do a compulsion, then you feel better, then that tells the brain like, yes, you should have done that. That was a scary thing.

• 9:07Regina Barber?

  Right.

• 9:07Speaker 02

  So ERP breaks that cycle. And so typically, that's done by organizing a hierarchy from the least feared stimulus to the most feared stimulus. So I'll give you an example. So somebody with contamination, let's say, they believe that the door handles have germs. You might take a tissue and just rub it, as a therapist, rub it across the door and then gently rub it over the individual's pinky and then encourage them not to do their compulsive behavior. That may be a little bit lower on the hierarchy. The very top of the hierarchy may be them putting their hand in the toilet at Grand Central Station.

• 9:51Speaker 02

  Right? So your reaction, your reaction speaks volumes, right? Which is, this is a scary and hard thing to do for anyone, let alone somebody with OCD. But it's very, very effective.

• 10:04Regina Barber?

  They would have won at that point. Wow.

• 10:06Speaker 02

  Well, it's effective, but from your reaction, I can see the challenge that we have as a field is how do you get somebody to do this really wonderful treatment when it involves doing the thing that you fear the most?

• 10:20Regina Barber?

  Yeah. What kind of medications are there then?

• 10:23Speaker 02

  Yeah. There are serotonin reuptake inhibitors. So these include things like sertraline or fluoxetine.

• 10:32Speaker 02

  And sometimes one of the things that clinicians don't realize in treating with OCD, you need to have it at much higher doses for longer periods of time than you do in treating depression.

• 10:45Regina Barber?

  And some of your work has been looking at like potential future treatments like ketamine. It's a dissociative anesthetic, but more recent research has looked at its potential to like treat things like depression and PTSD. What made you want to test it for OCD?

• 11:02Speaker 02

  Yeah, so as a clinical researcher, I felt really frustrated. The treatment of OCD with serotonin reuptake inhibitors can take a long time, like two to three months for symptom relief. And even then, roughly half of patients will experience only minor symptom reduction. And similarly with ERP, it can take two to three months. It's very helpful, but sometimes it takes a long time and individuals are worried and concerned about doing the treatment. And so I really wanted to try and find a way to quickly reduce symptoms and to help have it be a bridge to these really wonderful therapies.

• 11:44Speaker 02

  If you can knock down OCD a little bit and get people to do ERP, it would be wonderful. But you don't have to be in pain, right? And so I identified glutamate as a potential pathway and novel medication strategy based on increasing evidence that glutamate plays a significant role in OCD. And also at the time, there was really wonderful reports of ketamine having rapid antidepressive effects.

• 12:16Regina Barber?

  Right, and the research has like mixed results, right? It's not definitive treatment. In some studies with people with OCD, it hasn't shown any benefit. But you've seen some results in your work, right?

• 12:26Speaker 02

  With NIH funding, we completed a five-year study looking at a single infusion of IV ketamine compared to midazolam. Midazolam is a drug class called a benzodiazepine, and it's given to people sometimes before, you know, surgery. Sometimes these are medications that make people feel more relaxed. They can feel woozy. And so given that ketamine has this side effect of

• 12:56Speaker 02

  You know, feeling a little bit out of it, feeling a little bit dissociated. It serves as

• 13:00Regina Barber?

  Oh, it matches.

• 13:01Speaker 02

  Yeah, it serves as a better comparison.

• 13:03Regina Barber?

  Right.

• 13:04Speaker 02

  So that people can't tell as much that it is ketamine. It's not perfect.

• 13:08Regina Barber?

  Got it.

• 13:09Speaker 02

  Um, but it does blind things a little bit more. And what we found was that in little over half of individuals, the OCD symptom reduction was statistically significant and different between ketamine and midazolam, where ketamine had this decrease, clinically meaningful decrease in OCD symptoms. And further, what we found is when we continued assessing their symptoms, um, using the Yale Brown Obsessive Compulsive Scale, for up to four weeks after that initial infusion, there was a statistically significant separation between ketamine and midazolam out to three weeks and not four weeks.

• 13:51Regina Barber?

  Yeah, it's, it's going to be really interesting to see if these effects like can be widely replicated, right? And, and like safely continue for like long-term use. Um, so what would you want to see from the field in the next 10 years?

• 14:03Speaker 02

  One thing I'd like to see from the field in the next 10 years is using technology to support clinicians in trying to identify OCD symptoms as soon as possible and being able to offer first-line treatments. Because half of people will be helped by just trying one of these first-line treatments of medications or therapy. And then for people who are not helped by these first-line treatments, I'd love to be able to understand how we can relieve OCD symptoms quickly, how we can diversify our current tools. There's not one size fits all.

• 14:43Speaker 02

  Not everybody is going to want to do ERP, um, because they are afraid. How do we build bridges, um, so that people can get the most out of these treatments? And finally, unlocking the brain basis of OCD. So we can make even more precise treatments and even be able to understand who will respond to which treatment so that we can really greatly reduce the amount of time somebody, um, has between symptoms and symptom relief.

• 15:16Regina Barber?

  Thank you, Carolyn. Dr. Rodriguez, thank you so much.

• 15:19Speaker 02

  Thank you. It was such a pleasure to be here.

• 15:24Regina Barber?

  This episode was produced by Rachel Carlson and edited by our showrunner, Rebecca Ramirez. Tyler Jones checked the facts. Maggie Luthar was the audio engineer. Beth Donovan is our senior director and Colin Campbell is our senior vice president of podcasting strategy. I'm Regina Barber. Thanks for listening to Shore Wave from NPR.

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