OCD- Demystified Podcast Episode

Karen Conlon, LCSW invites Dr. Tatyana Mestechkina on an episode of "So, How's Therapy?" to talk about various ways OCD and OC Spectrum disorders can manifest, some common misconceptions about them, various types, and provides a sneak peak on what treatment can look like.


Click here to listen to the episode:

https://cohesivetherapynyc.com/blog/010-ocd-demystified/


Here is a transcript of it:

OCD Is Not An Adjective.

On this week’s episode of So, How’s Therapy?, I am joined by Tatyana Mestechkina, Ph.D. to dive deep into the topic of obsessive-compulsive disorder, or OCD.

Trigger Warning: Sexual Thoughts / Thoughts Of Harming Others: We discuss a few examples of intrusive thoughts within the context of OCD that have content of violent and/or sexual nature.

While the term OCD is commonly known, it is also commonly misunderstood. Obsessive-compulsive disorder is often portrayed in the media as someone who washes their hands over and over again, or someone who has to have everything in its place – but it’s much more than that.

Those who suffer from OCD are impacted across all aspects of their life. Today, we’ll be demystifying OCD, and helping you understand it at a much deeper level.

What You’ll Learn

  • What OCD Is (And What It Is Not)

  • Causes Of OCD

  • How OCD Affects The Lives Of Those Who Experience It

  • Different Types And Subtypes Of OCD

  • Treatment Of OCD


Transcript Episode 10 Karen Conlon: Hello, and welcome again to the So, How’s Therapy Podcast. This is a podcast that demystifies, debunks, and destigmatizes what happens in the therapy space. I’m your host, Karen Conlon, and today we are going to talk about a topic that is very widely known, but not widely understood. We are going to cover and demystify obsessive compulsive disorder, OCD. Now, people who suffer or experience OCD are incredibly impacted in all aspects of their lives. They may be engaging in different types of behaviors for hours at a time or a specific behavior for hours at a time and it really makes their life difficult, sometimes impacting their ability to maintain a job or to keep up with social relationships. There are the more traditional types of obsessive compulsive disorder symptoms that we all know about and that we hear about and that we see on TV. But today, we are also going to talk about the lesser known types of OCDs like intrusive thoughts and mental compulsions and other types of OCDs that we cannot even imagine, that we couldn’t even imagine are actually parts of obsessive compulsive disorder. I am super excited to introduce our guest today, Dr. Tatyana Mestechkina. She is going to talk to us today a little bit about herself and a lot about OCD. Tatyana, welcome to the So, How’s Therapy Podcast. How are you? Dr. Tatyana Mestechkina: Hello. Thank you so much for having me, Karen. I’m so excited to be here and talk about this. Karen Conlon: Yes, I’m super, super, super excited to talk about this. This is one of those topics where people tend to use the expression, “I’m OCD. He’s OCD. She’s OCD,” in a very loose way, not really understanding perhaps not just what it means, but just how difficult and stigmatizing actually really living with OCD can be. Now, there are two things that I want to mention before we start talking about what is exactly OCD. The first thing is I wanted to provide a what we call in our world a trigger alert, because today we may be discussing examples of intrusive thoughts within the context of OCD that have violent or sexual nature or that are of violent or sexual nature. So if this is something that you feel you might have some discomfort with, or if there are children in the house with you, in the car, in the area that you may be assess whether is something that you’re okay with them listening to, maybe put your ear buds on. Like now. The next thing that I kind of wanted to mention was this quote that I found with respect to OCD, Tatyana, and this quote says it is not the content of the thought that distinguishes between people with OCD and those people without OCD, right? The thoughts are the same. It’s the interpretation that the person gives the thought that matters. That interpretation is the difference between someone who has OCD and someone who does not. We’re going to explain that a little bit more. Let’s start by just giving a general explanation of what is obsessive compulsive disorder just kind of in layman’s terms. What OCD Is, And What It Is Not Dr. Tatyana Mestechkina: Sure. Absolutely. So a very kind of oversimplified version of OCD is that we all have this part of our brain called the amygdala. And this part of our brain is responsible for keeping us safe and warning us if there’s some sort of danger happening. And this part of the brain has been around for as long as humans have been around, has been super helpful. If there was a tiger in the room with us right now and our amygdala wasn’t warning us that there was a danger, we might say like, “Let’s watch some Netflix. Let’s take a nap,” and we would probably be dead very, very quickly. So while people with OCD also have a very well-functioning amygdala that’s going to warn them when there’s a tiger in the room or any other type of danger, it sometimes misfires and sends them this false alarm signal that there’s something dangerous, even though there isn’t. And the problem with that is that it sounds very, very real. It sounds exactly the same way as it would if there was an actual tiger or a fire or whatever was going on. And then the other problem with OCD, in fact, it doesn’t respond well and communicate to the logical rational part of our brain. If the person in that moment kind of response to that false alarm signal and treats it as if it’s real, they can often find themselves spiraling into the rabbit hole, treating these false alarms as if they’re real alarms, therefore validating their brains that this is something important and threatening, and then their brains give themselves a little imaginary pat on the back saying, “I’m doing a great job warning this person, because if I wasn’t, something dangerous or horrible might happen.” And that’s sort of kind of the vicious cycle of how OCD works. Karen Conlon: Right. What I’m hearing is that part of the brain, that alarm system, that amygdala gets activated and that part of the brain is very primal. It doesn’t really respond to rational thoughts. And quite the contrary, when you are experiencing OCD, there is this constant reaffirming, this constant reconfirmation that no, this is exactly what we need to be doing. We need to be on high alert. This is dangerous. We have a really difficult time bringing in the reality sometimes of what’s really in front of us, right? It’s almost like whether it’s a tiger chasing you or you’re just running late for work, the alert system is the same high response. Dr. Tatyana Mestechkina: Exactly. It almost feels irresponsible in that moment to not respond to it. I would say the majority of people I work with with OCD at some point when they’re not in the OCD episode are you able to say like, “I know it doesn’t make sense. I know this isn’t logical. I know this is very, very unlikely to be threatening.” But in that moment, all of that goes out the window and it feels like the tiger is in the room or their house is on fire. The urge to act out and treat this as something serious is really, really high. Karen Conlon: I want to ask you then, is there oftentimes a confusion or a misdiagnosis of obsessive compulsive disorder and general anxiety disorder? Dr. Tatyana Mestechkina: Mm-hmm (affirmative). Absolutely. Karen Conlon: Because a lot of the things that we’re talking about, the amygdala, the brain’s alarm system, sound very similar to what people with general anxiety disorder walk around experiencing. What’s the difference? How do we identify the difference? Dr. Tatyana Mestechkina: So that is an excellent question and that is something that’s constantly being discussed in the field, even within the OCD expert group. The way that I think about it is like a big Venn diagram. If you think about those diagrams with the two big circles with the overlap between the circles, the reality is the overlap is very, very large. The commonalities between OCD and general anxiety disorders, sometimes referred to as GAD, is that both people experience a lot of anxiety. That being the hallmark feature. There tends to be a lot of mental rumination going on, and there’s a lot of very low tolerance for uncertainty. Their brains kind of send them on a mission to get answers and to know for sure. With general anxiety disorder, the topics tend to be more exaggerations of everyday worries. Like, what if I run out of money and can’t pay my bills? What if I lose my job? What if this bad weather ruined something that I really, really want to do? And just maybe stuff that everybody worries about, but up a few notches. And with OCD, often the worries are less logical, but caveat is not always. A lot of times they’re like, what if I murder my husband, even though I love my husband. What if I am in the wrong relationship, even though I might generally be really satisfied with my relationship. What if I’m attracted to a child, even though I have consenting adult relationship. What if I did something to practice my religion the wrong way and God is mad at me, et cetera. And we’ll go into more specific details of that. However, again, the asterisk is it’s not always completely illogical. And with OCD, we tend to see more of the compulsive. So repetitive behaviors, either physically or mentally, to try to kind of undo the thought, escape the thought, more of that kind of urgency and repetition. And then the more important question is, what does that mean for treatment? The reality is that the treatment that we use for OCD tends to be very effective for people with general anxiety as well. A lot of overlap with the treatment. The only difference that we see is that with general anxiety, sometimes using cognitive techniques like restructuring unhelpful thinking patterns and using logic can be helpful for some people. And with OCD that usually is not helpful and sometimes even feeds into the disorder more long-term. Or if it’s helpful, it’s helpful very, very temporarily, but then they want an answer within a few minutes, a few hours. Karen Conlon: Right. You’ve touched on a lot of things that I want to kind of tease out a little bit more. This Venn diagram, I’m such a visual person. I love the fact that you mentioned the Venn diagram, and we will see if we can have one in the show notes. For people who are visual, such as myself, this makes so much sense, right? Now I get it. OCD on one end, general anxiety disorder, or GAD, on the other end, and then in the middle where these two circles overlap, this is where we see the similarities and where we can get misdiagnosed or diagnose ourselves sometimes incorrectly because we’re not able to see what’s on the other ends of each of the spectrums that really identify the difference between OCD and general anxiety disorder, general anxiety disorder being that daily exaggeration. What if I can’t? What if I do? Why do I always? Those types of thoughts that just linger ongoing versus OCD, where sometimes the worries are not always so logical and also there’s this compulsion to need to fix it. And then in terms of the approaches that you’re using with general anxiety disorder, the cognitive behavioral approach, which is where we help to retrain the brain to help see things in a different way, maybe we can appraise situation and reappraise them in a different way, find alternatives, there’s this flexibility that we can learn when you’re dealing with general anxiety disorder versus OCD, which is a little bit more… It sounds like it’s a lot more rigid. Dr. Tatyana Mestechkina: Yeah, exactly. I think with OCD, people’s brains on a mission for 100% certainty. We know in life, what is a 100% certain, that’s where the rabbit hole kind of comes in. It’s a never ending journey. Karen Conlon: I can see with wanting 100% certainty, I can see why cognitive behavioral techniques we have to be careful in applying those because cognitive behavioral techniques are all about not necessarily knowing anything 100% and being able to have that flexibility or learn to be flexible and looking at other possibilities. Dr. Tatyana Mestechkina: Absolutely. And also within OCD therapy, I will add, there is a little bit of room for that at the beginning. Especially as we’re laying the foundation of the therapy, I think it is important to provide someone the education about what OCD is, what isn’t, the fact that there’s nothing that’s 100% certain, the fact that it’s feeding the disorder is continuing to look for that certainty. There’s a little bit of that that is helpful and important even at [inaudible 00:12:17] We don’t want to use in the moment as the OCD episode is coming up. Karen Conlon: And by the way, folks, I know that you will hear some technical glitches and that is just the world that we’re living in today in the world of the pandemic. My apologies for any technical glitches that you hear, but we’ll definitely include any details you might miss in the show notes. Tatyana, do we know what causes OCD? Causes Of OCD Dr. Tatyana Mestechkina: That’s also very good question. The simple answer is we know a lot more than we did before, but we still don’t know a lot of it. One risk factor, we know that CD has a genetic component to it. And what that means is that if someone that you’re closely biologically related to, like a twin or a sibling or a parent, has OCD, you are more likely to get OCD. That doesn’t mean that you will, you just might be more vulnerable to it. We also know that there’s certain… We have some preliminary research about certain parts of the brain that might be implicated with OCD, certain neurotransmitters like serotonin and glutamate, and promising exciting research, but still a long way to go in terms of fully knowing or making any cause and effect relationships. We do know that certain things in the environment like certain stressors might bring on OCD episodes for people who are already biologically vulnerable to it. I do want to make an important note that it’s a very, very common misconception for people, even for therapists sometimes, trauma does not cause OCD. And I repeat, trauma does not cause OCD. We do know like life stressors and possibly even traumatic events, again, can trigger an OCD episode, but there’s no at least scientific knowledge at the moment that there is a direct cause and effect relationship in that way. In fact, I would say the majority of the patients that I work with have not experienced any sort of trauma. And therapeutically, even if they have experienced a certain trauma or even if it was around the same time that the OCD came up, therapeutically, it is not helpful in terms of what the current research said, that the treatment is not learning to kind of uncover or process the trauma. If anything, again, that can feed into the OCD symptoms and exacerbate them. Karen Conlon: I’m really glad that you brought this up because there are plenty of books out there in the field that talk about OCD or mention OCD as one of the ways that people develop to adapt to their environment as a result of trauma. This is really interesting that you bring this up because that is something that oftentimes we, therapists who are trained in trauma and obviously in anxiety, have been taught, at least through some of the literature out there. This is, for me at least, really groundbreaking. This is a perfect example, everyone, of just knowing that you don’t have everything 100%, that research will always bring about new information. This is why we need to be flexible and open to understanding what comes up, what’s new, different times in history, what are the things that make sense. And then research comes out and says, “Well, no, that doesn’t make sense anymore or that doesn’t apply anymore.” I’m really glad that you brought that up because that is something that in the trauma field many of us have read is part of what people do or part of what people develop in order to cope with their environment. I wanted to ask you also just really quickly going back to the brain and neurotransmitters, you mentioned serotonin and glutamate. Neurotransmitters are basically information messengers. Can you talk a little bit more… I’d like for people to understand the role and the importance of neurotransmitters in their bodies and why this is related to OCD. Dr. Tatyana Mestechkina: What we do now is there are certain types of neurotransmitters, such as serotonin and glutamate, that are implicated in certain mental health challenges that people experience and tend to regulate mood and whatnot. Those are examples of some of them that have been implicated in OCD. But again, it’s also a hard question to know like, is it the chicken or the egg? Is it that these neurotransmitters are not functioning the way that we’d want and that’s causing OCD, or someone having OCD, therefore triggering changes in neurotransmitters? One of the ideas behind serotonin particularly is that we know SSRI, which is a class of medications called selective serotonin reuptake inhibitor, like Zoloft, Prozac, things like that, are considered first-line treatment in OCD from a pharmacological perspective in that way, and those are also medications that are typically given in depression as well. How OCD Affects The Lives Of Those Who Experience It Karen Conlon: There’s just so much chemically it sounds like going on. Biologically, I’d like to talk about the internal world of what it’s like for someone who’s struggling with OCD. What is that internal world look like? Because we’ve been talking about things like genetics and brain structure and environment and all these things that obviously there are internal factors, but what about the psychological and emotional and social internal world of someone who’s struggling with OCD? Can we talk a little bit about what that’s like? Dr. Tatyana Mestechkina: I think some people might diminish or not understand how incredibly painful this experience could be and how incredibly debilitating this could be, right? If someone is spending a lot of time and energy ruminating, investigating, looking for reassurance, or doing a wide variety of rituals, that might, A, take up a lot of time in their life that they’re not dedicating to the things that are important to them. It might lead them to avoid doing certain things that are meaningful to them, like going to certain social events or riding the subway or going to school or certain relationships or certain TV shows. I think it sometimes makes it really hard for people to be present in their lives and to focus on what they’re doing or who they’re with and connecting with them if their brains are kind of pulling them away on a journey to engage with the obsessions and the compulsions in that way. It can also be a really lonely and isolating experience. And the reality is that OCD is very, very common. About two to 3% of the population is estimated to have it. But my guess is honestly even more because it’s so often missed and misdiagnosed in that way. A lot of that is because there is certain kind of missed portrayals of it in the media. My guess is that there’s more than we even know, and people are not alone, even though they might feel that way. Because I think we’ve come a really long way also in kind of the media in terms of destigmatizing and bringing some attention to it, bringing some good information out there, but we still have a long way to go. And a lot of people might not even know that they have OCD, especially some of the less common texts, which hopefully we’ll get a chance to talk about. And some of them who know that might not realize how many other people have that, because it’s not something people chat about at a cocktail party usually. Karen Conlon: I’ve worked with a number of clients who we are able to identify. Rule out some things then identify that they have some symptoms of obsessive compulsive disorder. And when you take a history of their lives and get some history of their childhood, it’s like nine times out of 10 I hear, “Well, when I was a kid, there were some things going on.” There seems to be this not wanting to look at it when they were children and now they’re struggling as adults. It’s been a very interesting pattern than I’ve seen in my practice. But typically there’s something in their childhood that has pointed to this and this all makes sense to them now as adults. What can parents look for in their kids? And is there a difference in terms of ages? Does a six-year-old with potential OCD have different habits potentially than someone who is 12 or 15? Dr. Tatyana Mestechkina: All very great questions. I think the reality is, even though we in the mental health field like to put labels on things and say it is or it isn’t, the reality is OCD falls on a spectrum. And most people, even who wouldn’t meet the formal diagnosis of OCD, have done certain things that are in line with obsessions or compulsive, myself included. Things that I probably wouldn’t have even thought about for a second if I wasn’t specializing in this. I’m like, “Oh yeah, that thing that I did when I was six, that was a little bit of compulsive.” I remember having a little “game” of not stepping on certain cracks and that way. Karen Conlon: I still do that. Dr. Tatyana Mestechkina: I probably wouldn’t have thought of it. Yeah, exactly. A lot of us do certain things where they’re repetitive or engage in rumination or make connections that aren’t really connections that we logically rationally believe in in that way. But for some people, it’s just kind of little “quirks” and little things that happen. And for other people, it can take over their whole life. A lot of times OCD does develop in childhood and some red flags that we see that are often missed are, like we mentioned, the repetitive behaviors, which are easier to spot if people have more traditional OCD, where their compulsions might be more like hand-washing, or knocking on something a certain way, or cleaning something a certain time, or tapping something, or having good numbers, bad numbers, things like that. A little bit more subtle and harder to miss, especially in children if they’re mental with things like ruminating. Avoidance behaviors could be a red flag of that. Reassurance seeking, so kids asking their parents the same questions over and over again, not taking the answer at face value, things like that. Karen Conlon: And when you mentioned that, one of the things that came up for me is actually a number of clients have said that they remember counting between say age of six and eight. And I guess when I think about it, I mean, counting is something that at that point, there’s a lot of mastery around. It’s something that might be easier for them to engage in. I remember people saying, “I counted the books all the time that were in my little shelf, my bookshelf, in my room. I counted steps up and down. I counted the steps up and down all the time.” Dr. Tatyana Mestechkina: Yeah, or like checking things, like consistently checking things like the door, the stove, under the bed, in the closet, and the repetition is also a big red flag. A lot of patients that I work with who are older and we’re working let’s say on a specific OCD theme that’s relevant in their life at the moment, usually within a few weeks of therapy, they’re like, “Oh, that thing that I did when I was eight, that kind of has some OCD red flags.” And then when they share it with me, it’s usually very classic manifestation of it that they just sit and put two and two together. Karen Conlon: You mentioned thoughts, right? Like reassurance. So that kind of brought me to my next question here, relationships. What if you’re in a relationship with someone and they’re exhibiting some symptoms of OCD, but they’re not obvious, what could those look like? Dr. Tatyana Mestechkina: Really similar to the question with the children, a lot of it is rumination, having a hard time being present, reassurance seeking, asking the same questions over and over again, googling, investigating, anything that’s sort of like the repetitive nature of it. This is really hard because sometimes the OCD beams even latch on to the relationship themselves, and I’ll be happy to give some examples of that. But even regardless of that, I think that can create confusion and disconnect in people’s relationship or even sometimes frustration. Why is my boyfriend, or why is my roommate constantly asking the same question over and over again? Or why are they getting frustrated at me if I don’t arrange things a certain way or clean things a certain way? Just whatever. I mean, the interesting thing about it is it can latch onto anything and everything. Karen Conlon: I think about the partner’s perspective who let’s say is living or in a relationship with someone with not so traditional OCD let’s say, or maybe with the traditional CD, but just not so obvious. If the partner feels like the dishes aren’t out of the sink before their partner gets home and they start feeling flustered around it or feeling very nervous like, “Oh my gosh, I have to get this done because I know that there’s going to be a reaction around it.” And not necessarily not a… We’re not talking about a violent reaction. We’re talking about a specific type of reaction. What might that reaction look like? Dr. Tatyana Mestechkina: We don’t live in a vacuum. And a lot of times when people have certain rituals, it does involve their environment and sometimes people, especially partners who they live with in that way. It can be very confusing when someone’s partner is doing things that seem very illogical in that way. Oftentimes, what I find is just the partner and the person experiencing the OCD having a name for it, having a diagnosis that’s confirmed by a mental health professional who has the qualifications of doing so can be so freeing in a certain way, right? A lot of people don’t like a lot of mental health labels. But with OCD, oftentimes I actually find it brings people a lot of relief. “Oh my gosh, I’m not the only one experiencing these things. I’m not going crazy. I’m not a psychopath. I’m not this horrible person, but it makes sense that I’ve been experiencing this because of this part of this OCD experience.” I think the first step, even knowing and understanding that can bring so much relief both to the person experiencing it and to their partners, who then I think are able to at least start the journey of having more kind of empathy, compassion, and understanding how this works. My partner isn’t just controlling or mean or rational, but here’s what’s happening in their brains that’s creating a lot of pain and sometimes suffering in their lives. And often the biggest challenge, I think, for loved ones with people with OCD is how to support someone with OCD. And this could be a whole other podcast episode, but the tricky thing is that balance between validating and supporting and being there with the person without giving them reassurance or feeding into the theme.Announcer:Thanks for listening. Be sure to tune into part two of this episode where we’ll dive deep into the lesser known types of OCD, how different treatment modalities can affect outcomes, and more. Episode 11 Karen Conlon: Hello and welcome again to the So, How’s Therapy podcast. This is a podcast that demystifies, debunks, and de stigmatizes, what happens in the therapy space. I am your host, Karen Conlon, and today we are going to talk about a topic that is very widely known, but not widely understood. We are going to cover and demystify obsessive-compulsive disorder (OCD). Different Types And Subtypes Of OCD So, in terms of those lesser knowns, because now we’re kind of going into these lesser known types of OCDs, let’s talk about some of those. Pure O OCD is related to intrusive thoughts and images, and if we think about the word intrusive, they’re not welcome. I mean, it’s not something that we really want in there. Can you tell us a little bit more about that type of OCD? Dr. Tatyana Mestechkina: Pure O stands for purely obsessional, which is a subtype of OCD that’s less known about, yet very, very, very common. It’s somewhat of a misnomer because people do have compulsions, but the compulsions are not ones that we typically observe, like the checking, the rearranging, the hand-washing, but are things that are more mental. So examples like ruminating, reassurance-seeking, investigating, Googling, answer-seeking, anything that’s in line with the pursuit of certainty in that way. And these are the types of examples that tend to kind of slip through the cracks often because people having this type of OCD might not even know that this is OCD. I’ll just go through some common examples. Things related to sexuality, for example, so someone who is heterosexual might have an intrusive thought, “But what if I’m actually gay?” But what’s interesting about that is it goes the other way as well. Someone who is in a homosexual relationship or identifies as such might have the thought of, “What if I’m actually straight?” And then they go into this kind of rumination of trying to figure out, “Is it true? Is it not true? But there was that person that I saw on the street or that character on TV and I was attracted to them, but was I really? Am I more attractive to them than my partner? What does this mean? What about this one thing that happened when I was 13,” et cetera, et cetera, et cetera. Another example is OCD often latches onto our relationships. So relationship OCD might lead someone to experience intrusive thoughts like, “What if I’m in the wrong relationship? What if I’m not as attracted to my partner as I should be? What if I don’t love them enough? What if I don’t feel the same way about my partner as that post that I saw on Instagram yesterday, or this character from this show? What if the fact that my partner has a bump on their nose means that I am really unattracted to them and I’m going to realize that one day and then have to break up with them and ruin our marriage,” et cetera, et cetera. Another really common one is a violent OCD, so people experiencing intrusive thoughts about either harming themselves or someone else. “What if I’m suicidal? What if I’m capable of hurting myself? What if when I had that chopping up my vegetables in the kitchen and then I looked at the knife and saw my arm and thought I could slit my wrist, what if that means I actually will do it?” People having intrusive thoughts about hurting other loved ones. Another common one is pedophilia OCD, which as you can imagine can be very distressing for people having intrusive thoughts about either being attracted to children or harming a child. “What if I’m attracted to that child? What if I felt something in my groinal sensation when I was on the street,” et cetera. So again, just a reminder that the content of these thoughts doesn’t matter and there’s a reason why some of the examples I brought up tend to be about more either taboo topics or topics that are very much in line with people’s values. Karen Conlon: I have to say that hearing all of the different thoughts and the types of ruminations and worries, just ongoing worries, it really promotes so much empathy. As I think about the exhaustion, the mental, emotional, and even physical exhaustion that people who struggle with OCD go through on a daily basis, it’s just really something that we all need to keep in mind the next time that we think of saying to someone, or talking, or just lightly saying about ourselves, “Oh, I’m OCD” or “They’re OCD.” Struggling with thoughts that really are so difficult because they do go against your value systems. I mean, the fact that you’re worried about hurting someone so much is probably because it goes totally against your values, but that’s how OCD works. It attacks… I don’t know if that’s the right use of the word, but to me it feels like an attack almost, and it’s an attack of your values and inability to correct that and just say, “No, no, no, that’s not how I am and we’re going to let go of that now.” Dr. Tatyana Mestechkina: Absolutely, and it’s interesting that you use that word because most patients use that word as well, because it very much feels like an attack. But I think something people find helpful therapeutically is kind of reconceptualizing that idea. Because as we talked about before with the mental example, our brains aren’t actually trying to attack us, they’re really trying to protect us and they just tend to maybe misattribute and have kind of a poor source of information for what actually is or isn’t dangerous. So in fact, I try to think about it and try to help patients think about it less as an attack, but more of like if you think about a little kid kind of running up to you, your child, a niece, a nephew, a cousin, being like, “Oh my gosh, there’s a monster under the bed! Ah, ah, ah! Run, run, run!” We normally wouldn’t think about that as an attack, we would think maybe like that little kid is really scared or he’s really trying to protect us because he might think there is a monster under the bed. And I think often kind of bringing that kind of more compassion to our brains who might just be really scared and really thinking there’s something dangerous and it’s their mission to keep us safe, can help us drop some of the kind of the hostility and the battle that people with OCD engage in with their brains, which is part of what makes this so exhausting in that way. And even going as far as, I know this might sound like a stretch for someone with OCD, but going as far as even thanking their brain. “Thank you brain for trying to protect me. I know you have the best intentions, but right now I’m not going to treat this as a relevant threat, but just one possibility out of many, many, many possibilities of things that may or may not be true in life.” Karen Conlon: Right, so rather than trying to change the thought or trying to find logic to it, or trying to look at it in a different way, kind of leaning into it and saying, “Okay, you know what? I get that you’re trying to protect me and thank you for that, and this is my OCD and I get it,” and it’s this form of acceptance almost. Dr. Tatyana Mestechkina: Exactly. That’s a really, really big, big word, so I’m glad that you brought that up. That is a huge component of the therapy, learning to accept these thoughts as just what they are, intrusive, unwanted thoughts, but thoughts that we are not responsible for bringing up and we’re also not responsible for trying to control, or push away, or run away from, but just looking at these as thoughts that come up with an alarm signal sometimes, and unfortunately that alarm signal can’t always be trusted. Karen Conlon: Let me ask you, because now, just thinking about these other forms, or as we call them, cousins of OCD, is that alarm system always constantly going off when you have OCD, or let’s say on the spectrum for those people who are struggling with other types of OCD that they may not be aware of, like body dysmorphic disorder for example, is the brain’s alarm system always going off as well there? I was actually shocked to learn that body dysmorphia falls in the spectrum of OCD, so can we talk about that and also maybe a couple of other ones that are quite common out there, but are not commonly known to fall into the spectrum of OCD? Dr. Tatyana Mestechkina: Yeah, definitely. So in the diagnostic manual, DSM-5 at the moment, there’s something called obsessive compulsive spectrum disorders. OCD is one of them and then there’s a few other types, I like to call them also the cousins of OCD because they’re related, a little bit different, but a lot of common denominators. So one big example of that is body dysmorphic disorder, sometimes called BDD for short, which is very similar to OCD, but the people’s obsessions tend to be focused on their appearance and their body image and often they’re focused on a perceived or actual physical imperfection. But often times its something that again the average person might not be able to see, or if they see it might be something very slight. But to that person experiencing BDD, their alarm signal goes off and they almost experience a distorted version of this physical appearance. Like they might think this slight bump on their nose looks like a 90-degree angle and that’s the first thing that anybody sees when they’re looking at that them. Or if there’s slight asymmetry in their eyebrow, again their brains might be putting the magnifying glass to it. Or if their hairline is like a centimeter one direction more than they’d want it to be, their brain might be telling them that this is the only thing people see when you walk into the room, it looks hideous, it defines who you are, then their brain sends us on another mission of a lot of compulsions like checking the mirror repeatedly, or sometimes for some people avoiding the mirror completely. Or kind of using a lot of products, seeking reassurance from loved ones, like “Does this look okay? Does this look bad?” Camouflaging, avoiding taking photos, avoiding maybe even going to certain social events because of their thoughts about their physical appearance, maybe using excessive products to try to change it. Some even go as far as having plastic surgery because of that, comparing their appearance with others. It kind of goes on and on. Karen Conlon: I just had a thought about social media and influencers and before social media there were magazines, television shows, but now it’s just out there everywhere you go. You turn your phone on, you go to any social media app, and there’s always some kind of focus on looks and presentation. Do you think, just purely your opinion, that social media can trigger or exacerbate some of these symptoms in people who are struggling with BDD? Dr. Tatyana Mestechkina: Yeah. It often really does. It’s just another, like you said, very easily accessible form for their brains to start kind of comparing and contrasting them and other people. I think even for their own social media, even posting a photo of themselves can be really, really anxiety-provoking. They might avoid posting or they might use a lot of filters or they might kind of check something and look over it or ruminate about which photo or which angle to post for a very long time. And I think beyond just BDD, but just on a more kind of general spectrum of body image dissatisfaction, I think social media can be really triggering for that in terms of creating unrealistic expectations of what the norms are when the reality is a lot of social media is the best of the best of people’s photos. There are images that are very controlled, filtered, angled, light, that people are comparing with their own kind of deepest, rawest versions of their physical appearance. Karen Conlon: What other cousins of OCD or that fall within the OCD spectrum would you want to tell us about today? Dr. Tatyana Mestechkina: Sure. So just to mention briefly, hoarding is also kind of a subtype where people experience a lot of kind of obsessions related usually to accumulating things, sometimes pets as well. And with hoarding it’s also not exactly just as simple as what we see on TV, but it’s very complicated in terms of there’s very different types of fears and thinking patterns that might motivate hoarding for some people. They really have a hard time letting go of things or kind of over acquiring things because of the sentimental value that they place on it. For some people, it comes from more of like a deprivation model, like “Well, what if I really need this later? What if I run out of these things?” Or sometimes there’s a big link between hoarding and perfectionism in that way, like “I need to keep all these articles and books because what if I need to get all this information? What if I miss something important?” Karen Conlon: Hoarding. I would never, again, have thought of that falling in the spectrum of OCD. One of the other things that has come up for some people that I’ve worked with in the past is the compulsion to pick. I remember actually when I was in middle school there was a boy that used to sit by me and the rest of his hair was completely straight, so I don’t know how this happened, but there was this one curl that he had and I mean if he was sitting there for eight hours, he was for eight hours just curling. And I remember this, I mean I’m talking a long time ago. I’m not going to age myself here, but this was a long time ago and it’s one of these things that I still remember because I was fascinated by the fact that this boy could sit there and just do that just continuously. And I don’t know that it’s OCD or that it was OCD, but I’m wondering are there also tendencies that we bring back to ourselves, that are not like about the hand-washing necessarily, but things like that, like picking? Dr. Tatyana Mestechkina: Yeah. So some other examples on the kind of obsessive compulsive spectrum category are people who engage in skin picking, which is called excoriation, or hair pulling, which is called trichotillomania. And often people are engaged in also repetitive behaviors that might feel very compulsive, very much out of their control, and are also like, with hoarding, motivated by different things. For some people, they might be trying to fix any imperfections. Like, “Well, because this part of my hair is coarse or not straight, or I have split ends,” their brain tells them, “You need to fix it, or you need to get rid of that hair to not have that,” or “There’s a little imperfection on your face or a pimple and you need to pick it until it’s gone.” And for other people, it becomes more of a self-soothing behavior or a distraction behavior when they’re maybe experiencing anxiety or stress or just excess energy that their bodies [inaudible 00:14:30]. This might be a way that that is released by that just kind of very kind of automatic repetitive behavior, which often they’re not even aware that they’re doing in the moment. Karen Conlon: What about boredom? Dr. Tatyana Mestechkina: Yeah. That’s a big trigger for people as well. Treatment Of OCD Karen Conlon: We have talked about all these different types and subtypes of OCD. We touched a little bit on treatment in terms of leaning into the thought. Let’s talk a little bit about how it’s treated. I know that providing education about what OCD is is really important because it’s important that people understand what it is and what it’s not, and also set expectations around what they can and really cannot do with it. But can you tell me a little bit more about what that psycho-education would involve? Like if you’re starting to work with someone new, what kind of things would you tell them about OCD to get them on the right track? Dr. Tatyana Mestechkina: Some of that would be just really helping them understand how it works from the amygdala example, helping them understand that these thoughts are not in their control in that way and practicing learning how to accept them as the independent system that they are. A lot of learning about how doubt and uncertainty is the common denominator between all OCD symptoms. So whether it’s traditional OCD, like counting and checking rituals, or more Pure O rumination, reassurance seeking behaviors. Whatever the theme is, usually it’s motivated by their brain telling them uncertainty and doubt is unacceptable. So the antidote to OCD is really learning how to welcome more doubt and uncertainty in our lives, how to make more room for it, and that’s where the true freedom from OCD comes. And in terms of the therapy, there’s a lot of research to support that the gold standard of treatment for OCD is exposure and response prevention therapy, otherwise known as ERP, and then also techniques from ACT, acceptance and commitment therapy, has been found to be very helpful as well. And a lot of other things in the mental health field are kind of to be debated in terms of pros and cons of one therapy versus another, but when it comes to OCD, at least right now, the literature is very clear and one of the reasons I chose to specialize in this is because it’s really exciting to work in a field where we really have a much better understanding of OCD than we ever have and that we have therapy that, by no means is easy, but it’s very effective for the people who are willing to engage it. And the way that I talk about ERP as a therapy is two-fold, reactive and proactive. And the reactive part is really helping people get equipped with different tools and strategies for how to deal with the OCD episode when it comes up. And all of those tools are kind of in the spectrum of learning to treat those thoughts, images, urges, as irrelevant, even though they feel very dangerous still and sort of retraining the brain. Karen Conlon: You mentioned exposure response prevention and ACT as being two of the what we call gold standards in treating OCD. Can you give us just a very simple example of what exposure response prevention looks like (ERP) and also ACT, what does that stand for and what’s an example of that? What might that look like? Dr. Tatyana Mestechkina: With ERP, essentially what we’re doing is we’re retraining the brain. So we talked a lot in our talk today about what doesn’t work for OCD, logic, reason, that approach, so we want to find kind of a backdoor way to respond to the OCD episodes by using different strategies to learn how to treat them as irrelevant. That’s sort of the keyword that we want to go to. And with ERP, the response prevention part is really about learning how to not engage in the rituals that feed the OCD, how to stop counting, checking, the reassurance seeking, the ruminating, and then the exposure part is really learning how to lean in and go towards some of the things that feel most triggering or distressing that our brains are telling us is dangerous for the purpose of practicing treating them as if they’re not dangerous, even though they still feel that way. So for example, someone with harm OCD who might have thoughts about, “Well, what if I stabbed my son with this knife,” and their rituals are throwing all the knives away or making sure not to be in the same room as their son when they’re cooking dinner. Exposure for them might be to practice chopping up some vegetables when the son is nearby in that way and letting their brains kind of go wild and bring up all types of intrusive thoughts. “What if you get angry at him? What if he does something to kind of trigger you and then you get really angry and lose control and stab him with this knife?” And their job during the exposure is to practice saying, “Okay brain, I hear you. Thanks for the warning. I’m going to let this thought be just a thought, or I’m going to let this be just one possibility of something that might happen.” Or in maybe later parts of the treatment that might be a little bit more aggressive, we might go towards the thought of being like, “Yep brain, you know what? Maybe I’m chopping up this carrot right now, but at any moment I might stick this knife in my child’s heart, chop him up in little pieces, and then saute him and make Hibachi for dinner.” Karen Conlon: Whoa. Whoa. Dr. Tatyana Mestechkina: Yes. Karen Conlon: This is why we gave the trigger alert. Dr. Tatyana Mestechkina: Like I mentioned, that’s a much more aggressive form of therapy. That’s usually in the more advanced stages, but what perfect way to treat something as irrelevant by making fun of it and by taking it to like an extreme animated kind of adventure of being like, “Hey brain, you’re creative with this possibility. Let me show you how creative I am that I’m able to take it down a notch to the most kind of animated, detailed example possible.” Karen Conlon: This is great to know because I think people often times will make assumptions about, “Oh, what does this look like? What is this supposed to look like?” So if possible, whenever possible, if you have identified that you might be dealing with some type or subtype of OCD, if it is possible to get treatment and professional help, you’re much better off than trying to figure it out yourself because without knowing it, you might actually be enabling and reinforcing certain behaviors. If you have interpreted what you think treatment is because you’ve done all this research and like, “Oh, this is what ERP is supposed to be.” And then without knowing it, you might be actually really reinforcing these behaviors that are actually the ones that you want to get away from or lean into and say, “Okay, this is what it is,” but then treat it in a certain way. Dr. Tatyana Mestechkina: Exactly, yeah. With a lot of therapy, but particularly with this type, it’s very, very important and really helpful to at least initially work with a qualified mental health professional who will help you both diagnose it correctly, provide you the education, and then guide you at least at the beginning to how to practice the spirit of the therapy. Because a lot of it isn’t about what you’re doing, but about the mentality that you’re doing it, because there’s such a fine line between an exposure and a compulsion and the difference is again the spirit in which you’re doing it. With that same example that I brought up with using a knife around the son, it could be an exposure if you’re saying, “Hey brain, look at me living life on the wild side. I’m tolerating this uncertainty. I’m letting this mystery be a mystery and I’m going to make a choice of my value of spending quality time with my son or having healthy home-cooked dinners for us,” et cetera, versus it becoming a ritual if you’re holding that knife and being like, “Oh my gosh, oh my gosh, don’t move it more than an inch because what if you lose control?” Or move the cutting board and the knife a few inches away from your son, or only do it when you’re in a good mood and everything’s great between you, or consistently ruminating about like, “Do I want to do this? Would I not? What about that serial killer I read about last week? Am I like him? We both have brown hair, what does that mean? Karen Conlon: And that brings me to the other gold standard that you mentioned, ACT, which is acceptance and commitment therapy. We talked earlier about the fact that OCD really latches onto your values. Can you tell us a little bit about ACT and how that works with that values piece? Dr. Tatyana Mestechkina: So ACT and ERP are both types of CBT, cognitive behavioral therapy. And I find that ACT really supplements the ERP work very nicely. And one of the biggest components, like you said Karen, is the values. So a big part of ACT treatment is helping people identify what are their values, what are the things that are most important to them in their life that they want to stand for, that they want to guide their choices, and getting clarity on that and then using those as sort of the map for how they want to live their life. It could be like family, it could be health. It could be really anything that’s really kind of important that they want to lay out as the compass of their life. And then it’s about helping them identify what are the barriers to making more choices in line with those values. And often, for many people, but especially with OCD, it’s the unwanted thoughts and feelings that might lead them to try to escape or avoid them. And then it’s about learning different techniques that are part of ACT that supplement the ERP works, such as, which we touched upon, the acceptance work. How to accept for things that are not in our control. With OCD, we don’t sign up for these thoughts and feelings. You don’t wake up in the morning with a menu of which thoughts and feelings you want to have for the day and you check the “I want to have thoughts about stabbing my son today” box in that way and practicing treating them as an independent system that we don’t have control over. A big technique in ACT is called cognitive diffusion, which just simply means learning how to identify and create separation from those thoughts, treating thoughts as just thoughts. Another huge component of ACT that’s really helpful are mindfulness techniques. A lot of times with OCD especially, but in life in generally, we get caught up with the past or the what ifs of the future, so a lot of mindfulness is learning how to be more in control of our attention to bring it back to the present moment, and also building a higher kind of willingness to experience some discomfort in our lives if that’s in the service of our values and brings us closer to it. I often like to use ACT as sort of a way to help people focus on the bigger picture. As you guys have kind of gotten the little hint that ERP is not always fun or easy, it’s very difficult work, but it could be very meaningful and can be very freeing if in one of the ways that people are willing to do the hard work is if it brings them closer to their values. If I’m doing this really hard practice, but that means I can spend more time with my son, spend more time with my child, to go to work on time and consistently, to see my friends when I want to see them, to be able to go to practice my religion the way that I want to, not kind of avoiding my religious practice because it’s filled with so many rituals. How to be able to drive my car to the places I want to go, to take the train, and all of the other things the OCD part of the brain might say are bad or dangerous. Karen Conlon: That makes so much sense. You want to bring it back to your values so that they understand that those thoughts are just thoughts and that they really are not in line with their values. So that’s a big part of making that connection with those thoughts and diffusing those thoughts. A lot of people seek out therapy to help with their OCD, but they might be doing different types of therapies, not necessarily these. Can other therapies also be helpful? Can some be harmful? Dr. Tatyana Mestechkina: Yes. That is a good question and I think the reality is unfortunately with OCD, aside from these ERP and ACT, other types of therapies can actually be harmful if they involve kind of giving content to the intrusive thoughts. A lot more kind of psychodynamic therapies might focus more on trying to uncover the origin of these thoughts, uncovering why these thoughts are what they are, which can actually do the opposite of what we want and put the spotlight on them and treat them as important significant things. And while it is true that sometimes OCD latches on to thoughts that are related to our values, it really is fair game and it could be about anything and everything, and the content doesn’t matter, which is a huge part of ERP work as well. So going kind of into the path and trying to make sense of these thoughts and give them meaning is actually very counterproductive at times. And even also with more traditional cognitive behavioral therapy, like doing cognitive restructuring, which we spoke about earlier, can also do some harm by feeding into the thoughts and continuing to use logic and reason to work through them. And that one could be tricky because it could feel like it’s working in the moment because that person can find short-term relief. Someone reflects a pedophile theme, their therapist saying, “You know what? I really am not concerned that you’d harm a child at all. You are the kindest person I know. I would even leave my baby with you because I think it’s so, so unlikely, that’s never going to happen.” While again that could feel very nice for the person experiencing OCD, but then their mind can show up a few minutes later and be like, “But do they really know me, or what about this one thought that I didn’t share with them exactly in the way that I had it? What if that would make them change their mind? Or that one time where I pushed someone on the swings when I was seven, maybe that means I am capable of violence in that way.” So those are just some examples of the types of therapy that can feed into it rather than help. Karen Conlon: And by the way, if a therapist says to you, you’re one of the kindest people that I know I would leave my baby with you, that’s a problem with boundaries. And I talk a little bit about that in one of my other episodes, Can Therapy Make you Worse, so just a little note on that. Okay, so a couple of last things here. Medication, is it always necessary? Yes or no? Dr. Tatyana Mestechkina: It’s not always necessary. Sometimes it can be helpful for some people. And what I usually recommend is if someone is coming in and their OCD is really severe in the way that it’s really affecting their ability to kind of live their life and function, if they’re avoiding, not able to get to work or to school, or are losing relationships because of it, then often starting medication and ERP at the same time would be the recommended approach. But for other people who are coming in and they’re obviously experiencing pain or suffering, that’s why they’re here, but they’re still kind of generally functioning, while medication is an option, we sometimes recommend, “Let’s start with ERP. Let’s give it a go for a few months and kind of see how it goes.” Because if we start both at the same time and then the person feels better and is living better in three months, it’s then hard to isolate is it the medication or is it the therapy. Also medication comes with risks of it not working or coming with side effects as well. So I’ll usually say, “Let’s see how we do for a few months and then reevaluate if we’re still making consistent improvement and moving forward. Let’s see how we do with that.” Or if we are getting stuck somewhere or have made some progress, but then hit a plateau, then let’s bring a psychiatrist on board to see if adding medication can help them kind of get over the hump and do the therapy more effectively. Karen Conlon: Well, what you said also just has me thinking about the different areas of care that one person can receive, medication or no medication, some people might be seeing a psychiatrist, some people might be working on their nutrition also. So it brings me to the thought of does it make sense for people with OCD to see two therapists at once? The reason I bring this up is because in our practice at Cohesive Therapy NYC, generally speaking, the policy that we have is if you’re going to work with us, work with us, give yourself the opportunity to really focus on things. Sometimes people come and they have other therapists, another therapist that they’ve been seeing for a few years, and they’re thinking well I talked to that therapist about this, and I’m going to talk to you guys about this, not really understanding that what they’re doing is not really allowing anybody to get the full picture and maybe what they might be struggling with is that that therapy relationship might need to be coming to a pause, but not wanting to let go. It might be a lot more work for you actually. You might be dealing with two therapists that are really great, but they have very different philosophies, very different orientations, that actually might be conflicting. In our practice, our policy is work with one therapist, whether it’s us or whoever, but give yourself the opportunity to really focus. Is that the case for OCD? Is it recommended? Is it okay because maybe they’re seeing a therapist that doesn’t specialize in OCD? What are your thoughts about that? Dr. Tatyana Mestechkina: I think you did a really excellent job summarizing exactly our treatment and my treatment philosophy as well in our practice CBT For Better Living. We pretty much say word for word what you’ve said. Can’t agree more. And again, we don’t want to diminish the value of people working with different people with different perspectives. And a lot of patients come in and say, “I love my therapist. We’ve done really great work together. Here are ways I’ve made improvement, but here’s this one area where this might not be their area of expertise.” And often we recommend the same thing, just let’s take a pause. If you want to try this, let’s go all in, try this for a few months and then reevaluate. And that way, because it can be therapy overload and it could be very confusing if there’s anything that’s contradicting or not perfectly aligned. It’s always, but especially with OCD, because the therapy, as you guys have heard, is so specific and sometimes involves doing things that seem counterintuitive in the short-term in that way. And then the other thought is that OCD doesn’t come in a vacuum. It would be really nice if we can sort of pause and put OCD in a bubble and just treat that in itself, but often OCD is really related to all other areas of people’s lives as well. And also, as you mentioned, this doesn’t have to be a long-term thing. We can always, once you kind of get a better sense and make some headway in this therapy, can always reassess and then resume with your previous therapist afterwards. Karen Conlon: Thinking about what you mentioned a couple of minutes ago about some therapies that actually can be harmful, if they’re seeing a therapist who is psychodynamically oriented or psychoanalytically oriented, and then they come see you at the same time, the work is going to be completely contradictory. What they’re doing with you is going to potentially be undone with their other therapist. Dr. Tatyana Mestechkina: Exactly. So we recommend pick a direction, stick with that, and then you can always reassess. It’s not a commitment. You’re not signing a contract to work for X amount of months. You’re just trying a different perspective and it’s important to be really present and immersed into it, and then of course making a decision in the future. And also one of the fun things that I really like is sometimes after we make headway with the OCD stuff, and that takes up less time and energy in people’s lives, then we can work on some more kind of actual things that are really important and valuable to them that OCD might’ve been clouding their ability to really kind of understand or tackle. Dr. Tatyana Mestechkina: And then another fun thing is that some of the strategies that we use for OCD are very applicable to other aspects of life. Who doesn’t have unwanted thoughts and feelings, OCD or not, and learning to make room for them, to accept them, to have a better relationship with our brains, to get them less power, to not let anxiety and fear kind of run the show in our decision-making process are all different things that are very applicable outside of OCD as well. Karen Conlon: This is so helpful. I have personally learned so much and I’m sure that people listening out there are really going to have a much more rich and different perspective on OCD. You know, because this podcast is about demystifying, debunking, and de stigmatizing what goes on in the therapy space, can you tell me, if you wanted to leave people with one aspect of OCD therapy that you want to demystify and you want people to walk away with that message, what would that be? Dr. Tatyana Mestechkina: The one hopeful takeaway from today’s episode and our discussion is for people to understand that OCD is not an adjective and it’s often misused in the media, or even by just lay people, to describe people who like things organized a certain way or like things cleaned a certain way, and that really doesn’t encompass what OCD actually is and how complex it can be and all the different ways it can manifest and also the incredible amount of pain that it might cause people. And that using it as an adjective to describe some perfectionistic tendencies or preferences can be really, really invalidating for people who are experiencing it and can also perpetuate misinformation and might make it less likely that people who actually are experiencing it to be able to identify it as such. And as we talked about, just having the name and label for it can be such an important first step towards the journey of learning how to then get freedom from it and not let it take away people from living the kind of lives that they want. Karen Conlon: So, OCD is not an adjective and so the next time that you experience even yourself or someone else engaging in a behavior where it feels to you like, “Oh, look at that, they’re really being OCD,” just kind of maybe think back at what we talked about today and perhaps think about what else might be going on. Is there an alternative way of thinking about it or is this something that maybe you want to look into if it’s a loved one where you feel might be important to address it with? But let’s try to make sure that we’re using OCD in the appropriate ways and not minimizing it and people’s experience. Tatyana, where can people find you? Please tell us because I know that this is something that people are going to need to know more about, they’re going to want to know more about, and any resources that you’d like to pass along. Dr. Tatyana Mestechkina: So we have a practice. We’re located in New York City, but currently seeing people in New York, New Jersey and Florida. It’s called CBT for Better Living, which stands for cognitive behavioral therapy for better living. And our website is cbtforbetterliving.com. Our email address is cbtforbetterliving@gmail.com. And you can also follow us on Instagram @ocdanxietyexpert. So on my website, CBT for Better Living, there’s a link to some resources that could be helpful and some main ones are IOCD app, which is the International OCD Foundation, and Made of Millions could also be kind of a great way to start kind of diving into all the knowledge that’s out there about OCD. Karen Conlon: Wonderful. Thank you so much. I am so happy that we were able to have you on today. Dr. Tatyana Mestechkina, expert specializing in OCD. And if you’d like to know more, please visit her group’s website, cbtforbetterliving.com. And as always, if you want to know more about our practice or this podcast, please be sure to head over to cohesivetherapynyc.com/podcast. You can get all the show notes here from this episode and from other episodes, resources, and how to get in touch. Thank you for being here today and see you next time when I once again ask, So how’s therapy?OCD Is Not An Adjective.

On this week’s episode of So, How’s Therapy?, I am joined by Tatyana Mestechkina, Ph.D. to dive deep into the topic of obsessive-compulsive disorder, or OCD.

Trigger Warning: Sexual Thoughts / Thoughts Of Harming Others: We discuss a few examples of intrusive thoughts within the context of OCD that have content of violent and/or sexual nature.

While the term OCD is commonly known, it is also commonly misunderstood. Obsessive-compulsive disorder is often portrayed in the media as someone who washes their hands over and over again, or someone who has to have everything in its place – but it’s much more than that.

Those who suffer from OCD are impacted across all aspects of their life. Today, we’ll be demystifying OCD, and helping you understand it at a much deeper level.

What You’ll Learn

  • What OCD Is (And What It Is Not)

  • Causes Of OCD

  • How OCD Affects The Lives Of Those Who Experience It

  • Different Types And Subtypes Of OCD

  • Treatment Of OCD


Transcript Episode 10 Karen Conlon: Hello, and welcome again to the So, How’s Therapy Podcast. This is a podcast that demystifies, debunks, and destigmatizes what happens in the therapy space. I’m your host, Karen Conlon, and today we are going to talk about a topic that is very widely known, but not widely understood. We are going to cover and demystify obsessive compulsive disorder, OCD. Now, people who suffer or experience OCD are incredibly impacted in all aspects of their lives. They may be engaging in different types of behaviors for hours at a time or a specific behavior for hours at a time and it really makes their life difficult, sometimes impacting their ability to maintain a job or to keep up with social relationships. There are the more traditional types of obsessive compulsive disorder symptoms that we all know about and that we hear about and that we see on TV. But today, we are also going to talk about the lesser known types of OCDs like intrusive thoughts and mental compulsions and other types of OCDs that we cannot even imagine, that we couldn’t even imagine are actually parts of obsessive compulsive disorder. I am super excited to introduce our guest today, Dr. Tatyana Mestechkina. She is going to talk to us today a little bit about herself and a lot about OCD. Tatyana, welcome to the So, How’s Therapy Podcast. How are you? Dr. Tatyana Mestechkina: Hello. Thank you so much for having me, Karen. I’m so excited to be here and talk about this. Karen Conlon: Yes, I’m super, super, super excited to talk about this. This is one of those topics where people tend to use the expression, “I’m OCD. He’s OCD. She’s OCD,” in a very loose way, not really understanding perhaps not just what it means, but just how difficult and stigmatizing actually really living with OCD can be. Now, there are two things that I want to mention before we start talking about what is exactly OCD. The first thing is I wanted to provide a what we call in our world a trigger alert, because today we may be discussing examples of intrusive thoughts within the context of OCD that have violent or sexual nature or that are of violent or sexual nature. So if this is something that you feel you might have some discomfort with, or if there are children in the house with you, in the car, in the area that you may be assess whether is something that you’re okay with them listening to, maybe put your ear buds on. Like now. The next thing that I kind of wanted to mention was this quote that I found with respect to OCD, Tatyana, and this quote says it is not the content of the thought that distinguishes between people with OCD and those people without OCD, right? The thoughts are the same. It’s the interpretation that the person gives the thought that matters. That interpretation is the difference between someone who has OCD and someone who does not. We’re going to explain that a little bit more. Let’s start by just giving a general explanation of what is obsessive compulsive disorder just kind of in layman’s terms. What OCD Is, And What It Is Not Dr. Tatyana Mestechkina: Sure. Absolutely. So a very kind of oversimplified version of OCD is that we all have this part of our brain called the amygdala. And this part of our brain is responsible for keeping us safe and warning us if there’s some sort of danger happening. And this part of the brain has been around for as long as humans have been around, has been super helpful. If there was a tiger in the room with us right now and our amygdala wasn’t warning us that there was a danger, we might say like, “Let’s watch some Netflix. Let’s take a nap,” and we would probably be dead very, very quickly. So while people with OCD also have a very well-functioning amygdala that’s going to warn them when there’s a tiger in the room or any other type of danger, it sometimes misfires and sends them this false alarm signal that there’s something dangerous, even though there isn’t. And the problem with that is that it sounds very, very real. It sounds exactly the same way as it would if there was an actual tiger or a fire or whatever was going on. And then the other problem with OCD, in fact, it doesn’t respond well and communicate to the logical rational part of our brain. If the person in that moment kind of response to that false alarm signal and treats it as if it’s real, they can often find themselves spiraling into the rabbit hole, treating these false alarms as if they’re real alarms, therefore validating their brains that this is something important and threatening, and then their brains give themselves a little imaginary pat on the back saying, “I’m doing a great job warning this person, because if I wasn’t, something dangerous or horrible might happen.” And that’s sort of kind of the vicious cycle of how OCD works. Karen Conlon: Right. What I’m hearing is that part of the brain, that alarm system, that amygdala gets activated and that part of the brain is very primal. It doesn’t really respond to rational thoughts. And quite the contrary, when you are experiencing OCD, there is this constant reaffirming, this constant reconfirmation that no, this is exactly what we need to be doing. We need to be on high alert. This is dangerous. We have a really difficult time bringing in the reality sometimes of what’s really in front of us, right? It’s almost like whether it’s a tiger chasing you or you’re just running late for work, the alert system is the same high response. Dr. Tatyana Mestechkina: Exactly. It almost feels irresponsible in that moment to not respond to it. I would say the majority of people I work with with OCD at some point when they’re not in the OCD episode are you able to say like, “I know it doesn’t make sense. I know this isn’t logical. I know this is very, very unlikely to be threatening.” But in that moment, all of that goes out the window and it feels like the tiger is in the room or their house is on fire. The urge to act out and treat this as something serious is really, really high. Karen Conlon: I want to ask you then, is there oftentimes a confusion or a misdiagnosis of obsessive compulsive disorder and general anxiety disorder? Dr. Tatyana Mestechkina: Mm-hmm (affirmative). Absolutely. Karen Conlon: Because a lot of the things that we’re talking about, the amygdala, the brain’s alarm system, sound very similar to what people with general anxiety disorder walk around experiencing. What’s the difference? How do we identify the difference? Dr. Tatyana Mestechkina: So that is an excellent question and that is something that’s constantly being discussed in the field, even within the OCD expert group. The way that I think about it is like a big Venn diagram. If you think about those diagrams with the two big circles with the overlap between the circles, the reality is the overlap is very, very large. The commonalities between OCD and general anxiety disorders, sometimes referred to as GAD, is that both people experience a lot of anxiety. That being the hallmark feature. There tends to be a lot of mental rumination going on, and there’s a lot of very low tolerance for uncertainty. Their brains kind of send them on a mission to get answers and to know for sure. With general anxiety disorder, the topics tend to be more exaggerations of everyday worries. Like, what if I run out of money and can’t pay my bills? What if I lose my job? What if this bad weather ruined something that I really, really want to do? And just maybe stuff that everybody worries about, but up a few notches. And with OCD, often the worries are less logical, but caveat is not always. A lot of times they’re like, what if I murder my husband, even though I love my husband. What if I am in the wrong relationship, even though I might generally be really satisfied with my relationship. What if I’m attracted to a child, even though I have consenting adult relationship. What if I did something to practice my religion the wrong way and God is mad at me, et cetera. And we’ll go into more specific details of that. However, again, the asterisk is it’s not always completely illogical. And with OCD, we tend to see more of the compulsive. So repetitive behaviors, either physically or mentally, to try to kind of undo the thought, escape the thought, more of that kind of urgency and repetition. And then the more important question is, what does that mean for treatment? The reality is that the treatment that we use for OCD tends to be very effective for people with general anxiety as well. A lot of overlap with the treatment. The only difference that we see is that with general anxiety, sometimes using cognitive techniques like restructuring unhelpful thinking patterns and using logic can be helpful for some people. And with OCD that usually is not helpful and sometimes even feeds into the disorder more long-term. Or if it’s helpful, it’s helpful very, very temporarily, but then they want an answer within a few minutes, a few hours. Karen Conlon: Right. You’ve touched on a lot of things that I want to kind of tease out a little bit more. This Venn diagram, I’m such a visual person. I love the fact that you mentioned the Venn diagram, and we will see if we can have one in the show notes. For people who are visual, such as myself, this makes so much sense, right? Now I get it. OCD on one end, general anxiety disorder, or GAD, on the other end, and then in the middle where these two circles overlap, this is where we see the similarities and where we can get misdiagnosed or diagnose ourselves sometimes incorrectly because we’re not able to see what’s on the other ends of each of the spectrums that really identify the difference between OCD and general anxiety disorder, general anxiety disorder being that daily exaggeration. What if I can’t? What if I do? Why do I always? Those types of thoughts that just linger ongoing versus OCD, where sometimes the worries are not always so logical and also there’s this compulsion to need to fix it. And then in terms of the approaches that you’re using with general anxiety disorder, the cognitive behavioral approach, which is where we help to retrain the brain to help see things in a different way, maybe we can appraise situation and reappraise them in a different way, find alternatives, there’s this flexibility that we can learn when you’re dealing with general anxiety disorder versus OCD, which is a little bit more… It sounds like it’s a lot more rigid. Dr. Tatyana Mestechkina: Yeah, exactly. I think with OCD, people’s brains on a mission for 100% certainty. We know in life, what is a 100% certain, that’s where the rabbit hole kind of comes in. It’s a never ending journey. Karen Conlon: I can see with wanting 100% certainty, I can see why cognitive behavioral techniques we have to be careful in applying those because cognitive behavioral techniques are all about not necessarily knowing anything 100% and being able to have that flexibility or learn to be flexible and looking at other possibilities. Dr. Tatyana Mestechkina: Absolutely. And also within OCD therapy, I will add, there is a little bit of room for that at the beginning. Especially as we’re laying the foundation of the therapy, I think it is important to provide someone the education about what OCD is, what isn’t, the fact that there’s nothing that’s 100% certain, the fact that it’s feeding the disorder is continuing to look for that certainty. There’s a little bit of that that is helpful and important even at [inaudible 00:12:17] We don’t want to use in the moment as the OCD episode is coming up. Karen Conlon: And by the way, folks, I know that you will hear some technical glitches and that is just the world that we’re living in today in the world of the pandemic. My apologies for any technical glitches that you hear, but we’ll definitely include any details you might miss in the show notes. Tatyana, do we know what causes OCD? Causes Of OCD Dr. Tatyana Mestechkina: That’s also very good question. The simple answer is we know a lot more than we did before, but we still don’t know a lot of it. One risk factor, we know that CD has a genetic component to it. And what that means is that if someone that you’re closely biologically related to, like a twin or a sibling or a parent, has OCD, you are more likely to get OCD. That doesn’t mean that you will, you just might be more vulnerable to it. We also know that there’s certain… We have some preliminary research about certain parts of the brain that might be implicated with OCD, certain neurotransmitters like serotonin and glutamate, and promising exciting research, but still a long way to go in terms of fully knowing or making any cause and effect relationships. We do know that certain things in the environment like certain stressors might bring on OCD episodes for people who are already biologically vulnerable to it. I do want to make an important note that it’s a very, very common misconception for people, even for therapists sometimes, trauma does not cause OCD. And I repeat, trauma does not cause OCD. We do know like life stressors and possibly even traumatic events, again, can trigger an OCD episode, but there’s no at least scientific knowledge at the moment that there is a direct cause and effect relationship in that way. In fact, I would say the majority of the patients that I work with have not experienced any sort of trauma. And therapeutically, even if they have experienced a certain trauma or even if it was around the same time that the OCD came up, therapeutically, it is not helpful in terms of what the current research said, that the treatment is not learning to kind of uncover or process the trauma. If anything, again, that can feed into the OCD symptoms and exacerbate them. Karen Conlon: I’m really glad that you brought this up because there are plenty of books out there in the field that talk about OCD or mention OCD as one of the ways that people develop to adapt to their environment as a result of trauma. This is really interesting that you bring this up because that is something that oftentimes we, therapists who are trained in trauma and obviously in anxiety, have been taught, at least through some of the literature out there. This is, for me at least, really groundbreaking. This is a perfect example, everyone, of just knowing that you don’t have everything 100%, that research will always bring about new information. This is why we need to be flexible and open to understanding what comes up, what’s new, different times in history, what are the things that make sense. And then research comes out and says, “Well, no, that doesn’t make sense anymore or that doesn’t apply anymore.” I’m really glad that you brought that up because that is something that in the trauma field many of us have read is part of what people do or part of what people develop in order to cope with their environment. I wanted to ask you also just really quickly going back to the brain and neurotransmitters, you mentioned serotonin and glutamate. Neurotransmitters are basically information messengers. Can you talk a little bit more… I’d like for people to understand the role and the importance of neurotransmitters in their bodies and why this is related to OCD. Dr. Tatyana Mestechkina: What we do now is there are certain types of neurotransmitters, such as serotonin and glutamate, that are implicated in certain mental health challenges that people experience and tend to regulate mood and whatnot. Those are examples of some of them that have been implicated in OCD. But again, it’s also a hard question to know like, is it the chicken or the egg? Is it that these neurotransmitters are not functioning the way that we’d want and that’s causing OCD, or someone having OCD, therefore triggering changes in neurotransmitters? One of the ideas behind serotonin particularly is that we know SSRI, which is a class of medications called selective serotonin reuptake inhibitor, like Zoloft, Prozac, things like that, are considered first-line treatment in OCD from a pharmacological perspective in that way, and those are also medications that are typically given in depression as well. How OCD Affects The Lives Of Those Who Experience It Karen Conlon: There’s just so much chemically it sounds like going on. Biologically, I’d like to talk about the internal world of what it’s like for someone who’s struggling with OCD. What is that internal world look like? Because we’ve been talking about things like genetics and brain structure and environment and all these things that obviously there are internal factors, but what about the psychological and emotional and social internal world of someone who’s struggling with OCD? Can we talk a little bit about what that’s like? Dr. Tatyana Mestechkina: I think some people might diminish or not understand how incredibly painful this experience could be and how incredibly debilitating this could be, right? If someone is spending a lot of time and energy ruminating, investigating, looking for reassurance, or doing a wide variety of rituals, that might, A, take up a lot of time in their life that they’re not dedicating to the things that are important to them. It might lead them to avoid doing certain things that are meaningful to them, like going to certain social events or riding the subway or going to school or certain relationships or certain TV shows. I think it sometimes makes it really hard for people to be present in their lives and to focus on what they’re doing or who they’re with and connecting with them if their brains are kind of pulling them away on a journey to engage with the obsessions and the compulsions in that way. It can also be a really lonely and isolating experience. And the reality is that OCD is very, very common. About two to 3% of the population is estimated to have it. But my guess is honestly even more because it’s so often missed and misdiagnosed in that way. A lot of that is because there is certain kind of missed portrayals of it in the media. My guess is that there’s more than we even know, and people are not alone, even though they might feel that way. Because I think we’ve come a really long way also in kind of the media in terms of destigmatizing and bringing some attention to it, bringing some good information out there, but we still have a long way to go. And a lot of people might not even know that they have OCD, especially some of the less common texts, which hopefully we’ll get a chance to talk about. And some of them who know that might not realize how many other people have that, because it’s not something people chat about at a cocktail party usually. Karen Conlon: I’ve worked with a number of clients who we are able to identify. Rule out some things then identify that they have some symptoms of obsessive compulsive disorder. And when you take a history of their lives and get some history of their childhood, it’s like nine times out of 10 I hear, “Well, when I was a kid, there were some things going on.” There seems to be this not wanting to look at it when they were children and now they’re struggling as adults. It’s been a very interesting pattern than I’ve seen in my practice. But typically there’s something in their childhood that has pointed to this and this all makes sense to them now as adults. What can parents look for in their kids? And is there a difference in terms of ages? Does a six-year-old with potential OCD have different habits potentially than someone who is 12 or 15? Dr. Tatyana Mestechkina: All very great questions. I think the reality is, even though we in the mental health field like to put labels on things and say it is or it isn’t, the reality is OCD falls on a spectrum. And most people, even who wouldn’t meet the formal diagnosis of OCD, have done certain things that are in line with obsessions or compulsive, myself included. Things that I probably wouldn’t have even thought about for a second if I wasn’t specializing in this. I’m like, “Oh yeah, that thing that I did when I was six, that was a little bit of compulsive.” I remember having a little “game” of not stepping on certain cracks and that way. Karen Conlon: I still do that. Dr. Tatyana Mestechkina: I probably wouldn’t have thought of it. Yeah, exactly. A lot of us do certain things where they’re repetitive or engage in rumination or make connections that aren’t really connections that we logically rationally believe in in that way. But for some people, it’s just kind of little “quirks” and little things that happen. And for other people, it can take over their whole life. A lot of times OCD does develop in childhood and some red flags that we see that are often missed are, like we mentioned, the repetitive behaviors, which are easier to spot if people have more traditional OCD, where their compulsions might be more like hand-washing, or knocking on something a certain way, or cleaning something a certain time, or tapping something, or having good numbers, bad numbers, things like that. A little bit more subtle and harder to miss, especially in children if they’re mental with things like ruminating. Avoidance behaviors could be a red flag of that. Reassurance seeking, so kids asking their parents the same questions over and over again, not taking the answer at face value, things like that. Karen Conlon: And when you mentioned that, one of the things that came up for me is actually a number of clients have said that they remember counting between say age of six and eight. And I guess when I think about it, I mean, counting is something that at that point, there’s a lot of mastery around. It’s something that might be easier for them to engage in. I remember people saying, “I counted the books all the time that were in my little shelf, my bookshelf, in my room. I counted steps up and down. I counted the steps up and down all the time.” Dr. Tatyana Mestechkina: Yeah, or like checking things, like consistently checking things like the door, the stove, under the bed, in the closet, and the repetition is also a big red flag. A lot of patients that I work with who are older and we’re working let’s say on a specific OCD theme that’s relevant in their life at the moment, usually within a few weeks of therapy, they’re like, “Oh, that thing that I did when I was eight, that kind of has some OCD red flags.” And then when they share it with me, it’s usually very classic manifestation of it that they just sit and put two and two together. Karen Conlon: You mentioned thoughts, right? Like reassurance. So that kind of brought me to my next question here, relationships. What if you’re in a relationship with someone and they’re exhibiting some symptoms of OCD, but they’re not obvious, what could those look like? Dr. Tatyana Mestechkina: Really similar to the question with the children, a lot of it is rumination, having a hard time being present, reassurance seeking, asking the same questions over and over again, googling, investigating, anything that’s sort of like the repetitive nature of it. This is really hard because sometimes the OCD beams even latch on to the relationship themselves, and I’ll be happy to give some examples of that. But even regardless of that, I think that can create confusion and disconnect in people’s relationship or even sometimes frustration. Why is my boyfriend, or why is my roommate constantly asking the same question over and over again? Or why are they getting frustrated at me if I don’t arrange things a certain way or clean things a certain way? Just whatever. I mean, the interesting thing about it is it can latch onto anything and everything. Karen Conlon: I think about the partner’s perspective who let’s say is living or in a relationship with someone with not so traditional OCD let’s say, or maybe with the traditional CD, but just not so obvious. If the partner feels like the dishes aren’t out of the sink before their partner gets home and they start feeling flustered around it or feeling very nervous like, “Oh my gosh, I have to get this done because I know that there’s going to be a reaction around it.” And not necessarily not a… We’re not talking about a violent reaction. We’re talking about a specific type of reaction. What might that reaction look like? Dr. Tatyana Mestechkina: We don’t live in a vacuum. And a lot of times when people have certain rituals, it does involve their environment and sometimes people, especially partners who they live with in that way. It can be very confusing when someone’s partner is doing things that seem very illogical in that way. Oftentimes, what I find is just the partner and the person experiencing the OCD having a name for it, having a diagnosis that’s confirmed by a mental health professional who has the qualifications of doing so can be so freeing in a certain way, right? A lot of people don’t like a lot of mental health labels. But with OCD, oftentimes I actually find it brings people a lot of relief. “Oh my gosh, I’m not the only one experiencing these things. I’m not going crazy. I’m not a psychopath. I’m not this horrible person, but it makes sense that I’ve been experiencing this because of this part of this OCD experience.” I think the first step, even knowing and understanding that can bring so much relief both to the person experiencing it and to their partners, who then I think are able to at least start the journey of having more kind of empathy, compassion, and understanding how this works. My partner isn’t just controlling or mean or rational, but here’s what’s happening in their brains that’s creating a lot of pain and sometimes suffering in their lives. And often the biggest challenge, I think, for loved ones with people with OCD is how to support someone with OCD. And this could be a whole other podcast episode, but the tricky thing is that balance between validating and supporting and being there with the person without giving them reassurance or feeding into the theme.Announcer:Thanks for listening. Be sure to tune into part two of this episode where we’ll dive deep into the lesser known types of OCD, how different treatment modalities can affect outcomes, and more. Episode 11 Karen Conlon: Hello and welcome again to the So, How’s Therapy podcast. This is a podcast that demystifies, debunks, and de stigmatizes, what happens in the therapy space. I am your host, Karen Conlon, and today we are going to talk about a topic that is very widely known, but not widely understood. We are going to cover and demystify obsessive-compulsive disorder (OCD). Different Types And Subtypes Of OCD So, in terms of those lesser knowns, because now we’re kind of going into these lesser known types of OCDs, let’s talk about some of those. Pure O OCD is related to intrusive thoughts and images, and if we think about the word intrusive, they’re not welcome. I mean, it’s not something that we really want in there. Can you tell us a little bit more about that type of OCD? Dr. Tatyana Mestechkina: Pure O stands for purely obsessional, which is a subtype of OCD that’s less known about, yet very, very, very common. It’s somewhat of a misnomer because people do have compulsions, but the compulsions are not ones that we typically observe, like the checking, the rearranging, the hand-washing, but are things that are more mental. So examples like ruminating, reassurance-seeking, investigating, Googling, answer-seeking, anything that’s in line with the pursuit of certainty in that way. And these are the types of examples that tend to kind of slip through the cracks often because people having this type of OCD might not even know that this is OCD. I’ll just go through some common examples. Things related to sexuality, for example, so someone who is heterosexual might have an intrusive thought, “But what if I’m actually gay?” But what’s interesting about that is it goes the other way as well. Someone who is in a homosexual relationship or identifies as such might have the thought of, “What if I’m actually straight?” And then they go into this kind of rumination of trying to figure out, “Is it true? Is it not true? But there was that person that I saw on the street or that character on TV and I was attracted to them, but was I really? Am I more attractive to them than my partner? What does this mean? What about this one thing that happened when I was 13,” et cetera, et cetera, et cetera. Another example is OCD often latches onto our relationships. So relationship OCD might lead someone to experience intrusive thoughts like, “What if I’m in the wrong relationship? What if I’m not as attracted to my partner as I should be? What if I don’t love them enough? What if I don’t feel the same way about my partner as that post that I saw on Instagram yesterday, or this character from this show? What if the fact that my partner has a bump on their nose means that I am really unattracted to them and I’m going to realize that one day and then have to break up with them and ruin our marriage,” et cetera, et cetera. Another really common one is a violent OCD, so people experiencing intrusive thoughts about either harming themselves or someone else. “What if I’m suicidal? What if I’m capable of hurting myself? What if when I had that chopping up my vegetables in the kitchen and then I looked at the knife and saw my arm and thought I could slit my wrist, what if that means I actually will do it?” People having intrusive thoughts about hurting other loved ones. Another common one is pedophilia OCD, which as you can imagine can be very distressing for people having intrusive thoughts about either being attracted to children or harming a child. “What if I’m attracted to that child? What if I felt something in my groinal sensation when I was on the street,” et cetera. So again, just a reminder that the content of these thoughts doesn’t matter and there’s a reason why some of the examples I brought up tend to be about more either taboo topics or topics that are very much in line with people’s values. Karen Conlon: I have to say that hearing all of the different thoughts and the types of ruminations and worries, just ongoing worries, it really promotes so much empathy. As I think about the exhaustion, the mental, emotional, and even physical exhaustion that people who struggle with OCD go through on a daily basis, it’s just really something that we all need to keep in mind the next time that we think of saying to someone, or talking, or just lightly saying about ourselves, “Oh, I’m OCD” or “They’re OCD.” Struggling with thoughts that really are so difficult because they do go against your value systems. I mean, the fact that you’re worried about hurting someone so much is probably because it goes totally against your values, but that’s how OCD works. It attacks… I don’t know if that’s the right use of the word, but to me it feels like an attack almost, and it’s an attack of your values and inability to correct that and just say, “No, no, no, that’s not how I am and we’re going to let go of that now.” Dr. Tatyana Mestechkina: Absolutely, and it’s interesting that you use that word because most patients use that word as well, because it very much feels like an attack. But I think something people find helpful therapeutically is kind of reconceptualizing that idea. Because as we talked about before with the mental example, our brains aren’t actually trying to attack us, they’re really trying to protect us and they just tend to maybe misattribute and have kind of a poor source of information for what actually is or isn’t dangerous. So in fact, I try to think about it and try to help patients think about it less as an attack, but more of like if you think about a little kid kind of running up to you, your child, a niece, a nephew, a cousin, being like, “Oh my gosh, there’s a monster under the bed! Ah, ah, ah! Run, run, run!” We normally wouldn’t think about that as an attack, we would think maybe like that little kid is really scared or he’s really trying to protect us because he might think there is a monster under the bed. And I think often kind of bringing that kind of more compassion to our brains who might just be really scared and really thinking there’s something dangerous and it’s their mission to keep us safe, can help us drop some of the kind of the hostility and the battle that people with OCD engage in with their brains, which is part of what makes this so exhausting in that way. And even going as far as, I know this might sound like a stretch for someone with OCD, but going as far as even thanking their brain. “Thank you brain for trying to protect me. I know you have the best intentions, but right now I’m not going to treat this as a relevant threat, but just one possibility out of many, many, many possibilities of things that may or may not be true in life.” Karen Conlon: Right, so rather than trying to change the thought or trying to find logic to it, or trying to look at it in a different way, kind of leaning into it and saying, “Okay, you know what? I get that you’re trying to protect me and thank you for that, and this is my OCD and I get it,” and it’s this form of acceptance almost. Dr. Tatyana Mestechkina: Exactly. That’s a really, really big, big word, so I’m glad that you brought that up. That is a huge component of the therapy, learning to accept these thoughts as just what they are, intrusive, unwanted thoughts, but thoughts that we are not responsible for bringing up and we’re also not responsible for trying to control, or push away, or run away from, but just looking at these as thoughts that come up with an alarm signal sometimes, and unfortunately that alarm signal can’t always be trusted. Karen Conlon: Let me ask you, because now, just thinking about these other forms, or as we call them, cousins of OCD, is that alarm system always constantly going off when you have OCD, or let’s say on the spectrum for those people who are struggling with other types of OCD that they may not be aware of, like body dysmorphic disorder for example, is the brain’s alarm system always going off as well there? I was actually shocked to learn that body dysmorphia falls in the spectrum of OCD, so can we talk about that and also maybe a couple of other ones that are quite common out there, but are not commonly known to fall into the spectrum of OCD? Dr. Tatyana Mestechkina: Yeah, definitely. So in the diagnostic manual, DSM-5 at the moment, there’s something called obsessive compulsive spectrum disorders. OCD is one of them and then there’s a few other types, I like to call them also the cousins of OCD because they’re related, a little bit different, but a lot of common denominators. So one big example of that is body dysmorphic disorder, sometimes called BDD for short, which is very similar to OCD, but the people’s obsessions tend to be focused on their appearance and their body image and often they’re focused on a perceived or actual physical imperfection. But often times its something that again the average person might not be able to see, or if they see it might be something very slight. But to that person experiencing BDD, their alarm signal goes off and they almost experience a distorted version of this physical appearance. Like they might think this slight bump on their nose looks like a 90-degree angle and that’s the first thing that anybody sees when they’re looking at that them. Or if there’s slight asymmetry in their eyebrow, again their brains might be putting the magnifying glass to it. Or if their hairline is like a centimeter one direction more than they’d want it to be, their brain might be telling them that this is the only thing people see when you walk into the room, it looks hideous, it defines who you are, then their brain sends us on another mission of a lot of compulsions like checking the mirror repeatedly, or sometimes for some people avoiding the mirror completely. Or kind of using a lot of products, seeking reassurance from loved ones, like “Does this look okay? Does this look bad?” Camouflaging, avoiding taking photos, avoiding maybe even going to certain social events because of their thoughts about their physical appearance, maybe using excessive products to try to change it. Some even go as far as having plastic surgery because of that, comparing their appearance with others. It kind of goes on and on. Karen Conlon: I just had a thought about social media and influencers and before social media there were magazines, television shows, but now it’s just out there everywhere you go. You turn your phone on, you go to any social media app, and there’s always some kind of focus on looks and presentation. Do you think, just purely your opinion, that social media can trigger or exacerbate some of these symptoms in people who are struggling with BDD? Dr. Tatyana Mestechkina: Yeah. It often really does. It’s just another, like you said, very easily accessible form for their brains to start kind of comparing and contrasting them and other people. I think even for their own social media, even posting a photo of themselves can be really, really anxiety-provoking. They might avoid posting or they might use a lot of filters or they might kind of check something and look over it or ruminate about which photo or which angle to post for a very long time. And I think beyond just BDD, but just on a more kind of general spectrum of body image dissatisfaction, I think social media can be really triggering for that in terms of creating unrealistic expectations of what the norms are when the reality is a lot of social media is the best of the best of people’s photos. There are images that are very controlled, filtered, angled, light, that people are comparing with their own kind of deepest, rawest versions of their physical appearance. Karen Conlon: What other cousins of OCD or that fall within the OCD spectrum would you want to tell us about today? Dr. Tatyana Mestechkina: Sure. So just to mention briefly, hoarding is also kind of a subtype where people experience a lot of kind of obsessions related usually to accumulating things, sometimes pets as well. And with hoarding it’s also not exactly just as simple as what we see on TV, but it’s very complicated in terms of there’s very different types of fears and thinking patterns that might motivate hoarding for some people. They really have a hard time letting go of things or kind of over acquiring things because of the sentimental value that they place on it. For some people, it comes from more of like a deprivation model, like “Well, what if I really need this later? What if I run out of these things?” Or sometimes there’s a big link between hoarding and perfectionism in that way, like “I need to keep all these articles and books because what if I need to get all this information? What if I miss something important?” Karen Conlon: Hoarding. I would never, again, have thought of that falling in the spectrum of OCD. One of the other things that has come up for some people that I’ve worked with in the past is the compulsion to pick. I remember actually when I was in middle school there was a boy that used to sit by me and the rest of his hair was completely straight, so I don’t know how this happened, but there was this one curl that he had and I mean if he was sitting there for eight hours, he was for eight hours just curling. And I remember this, I mean I’m talking a long time ago. I’m not going to age myself here, but this was a long time ago and it’s one of these things that I still remember because I was fascinated by the fact that this boy could sit there and just do that just continuously. And I don’t know that it’s OCD or that it was OCD, but I’m wondering are there also tendencies that we bring back to ourselves, that are not like about the hand-washing necessarily, but things like that, like picking? Dr. Tatyana Mestechkina: Yeah. So some other examples on the kind of obsessive compulsive spectrum category are people who engage in skin picking, which is called excoriation, or hair pulling, which is called trichotillomania. And often people are engaged in also repetitive behaviors that might feel very compulsive, very much out of their control, and are also like, with hoarding, motivated by different things. For some people, they might be trying to fix any imperfections. Like, “Well, because this part of my hair is coarse or not straight, or I have split ends,” their brain tells them, “You need to fix it, or you need to get rid of that hair to not have that,” or “There’s a little imperfection on your face or a pimple and you need to pick it until it’s gone.” And for other people, it becomes more of a self-soothing behavior or a distraction behavior when they’re maybe experiencing anxiety or stress or just excess energy that their bodies [inaudible 00:14:30]. This might be a way that that is released by that just kind of very kind of automatic repetitive behavior, which often they’re not even aware that they’re doing in the moment. Karen Conlon: What about boredom? Dr. Tatyana Mestechkina: Yeah. That’s a big trigger for people as well. Treatment Of OCD Karen Conlon: We have talked about all these different types and subtypes of OCD. We touched a little bit on treatment in terms of leaning into the thought. Let’s talk a little bit about how it’s treated. I know that providing education about what OCD is is really important because it’s important that people understand what it is and what it’s not, and also set expectations around what they can and really cannot do with it. But can you tell me a little bit more about what that psycho-education would involve? Like if you’re starting to work with someone new, what kind of things would you tell them about OCD to get them on the right track? Dr. Tatyana Mestechkina: Some of that would be just really helping them understand how it works from the amygdala example, helping them understand that these thoughts are not in their control in that way and practicing learning how to accept them as the independent system that they are. A lot of learning about how doubt and uncertainty is the common denominator between all OCD symptoms. So whether it’s traditional OCD, like counting and checking rituals, or more Pure O rumination, reassurance seeking behaviors. Whatever the theme is, usually it’s motivated by their brain telling them uncertainty and doubt is unacceptable. So the antidote to OCD is really learning how to welcome more doubt and uncertainty in our lives, how to make more room for it, and that’s where the true freedom from OCD comes. And in terms of the therapy, there’s a lot of research to support that the gold standard of treatment for OCD is exposure and response prevention therapy, otherwise known as ERP, and then also techniques from ACT, acceptance and commitment therapy, has been found to be very helpful as well. And a lot of other things in the mental health field are kind of to be debated in terms of pros and cons of one therapy versus another, but when it comes to OCD, at least right now, the literature is very clear and one of the reasons I chose to specialize in this is because it’s really exciting to work in a field where we really have a much better understanding of OCD than we ever have and that we have therapy that, by no means is easy, but it’s very effective for the people who are willing to engage it. And the way that I talk about ERP as a therapy is two-fold, reactive and proactive. And the reactive part is really helping people get equipped with different tools and strategies for how to deal with the OCD episode when it comes up. And all of those tools are kind of in the spectrum of learning to treat those thoughts, images, urges, as irrelevant, even though they feel very dangerous still and sort of retraining the brain. Karen Conlon: You mentioned exposure response prevention and ACT as being two of the what we call gold standards in treating OCD. Can you give us just a very simple example of what exposure response prevention looks like (ERP) and also ACT, what does that stand for and what’s an example of that? What might that look like? Dr. Tatyana Mestechkina: With ERP, essentially what we’re doing is we’re retraining the brain. So we talked a lot in our talk today about what doesn’t work for OCD, logic, reason, that approach, so we want to find kind of a backdoor way to respond to the OCD episodes by using different strategies to learn how to treat them as irrelevant. That’s sort of the keyword that we want to go to. And with ERP, the response prevention part is really about learning how to not engage in the rituals that feed the OCD, how to stop counting, checking, the reassurance seeking, the ruminating, and then the exposure part is really learning how to lean in and go towards some of the things that feel most triggering or distressing that our brains are telling us is dangerous for the purpose of practicing treating them as if they’re not dangerous, even though they still feel that way. So for example, someone with harm OCD who might have thoughts about, “Well, what if I stabbed my son with this knife,” and their rituals are throwing all the knives away or making sure not to be in the same room as their son when they’re cooking dinner. Exposure for them might be to practice chopping up some vegetables when the son is nearby in that way and letting their brains kind of go wild and bring up all types of intrusive thoughts. “What if you get angry at him? What if he does something to kind of trigger you and then you get really angry and lose control and stab him with this knife?” And their job during the exposure is to practice saying, “Okay brain, I hear you. Thanks for the warning. I’m going to let this thought be just a thought, or I’m going to let this be just one possibility of something that might happen.” Or in maybe later parts of the treatment that might be a little bit more aggressive, we might go towards the thought of being like, “Yep brain, you know what? Maybe I’m chopping up this carrot right now, but at any moment I might stick this knife in my child’s heart, chop him up in little pieces, and then saute him and make Hibachi for dinner.” Karen Conlon: Whoa. Whoa. Dr. Tatyana Mestechkina: Yes. Karen Conlon: This is why we gave the trigger alert. Dr. Tatyana Mestechkina: Like I mentioned, that’s a much more aggressive form of therapy. That’s usually in the more advanced stages, but what perfect way to treat something as irrelevant by making fun of it and by taking it to like an extreme animated kind of adventure of being like, “Hey brain, you’re creative with this possibility. Let me show you how creative I am that I’m able to take it down a notch to the most kind of animated, detailed example possible.” Karen Conlon: This is great to know because I think people often times will make assumptions about, “Oh, what does this look like? What is this supposed to look like?” So if possible, whenever possible, if you have identified that you might be dealing with some type or subtype of OCD, if it is possible to get treatment and professional help, you’re much better off than trying to figure it out yourself because without knowing it, you might actually be enabling and reinforcing certain behaviors. If you have interpreted what you think treatment is because you’ve done all this research and like, “Oh, this is what ERP is supposed to be.” And then without knowing it, you might be actually really reinforcing these behaviors that are actually the ones that you want to get away from or lean into and say, “Okay, this is what it is,” but then treat it in a certain way. Dr. Tatyana Mestechkina: Exactly, yeah. With a lot of therapy, but particularly with this type, it’s very, very important and really helpful to at least initially work with a qualified mental health professional who will help you both diagnose it correctly, provide you the education, and then guide you at least at the beginning to how to practice the spirit of the therapy. Because a lot of it isn’t about what you’re doing, but about the mentality that you’re doing it, because there’s such a fine line between an exposure and a compulsion and the difference is again the spirit in which you’re doing it. With that same example that I brought up with using a knife around the son, it could be an exposure if you’re saying, “Hey brain, look at me living life on the wild side. I’m tolerating this uncertainty. I’m letting this mystery be a mystery and I’m going to make a choice of my value of spending quality time with my son or having healthy home-cooked dinners for us,” et cetera, versus it becoming a ritual if you’re holding that knife and being like, “Oh my gosh, oh my gosh, don’t move it more than an inch because what if you lose control?” Or move the cutting board and the knife a few inches away from your son, or only do it when you’re in a good mood and everything’s great between you, or consistently ruminating about like, “Do I want to do this? Would I not? What about that serial killer I read about last week? Am I like him? We both have brown hair, what does that mean? Karen Conlon: And that brings me to the other gold standard that you mentioned, ACT, which is acceptance and commitment therapy. We talked earlier about the fact that OCD really latches onto your values. Can you tell us a little bit about ACT and how that works with that values piece? Dr. Tatyana Mestechkina: So ACT and ERP are both types of CBT, cognitive behavioral therapy. And I find that ACT really supplements the ERP work very nicely. And one of the biggest components, like you said Karen, is the values. So a big part of ACT treatment is helping people identify what are their values, what are the things that are most important to them in their life that they want to stand for, that they want to guide their choices, and getting clarity on that and then using those as sort of the map for how they want to live their life. It could be like family, it could be health. It could be really anything that’s really kind of important that they want to lay out as the compass of their life. And then it’s about helping them identify what are the barriers to making more choices in line with those values. And often, for many people, but especially with OCD, it’s the unwanted thoughts and feelings that might lead them to try to escape or avoid them. And then it’s about learning different techniques that are part of ACT that supplement the ERP works, such as, which we touched upon, the acceptance work. How to accept for things that are not in our control. With OCD, we don’t sign up for these thoughts and feelings. You don’t wake up in the morning with a menu of which thoughts and feelings you want to have for the day and you check the “I want to have thoughts about stabbing my son today” box in that way and practicing treating them as an independent system that we don’t have control over. A big technique in ACT is called cognitive diffusion, which just simply means learning how to identify and create separation from those thoughts, treating thoughts as just thoughts. Another huge component of ACT that’s really helpful are mindfulness techniques. A lot of times with OCD especially, but in life in generally, we get caught up with the past or the what ifs of the future, so a lot of mindfulness is learning how to be more in control of our attention to bring it back to the present moment, and also building a higher kind of willingness to experience some discomfort in our lives if that’s in the service of our values and brings us closer to it. I often like to use ACT as sort of a way to help people focus on the bigger picture. As you guys have kind of gotten the little hint that ERP is not always fun or easy, it’s very difficult work, but it could be very meaningful and can be very freeing if in one of the ways that people are willing to do the hard work is if it brings them closer to their values. If I’m doing this really hard practice, but that means I can spend more time with my son, spend more time with my child, to go to work on time and consistently, to see my friends when I want to see them, to be able to go to practice my religion the way that I want to, not kind of avoiding my religious practice because it’s filled with so many rituals. How to be able to drive my car to the places I want to go, to take the train, and all of the other things the OCD part of the brain might say are bad or dangerous. Karen Conlon: That makes so much sense. You want to bring it back to your values so that they understand that those thoughts are just thoughts and that they really are not in line with their values. So that’s a big part of making that connection with those thoughts and diffusing those thoughts. A lot of people seek out therapy to help with their OCD, but they might be doing different types of therapies, not necessarily these. Can other therapies also be helpful? Can some be harmful? Dr. Tatyana Mestechkina: Yes. That is a good question and I think the reality is unfortunately with OCD, aside from these ERP and ACT, other types of therapies can actually be harmful if they involve kind of giving content to the intrusive thoughts. A lot more kind of psychodynamic therapies might focus more on trying to uncover the origin of these thoughts, uncovering why these thoughts are what they are, which can actually do the opposite of what we want and put the spotlight on them and treat them as important significant things. And while it is true that sometimes OCD latches on to thoughts that are related to our values, it really is fair game and it could be about anything and everything, and the content doesn’t matter, which is a huge part of ERP work as well. So going kind of into the path and trying to make sense of these thoughts and give them meaning is actually very counterproductive at times. And even also with more traditional cognitive behavioral therapy, like doing cognitive restructuring, which we spoke about earlier, can also do some harm by feeding into the thoughts and continuing to use logic and reason to work through them. And that one could be tricky because it could feel like it’s working in the moment because that person can find short-term relief. Someone reflects a pedophile theme, their therapist saying, “You know what? I really am not concerned that you’d harm a child at all. You are the kindest person I know. I would even leave my baby with you because I think it’s so, so unlikely, that’s never going to happen.” While again that could feel very nice for the person experiencing OCD, but then their mind can show up a few minutes later and be like, “But do they really know me, or what about this one thought that I didn’t share with them exactly in the way that I had it? What if that would make them change their mind? Or that one time where I pushed someone on the swings when I was seven, maybe that means I am capable of violence in that way.” So those are just some examples of the types of therapy that can feed into it rather than help. Karen Conlon: And by the way, if a therapist says to you, you’re one of the kindest people that I know I would leave my baby with you, that’s a problem with boundaries. And I talk a little bit about that in one of my other episodes, Can Therapy Make you Worse, so just a little note on that. Okay, so a couple of last things here. Medication, is it always necessary? Yes or no? Dr. Tatyana Mestechkina: It’s not always necessary. Sometimes it can be helpful for some people. And what I usually recommend is if someone is coming in and their OCD is really severe in the way that it’s really affecting their ability to kind of live their life and function, if they’re avoiding, not able to get to work or to school, or are losing relationships because of it, then often starting medication and ERP at the same time would be the recommended approach. But for other people who are coming in and they’re obviously experiencing pain or suffering, that’s why they’re here, but they’re still kind of generally functioning, while medication is an option, we sometimes recommend, “Let’s start with ERP. Let’s give it a go for a few months and kind of see how it goes.” Because if we start both at the same time and then the person feels better and is living better in three months, it’s then hard to isolate is it the medication or is it the therapy. Also medication comes with risks of it not working or coming with side effects as well. So I’ll usually say, “Let’s see how we do for a few months and then reevaluate if we’re still making consistent improvement and moving forward. Let’s see how we do with that.” Or if we are getting stuck somewhere or have made some progress, but then hit a plateau, then let’s bring a psychiatrist on board to see if adding medication can help them kind of get over the hump and do the therapy more effectively. Karen Conlon: Well, what you said also just has me thinking about the different areas of care that one person can receive, medication or no medication, some people might be seeing a psychiatrist, some people might be working on their nutrition also. So it brings me to the thought of does it make sense for people with OCD to see two therapists at once? The reason I bring this up is because in our practice at Cohesive Therapy NYC, generally speaking, the policy that we have is if you’re going to work with us, work with us, give yourself the opportunity to really focus on things. Sometimes people come and they have other therapists, another therapist that they’ve been seeing for a few years, and they’re thinking well I talked to that therapist about this, and I’m going to talk to you guys about this, not really understanding that what they’re doing is not really allowing anybody to get the full picture and maybe what they might be struggling with is that that therapy relationship might need to be coming to a pause, but not wanting to let go. It might be a lot more work for you actually. You might be dealing with two therapists that are really great, but they have very different philosophies, very different orientations, that actually might be conflicting. In our practice, our policy is work with one therapist, whether it’s us or whoever, but give yourself the opportunity to really focus. Is that the case for OCD? Is it recommended? Is it okay because maybe they’re seeing a therapist that doesn’t specialize in OCD? What are your thoughts about that? Dr. Tatyana Mestechkina: I think you did a really excellent job summarizing exactly our treatment and my treatment philosophy as well in our practice CBT For Better Living. We pretty much say word for word what you’ve said. Can’t agree more. And again, we don’t want to diminish the value of people working with different people with different perspectives. And a lot of patients come in and say, “I love my therapist. We’ve done really great work together. Here are ways I’ve made improvement, but here’s this one area where this might not be their area of expertise.” And often we recommend the same thing, just let’s take a pause. If you want to try this, let’s go all in, try this for a few months and then reevaluate. And that way, because it can be therapy overload and it could be very confusing if there’s anything that’s contradicting or not perfectly aligned. It’s always, but especially with OCD, because the therapy, as you guys have heard, is so specific and sometimes involves doing things that seem counterintuitive in the short-term in that way. And then the other thought is that OCD doesn’t come in a vacuum. It would be really nice if we can sort of pause and put OCD in a bubble and just treat that in itself, but often OCD is really related to all other areas of people’s lives as well. And also, as you mentioned, this doesn’t have to be a long-term thing. We can always, once you kind of get a better sense and make some headway in this therapy, can always reassess and then resume with your previous therapist afterwards. Karen Conlon: Thinking about what you mentioned a couple of minutes ago about some therapies that actually can be harmful, if they’re seeing a therapist who is psychodynamically oriented or psychoanalytically oriented, and then they come see you at the same time, the work is going to be completely contradictory. What they’re doing with you is going to potentially be undone with their other therapist. Dr. Tatyana Mestechkina: Exactly. So we recommend pick a direction, stick with that, and then you can always reassess. It’s not a commitment. Y