Yale University Professor Explains How OCD Really Works

Hi. Welcome back to another episode of The Mindful Space. Today. With us we have Dr. Christopher Pittinger. How are you today? Doing well. It’s a pleasure to be here. Yes, thank you for coming. I know it was a little back and forth, but I’m glad you made it. Now I’m going to go ahead and let you introduce yourself for our active listeners. Sure do a better job. My name is is Pittenger. I’m a professor at Yale in the medical school. I’m a psychiatrist, and I direct the Yale OCD research program. And that’s, I guess, what we’re here to talk about today is obsessive compulsive disorder. I also do a lot of teaching and mentoring and other aspects of training people in psychiatry and pursuing different kinds of research and treatment in psychiatry. But for today, we’re here to talk about OCD. Correct. Now, what made you get into this field, specifically OCD? Research. Yeah, my answer to that question is a little bit, I think, unusual. Most people, when they go into psychiatry, OCD or whatever it is, that they do, have a long personal story. I got interested in the science first. I was actually not planning on being a doctor. I was planning on being a neuroscientist. And I wanted to understand the brain, understand how this sort of chunk of stuff in our heads somehow creates who we are. So my plan was to get a PhD in neuroscience, and I decided while I was in high school that I would also get both an MD. And a PhD. So that I could better understand what questions are worth answering, so that I could solve problems that would matter, as opposed to just problems that I found. And this was in high school? This is in college, not college. I was like, wow. So I tell people that I went to med school for fun, which is kind of almost true, because I didn’t go intending to be a doctor. I went intending to be a scientist, but wanting that background. And during my studies, I got interested in the things we do automatically, habits. I would propose 95% of what we do every day that we’re really not choosing to do or thinking about. It’s just what we do right. And that made me start thinking about what it’s like when habits go wrong, when habits become excessive, inflexible, maladaptive, problematic. And I conceptualized from a really naive, non clinical, not knowing anything about OCD perspective. I conceptualized OCD in those terms. Does it make sense that people might be getting stuck in habits and habits of thought and habits of behavior, but all of this was problems in science and kind of cold and intellectual? But then when I went into my psychiatry training, I discovered I loved it. I loved spending time with people and hearing their stories and trying to think about how to blend the science, what we know about brains and medications and so forth, with a sort of more humanistic understanding of people as they are and in their unique experience. And I loved that. So I pursued psychiatry training and then had the opportunity during my residency to get involved in some clinical I mean, I was working in the lab, I was doing my sciency stuff. But I had an opportunity to work clinically and in clinical research with some patients with obsessive compulsive disorder. And I figured I jumped at the opportunity and I loved it. I loved working with patients. I love doing my research that’s sort of rigorous problem solving. But I also loved doing research that actually helps people. Right? So I found myself wanting to do both, which was not a good idea. It was just too much. Too much. But I got lucky and I had got some good people came to work with me and I managed to bring together a career that does both where I do study some of the basic mechanisms in brain biology as well as some of the clinical how do we help people better? Be that with medications, with psychotherapy, be that with advocacy to try to improve health systems. So it’s been kind of a twisty road and not a simple answer to but that’s how I ended up. That’s how it started. That’s how it start, I guess. This is how it was. This is how it’s going. This is where we are now. Now, when we talk about OCD, we’re talking about obsessions and compulsions. Do you mind explaining what that is? Sure. What entails? Yeah. And that’s a simple but a really important question because OCD has taken on sort of a life of its own in our culture. Oh, I’m so OCD about that. Right? And that can be almost trivializing, like it’s kind of cute or funny. And that doesn’t do justice to the pain that severe obsessive compulsive disorder causes people. So OCD well, it does consist of obsessions and compulsions, technically, according to the way the diagnosis is made. Now, you don’t need to have both. But almost everyone with OCD does have both obsessions and compulsions. So an obsession is a thought that comes into one’s mind unbidden and is excessive or irrational and feels in some way foreign. We use the word egodist tonic, which is from Freudian psychology, but it means that it doesn’t feel the same as other thoughts that you sort of feel ownership of and they’re part of your normal stream of consciousness. This feels in some way foreign, not from out there, not from some mysterious outside place. It’s from people, but unusual and unwanted and imposed in some way and they cause some kind of anxiety or distress. If they didn’t, there wouldn’t be a symptom. No, we wouldn’t care. And they tend to be stereotyped and somewhat rigid. So people will have the same kind of thought over and over. Now, something that’s important to recognize is we all have these thoughts, right? We all have thoughts that are kind of unwanted and not entirely pleasant that come into our minds. Thoughts about violence that might happen or that we might do. Thoughts about contamination or danger or just thoughts about things feeling uncomfortable or wrong in an incoherent sense. This is a normal part of human mental activity. There was a study done by some psychologists, I think it was at Harvard once, where they just did a survey and asked people, do you ever have thoughts like this? Unwanted intrusive? You wish they’d go away. 90% of people said yes, and I guarantee the other 10% were lying. I just think that this is something that brains normal, right? This is just something that brains do. What’s different in OCD is that those thoughts, first of all, they’re frequent, they’re strong, but they’re treated as powerful and important. So I do not have OCD. I’m asked that question. Sometimes I don’t. And if I have a thought about something terrible happening to me or to my children, which is a kind of distressing, intrusive thought that I know isn’t realistic, right. Then if my reaction to that is, oh, that was an unpleasant thought, brains are weird, I’m going to go on with my day, right? So that’s fine, that’s normal. If I had that same thought and my reaction was, this is a danger sign, the fact that I’m having a thought means something, and now I must change my behavior, I have to do something about it, even if I know that that’s irrational. Yeah, I know it’s fine, but I’m having this thought, I have to deal with it. That’s the difference. That’s what takes it from a completely normal, not entirely pleasant, but completely normal aspect of mental functioning into a nascent obsession. So it’s not the existence of the thought. It’s not the content of the thought. It’s that it is treated as powerful and important. So then the compulsions are the behaviors that people do in order to try to manage the distress or the content of the thought. So an obsession can be almost anything, but there are certain common ones, like I’m contaminated, or like something dreadful is going to happen to me, or even that I am going to do something dreadful. The thought that I might hurt someone, the thought that I might violate social norms in some way. So the compulsion is then, okay, I have a thought that I’m contaminated. I’m going to wash my hands. And again, having a thought that you’re contaminated, you wash your hands perfectly normal. The problem comes when you don’t feel done. You have to wash your hands again. And it happens again. I steal the thought still coming back. I have to do it again. And you get to a point if you’re washing your hands 100 times, 200 times, 400 times in a day, where it’s clearly excessive, or I have the thought that someone is going to break into my home. I’m going to check the windows again. Perfectly normal. Depending on where you live might be a really good idea. It’s a perfectly normal thing to do. But if you then can’t get to sleep, the thought is still there. You go back and check again, and then five minutes later you come back and check again. Or you have to check it’s. That excessiveness. That makes it a compulsion when it basically starts disturbing your normal life. When we don’t call it a disorder until it’s a problem. Right. So there are plenty of people who have a little tiny bit of this kind of these obsessions and compulsions. But if it’s not causing a problem, as long as it’s manageable, then it wouldn’t be a diagnosis. And then so the last thing I’ll say is the relationship. I mean, it’s kind of been implicit. The first part of the relationship between obsessions and compulsions, I think, has been implicit in what I said, where people have the obsessions, these intrusive thoughts, they do something, it makes them feel a little better, so they get some relief. But here’s the pernicious part. That relief reinforces the idea that those thoughts were powerful and important. Phew. I didn’t get contaminated. There wasn’t a problem. Good thing I took that seriously and washed my hands. All of this at a preconscious level, of course. I have the thought, it makes me uncomfortable. I do something, it makes me feel better. That’s all perfectly natural. The problem is that the relief reinforces the importance of the thought. And then you get stuck in a loop. And it’s when people are stuck in that loop and the obsessions begin to dominate for hours a day, their mental life and the compulsions become problematic in their physical life. That’s when it becomes oct. Yeah. I mean, you couldn’t have explained it better. I think you even answered my next question, which was going to be, what is it like to live with OCD? But you set so many examples that at least I got a clear idea. Yeah. The one thing that I don’t think I’ve said yet, and I want to emphasize, is that most people with OCD, more than 90% of people with OCD have very good insights. So it’s not that they think they truly are contaminated. It’s that they have the thought that they might be contaminated. They feel that they’re contaminated. They know that’s not true, or at least very unlikely to be true. But the thought and the discomfort that goes with it is sufficiently intense that it dominates, takes over their lives anyway. And that insight. I call it the curse of insight. It actually leads to a second order kind of suffering. So first of all, I had someone with OCD once say to me that they felt crazy in a way that crazy people don’t. Okay. Now, as a psychiatrist, I try to avoid the word crazy, but I thought it was a very evocative statement. They found themselves spending hours a day preoccupied by these thoughts or engaged in these compulsive behaviors which they knew made no sense, right? But they still found themselves doing it. And so that alienation from the self, that feeling of a loss of control is an additional part of the experience and the suffering of people with OCD. The other thing that since people tend to have good insight, they usually know that other people might not understand or might react badly to the fact that they’re washing their hands for the hundredth time, or the fact that they’re checking the door five times or doing these other rituals, and they might look at them funny. And so because of that insight, people with OCD are very good at hiding their symptoms, which helps their lives and maybe reduces social distress. But it actually has a problematic side effect because often the people around them, even their loved ones, don’t recognize how much they’re suffering. And often diagnosis is hard to come by and is delayed because people, even if they go for help, they’ll say I have anxiety, and they’ll get generic help for anxiety, which ends up not being very helpful for OCD. Whereas once the diagnosis is made, then there are additional things that can be more helpful that people can. And I wanted to ask you that, because a lot of people confuse OCD behaviors with anxiety or they think they have anxiety and they use it very interchangeably. So what would be the main difference between the OCD or the anxiety? Well, anxiety is a very I mean, in my mind, I think of anxiety as like pain. It’s a very generic thing that can happen in lots of conditions. It can be adaptive in some cases, just like pain can be useful in some cases, it can be usually unpleasant, it can be problematic in other cases, right? But it’s very generic. So anxiety isn’t a diagnosis. It’s not a specific thing. We see people with anxiety who have panic disorder, social anxiety, a phobia generalized anxiety disorder. Often people with depression, 30 or 40% of people with depression have a lot of anxiety. So anxiety is very general. A lot of people with OCD do have a lot of anxiety. I mean, I’ve talked about how the thought comes into the mind and is associated with some distress, some discomfort, often that’s experienced or described as anxiety. It’s about 70% of the time people say that, what is the discomfort? It’s anxiety, especially if the thought is something dreadful might happen to my children, or if that is the nature of the thought that’s often anxiety. But it’s not always. It can be guilt, it can be disgust, it can be any negative emotion, but it’s often anxiety. So many people with OCD do have anxiety. Many people with anxiety don’t have OCD, right? What makes it OCD is when that anxiety plays into getting stuck in a rigid pattern of thoughts and behavior. It’s that rigidity of thoughts and behavior that makes it OCD. So many people with anxiety don’t have OCD. Some people with OCD don’t have anxiety. They have some other emotional state like as I said, disgust or guilt or some people have this kind of incohate feeling of wrongness that just things aren’t sometimes uncomfortable feeling like something isn’t complete and I have to repeat it until it is complete. And that’s not really anxiety. It’s more of a physical feeling that some people feel. So they overlap but they’re not the same. But then somebody to clarify OCD can go with anxiety. Absolutely not. The opposite? In some cases, yes. When we talk about OCD, what causes? Is there a main cost for it, born with it or yeah, what is it? I mean, the short answer is we don’t really know. Okay, but I don’t give short answers going on a little more. We do know it’s partially genetic. We know it runs in families. I mean, the number is it’s approximately 40% genetic. So that means there are some genetic causes but then there are clearly other causes. And in one person it might be that that person was fated to get OCD because they had got the wrong set of genes and another person might have very little genetic risk but something happened during their development and I say behavior environment. Exactly. So that’s one part of the cause. We don’t know that much about the genetics of OCD yet. We don’t have any genes that we know where a mutation in that gene causes it. And that’s just a question of more research in conditions like schizophrenia and depression. We’re finally getting a handle on the genetics after studying hundreds of thousands of patients. And in OCD, the biggest study is 2500 patients. So that’s just a question of doing a lot under research. We need a lot more work there. There’s some evidence that in some cases it’s associated with illness or inflammation or even autoimmunity. There’s a type of pediatric OCD called pediatric acute neuropsychiatric, acute onset neuropsychiatric syndrome where the OCD happens very quickly and it appears to be associated with the immune system’s reaction to an infection. Now there’s a genetic component to that because everyone gets infections. But in some rare cases that can lead to the immune system affecting the brain, leading to symptoms of OCD. It’s a matter of some debate how common an immunological or autoimmune contribution is to OCD. My guess is it’s probably not that common. It certainly happens and we’re doing some research on it, but it’s probably a small minority. But that’s another possible set of causes. And there’s an interesting work on the relationship of stress or trauma to OCD. OCD isn’t caused by trauma in the way that PTSD most obviously is post traumatic stress disorder. But it is sometimes triggered by trauma and it’s sometimes shaped by trauma. What I mean by that is if two people have a traumatic event, or just a very stressful event that maybe doesn’t go all the way to being traumatic. One of them may develop anxiety, one of them may be fine, may metabolize it, move on, and no problem. Another may develop anxiety or PTSD or some other express in some other way. But another person, it might trigger their OCD. The way I think about that is that they probably were already at risk for OCD, whether that be genetic or earlier developmental. And then this is sort of what triggered it. And if it hadn’t been that trauma, it might have been something else later. So is that a cause? I don’t know. They’re kind of both. No. But it’s important to mention, because I do believe with trauma, so many different things could be triggered depending on the person exactly. To whatever the vulnerability is there. Exactly. And the other thing that trauma can do is it can sort of sculpt the content of the thoughts. I’ve emphasized how pretty much any like an intrusive thought, an intrusive distressing thought, can be almost about anything. But often the only thing that matters for an intrusive thought to become an obsession is that it’s distressing. Well, thoughts about trauma are distressing, so it’s not uncommon for thoughts about trauma to then in a vulnerable person develop into OCD. And there is some overlap between OCD and PTSD, but they’re not the same thing. They’re not the same. But I can definitely see how there could be the relation between both of them, though. Definitely we kind of touched based upon how people use the term OCD very lightly. Right. So I want to go ahead and direct this conversation towards the stigma, which is why we come here and we talk about all these things. What do you feel has the most impact on the stigma upon OCD? Because people are just using the term lightly because people are afraid to getting professional help, being misdiagnosed. How do you feel about that? Well, there’s stigma about mental illness in general, and so many people don’t want to feel like they have a mental illness or admit to others that they have a mental illness for reasons that go far beyond OCD because of stigma in our society. I do think that that’s improving over time, both in general and in OCD in particular. A second thing about OCD is it’s just relatively poorly understood, and unfortunately, this is true of many mental health providers as well as in the public at large. I think that the public has some idea of what depression is, the public has some idea of what addiction is, PTSD, autism. I think that the public understanding of these conditions is pretty good and not too far off from a clinical understanding. And in OCD that’s not true. This is getting better over time. And there have been really wonderful efforts by advocates like the International OCD Foundation and others to try to help people understand. But I do think that that contributes to the problem. And I’ve talked about this a little how people with OCD know that their behaviors may be seen as odd by those around them and they have the insight and the control that they’re able to hide their behaviors. So I think the stigma plays into that and it absolutely plays into delays in diagnosis and in finding the correct treatment. And unfortunately, these dynamics play out in the education of mental health care providers as well. Almost every unless you’re training at a specialty center, psychiatrists, psychologists, nurse practitioners will see lots of addiction, lots of depression, some cases of bipolar disorder, but they read about it, they won’t see a lot of OCD, typically for all of the reasons that we’ve said, and there are really good evidence based treatments. Once you get the diagnosis right, you can really help people. But unfortunately, often the diagnosis gets delayed. Sometimes because people are hiding their symptoms, but sometimes because the provider is not asking the right questions. Okay, this is also something that I think has improving gradually over time. But we have a long way to go. Yeah, I mean, there has to be more training, but if the clients are not coming forward, then it’s a bad well, and then the fact that they don’t come forward means it’s not diagnosed, which means that the trainees don’t see it. Exactly. It makes sense. And just the one other thing about stigma. I think people I shared that quote earlier, I feel crazy in ways that people that crazy people don’t, again, bracketing the use of the word crazy. But I think people with OCD are often very concerned that they will be seen as crazy because they’re washing their hands so much, because they’re doing whatever it is that they feel compelled to do. And that’s an additional, I think, level of stigma that they experience. And unfortunately, sometimes they’re right. Sometimes someone will come out and get a negative reaction from a family member or someone in the public or a healthcare provider. And that does happen. Again, I do think these things are getting better over time. I think psychoeducation for the family members or your friends, if you do have it and talking about it does help because it’s only normal. Human beings see something that is uncommon for not calling it weird. And of course we stare, we think, we wonder, but making it or breaking a stigma and talking about it and just making it more normal might help a little. When you talked a little bit about treatments, what kind of treatments are available for the OCD? So we do have good treatment that can help most people with OCD, though unfortunately not everyone. And that’s why we’re still doing more research to try, to try to increase the numbers. There are both medications that can be helpful and there’s psychotherapy that can be helpful, but in both cases, it needs to be done properly. So the medications that work for OCD are a type of antidepressant, the SSRI, selective serotonin reuptake inhibitor antidepressants with familiar names like Prozac, also called Fluoxetine, acetylapram, also called Luvox I’m sorry, Lexapro. The other ones are Luvox, Paxil, Zoloft, and Selexa. Other antidepressants don’t work particularly well for OCD. So something I see very often when people are treated in the community by non specialists is they just threw some antidepressants at them and they weren’t the right ones. So those antidepressants work when I say they work. They work about 40% to 50% of the time, and they work dramatically about a quarter of the time. So about a quarter of patients will have a good response, and they can stay on that medication for as long as they need to, and it’d make a big difference, and then maybe another quarter get some response. On average, their side effects aren’t dreadful, but they do have side effects. And for some people, they’re more they’re more significant. There’s also an older drug called Chlamypramine that can be very helpful with OCD, but it has more side effects. And so we usually don’t use that first resource. Yeah, and then there are some other medications that you can add on. This is a problem. There’s no other type of medication that works by itself. So unlike in depression, where we have all of these different categories, wellbutrin didn’t work. So you try an SSRI that didn’t work, so you try FX. Or there are these different types of meds. We don’t have that with OCD. We only have this one type that works. So then yes, then you can get into adding second and third medications. I’m a big fan of trying real hard to get as much benefit as you can out of one medication before adding a second. But again, they only work about half the time. So we often find ourselves in the position of adding a second or a third medication. Even more so when OCD is comorbid, when it coexists with depression or panic or addiction or something else, which is common. Many people with OCD have other conditions, and that complicates treatment. So medication is one way of treating the other. One is a particular form of cognitive behavioral therapy called Symptom Evocation and Response Prevention, or ERP. And the idea here, you’ll have some people in your audience who don’t want to have anything to do with medications and just want therapy. You’ll have others who think that it’s all brain biology and chemical imbalance and don’t want therapy. It’s really important for everyone to hear both of these can work. And both we consider first line treatments. So which one a particular patient tries depends on all sorts of individual factors. But there’s no right. Everyone should try medication first. Everyone should try therapy first. They’re both first line effective approaches. And the other important thing is that there’s a lot of wonderful therapists who don’t really know how to treat OCD. And there are a lot of wonderful CBT therapists who are great at treating depression using the Beck model of CBT for depression and don’t know how to treat OCD. Because what you have to do I want to go back to the way I described the relationship between obsessions and compulsions where obsessions are these distressing thoughts that come into the mind. They cause anxiety. You then engage in compulsions to relieve the anxiety that leads to relief, and that reinforces the obsessions. And I’ve illustrated that as this feedback looper circle. The point of therapy is to break the cycle. And the way that one does that is one induces the obsessions experiences the anxiety and doesn’t respond. Okay? And that’s hard. That’s the goal. Well, that’s the tool. So, for example, and I often find myself using the example of contamination because it makes sense, only about one person in three with OCD has primary contamination. So that’s not all of OCD, but it’s a useful example. So if someone with contamination when they touch something that might be dirty, then they start to have these overwhelming concerns or fears that they’re contaminated. So what you do in therapy is you contaminate. Contaminate? Like actually contaminate? Yes. And then you sit there and the anxiety goes up. And now the person wants to wash their hands or symbolically wash their hands or say a little prayer that they’ve learned or ask for reassurance. I’m going to be okay. Right. None of those things are allowed in therapy. You have to sit there with the anxiety and it goes up. And then a new concern comes up, which is, well, this anxiety is going to keep going up forever until my head explodes and I won’t be right. Sort of the second order anxiety comes up and the goal is to sit there with it. And here’s what happens. It goes up and then it plateaus. And then by itself, without doing anything, it comes down. Okay? Most people haven’t had that experience because if you’re experiencing anxiety and you know how to make it go away, why wouldn’t you do that? Right? It’s kind of like putting your hand on a hot stove and choosing to leave it there. Right. It’s not a natural thing to do. But it turns out that as you do this, the first thing that happens is you get better at tolerating anxiety, which can be useful. It’s not fun, but it can be useful. But the second thing that happens is that anxiety goes down the second time you do do it again, it’s not as bad. Do it again, it’s not as bad. And then the third thing that happens is you’ve interrupted this loop having the thoughts, you’re having the anxiety, but you’re not doing the behaviors. You’re not experiencing the relief that takes the fuel away from the fire. And over time, the obsessions themselves get calmer. They get less frequent, they get less powerful, they get easier to manage. And that’s the long term benefit, is that you’ve broken this feedback loop. So as I’ve described that, I mean, if you try to imagine doing this with something that really causes you a great deal of distress, it’s really difficult and unpleasant. I don’t know why it’s coming to me like something’s itching and you want to scratch it, but you can’t. Exactly. Hard. It’s really hard. And honestly, it’s hard for therapists, too, because people get into the therapy game because they want to make people feel better. And here it’s their job to make people feel worse in the short term. So it’s like exposure. It’s exposure therapy. Yeah, it’s a form of making them go through it. And your job is just to be there and witness that they have. And also the goal you make what’s called a hierarchy, which is where what’s the thing that would be so overwhelming you can’t imagine doing it, and what’s the thing that you would prefer not to, but it’s not a big deal. And you want to start somewhere in the middle. So trying to structure this to make it difficult, but doable okay. Is part of the therapist. Maybe during the first I’m just trying to get a better picture. During the first couple of sessions, if the person lasts 10 seconds, then the next one would be 30 seconds. Or do you make them go through it? You have to go through it. You have to go through it because if you only go 10 seconds and then you wash your hands, okay, there’s no benefit. Exposure without response. Prevention is just torture. It’s not actually helpful for those listening. So instead of doing it for 10 seconds and then 30 seconds, what you have to do is do something that’s not as bad, right? So instead of rubbing the shoe, you could look at the shoe. Maybe that’s the first one. Right. Or maybe touch it like that. Right. So you have to start with something that’s difficult but manageable and then work your way up. Got it. But the response cannot be you can’t know, wash the hand. Right? Because that reinforces the cycle. It’s almost like training your child or your dog. Well, the principles are the same. The principles are the same. This isn’t about understanding. Most people with OCD have perfect have excellent understanding or with one conversation, they have a pretty good conception of what’s going on. It’s not about understanding. It’s more like exercise, right? We all know that we should exercise, right? But to actually go do it enough to make a difference is hard, and the coach helps, and it goes back to the way you started the conversation. It’s a habit. So you’re breaking one habit and putting another one. And you don’t break habits by understanding them. You break habits with exercise practice. That’s true repetition. I know that you’re into additionally the field of psychedelics and I guess my everyone always wants to know about the psychedelics. I feel like it’s the future to be honest. But what do I know, right? I just want to talk a little bit of it because I know it could be a whole other episode, but how does the psychedelics go with your research or the OCD? How do you interrelate those? Yeah, well, so there is a lot of excitement in the field right now about how proper controlled use of psychedelics and most of the work, including our own, is with psilocybin, which is the psychedelic compound that’s found in Magic Mushrooms. So how psychedelics may be a new way of treating mental illness and the best evidence out there is in depression and there’s starting to be some pretty good evidence in addiction and it’s a new way. Well, it’s also an old way because of course psilocybin was used by people in the Acera Mazteca region of Mexico for hundreds of years and then there was a lot of interest in the so we’re in sort of this new phase of interest in the use of psychedelics, but it’s different from both medication and therapy. And sometimes people use the word psychedelic to mean the drug, sometimes they use it to mean the model and the model of treatment. So if therapy is regular meetings and it’s something about either the content of what we’re talking about or the interpersonal relationship is therapeutic over time. Medication, most medications we use in psychiatry are you take it, it sort of helps your brain rebalance in some way that typically we don’t understand particularly well, but we know that it can help some percentage of the time and you keep taking it indefinitely in order to maintain that new more functional balance in your brain. With the psychedelics, the models that are being explored are you take them once or twice and it’s in conjunction with therapy and people have different opinions about how this works, but the majority opinion is that both are really important. You need the drug and you need the therapeutic environment. So that’s different in two ways from most treatment. The first is the interaction. Obviously we treat people with both medicines and therapy, but generally those are separate and we hope that they’re additive, but in this case it’s the interaction between the two. And then the second is that it’s a single treatment which then we hope has lasting effects. So this is true generally, and you’ve probably talked about it on this show before. So in OCD, there’s relatively little work, but there are a growing number of people who’ve tried it and found it beneficial. And so we started talking with some of those folks six or seven years ago now, and looked in the literature, and there’s some case reports, meaning a person responded and someone published. And then there’s blogs, and there’s a reddit. So there’s people with anecdotal experience but there’s very little literature. There’s a single paper back in 2006 where a psychiatrist named Moreno in Arizona did a small study, but very little. So we decided to do the first placebo controlled, careful trial of psilocybin in OCD. And I’ll be honest, many people who are working with psychedelics as therapy have almost see it as a mission and sometimes it’s driven by their own experience or by their own belief that this is, as you said, the future of psychiatry. I came in as a bit of a skeptic. I mean, I’m a hard nosed neuroscientist, okay, this might work, this person says it should, let’s try it. And I became quite convinced by some of the early responses. We had some early very impressive responses where people took a single dose of psilocybin and their OCD was dramatically improved for months or in at least some cases years. Now it’s not everyone, it’s about 50%, but that’s with every, of course, drug treatment, anything. So it’s not everyone. And the people we’re treating are a very, I mean, we get a lot of phone calls and they have no substance abuse and they’re on no medications and they have no risk factors. So on the one hand I’ve come to share the excitement that a lot of other people have in the field about how this is something that is really going to bring, has the potential to bring new relief to a lot of people. And on the other hand, I think it’s very important not to get carried away with the excitement because we don’t know how well it will work in someone with a lot of comorbidities, in someone who has a family history of psychosis, in someone who’s abusing other substances. We don’t know. So I’m hopeful and we’re doing an increasing amount of work in this area, but with that comes just more research. The fact that now we’re being allowed to do more research, it’s a different world than it was ten years ago in terms of but ten years ago, and I was not doing this work ten years ago. And I have enormous respect for the people who were, people like Rick Doblin and Roland Griffiths who kind of pushed back the field when no one wanted them to, when it was sort of an uphill swim against the legal system and bureaucracy. Now people are accepting this as something that needs to be at least research. Like you said, no promises or don’t get all excited, but the fact that we can little excited. Me too. Well, I loved all this conversation about OCD. I know we can spend here another hour, but to close it out, I wanted to ask you what would be your last message or recommendation for those that might be listening, going through their own OCD diagnosis or maybe considering they think they have it or they want to reach out but they don’t know. Yeah, I think the most important thing. And this is just recapping things that we’ve already said in this conversation. I think the most important thing is to understand what it is, because as I said, there are lots of people out there who are experiencing obsessions and compulsions and don’t recognize that this is an experience that people have. It’s fairly common. It affects one person in 40 over a lifetime. So that’s fairly common. A guarantee that, you know, other people who are having these experiences, they’re just probably not sharing them. And so recognizing that this is a thing that happens and has a name and it has treatments, and there are communities of people who can share these experiences and could provide help, that’s the most important thing. And in terms of combating stigma, I think that getting that knowledge out there is hugely important. So that’s the first thing. The second thing is to recognize that this is just a variation on what the brain does. As I said, every piece of what goes into OCD is just a normal part of the way the human brain and mind function. It’s just that they come together in this unfortunate way in people with OCD where people get stuck in this cycle. The third thing is that there is effective help out there. As I said, the medications can help perhaps as much as 50% of the time. Not everyone, not always without side effects, but they can help the therapy if done properly. It’s difficult, it’s hard work, it’s like exercise. But if done properly, can help. Probably 50, 60, 70% of people, though it’s a little hard to pin down that number, but it can absolutely help. The combination can help. And then there’s a lot more research on the horizon, as we’ve talked about a little bit. So there is help, there is hope. And the first step is recognizing what’s going on. And that that’s the cause, because that can allow the targeted treatments, that can allow greater understanding, and it can allow the treatments that work to be brought to bear. And that’s what I would want people to hear. Love it. Well, thank you again for coming. I hope we can have you in another session. Hopefully in the future, maybe we can talk more about the psychedelic findings in your research. Sure. But for now, thank you. Thank you so much. It’s been a pleasure to be with you here today. Thank you. Okay, thank you, everyone, for watching. Don’t forget to, like, subscribe and leave us a comment. Let us know what you thought of this interview. I’ll see you next weekend.