OCD – Your Questions Answered – With Dr. Kat Green

Emma – Studio Mic: Awesome. Okay. We are just going to jump right in. We’ve been we’ve had so many good questions asked about OCD. How many? A couple hundred at least.

Dr. Green: Yes.

Emma – Studio Mic: Yeah. So we’re just going to jump right in. The first one is great. This person says what’s the difference between OCD as a diagnosis versus OCD as a slang term?

Dr. Green: Oh, that comes up all the time. It’s such a good question. I’m going to do a brief kind of overview of OCD, an OCD 101, to help answer that question. So OCD stands for Obsessive Compulsive Disorder. Obsessions are repeated, intrusive, unwanted thoughts. They could be words, images, physical sensations, emotions or feelings that you just can’t get out of your head.

They’re just repeated and they cause a lot of distress. And then the compulsion side of things are rituals, routines, behaviors. I even branch out a little bit to include lots of avoidance of things. Basically anything to make the stress from the obsessions go away to neutralize that threat. So when we talk about OCD, we’re talking about incredibly distressing, intrusive thoughts, and then these behaviors, rituals, routines that are just on repeat.

Versus in kind of colloquial language, it’s someone sees a book off kilter and they go fix it. And they’re like, Oh, sorry. That’s my OCD coming out. And that is it’s hard for me as an OCD specialist, but it’s really hard for people with a diagnosis of OCD. They’re like, oh yeah, that’s nope.

Because there’s we, as humans, most of us have a preference for symmetry. Most of us have a preference to do things. There’s a reason that when we were feeling really mischievous, we’d go knock all the pictures in my house growing up, just a little bit off until my mom would be like, stop, what are you doing?

Every human generally prefers that symmetry. And some of us prefer it more than others. That’s very different than a clinical diagnosis of OCD. I typically won’t, when I’m working with individuals with OCD, I don’t talk about obsessions. I typically will talk about intrusive thoughts because I think even that word obsessed has gotten skewed in cultural language, and I want to be really clear what we’re talking about with those intrusive thoughts.

So that’s what comes to mind. Any follow up on that before I jump into our common themes?

Emma – Studio Mic: Yeah, and I do want to follow up on common themes of intrusive thoughts. I want to mention before we get too far into this, that Dr. Green does have an excellent course on intrusive thoughts. So today we have one hour and 50 questions, but if you want like the two-hour version on intrusive thoughts, like she does have an online course and I’ll make sure and put the link in the description.

Okay, so let’s go to common themes. So like, how does OCD show up?

Dr. Green: Yes, so most people may think OCD, they think monk monks making a comeback now, cycling through streams. We think about germs, we think about germs and hand washing. Contamination is a really common theme of OCD, and it does include a fear of germs.

But it can also include fear of environmental contaminants, right? Exhaust bodily fluids, chemicals, cleaners, the idea of getting something on you. It will harm yourself or someone else above and beyond what you might expect or what you see kind of other people worrying about. And it can include both a fear or a disgust element.

Disgust-focused OCD is usually blended with contamination. And a lot of people experience that a little bit differently. They’re not afraid of getting sick. It just feels too gross to stand and it feels like it will never go away. If they just let it stand there. Related to contamination kind of somatic or health related, it’s now illness anxiety disorder. They pulled it out of OCD, but it’s conceptualized remarkably similarly to OCD, essentially where body sensations cue a lot of fears that maybe I’m having a heart attack. Maybe I’m going to die. Maybe the doctors missed something, that often plays in the same sandbox as contamination responsibility for harm.

So a lot of intrusive images or thoughts that you’ll just lose control and do something just unacceptable, right? Aggressive or sexual towards someone else or that you have done it Just fears that has happened or will or that your failure to do some routine or ritual will mean someone else gets hurt.

Morality-focused OCD, sometimes talked about is really just OCD scrupulosity, just a general fear of offending God or offending others, just doing the wrong thing. We have just right OCD that tends to be its own kind of beast, where it sometimes is associated with a fear. If I don’t walk in this order, if I don’t even this out, if I don’t think in this order or do whatever it is, something bad will happen.

But often it’s just like a physical discomfort. If I don’t tap this many times, I just feel like I’m going to explode. So those are the most kind of common themes. I did want to talk, there are several questions about perfectionism related to OCD.

Emma – Studio Mic: Oh yeah.

Dr. Green: It’s an interesting question because perfectionism isn’t a diagnosis, right?

So it’s, hard to know always what people are talking about. There’s certainly, a theme of perfectionism that can show up in OCD, and it’s typically related to, not surprisingly, things need to be perfect, right? But it tends to come with specific, the same kind of thoughts over and over, and behaviors to fix it or to neutralize it, right?

So having to do something over and over or avoid something over and over. In order to make something feel perfect versus I think sometimes people are talking about perfectionism and more of a generalized worry kind of way where you’re just living in your head and worrying about the future. Is this going to be okay?

Am I going to be good enough? Are those things, we tend to treat that a little bit differently than more frank OCD. It falls more into this generalized anxiety and we use slightly different approaches for that. But that kind of covers our common themes. I know a lot of people had questions about that.

One of the Interesting things. I want to follow up. There’s a lot of questions about doesn’t everyone worry about some of these things? And the truth is

Emma – Studio Mic: Hang on. I want to get to that question, but I want to pause it first. I want to go back to this perfectionism versus OCD thing. So would it be fair to say, I heard an example of someone who said, my grandma has OCD and I said, “Oh really?”

And then she said, yeah, she vacuums her living room 50 times in a row. And I was like, oh, actually. And that’s not enough to diagnose it. Sure. But like a perfectionist might vacuum their living room incredibly, strictly, or incredibly carefully. Or a perfect, you tell me if I’m right on this or wrong, or a perfectionist might be like very critical of someone else, but how they vacuum the living room.

And it has to be done a certain way. But someone with OCD would be more likely to do that behavior, like repeatedly just like I vacuumed, but now I’m not sure if I vacuumed good enough. Okay, I’m going to vacuum again. No, I’m not sure if I vacuumed good enough.

Dr. Green: Yep. I think that’s a kind of perfect example or conceptualization of that.

There’s often that we call it pathological doubt and that exists again, anxiety underlies both OCD and all other anxieties. But that doubt tends to be like, I don’t know if it, I did it well enough. If I didn’t do it well enough, something horrible will happen. Or I just have to do it until it feels right.

I can’t stop until it feels like it’s done perfectly.

Emma – Studio Mic: Okay.

Dr. Green: Can I also yeah, you certainly, so individuals lots of really helpful traits, can get hijacked in OCD. So OCD tends to strike individuals that are pretty conscientious anyway. So they care about. doing good in the world.

They care about the welfare of others. They care about relationships. Like those are important values to them. They tend to be individuals that are more, a little on the hyper responsible side anyway, they’re always taking responsibility, like even without OCD similar to some of our other anxious individuals.

So you could definitely experience both OCD and broader worry and perfectionism, right? This is then as part of treatment, we’re sorting out, okay, what do we want to treat with exposure and response prevention for OCD? And if it doesn’t have a similar response, then I might take more of an ACT or CBT-based approach for more of the generalized worry.

Emma – Studio Mic: Yeah, interesting. I love it. Okay, I interrupted you. Do you remember what your stream of thought was before I interrupted you?

Dr. Green: I wouldn’t normally, but I wrote it down.

Emma – Studio Mic: Okay, perfect. Let’s go.

Dr. Green: One of those that counts is remembering. But this question that came up with common themes is essentially so does having intrusive thoughts mean you have OCD?

No, it means that you’re a human and Emma, I love your term of what do you call it? A talking machine on top of your shoulders or something.

Emma – Studio Mic: Our brain is a word machine.

Dr. Green: Yeah. Essentially by virtue of being human, we just have constant verbal chatter in our head. It has to happen for us to be able to function.

But it means we’re gonna get lots of unreliable content coming in. Those themes of OCD are actually the themes of intrusive thoughts that everyone experiences, even without OCD. When they’ve done surveys where they were curious to say, okay, so individuals without OCD have you experienced any of these intrusive thoughts?

And they all marked, they’re like, yes, lots of these. And they’re like writing more on the sheet, but they’re like, how about this? These are things a lot of people experience. What if I just drove off this bridge right now? Or what, that seemed bizarre or surprising. They’re intrusive. Those themes, intrusive thoughts, are normal, but, and we’ll talk, I suspect we’ll talk a little bit more about where OCD comes from, how it develops, the differences in individuals without OCD, they’re like, whoa, that was weird, and then that thought just goes on its merry way, and they keep going.

An individual with OCD or a high risk of OCD goes, where did that come from? What does that mean about me and my life and humanity, right? They’re like trying to make sense of it And that’s when we start to get caught in that loop and those intrusive thoughts get some teeth

Emma – Studio Mic: So you make meaning, you think, oh like you walk to the kitchen with it with a knife and you know, going to cut your onion and you think, what if I stabbed someone an average person like so most people would have this thought at some point, pop in their brain pretty normal.

I think some of the data was like 87 percent of people can recognize that they’ve had it Intrusive thought.

Dr. Green: Oh yeah.

Emma – Studio Mic: Same type of intrusive thought, maybe more than that. And so an average person would be like, oh, that was a weird thought. Okay. And then they’d go cut their onion. And someone who develops OCD, whether that’s because of something working differently in their brain or the behaviors that they that both really that contributes. Yeah, it contributes to this would be like, oh my gosh, what does this mean about me? Am I my psychopath? I’m like dangerous? I have to make this thought go away because this thought means something and then they start engaging in these behaviors to avoid this thought like I can’t look at knives.

I can’t think about knives I have to keep my brain busy. I have to do these obsession or these compulsions to avoid and control and suppress this thought

Dr. Green: And I want it so intrusive thoughts are normal, but I will say too, even without the compulsive behaviors, the frequency, and the intensity of the thoughts tends to be much higher in individuals with OCD.

So there are, it’s not it’s not like someone with OCD, I’m like those are all just normal thoughts. The frequency, intensity, all of them. It’s no, a lot of people have these kind of, random normal thoughts.

Emma – Studio Mic: Yeah,

Dr. Green: But they’re very focused. They tend to be much more vivid much more intense. And then they build on each other as the cycle kind of kicks on.

Emma – Studio Mic: That makes sense. That makes sense.

Dr. Green: Yeah

Emma – Studio Mic: Okay, so let me pull another question. So someone asked What is the root cause of OCD? Are you born with it, or does it develop?

Dr. Green: Wouldn’t that be cool if we had answers to those questions?

Emma – Studio Mic: For each individual person?

Dr. Green: For every person, yeah. We have pretty good data on OCD, and really it is surprise!

Yes, all of the above, it’s both. OCD does have some pretty strong genetic components. Anxiety and depression tend to run in families, but it might be like some social fears and then some depression and then some worry. It kind of changes from generation to generation. OCD has a little bit more what we call specific heritability.

So it’s actually more likely to see OCD and OCD. So it does function a little bit differently. There is a stronger genetic component to it. It’s got a closer relationship with tics and a few of these other conditions where things seem to get a little bit stuck. Put on repeat. So most of the time there is some genetic component and it may not be anyone has a full diagnosis. It’s pieces there and then that’s just how the temperament and personality. We tend to see high degrees of kind of not being able to tolerate uncertainty. As humans we hate uncertainty.

Emma – Studio Mic: No one likes that Yeah.

Dr. Green: But within the OCD community, it tends to be much higher levels of kind of difficulty tolerating uncertainty again that hyper responsibility really wanting to make sure you’re doing the best and the most and that you’re in charge of keeping people happy. You have the brain pieces and those temperamental pieces come together Then certainly you’ve got circumstances. How you’re raised, what the response was to those fears behaviors.

So, it’s a mix. I’m gonna go a little bit out of order. There’s a couple of questions I think related to this that come up. Several of them related to trauma. As with any trauma, you can never say, “Oh, this trauma means that.” Certainly, not all OCD has a root in trauma. Some OCD is triggered by a traumatic event and it’s most of the time, not always, most of the time there’s all those bits and pieces already there. And then some traumatic or stressful event, whether it’s a major capital T trauma, right, a threat to life or limb. Puberty is a really common one.

That’s pretty traumatic. Moving away from home. Postpartum, just major big changes bring everything to the surface. It’s that tipping point that seems like the onset where everything starts, most of the time, there’s kind of bits and pieces that are there and then trauma or major changes tend to just bring all that up. And can flip the switch into full blown kind of OCD. The other common one a question that came up is about PANS or PANDAS. So Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. They’ve now set that back to be not just strep. We could have a whole discussion back and forth.

There’s you will find lots of controversy in the PANS kind of sphere, but not as much as there was. Basically, the research agrees that sometimes an acute bacterial infection can be what tips those kind of underlying most of the time when we see ticks or OCD start out of the blue with an infection.

Most, not all, there’s been some pieces where there’s a strong family history, right? So it’s almost just something that was enough to neurologically flip the switch. And the treatment is if you have an acute bacterial infection, do antibiotics, get that treated. And then you actually treat it just like If there wasn’t an infection, you treat it with exposure and response prevention the same way. As far as where it comes from.

Emma – Studio Mic: Just to clarify, in some situations, OCD can be triggered by an autoimmune response to an infection. And that’s called PANS or PANDAS. And, Then you treat the infection and then you still treat the psychiatric aspect of it with exposure response prevention the one approach to it Yeah, so interesting. There’s still so much we don’t know about the cause of certain mental health disorders. I mean we can say, oh statistically it looks OCD is 50 60 percent heritable compared to other mental health disorders, but there’s so much we don’t really know and we could talk about some of the stuff going on in the brain, but when it comes down to like, when the rubber hits the road, this is the treatment that’s effective.

And that’s really what at least I focus on. It’s oh, we could look at the brain science or we could talk big words and make, ourselves sound like Andrew Huberman if we really wanted to. But I’d rather focus on the treatment. So that’s where we’re going today.

Dr. Green: And if we, depending on time, if we want to come back to that [inaudible] I tell people from the get go when they want to work with me, I’m not going to spend a lot of time on the why out of the gate, because what we know is how to interrupt that cycle.

But it doesn’t mean I don’t care about the why. It doesn’t mean we should completely ignore it. If there’s some clear event in their history that it’s like, oh. yeah, I could totally see how this is related. We’re still going to use that exposure response prevention, but a lot of people find that as that cycle loosens up a little bit, then they can explore some of those whys, but still be moving forward in their life today to be more functional as they mull on and figure out, sort out some of the pieces that led up to it.

Emma – Studio Mic: Interesting. Okay. I have a question that was submitted earlier by one of our members and I am going to put a very quick plug for my membership out there. So just so people know I am offering all my courses now for a monthly subscription and you can get all the workbooks and memberships there.

This is just for the courses that I’ve personally made. And that is, so Kat Green’s course, Dr. Green’s course is, She’s got a couple of courses, actually. She’s got health anxiety and OCD that relate to this. But you can access our membership where we do a monthly Q and A with me. Usually there’s under 50 people there.

Most of the time it’s like 10, but we’ve lately expanded our membership a lot. So there’s a place to do questions with me once a month in our membership. If you want to do that, you can check out the link in the description, but this is where this question was submitted. Oh, and then my brain just fell apart.

Okay. This question was is OCD on a spectrum? And I think this also speaks to my question of, and we’ll see if you think these are related and I’ll ramble on for a second to give you time to think, but is OCD permanent? And I, personally have a theory is at least when it comes to depression and anxiety that we should not make the default assumption that the disorder part of that is permanent, that when we have all of those symptoms of a depressive disorder or an anxiety disorder, not, I’m not specifically saying OCD, I’m talking about general anxiety disorders, we have those symptoms and those symptoms are interfering with our life in a significant way.

Then we have the disorder. And when we develop adaptive and functional ways to make our lives healthier and our thinking healthier, we shift our way down on this spectrum of stressed outness. At some point, we no longer meet the criteria. for those disorders and those disorders are no longer permanent.

That’s my conceptualization of a mood disorder. Now you can, first off, tell me, do you disagree or agree? And what do you think about how that applies to OCD?

Dr. Green: I think most of these conditions are considered on a spectrum. So OCD absolutely varies from a subclinical where it’s like just enough that it’s bugging you but doesn’t feel like it’s really getting in the way of your life to it’s more than an hour a day that I’m spending engaging in these routines. And it’s really stressing me out where it’s this full, just one of the most important parts of good treatment is that you’re measuring outcomes.

You’re measuring where those symptoms are at. So we have symptom measures that kind of assess mild, moderate, severe in that spectrum because you want to see movement over time. So I absolutely, I think it falls on a spectrum. And then to the question of permanence I, think this is, I agree. I think the.

This is how we conceptualize as a field, whether it meets criteria for a disorder where it goes from disorder to just these are some of the tendencies, characteristics you have that you keep an eye on. And then if they get to the point that they’re really getting in the way of your life, you might move in and out of that kind of into remission versus not.

OCD is very similar. So with good treatment, you absolutely see individuals go into remission. There’s a lot of factors that affect. If it started in childhood, it was really severe. It’s really long standing. It’s likely going to be more walking alongside you for longer, right? But even with that, even in severe cases, we often we’ll see a significant decrease in the distress, in how frequent, how intense it is, right?

We, see that drop. So, we absolutely see progress. OCD, we also see a fair amount of relapse. OCD has what we call a waxing and waning pattern over the lifespan, and it’s true from kids all the way through. So it tends to have periods where it peaks, and then it abates, and then it peaks, right? It goes up and down.

And for some people, it started small, and then it grows over time. So I expect it, the frequency of intrusive thoughts to follow a similar waxing and waning pattern. So if you have a really great treatment response, things are much better. It’s likely that at some point, often associated with a stressor, a move, big changes, you’re going to see those intrusive thoughts wax again, you’re going to see them come back.

Most of the time those periods don’t last as long or get as intense. But it is, so it’s a hard question because there’s a lot of reason for hope. And a lot of recognition for people that have done treatment over time. But yeah, the frequency of intrusive thoughts may always be higher for someone with OCD than without OCD. Their brain just is not filtering out as many of those intrusive thoughts as it ought to be, and that may not change, but I do expect it to feel a lot better with good treatment over time.

And a lot of people experience remission on its own. They’re like, oh, it seemed to get a lot better. And then the next time they’re like, oh, I’m like, yep, that’s exactly, I expect that, that kind of pattern.

Emma – Studio Mic: Yeah. I think a lot of people don’t know that even with depression the majority of people remit from depression without any treatment, like with zero treatment, the majority of people remit from depression. But that doesn’t mean that maybe some of the underlying mechanisms have been solved.

Dr. Green: And OCD is a little bit different in that once I’m too close to the computer for my,

Emma – Studio Mic: My spectrum was off the ….

Dr. Green: I know. Essentially OCD is a little bit different where the majority do not remit without treatment. So that is one important difference because a lot of people will say, oh, especially I work a lot with kids, teens, and young adults. [inaudible] It’ll get better when the stressor passes.

And sometimes it does. But it tends to wax and wane, but on an increasing pattern without treatment. So, sometimes it does remit. I think there’s a lot of people that are like, yeah, it got bad. And then, but majority of the time when it meets that clinical threshold, it doesn’t get better on its own.

It’s just the waxing and waning happens within the disorder, still maintaining that diagnosis.

Emma – Studio Mic: Yeah, that’s really interesting. And we’re going to move into talking about treatment. So I think some people have asked, and I’m going to pull up one of the specific questions.

Dr. Green: Sure.

Emma – Studio Mic: What is the best form of therapy for OCD? And I do want to say I feel very strongly, that like some disorders like depression and anxiety can be treated with 50 or 60 different techniques and many of them show similar outcomes or you can try each of them and gain a little bit from each of them. But I feel very strongly that OCD needs to be treated by a specialist with specialized techniques. Tell us about that. Tell us about the treatment for OCD.

Dr. Green: Yeah, so our, data, the most data we have, the longest standing, and it falls with kids, teens, and adults, is exposure and response prevention. So the idea, and I know you’ve talked a lot about this on your channel, I know you talk a lot even when you were talking with

Emma – Studio Mic: Drew Linslata

Dr. Green: Yes, you, read my mind. A a lot of your stuff is focused on that exposure kind of piece. So the idea is when you’ve got that intrusive thought you have the panic and then your brain says you got to do something about it. You got to fix it. You got to avoid it. You got to do something right now and that relief convinces your brain like, oh my gosh, if I hadn’t done that thing, I’d be dead.

Or if I hadn’t done that thing, the terrible thought would have happened. So that immediate relief from the behavior kind of strengthens it. This is why we, I would say

Emma – Studio Mic: So let me just pause you. Let me just pause you. She’s describing the anxiety cycle. I have a poster of this. Ah! My headphones! This is not the poster.

Just a sec.

This is the poster and I just want to spend a second on this because this is important. So maybe you have some kind of stimulus, like your hands get dirty. You have a thought like, oh my gosh, what if my hands are dirty? And the intrusive thought might be the stimulus. You maybe have an anxiety response to that.

The minute you avoid doing some kind of behavior to avoid those intrusive thoughts or control or suppress or manage those intrusive thoughts in some way. You’re going to feel a tiny bit of relief and your brain is like, phew, okay, good thing I did that avoidance behavior. And your brain is I’m going to make my human do that again.

That’s the only reason we survived. That intrusive thought must’ve been terribly dangerous. I’m going to make my human wash their hands 600 times. But basically the more you do that, the brain’s okay, I’m going to make my human more anxious. I’m going to make that intrusive thought louder. And that intrusive thought comes again and you get stuck in this cycle of avoidance with OCD. Is this, correct with OCD? This is the anxiety cycle, but tell me about how it applies to OCD.

Dr. Green: Yeah, it fits a very similar pattern of OCD models the pattern of any fear-based.

Emma – Studio Mic: I’m trying to cover up the trauma part. That’s not what we’re talking about at all. We’re just talking about this little part.

Dr. Green: Any fear-based, so social anxiety disorder, OCD, any specific phobia And a lot of forms of PTSD that have more of that adrenaline fear-based response follow that cycle [00:28:00] and part of the reason the specific care is important is because if you have a clinician again, most treatments do great with generalized anxiety, depression, they can help with kind of progress.

There’s some that definitely help more than others. But in OCD, one of the most reinforcing elements is this checking or reassurance. And so you go in to talk to a therapist who just isn’t familiar with OCD and you’re like, I’m afraid I’m going to stab my baby. And you have a couple of things. One of them I go, are you really going to stab your baby?

Do I need to worry about, right? It sends them into the exact opposite or they say, no you’re not going to stab your baby.

Emma – Studio Mic: You’re a good person. You would never do that. Yeah.

Dr. Green: So, they talk, traditional talk therapy often can actually do harm in frank OCD because you get caught in that reassurance cycle. And I would say

Emma – Studio Mic: So let me pause you. So you go into therapy, you say, I’m afraid I’m going to stab my baby. The traditional talk therapist or a coach who maybe doesn’t know what they’re doing says, “Oh no you won’t, you’re okay.” And then that person feels, “Oh, I feel a little bit better. They reassured me that I won’t.” And then they go back home and that thought pops up and they’re like, I need reassurance. I need reassurance. I need someone to tell me I’m not going to or I need to control this thought some more.

Dr. Green: Yeah. They, you get back home or, and I tell my clients this all the time, I can give you reassurance, but you’re going to walk out my door and say, “Oh, but you know what? She didn’t know this about me.” It wasn’t the whole truth. She didn’t know this. So maybe it wouldn’t, OCD is all about doubt. And at least a slight majority, maybe solid majority of my OCD clients have gone through therapy before. And so there’s already this barrier of saying, “I don’t know what to do. I’ve tried the therapy thing before. I’m not seeing a lot of, or it helps for a while. I loved going, but things have just gotten worse.” So that is why I generally I’m recommending people go to someone with familiarity with OCD or at least if you have a specialist in social anxiety disorder who does ERP, oftentimes they’ll be able to do good work with OCD.

But I think that’s just trying to tackle the thought cause most people, 96 percent of people with OCD understand when they’re calm that the intrusive thought doesn’t make sense. They’re like, I know in my head that flipping the light switch isn’t connected to the health of my brother. But in the moment, man, that just, it doesn’t like the brain very rudely overrides all of that logic as soon as it gets that relief, it goes you can tell yourself whatever you want, but if you hadn’t flipped that light switch, he’d be dead.

Emma – Studio Mic: Yeah. But he didn’t die and I flipped the light switch. See, so there’s that feeling. And that’s, where it’s really interesting. Like with OCD, if you try to use a traditional CBT approach where you’re focusing on the thinking, okay, let’s check that thought.

Is it rational? Does it, is it truthful? What’s the evidence for that thought? You could spend 20 years, like going in circles about the rationality or irrationality of that thought. You could just spend more and more time on that thought. And so this is where it’s like we have to shift from a cognitive type therapy or even like a body calming type therapy to okay, we just have to do the behavioral therapy.

Dr. Green: Yes, and I think it’s so the inhibitory learning model of ER. This is too nerdy,

Emma – Studio Mic: Go nerdy. We like nerdy. Go!

Dr. Green: Some of the newer approaches because I think a long standing criticism of ERP is like it’s so mean and I’m like then you need to find someone else who’s doing it. A lot of, it’s actually a lot of clinician timidity.

I do a lot of trainings for clinicians. When they’ve done research, clinicians that aren’t doing it are not doing it because they’re scared. They’re like, it will be so uncomfortable, but when they survey clients, prefer it. Because it works. So the other thing is I wouldn’t like, depending on severity of symptoms, having someone who’s familiar enough to help grade those exposures.

So you’re not just, I often will say, I’ll give the example of oh, what if I were afraid of water and what if you took the approach of every loving parent? That’s just like I’m just gonna throw them in the deep end.

Emma – Studio Mic: Right.

Dr. Green: Just one time it would make it worse If you did a hundred times it would help and you’d hate them, right?

So like there you also want someone especially when you’re working with kids, teens, even young adults, you need someone who’s, I think even more experienced and sensitive to how to manage the level of exposure. And one of the questions was about like, how do I help a family member?

And this is built into good ERP is looking at accommodation. Cause OCD is ….

Emma – Studio Mic: I want to pause you. I want to come right back to accommodation. This is so fascinating. And this is why I love talking with you. Okay. So she used the word grade and I’m just going to interpret this. Okay. Graded exposure therapy means gradual, basically.

It means breaking down the things you’re scared of into tiny chunks and then facing them repeatedly over and over again until, you feel less scared of them. How am I doing? Am I doing okay? Okay. So like you just said, when we think of exposure therapy, everyone thinks of doing the hardest thing in the scariest way possible and good exposure therapy, actually one of the hardest things about it is breaking a task down into teeny, teeny, steps.

And I did this exact, I felt this exact same way. I just, I made a video a few weeks, months ago about exposure therapy. And I was, it was about climbing. Did I tell you about this, Kat? Oh, so I used to climb all the time. I used to climb five days a week, and then I had kids. And then, I didn’t climb for eight years.

I didn’t lead climb for eight years. Lead climbing involves falling like large distances, whereas regular climbing involves like falling an inch or two, like top roping, right? There’s a lot of types of climbing. And so I was, I’m terrified of falling now or I was. I was and so I was like, okay, I need to do exposure therapy on this.

And all I could think of was taking these big falls, like making myself do these big falls. And I’m like, I’m not going to make that video. I don’t want to do this. I’m just going to avoid all good climbing for a while. And then I sat down with my exposure hierarchy ladder and I broke it down into like tiny steps.

And I realized like the first steps was just like top roping. And then the next steps were like lead climbing without falling. And then the next steps we’re taking like two inch falls. And I was like, oh, I could do that. I could do two-inch falls. So I went to the gym and I did 10 two-inch falls in a row.

And I was like, okay, I’m checking that box. Good. And then the next week I came back and I did 10 one-foot falls. And I was like, okay. And it was not, I still dreaded it a little bit, but every time I did it, I was like, oh, okay. And I felt like better and better about myself every time. And then the last time I went to the gym, I was doing like 10-foot falls.

And I was like, oh, this is okay. I still dread it a little bit, but it’s okay. It’s not freaking me out anymore. So that’s, like what you’re talking about, right? Grading. Yes. It’s like breaking tasks down.

Dr. Green: And your combination of dread but also feeling good is what’s the most common. If I try to describe in a nutshell what I’m doing to someone, they’re like, so you torture people for a living.

And I’m like, no, but I can see how you think that, right? Like it’s voluntary, right? These are something where clients are helping drive what comes next, but it builds a sense typically there’s a sense of feeling trapped, right? Completely governed. by all your routines. It’s not like I was feeling so good and in control of my life, and now I’m going to go do some hard stuff.

It’s I need my life back. And so we’re, it’s a very collaborative process. And for kids and even young adults, it’s often involving family for adults. It’s often involving spouses because OCD does not tend to be a like one person, problem. It tends to be like, who else can we involve in this, right?

Let’s get the whole family and social network on board. And so typically we’re working on multiple pieces, graded exposure, facing the fear. And this is where it’s one of the benefits of working with someone who specializes in OCD is it’s really hard to come up with exposure sometimes because OCD doesn’t feel like a specific phobia.

It’s how am I supposed to confront this, right? Because it’s not actually stabbing someone. That’s not what you’re confronting. You’re confronting the thought or you’re confronting holding a knife or you’re confronting the behavior that in many times you used to be able to do, but can’t do anymore.

So there’s one, like often you need. help setting up the exposures and then the accommodation of spouses and family members when they’re like, okay what, am I supposed to do when they’re coming to me or when I’m seeing it? That’s a lot of that coaching as well. You’re gradually reducing the accommodation there too.

Emma – Studio Mic: Yeah. Could you give an example of, exposure therapy that you’ve done? I mean, it’s easy to think of how you would do it with germs, so I want you to think of an example that’s harder, like an intrusive thought of harming someone maybe. Because with germs it’s oh let’s start by touching dirty things or like small dirty things or thinking about touching dirty things or talking about touching dirty things or watching videos of people touching dirty things.

Dr. Green: Yeah.

Emma – Studio Mic: So that’s like easy. Can you do, a hard one for us?

Dr. Green: I mean, I think another common one I’m trying to think of kind of specifics with responsibility for harm like the knife exposure is another great example that you’re I’m afraid I’m going to stab someone. And so I’ve locked up my knives and we go from locking up knives to having them on the counter to walking in the kitchen while they’re on the counter to holding them.

I’ve, yeah so if you’re had responsibility for harm, if I don’t check the stove then my family will all die. If I don’t check it five times, right? So you can reduce the responses, you can reduce the checking, but also some of the exposure you can deliberately go turn the stove on for five minutes and walk away and say, that’s it.

I’ve done it. Yeah, you’re always up, you’re always operating in like we, I, one of my favorite mentors of all time would talk about like reasonable exposures and bad ideas. I think a lot of people think exposure and they’re like, yeah, you’re just going to burn the house down. I’m like, okay, that’s not the goal.

The goal is to tolerate being able to leave the house without checking. So you’re actually confronting, we use a lot of scripts, right? So I’m deliberately not checking the stove. I’m deliberately doing it and maybe that means that it’s gonna blow up.

Emma – Studio Mic: Yeah,

Dr. Green: So exposure is more than just reducing the checking. It’s invoking the fear. It’s bringing on the fear to say I had then this is again probably not the hard one you’re thinking of but like a lot of superstitious kind of things in exposure. So favorite numbers stepping on cracks. I can’t tell you how many times, especially with kids and teens, we’ve walked around stepping on cracks deliberately, cause it’s like, oh, it will hurt someone.

So we’ll go and we’ll step on it and be like, oh, I got another one. Oh, hurt someone else. You’re deliberately doing that in a way they can tolerate. So you’re invoking that you’re not just saying, okay, we’ll just try to walk normally instead of something like, no, I actually want you to make OCD pretty mad.

Emma – Studio Mic: And that’s where like the similarities with it and anxiety or other anxiety disorders line up, because basically it’s saying I’m going to feel scared and show, I’m going to learn by experience that I can have this uncomfortable thought. I can feel this uncomfortable feeling. I can have uncomfortable sensations in my body and either not do the compulsion or just sit with it and be okay. And there’s like a learning aspect to this, right? Like your brain learns through experience in a way that you can’t just convince it to shut up.

Dr. Green: And I think sometimes when I hear when things stagnate in treatment, I’ll often hear, yeah and the thought came up and I just had to remind myself, that’s not real.

It’s not going to happen. And I’m like, okay, so that’s an option. Or right, I typically use the go tos of challenging it with accepting a tiny bit of uncertainty. If the idea is, if I don’t check the baby three times before they go to sleep, then they’ll die. So you can say, and if it works for you, great.

Okay. That’s not real. I’m not going to do that.

Emma – Studio Mic: Yeah you can argue, or disagree.

Dr. Green: You can argue.

Emma – Studio Mic: Rationalize against this thought. You can, yeah, you can try to be like, that’s not a rational thought. You can, try that. Try that approach if it works.

Dr. Green: Exactly right. If it works, that’s great. But the other, my kind of go tos were as either accepting a little bit of uncertainty. I guess there is a small chance that despite all the evidence, if I didn’t check their blanket, they would die. But it’s accepting you’re not taking a definitive position or I’ll go to the absurd, right? So accepting a tiny bit of uncertainty or going to the sarcastic or absurd being like, yes, because every human in the world checks their baby three times a night or they kill all the babies in the world, right?

So trying to bring that to the extreme often gets you to a place that it’s you’re not actually saying that doesn’t feel great. You’re not getting to a place that you’re like, that would never happen, but it tends to loosen OCDs hold a little bit.

Emma – Studio Mic: Yeah. Sorry. My, apparently my notifications are on. Did you hear that little

Dr. Green: I did. I like, it just reminds me how popular you are.

Emma – Studio Mic: I’m so popular. I’ve had one person text me twice this call. Okay. So ERP premier treatment or the, like the best evidence based treatment for OCD. You learn to face those intrusive thoughts without engaging in the compulsions. Is that the simplest way to describe that? Okay.

Dr. Green: Okay I think more than learning to face the thoughts, you’re deliberately invoking them. So social anxiety is a great example too, right, of I’m afraid I’ll be embarrassed. I’ll do something humiliating. So, so we might deliberately walk around a public place after having spilled water on our shirts.

That we might have to work up to that.

Emma – Studio Mic: Yeah

Dr. Green: It may have started a lot smaller, but I think that exposure you’re just like you were doing with the rock climbing, right? You’re deliberately challenging that fear and invoking that fear you’re inviting it and then ignoring it.

Emma – Studio Mic: Yeah

Dr. Green: You’re a great host.

Emma – Studio Mic: Yep. I love it. Because yeah the alternative is trying to never embarrass yourself ever and white knuckling your way through life and all relationships and all social situations and at some point in your life you have to say is this working for me? Is this working for me? Okay. Okay. Now I interrupted you when you were talking about accommodations. We were talking about ERP, we were talking about exposure therapy for OCD, and you said, and this isn’t an individual problem, and we often accommodate other people when they have it. Do you want to go down that road anymore?

Dr. Green: Yeah. I can give you some examples. And I think by far, the most common sneaky accommodation is just giving reassurance.

Emma – Studio Mic: Yep.

Dr. Green: And it’s because as humans, who care about other humans, we want their distress to go away immediately, too. Or we’re really exasperated, so we want the distress to go away. We certainly can see this in, parents, right? If I’ve got an adolescent who’s afraid that they made a mistake, right?

If they say, “Mom I think I offended someone today.” Mom’s gonna say, the first time she ever hears it, she’s gonna say, “What happened? Tell me about it No, I think you’re good.”

Emma – Studio Mic: Yeah

Dr. Green: And then it’s gonna be like but I forgot to tell you a part. So we come back about the same thing, come back, come back, and every time it starts as like I feel so bad and then ends with I’m so frustrated with you, right?

That’s like it’s fine. It’s fine. Stop worrying about it.

Emma – Studio Mic: Yeah.

Dr. Green: And then you may go there’s probably multiple compulsions I said, like maybe they have a prayer routine that they also have to do however many times in a very specific order to feel like they can move on to the next kind of piece So what we do in that case is making when we can collaboratively say, okay, so OCDs, we talked about feeding it cake.

It’s getting cake every time you’re doing what it wants, right? It showed up at your party. Yeah. And so we talk about for parents coming up with a different response, a more neutral response. Eli Lebowitz wrote Breaking Free of Childhood Anxiety and OCD. I think I got that but he does a lot of school refusal OCD up through young adulthood.

And he’s got some great resources for parents of children up to young adults, young adult children, adults about kind of ways to say, okay, here’s how we collaboratively, or if the kid’s no, I’m very happy with you reassuring me. Okay. Here’s how we’re going to fade that back. So then we have a plan each week that every time they come to you and say blank, sometimes they have a certain number of passes they can use and they get rewards if they don’t.

Sometimes if the kid’s no, I’m still going to ask, the parents will be like, oh, mom dad, pancakes. Just like a total nonsense.

Emma – Studio Mic: Some nonsense where it’s I’m not going to feed this.

Dr. Green: I’m not going to feed this. You’re still giving, like a lot of, my teens will be like, but I still know that they heard me.

And they would tell me if I did. Then you can go to increase sensors and be like, I don’t know maybe you didn’t. So you’re, again, the exposure is, Invoking the uncertainty, but you whenever possible, I’m trying to do this in a graded way where they’re fully on board when I’m working with adults, I often end up working with partners or spouses because that reassurance tends to be very similar, right? I think I hurt our child. And the first time it’s wait, what? Tell me about it. Tell me to do it. And it’s it doesn’t seem like you did. And it’s oh, I forgot some details.

And then it’s back and then we’re back and then we’re back. So spouses and partners often get pulled into the same no, I think you’re fine. I think you’re fine. I think you’re fine. And yes, I love you. I love you. I love you. And so we’re often having to interrupt that cycle as well. Tends to go better if we can have them working as a team as part of that.

Emma – Studio Mic: Interesting. And so it’s, it seems so important. I love it. And I have so many questions, there’s so many good things. I feel like we could just talk for hours. We’ll have to do this again soon. The one question that I see come up over and over again is scrupulosity.

Can you give us a definition of this or what did you call it? Moral OCD.

Dr. Green: Yeah, so and it’s scrupulosity sometimes I’ll call it religious OCD, moral OCD. It’s essentially OCD has taken over the valued part of your life that is typically your relationship with God. In whatever religious context or non religious context that is, it tends to happen more in religious groups.

Religion does not cause OCD. If it’s something you value and you have OCD, it likes to go after it. So it’s one of these. Tends to be a lot of concerns, like I’m afraid that I hurt someone’s feelings, I wronged someone. I offended God, I sinned, whatever that looks like in the really common compulsions might repeated prayer, and ritualized prayer, like you have to say it the right way in the right order, it doesn’t count.

It does for everyone else. Just not for you. And most clients know that. Most are like, yes, I know. I know. So this is why it doesn’t help when people are like, that doesn’t make sense. And they’re like, yeah, I know. Thank you. Confessing. So repeated confessing, I will get referrals from clergy or I’ll talk with clergy that are like, okay, the first few times I was like, oh, is something happening? it’s

I don’t know if this is happening. Or confessing to parents, to friends, and then lots of reassurance seeking, lots of checking for scrupulosity often goes with some of the taboo thought OCD, right? So if there’s a lot of intrusive sexual thoughts oh my gosh, what if I’m attracted to children?

Then we’ll see the confessing and sin pieces integrated in. They’re not neatly packaged as Here’s scrupulosity. Here’s pedophilia themed OCD. Here’s this. That’s why I generally will just call it all OCD. I will acknowledge those themes, but when people say I have scrupulosity and perfectionism and OCD, I will talk about why I’m going to talk about those as one thing, because it tends to just be a similar process that’s weaseled its way into multiple places.

Emma – Studio Mic: That is really interesting and I’m just gonna pop a comment up here because I have to like rise to the bait on this one.

But just to be clear. I’m a Christian. I’ve mentioned this in all of my descriptions on all of my YouTube videos and The majority actually of mental health providers are less religious than the population of the United States and there is a more, like, there’s some leaning toward a lot more talk about religious trauma.

And that is not what we’re talking about. We’re not talking about religion being harmful and we’re not talking about like religion makes people OCD. We’re talking about how when someone has a tendency towards OCD, one of the ways OCD can manifest is with fear and guilt based loops that they get stuck in their religious practice that takes them away from their value based religious practice of oh, I love God.

I want to serve God. I want to do good in the world. I want to make my life right and good. And that’s very different from the scrupulosity, which is did I sin? Did I sin? Did I sin? Did I sin? Did I sin? Did I sin? Did I sin? Did I sin over and over again? And that’s not like faith or love-based, value-based service towards God. That’s oh, your brain got stuck.

Dr. Green: Yeah and I, appreciate that. This is something that especially like I work and my clinic director in a religious state. And so this comes up a lot with my graduate students as we’re training, but your description, I think fits beautifully in any theme of OCD.

So I typically would, they say, why this for me, why do I worry about this? OCD tends to go after what people value the most, right? So it’s, you’re going to have a tendency towards OCD. And I, when I worked in a medical, huge medical area I saw way more contamination-based, lots of, they’re constantly surrounded by people working as physicians and in the CDC. Like there’s a huge value on health and wellness in a great adaptive, positive way. And it was just a playground, right, for OCD. So OCD tends to go after what people value. So I love when it goes, I talk a lot about OCD being very, there’s just rules. You have a bunch of rules you feel like you have to follow that don’t make sense for other people, but just you.

And it just tends to go after things like it that you care about the most because that’s the stuff that’s so scary when you have an intrusive thought. If you have an intrusive thought about what if this has what if I get AIDS from this? But you’re not worried about that. It’s not something you think about a lot. It just goes away. Whereas if you love spending time with kids and all you want to do is be a parent and you have this random intrusive thought of what if I’m attracted to that kid, your brain’s oh my gosh, what’s rather get your values drive what OCD latches onto. So I appreciate, I conceptualize it just like any other area of OCD it’s based on trying to rob value decisions into rule bound OCDs in charge.

Emma – Studio Mic: Yeah, I appreciate that. And that’s so interesting, because it’s like, if we have an intrusive thought that kind of threatens something we care about, then we’re going to have this fear response or cortisol response or whatever it is and that’s going to make that thought seem really loud, really important.

Dr. Green: Yep. Yeah. Can I answer one question I’ve seen come up a few times on the chat, just in the last minute? I saw a lot of questions about medication. We talk about treatment for OCD, behavioral treatment, We’re looking at exposure response prevention That there are a lot there’s lots of good data on medication support as well. If that’s something typically the data similar to actually, similar to other kind of mental health conditions, if you’re in that mild to moderate range a lot of people prefer to just try starting with behavioral treatment. If that’s not working or you’re in this moderate into the severe range a combination of medication and ERP, generally in the data, is a better response and it lasts longer than medication by itself.

I have also had some people that are like, I literally can’t do ERP right now, I’m going abroad for three months and there’s nothing. You can also do medication only as you need to, you might just notice that the effect doesn’t last as long if you stop the medication. But those absolutely can work together in combination.

Emma – Studio Mic: Yeah. Yeah. I’m so glad you mentioned medication. Someone else popped in the chat. This is what’s like at the top of my Post It note. It’s like medication. Oops. And meditation. Someone else is you should meditate. You should meditate more. Mindfulness cause that’s a cool thing of the last 15 years.

Thoughts on, one-minute take, mindfulness and OCD.

Dr. Green: I think there’s absolutely ways to integrate mindfulness and meditation into OCD treatment. Generally the research right now, you have to be careful that you’re not using mindfulness or grounding or relaxation strategies. Most ERP clinicians wait on that because otherwise your body tries to use it as a way to feel better right away.

Emma – Studio Mic: Yep.

Dr. Green: So it can, OCD has a tendency to grab onto things and turn them into compulsions. If you start to get that feeling, be like, I need to go do my meditation and it tends to be rule bound. But with that said, there, absolutely really great and effective ways mindful. I don’t love anytime meditation is not going to cure OCD.

Mindfulness is, it might for some, but across the board, I’m not going to say yes, just do that. But there’s definitely good data. There’s great clinicians that are able to incorporate elements of that into helping with progress in most treatment, but including OCD.

Emma – Studio Mic: I think that’s a really good description. And in my previous live stream with Drew Linsalata, he also mentioned this, he described this in an interesting way. He said, we were talking about panic attacks and agoraphobia, which is where you get stuck in a different kind of loop of avoidance of your internal sensations. And he said anything you do to try and technique yourself into feeling better and doing then facing your fears is going to actually be a form of avoidance.

And if you face your fears and you’re willing to go and show up, even though whether that’s with a panic attack, you’re showing up to your body sensations, agoraphobia, you’re leaving your house OCD. You’re like, hello, intrusive thought. I hear you. You’re at my party. Okay. Who else is at my party?

Like you’ve got to be willing to face it first. And then in my opinion, you can do other strategies to help improve.

Dr. Green: I love the, he has a few of those like one-liners and I’m like, that is so beautifully said in one. The techniquing yourself, right? Like sometimes I will, sometimes it’s just too hard and I do have to introduce it and then we grad, it just always has to be a goal to be fading that out.

And one other, just a quick note, if I know this is separate from OCD, but when we talk about exposure-based therapies, the one exception is in PTSD, so capital T trauma, threatened to sexual violence, threatened of loss of body or loved one, right? Like capital T trauma, you often in, it’s called TF CBT or even prolonged exposure, you often will see some of those, management strategies, the technique things first.

If that’s something you’re dealing with, it’s much more trauma-focused, work with someone to know where you need to start. But with OCD in general, that’s the recommendation is to start with the exposure, but with someone who is warm and supportive. You’re not just feeling like you’re thrown in the deep end.

Emma – Studio Mic: Yeah. Oh, I’m so glad you mentioned that because there is a difference in treatment and with PTSD. So you’ll see with a good PTSD therapist, which I feel like slightly more expert on than OCD, is you do a lot of resourcing. They call it building up the ability to manage your body and your nervous system because your nervous system is basically, overactive In that and so we spend a lot more time resourcing. We don’t just do straight up let’s just talk about your trauma over and over again because that can be very retraumatizing.

Dr. Green: Yeah, and yes. So prolonged exposure, trauma scripts and stuff are a really essential ingredient, but often there is that build up period So I just wanted to most other things fear based anxiety, ERP is going to have you go at it without the technique pieces And that’s where you’re going to see the progress

Emma – Studio Mic: So, important to clarify, so important to clarify. And this is also why getting all your medical advice from TikTok is not ideal.

Dr. Green: I can’t even follow TikTok because it’s just so hard.

Emma – Studio Mic: I actually don’t have it on my phone. And I also, don’t have Instagram on my phone, but I do sometimes use it. But. Yeah, it’s okay, I wish we had more time, but we don’t. We have one more minute. And let’s say, Kat, do you have any resources you’d like to recommend to people?

Or if people want to find you, do you want to be found? Any books, resources, websites, apps, or you? Yeah.

Dr. Green: Yeah I think the courses on intrusive thoughts and health anxiety are, I think, they’re a good place to start.

Emma – Studio Mic: Link in the description.

Dr. Green: I think one of the kind of go-to resources is the International OCD Foundation So IOCDF.org. And they have, they’re generally doing good evidence-based stuff. They have a [inaudible] resources that are across the world. I know there aren’t as many resources as we would like in all places but that’s where I would get a lot of that information. They have a lot of articles. What is it?

Where do I start looking? How do I know if it’s good therapy or evidence-based is where I really like to start.

Emma – Studio Mic: Yeah. Awesome. Are you familiar with the app, NOCD?

Dr. Green: I am.

Emma – Studio Mic: Okay. Any books you recommend?

Dr. Green: Like I said I, like and I’m probably more on the, child-side or the parenting-side, the Eli Lebowitz book Is fantastic and he talks about obviously kids and teens, but also failure to launch, right?

So if you’ve got young adults that are just can’t they’ve got so much anxiety. They can’t get out in the world. This is one of the newer ones that I have liked. John Hershfield has some great stuff. So he’s written, it wouldn’t surprise me if you guys had talked about him before, but he’s written some great books on OCD.

He’s got some great books on scrupulosity, on moral OCD. And he’s a solid ERP And he’s just very evidence-based. He integrates other evidence-based approaches, which some people are like, no ERP or can. I’m like, yes, we can. As long as it’s good support, right? He does DBT and ERP together. So that’s where I, for adults, that’s where I’d send them.

Emma – Studio Mic: Awesome. Okay. So the links to Kat’s courses are in the description. And again, if you want to join our membership where we do Q&As every month, and we’re going to do more in depth webinars there, you can check that out as well. Dr. Green, thank you. Thank you so much for your time.

Dr. Green: Thank you. And thank you for the questions. They were excellent questions. Okay. Take care.

Emma – Studio Mic: Take care everyone. We’ll see you.

Click below to access Dr. Green’s course, Taking Charge of Intrusive Thoughts.