OCD Medication Explained — SSRIs, What Works & What Doesn’t | Dr. Steven Poskar

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I'm Alicia.
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And I'm Liam.
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We both have OCD, and instead of spiraling alone, we decided to turn our symptoms into a podcast.
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You're welcome.
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Here we overshare real stories, laugh through the anxiety, and talk to actual experts who can explain why your brain keeps asking, What if I accidentally marry my cousin?
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Whether your thing is hand washing, mental rituals, or just silently panicking during normal conversations, congrats.
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You have found your people.
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This is a safe place, unless you're an intrusive thought.
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In which case, get in line, buddy.
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We're booked.
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So grab a weighted blanket, cancel your plans for the fifth time, and let's dive in.
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This is the OCD Confessional.
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And yes, we did check this recording four times before uploading it.
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Today on the OCD Confessional, we are honored to welcome Dr.
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Stephen Poscar.
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Dr.
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Posgar is a leading psychiatrist specializing in the treatment of OCD and related disorders.
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His work focuses on helping individuals struggling with OCD, body dysmorphic disorder, trichotillemonia, hoarding disorder, and skin picking disorder.
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He is the director of OCD NYC, a specialized treatment center serving patients across Connecticut, New York, New Jersey, Florida, Virginia, and Washington.
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We are so grateful to have him here to share his expertise, insight, and compassion with our community.
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So, Dr.
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Poskar, thanks so much for being on the OCD Confessional.
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Thank you guys so much for having me.
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I really, really am looking forward to it.
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Thanks for being here.
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We're going to jump right in.
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Should someone with moderate to severe OCD be on medication?
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So that's a great question.
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And I think it's it's always kind of hard when we say should, right?
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You know, as we know, there are there are some people, even with moderate to severe OCD, that can do the standard therapy, which in OCD is exposure and response prevention, and get really good results.
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And so, you know, typically when I see somebody with moderate to severe OCD, often I'm thinking that it's more likely than not that medication would be helpful for them.
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And, you know, and then I really talk to patients about patient preference, right?
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And so some of this is also about like urgency and timeline, right?
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So if somebody comes to me, even if they have moderate to severe OCD, but they say, like, I'm willing to do therapy alone, I want to try it and give it some time, and then if it's not moving in the right direction, I'll do medicine, which is fine.
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On the other hand, if somebody comes to me really severe and either they're just really suffering or not functioning, then in that case, usually I want to start them on medicine, you know, and and again, you know, therapy is always the most important piece, right?
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And and the best thing the medicine can do is often kind of lower symptoms down enough to allow people to be able to do the therapy.
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And I think I always go back to with patients, right, that the nice thing about medicine is it's not surgery, right?
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It's not something we can't undo.
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So to me, trying medicine is sometimes worthwhile because you'll see.
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Is it is it helpful to you?
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If it's not, we stop it.
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If you're getting side effects and you're not worth it, we stop it.
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But often people can see it's helpful for them.
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And then sometimes if people are doing therapy for a while, sometimes we can lower and even stop the medicine and they keep their gain.
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So again, sometimes medicine's a long-term thing, but sometimes it's just a thing that we need sometimes to get people to be able to kind of take those kind of steps and end their therapy.
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We can speak to this a little bit.
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I think the research shows that the best results come from some combination, right, of medication and therapy, obviously depending on the patient and the circumstances.
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But overall, I think that's what the literature says.
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You can correct me if I'm wrong on that.
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But I did want to ask how you got into this field.
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How did you get to OCD NYC and why the focus on OCD for you?
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Yeah.
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So first on the research, so this is a this is a contentious issue.
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Uh some research that that, you know, and when we were writing kind of um, you know, so I wrote the the biological treatment guidelines for the OCD Foundation.
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And when we were writing them, we got pushback from a lot of people, which is great.
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I mean, people have questions and things.
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And so depending on like how you look at things, there are some people that would say, I don't know.
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There are a bunch of studies that show that Sarah Kes just as well as medicine and therapy.
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Others, not so much.
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And then it's a question of what's the difference if it's moderate to severe versus more mild?
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What's the difference between if somebody has comorbid depression with it?
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So it's it's it's it's it's a debated subject.
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Um, for me, I got into this because I had a couple of family members with OCD.
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Um, I actually never planned on being a doctor ever.
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Um, you know, I didn't go back to school to do even pre-med till I was 28.
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And I started when I was 30.
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Um, but I went in and did all this because I realized that I wanted to help people with OCD.
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And so I really went to medical school knowing this was what I was gonna do.
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I I went to medical school for for that reason.
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As it relates to the research on the combination of medication and therapy, um where does heroin fit into that?
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Where does what?
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What'd you say?
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Where does heroin fit into that?
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Sorry, you'll have to excuse my friend.
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He he had a rough night last night.
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Uh yeah, that that that is beyond, I think, the re what the research has has delved into.
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Uh on a more serious note, a lot of people wonder um, they're newly diagnosed with OCD.
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So I'll give you a little bit of my experience.
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And Alicia's experience on this was kind of similar, where I was super reluctant to do medication.
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Um I actually became kind of obsessed with the thought of the side effects and wanted to avoid those at all costs.
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And thought if I take those very black and white thinking, then this is going to happen.
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I'm going to have these side effects.
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My life is actually going to get worse.
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And so I was really opposed to it.
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How do you talk to someone who's in that position?
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They're they're newly diagnosed, they know they need help, but they're just so reluctant to take medication, almost to a point where it is its own obsession.
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Well, it's I I love that you ended on that, right?
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Like almost like good if it's own this obsession.
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Because I think you want to see, you know, there's there's normal being afraid of medicine and things like that.
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And that's a certain conversation.
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But I also think we have to see when this is just in part of an OCD symptom, right?
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That you're that no matter how much we tell you, no matter how much, you keep researching and researching, and you never feel certain, right?
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Because I think at that point, then right, we, you know, part of it is informational, right?
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Like so when somebody asks a question about medicine or they're nervous, I want to give them information.
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And and but at some point, when they've asked me the same question four or five times, when, you know, and it goes back, then I do want to identify with them and if they're working with a therapist to their therapist, is this something we actually have to address also from an OCD perspective, right?
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And and not looking things up and things like that.
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But again, I think I go back to, you know, what I kind of said a little earlier, which is one of the things I really drive home with people, you know, that have your situation that either want to be with is it's not surgery.
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There, there, there is kind of it is there's nothing we start that we can't stop.
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And and we start things gradually and slowly.
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And, you know, and and part of it's also just being with people.
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I think one place where this stuff fails is when the doctor doesn't see the patient frequently enough at the beginning if they have medicine anxiety.
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I think sometimes you need to help them get through that at the beginning when they have some side effects, right?
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Typically, side, you know, the problem is side effects tend to come early with medicine and then go away if it's a while to accrue.
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So it's hard, right?
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Because at the beginning you might be getting side effects and no benefit.
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Yeah.
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And so, you know, I think educating them on what the timelines are, educating them on what the side effects are, right?
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Because if people don't want to take medicine because of certain side effects, I want to make sure these are actually true side effects, right?
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So people will come in and they'll say, I I don't want to be on Prozac because I'm worried about my kidneys.
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Prozac has will not does not get dealt with by your kidneys.
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It doesn't do anything for your kidneys.
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So I want to also make sure I want to hear their concerns because some of them just aren't true.
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And then others do have validity, and then it's going over kind of and explaining those.
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How do you decide what to prescribe?
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So, you know, when OCD typically writes, the standard of care is SSRIs.
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And those are selective serotonin reuptake inhibitors, and those are Zolof, Prozac, Lexapro, Selexa, Luvac, and Paxel.
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Uh-huh.
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And, you know, typically in OCD, we often need higher dosages than are used for things like depression or anxiety.
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There's not a shred of evidence anywhere to show that any SSRI is better than any other for OCD or for anything for that matter.
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Wait, can I interrupt you really quick?
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Is there evidence to show that OCD is a low serotonin issue?
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Because I think that No, no.
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So let's talk about that.
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Okay.
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Sorry, I if I don't get it out right away, then I forget.
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That's a good question.
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So we think I think there's thinking that just people don't have not thought out, right?
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So you we can say that people have OCD and we give them an SSRI.
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And an SSRI, you know, can cause increased serotonin in the synapse.
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And therefore, if it works, it must be because they have low serotonin.
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Right?
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False.
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It really doesn't make any sense, right?
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So I always I always tell people, you know, imagine you're an alien or you're coming to Earth and you become a human and you don't know anything.
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We don't have to imagine, Doc.
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I imagine that every day I basically am an alien.
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And you only sleep for four hours, but you don't know what causes tiredness.
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And next day you wake up tired and I give you coffee and you feel less tired.
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Were you caffeine?
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Did you have low caffeine?
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No.
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Just because something helps doesn't mean it's the cause, right?
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You know, when you have a headache and you take a Tylenol, you didn't have a headache because you were low on Tylenol.
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And so, you know, the assumption that that is a mechanism, and when you actually look, people with OCD don't appear to have lower levels of serotonin, nor do nor do people in depression.
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So why are we giving them more?
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So so again, we're we're starting a chain reaction, right?
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Where we're and we're doing something pretty specific, right?
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Because not all medicines that increase serotonin work for OCD, right?
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There are other medicines like Remaron is an antidepressant anti-anxiety.
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It increases serotonin.
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It doesn't treat OCD, right?
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That OCD seems not to just be treated in particular by things that affect the serotonin reuptake pump.
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But remember, your body and your brain, these are all interjoining neural circuits.
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So serotonin is going to affect dopamine and affect glutamate, and glutamate's going to affect this and that, and it's going to go downstream and do a million other things, right?
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And we kind of all we can say is we know that this starts some cascade of reactions that eventually lead to improvement in OCD symptoms.
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We don't really know the mechanism then, right?
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We just know that the research shows that people who take this tend to do better.
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And Alicia and I are, I think you're okay with me saying this, right?
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Alicia, we're both on them.
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Um, Liam at this point.
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At this point, we've we've really said that.
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Yeah, we've we've shared we've shared a heck of a lot on this podcast, which is good.
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Um we're both on them.
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We both have seen improvement as a result of them, but it sounds like even the experts, you, don't really know why.
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Is that the case?
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Well, we have theories.
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I mean, a couple of things we we kind of have a sense of, right?
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Which is, you know, one of the things we see in people with OCD is kind of a what we call a hyperactive brain circuit, right?
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And and an OCD, and and you know, this there will not be a test on this, but in OCD, these are what we know we'll call cortico, striatal, thalamic, cortical loops.
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And and an OCD in particular, the areas in like the cortex are usually like we see hyperactivity in the orbital front frontal cortex and the anterior cingulate, and then it goes to an area called the striatum, and then to your thalamus and back.
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And in people with OCD, it looks like these areas are hyperactive.
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Interestingly, when we treat people with medicine and they get better, often we can see that actually these loops have slowed down.
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So we kind of know that there's possibly an endpoint of where it's doing things, but exactly how we don't know.
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And there are theories, um, but nobody knows for sure.
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Um, the interesting thing is when we do therapy and it works, those loops also slow down.
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And that's important for people to remember.
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Some people assume, well, if I have a brain or biological illness, I need medicine.
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But tons of things change your biology.
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Learning changes your biology, and therapy changes your biology.
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So it is not in that way, while you're not taking a biologic medicine, it is absolutely changing your biology.
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I would say for me, my my experience with it is it's allowed me to I I used to get very anxious very quickly, and now it slows, it's has slown that down, right?
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So I don't go into these OCD spirals as fast.
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I'm able to rationally think things through without being uh so anxious through the process.
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And I haven't had a depression episode since I've started.
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So whether it's helping with depression or anxiety, whatever it's doing, it's allowing my body to have a um uh a calmer response.
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And that and that's when people ask me, you know, what you know, what what am I gonna feel, right?
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Like what's what's the response feel like?
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And I I kind of always talk about it almost of a lowering of the volume, right?
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It's not that the OCD goes away.
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No.
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But it's the volumes lower.
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Sometimes I tell people it's like the difference between me poking you in the arm with a pin and then you rolling a sweatshirt down and me poking you.
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You feel it, but it's not as strong, right?
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People say, yeah, sometimes the thoughts are less.
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Sometimes the thoughts just don't have the same emotional heft, right?
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They're just easier for me kind of to kind of let be there and walk past.
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It's easier for me not to give in to compulsions.
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And and again, I think that's what also just allows people that ability now to really engage in the therapy, because they have a little bit of everything's a little calmer, because sometimes it's just so overwhelming that it's hard to even hear what the therapist is saying.
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So that's why the ERP with it is so helpful.
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You have to.
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Yeah, I like thinking about it that way, that that scaffolding, that's nice.
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You you mentioned that typically the dosages are higher for someone with OCD than with an anxiety disorder or depression.
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Why is that?
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So we don't know again, you know, we don't know exactly why.
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We know just from you know doing this and studying it that people seem to require higher dosages.
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And it's just remember that, you know, we're we're probably kind of targeting and hitting different brain areas.
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And and, you know, just like just by like in the same way, you know, on your skin, right?
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Yeah, I can kind of touch some of the skin on parts of your body and you barely feel it.
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And I can touch areas that are really sensitive.
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And so there are probably going to be areas of the brain that are more sensitive that you need a lower dosage to get a response, and other areas that are not as sensitive in that way that that require a higher dosage.
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And again, we see this in OCD, and we also see the same thing in one of the other OCD-related disorders, body dysmorphic disorder, where we also tend to kind of need the same kind of OCD dosages.
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I imagine it gets pretty hard to figure out what's best for someone who is who has been battling severe OCD for a long time because they don't even know who they are outside of the OCD.
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And then you medicate them and they're trying to figure out how they should be showing up in situations and respond the numbing versus symptom relief.
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You know what I mean?
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Because sometimes you're like, well, I feel really numb, but it's better than feeling bad, but I should feel good.
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At what point do you say, okay, maybe we need to increase your dose or maybe try something different?
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How long?
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I know it's a loaded question.
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I'm all over the place.
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Good question.
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It's a great question.
00:17:16.799 --> 00:17:22.319
So, you know, look, you know, it's first, you know, it's always first you want to kind of try to figure things out, right?
00:17:22.559 --> 00:17:30.880
So one thing is sometimes when people have been, you know, a certain way for a while, anything different feels wrong.
00:17:31.200 --> 00:17:31.440
Right.
00:17:31.920 --> 00:17:34.240
And and so they don't know, like, well, I don't know.
00:17:34.400 --> 00:17:41.359
It doesn't feel right, but it it doesn't not feel right because it's not your normal, and everything that's not your normal might feel weird.
00:17:41.599 --> 00:17:50.079
Um, and especially like when people, you know, and again, like when people are, you know, one of the things you'll hear, right, is is patients say, I can't cry anymore.
00:17:50.319 --> 00:17:50.559
Right?
00:17:50.720 --> 00:17:54.880
Like, you know, when I'm I can't cry anymore.
00:17:55.359 --> 00:18:00.079
When I watch sad movies and they're kind of like, And all I do is cry.
00:18:01.200 --> 00:18:03.759
Like I'd like to I'd like to cry every now and then.
00:18:04.000 --> 00:18:08.400
Um again, so one thing is like thinking, like, you know, have you overshot the mark, right?
00:18:08.480 --> 00:18:10.400
We don't want them crying all the time.
00:18:10.640 --> 00:18:15.839
Um, and you know, we talk about this kind of what some people would call an apathy syndrome, right?
00:18:15.920 --> 00:18:27.440
From SSRIs and as dosages get higher, and you know, as dosages get higher, it looks like there's kind of becomes this misbalance between you know between serotonin and things like dopamine and norepinephrine.
00:18:27.680 --> 00:18:33.920
And you know, sometimes as serotonin gets higher, it can kind of actually impact levels of those things and inhibit them.
00:18:34.240 --> 00:18:43.440
So when people do have it, and and we we do think this is you know be caused by the medicine, one of the most common medicines we use is well butrin.
00:18:43.839 --> 00:18:46.400
And well butrin is an antidepressant.
00:18:46.559 --> 00:18:49.680
Uh it is one of the antidepressants that is not good for OCD.
00:18:49.759 --> 00:18:52.880
It doesn't affect I started off with that.
00:18:53.119 --> 00:18:57.039
Also prescribed that to me, and it was horrible.
00:18:57.200 --> 00:18:59.599
My intrusive thoughts were through the roof.
00:18:59.759 --> 00:19:00.559
I didn't know why.
00:19:00.640 --> 00:19:03.519
I told Liam, I'm like, this is you warned me though, didn't you, Liam?
00:19:03.599 --> 00:19:06.079
You said I did start with that.
00:19:06.720 --> 00:19:09.599
And I was like, well, I'm trusting the doctor.
00:19:11.599 --> 00:19:14.880
Well, well, so you know, I talked about this when I lecture a lot, right?
00:19:15.039 --> 00:19:18.240
There's it it gets confusing because of the language, right?
00:19:18.400 --> 00:19:24.000
You know, because we used SSI, often things get a name for what we use them for first.
00:19:24.319 --> 00:19:27.920
And so SSRIs we started using for depression originally.
00:19:28.000 --> 00:19:30.559
So people just started calling them antidepressants.
00:19:30.720 --> 00:19:35.119
And then people just like, well, antidepressants work for OCD.
00:19:35.599 --> 00:19:43.039
But not all SSRIs are antidepressants, not all antidepressants are SSRIs.
00:19:43.440 --> 00:19:48.079
And so I think people just sometimes go, oh, well, it's it's it's an antidepressant.
00:19:48.240 --> 00:19:58.640
But again, the only antidepressants that help OCD are, as far as we know, are things that block the serotonin reuptake pump, things that are serotonin reuptake inhibitors.
00:19:58.880 --> 00:20:00.000
Well, butrin is not.
00:20:00.079 --> 00:20:04.079
Well, butin actually inhibits the reuptake of dopamine and norepinephrine.
00:20:04.240 --> 00:20:07.279
And so it's good for depression, doesn't help with anxiety.
00:20:07.440 --> 00:20:11.119
Sometimes it actually in some people can kind of cause an uptick in anxiety.
00:20:11.359 --> 00:20:12.640
It caused one for me.
00:20:13.599 --> 00:20:22.559
You know, and it's it's sometimes good for some people with ADHD, um, often ones who can't tolerate stimulants or other other medications.
00:20:23.039 --> 00:20:26.160
Yeah, but you most people who have OCD also have ADHD.
00:20:26.240 --> 00:20:27.039
So how do you treat both?
00:20:27.200 --> 00:20:28.480
Liam and I both have OCD.
00:20:28.720 --> 00:20:31.839
Well, I'm gonna we're gonna it's less than most, but a lot.
00:20:32.000 --> 00:20:32.720
But we'll talk about it.
00:20:32.880 --> 00:20:33.119
Yeah.
00:20:33.359 --> 00:20:33.599
Okay.
00:20:34.319 --> 00:20:36.079
But again, I think so.
00:20:36.160 --> 00:20:44.480
Well butrine can often help because again, some of this apathy seems like it's due to kind of an imbalance with the serotonin, dopamine, and norepinephrine.
00:20:44.559 --> 00:20:51.039
So if you give somebody well butrin and increase the dopamine and norepinephrine, we can often see improvements in that.
00:20:51.200 --> 00:20:52.799
Uh and it happens to some people.
00:20:52.960 --> 00:20:58.720
But I also think that sometimes patients come in, especially artists, and they really worry.
00:20:58.960 --> 00:21:04.400
They really worry about uh what if uh if I can't feel sad or I can't feel this, I can't do my art.
00:21:04.559 --> 00:21:06.720
Or even being medicated, period.
00:21:06.799 --> 00:21:11.519
They're like, if it's gonna make me anybody different than who I am, I I can't do that.
00:21:11.680 --> 00:21:16.720
This is my you know, and and and what most people find is it does quite the opposite.
00:21:16.960 --> 00:21:20.000
It tends to make you better artists and and better.
00:21:20.319 --> 00:21:22.640
They're like, then why are we why are you here then?
00:21:23.519 --> 00:21:26.079
You know, like what what what is it that's wrong?
00:21:26.160 --> 00:21:28.880
If you like the ups and downs, then we have nothing to talk about.
00:21:29.359 --> 00:21:32.559
Yeah, but like you said, it they like some of it and not others, right?
00:21:32.960 --> 00:21:34.240
People are ambivalent.
00:21:34.480 --> 00:21:40.000
They're they they you know, and and that's always what you do with patients is working on kind of ambivalence.
00:21:40.319 --> 00:21:56.000
You talk about how with some of these medications, uh uh, probably with all of them, you have to give them time to understand whether or not they're working for you because those first few weeks, the side effects can be higher and the benefits are not quite delivered yet.
00:21:56.240 --> 00:21:59.680
So Alicia and I both had our experience with Well Butrin.
00:22:00.160 --> 00:22:01.039
She gave it a while.
00:22:01.200 --> 00:22:02.079
I gave it a while.
00:22:02.160 --> 00:22:03.039
It was not good.
00:22:03.200 --> 00:22:04.799
I I moved on to something else.
00:22:04.960 --> 00:22:07.839
I forget what it was even called, but it wasn't an SSRI.
00:22:08.000 --> 00:22:12.799
And I'll be completely honest, just because this is the way this podcast is, it's the confessional.
00:22:13.039 --> 00:22:16.720
I was super worried about erectile dysfunction with SSRI.
00:22:16.880 --> 00:22:22.079
You know, I like that I was I just became obsessed with the idea that that was going to happen to me.
00:22:22.240 --> 00:22:23.599
And so that was a big part of it.
00:22:29.440 --> 00:22:29.680
Dr.
00:22:29.920 --> 00:22:32.160
Pascar doesn't have any idea why you just said that.
00:22:34.559 --> 00:22:38.559
Man, OCD got a hold of him and thought he had Peyroney's disease.
00:22:38.640 --> 00:22:41.839
So he went to the doctor to make sure that his Yeah.
00:22:42.160 --> 00:22:42.799
Okay, sorry.
00:22:42.880 --> 00:22:43.519
I had to do that.
00:22:43.680 --> 00:22:44.319
Oh my God.
00:22:45.039 --> 00:22:47.519
Health OCD has been one of my subtypes, Dr.
00:22:47.680 --> 00:22:50.480
Poscar, as you might be able to tell already.
00:22:50.559 --> 00:22:58.000
And and I became obsessed that I was going to get Peyroni's disease because I had seen a I'd seen it pop up in a TV show and uh it was like, oh my god, what if I have that?
00:22:58.079 --> 00:22:59.440
It was the whole thing.
00:23:00.559 --> 00:23:02.319
Uh oh, right.
00:23:02.480 --> 00:23:09.200
So you can get the sense that for SSRI, the erectile dysfunction risk really concerned me.
00:23:09.359 --> 00:23:10.960
And as you say, it's not surgery.
00:23:11.039 --> 00:23:16.240
I could have just, if that ended up being a problem, I could have just stopped taking it, but OCD wouldn't let me believe that.
00:23:16.400 --> 00:23:23.359
Um I do want to say like this is a point that we talked about earlier about educating, right?
00:23:23.519 --> 00:23:28.400
So so one of the common things SSRIs cause are sexual side effects.
00:23:28.960 --> 00:23:33.039
Erectile dysfunction is not common, right, with SSRIs.
00:23:33.200 --> 00:23:34.960
What's common with SSRIs, right?
00:23:35.039 --> 00:23:39.920
The most common sexual side effect, both for men and women, is anorgasmia, right?
00:23:40.079 --> 00:23:43.440
A delayed orgasm phase, it takes a really long time.
00:23:43.680 --> 00:23:48.319
And the second behind that is lowering libido and sexual interest.
00:23:48.640 --> 00:23:54.000
Erectile dysfunction happens, but it's not common with, you know, it's not a super common thing.
00:23:54.160 --> 00:24:02.079
And again, that goes back to like making sure you educate the patient on like, no, there are side effects, and and but these are the more common ones.
00:24:02.240 --> 00:24:03.440
These are kind of less common.
00:24:03.680 --> 00:24:09.440
Yeah, it was just like for me, if it was a 1% chance, even I I was I was uh locked into that.
00:24:09.680 --> 00:24:18.480
But um uh ultimately I decided, you know what, my life is in horrible shape, even if I end up with ED, I'm gonna do this.
00:24:18.640 --> 00:24:29.519
So I did, and and then I my first two weeks were tough with fortunately with not those side effects, but just headaches, sleeplessness, you know, some muscle cramping.
00:24:29.759 --> 00:24:32.319
Um but I waited it out.
00:24:32.480 --> 00:24:39.440
And about six weeks in, I had this kind of light bulb moment of one day where I was like, wow, everything's a little quieter in here.
00:24:39.680 --> 00:24:49.680
Um how long do you recommend typically people give it to see that impact before you're willing to say, all right, let's move to something else?
00:24:50.559 --> 00:24:51.759
So it's a great question.
00:24:51.920 --> 00:24:56.480
So remember, you know, we don't know what your dosage is going to be ahead of time, right?
00:24:56.640 --> 00:25:01.599
So, you know, we know kind of estimates of typical dosages that work for OCD.
00:25:01.920 --> 00:25:11.839
So when you get to a dosage that you think is a high enough dosage that it could work for OCD, you know, you usually want to give it four to six weeks at that dosage, right?
00:25:12.000 --> 00:25:14.559
That the the getting there doesn't count, right?
00:25:14.720 --> 00:25:16.319
It's it's at that dosage.
00:25:16.559 --> 00:25:20.720
After four to six weeks, I usually want to see something, right?
00:25:20.880 --> 00:25:24.720
Not everything, not not whatever, but you're telling me that something's different.
00:25:24.960 --> 00:25:33.519
If something's different after four to six weeks, then I usually keep my hands off of it, even if it's small, because we often see these grow over time.
00:25:33.920 --> 00:25:41.440
If at four to six weeks I don't see anything and they're tolerating it well, then I'm gonna go to a higher dose, right?
00:25:41.599 --> 00:25:44.640
And so you want to kind of get them to a decent dose.
00:25:44.720 --> 00:25:54.640
And if you still see nothing at a at a fairly high dose, you know, and or they're getting side effects because of dosage, then you might want to switch to another agent.
00:25:54.799 --> 00:26:05.279
You know, but one of the problems we typically see, right, um, you know, when you do this specifically is patients come to me and they say, I've been on Prozac and I've been on Zolof and I've been on whatever.
00:26:05.519 --> 00:26:07.519
And then I say, how long were you on them?
00:26:07.599 --> 00:26:12.960
And at what dosage, and and for how long, because often they haven't been on very high dosages.
00:26:13.039 --> 00:26:19.200
They either haven't been on OCD dosages or maybe they're in the low end of what could be OCD dosages.
00:26:19.440 --> 00:26:27.119
And so it's making sure that you're actually using kind of, again, those kind of upper dosages, you know, before you give up on a drug.
00:26:27.440 --> 00:26:32.000
We're gonna pause for a moment because this part of the conversation is brought to you by our partners, No C D.
00:26:32.319 --> 00:26:36.319
The same distressing, unwanted thoughts keep playing over and over in your mind.
00:26:36.480 --> 00:26:41.119
The same rituals keep eating up your time, holding you back from enjoying your life.
00:26:41.359 --> 00:26:50.799
You've tried talk therapy before and spent session after session diving into those thoughts, trying to understand them, trying to fix them, but somehow they just get worse.
00:26:51.119 --> 00:26:54.079
And the shame piles on because you think, why isn't this working?
00:26:54.240 --> 00:26:55.119
What's wrong with me?
00:26:55.599 --> 00:26:58.000
If this sounds familiar, here's what you need to know.
00:26:58.319 --> 00:26:59.839
You are not the problem.
00:27:00.079 --> 00:27:03.920
You're experiencing something that a lot of people with OCD experience.
00:27:04.559 --> 00:27:08.880
Getting your life back is possible because OCD is highly treatable.
00:27:09.119 --> 00:27:13.200
It just requires a completely different approach than other mental health conditions.
00:27:13.440 --> 00:27:21.759
In fact, standard talk therapy often makes OCD worse because it encourages you to analyze those intrusive thoughts or try to replace them with positive ones.
00:27:21.920 --> 00:27:26.240
But with OCD, the more attention you give the thoughts, the stickier they become.
00:27:26.880 --> 00:27:28.880
That's where no CD comes in.
00:27:29.200 --> 00:27:33.440
No CD provides virtual therapy designed specifically for OCD.
00:27:33.680 --> 00:27:43.920
Every single one of their therapists is extensively trained in a type of therapy called ERP, or exposure and response prevention, which is the most effective treatment available for OCD.
00:27:44.079 --> 00:27:53.519
And they get their training from world-renowned OCD experts so they truly understand what you're dealing with, even this stuff that feels impossible to say out loud.
00:27:53.759 --> 00:28:03.759
In live, face-to-face virtual sessions, your No CD therapist will teach you how to take the power away from intrusive thoughts so you can live the life you want to live.
00:28:03.920 --> 00:28:14.160
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00:28:14.400 --> 00:28:22.240
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00:28:22.480 --> 00:28:26.720
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00:28:26.799 --> 00:28:35.839
That's n-ocd.com to learn more and talk to someone who can help because you deserve treatment that actually works for OCD.
00:28:36.640 --> 00:28:38.400
And now, back to our show.
00:28:38.720 --> 00:28:41.839
How do you decide when it's time for someone to wean off?
00:28:42.160 --> 00:28:47.200
And do you recommend that at some point if they are doing therapy with uh medication?
00:28:47.359 --> 00:28:49.519
When do you know it's time to maybe Tula?
00:28:49.920 --> 00:28:53.680
There are a lot of people with OCD that stay on SSRIs for their life.
00:28:53.920 --> 00:28:58.960
And because they just do well on them, and we know that when we stop them, there's a high relapse rate.
00:28:59.200 --> 00:29:07.039
Um I think there's this group of people where we start them on SSRIs and then they really push the therapy and they're doing well.
00:29:07.119 --> 00:29:08.640
And it's hard to know what's doing what.
00:29:08.799 --> 00:29:10.799
Do they just do they need the SSRI?
00:29:10.960 --> 00:29:16.079
And then if you're gonna lower an SSRI, you do it incredibly slowly, right?
00:29:16.160 --> 00:29:19.599
Because I want to catch it if it gets a little worse, right?
00:29:19.839 --> 00:29:28.400
So I might lower, you know, a Prozac if somebody's on 80 milligrams of Prozac, I'm gonna lower it to 70 for two months.
00:29:28.640 --> 00:29:34.799
Because I don't see the effect, just like it takes a while for the drum to work, it doesn't unwork right away, right?
00:29:34.880 --> 00:29:39.440
And so I want to see to see what you really look like on 70, I want a couple months.
00:29:39.599 --> 00:29:41.680
If you're doing okay, I'll drop it.
00:29:41.759 --> 00:29:51.680
And I just keep dropping it until either you're off of it or you might get to a point where we drop it and you're good, and you drop it and we're good, and then we drop it beyond the third point and you go, I don't feel so great.
00:29:51.839 --> 00:29:54.079
In which case we got you to a lower dose.
00:29:54.319 --> 00:29:58.720
But I also think, you know, the when when people are deciding whether to be on something or not, right?
00:29:58.799 --> 00:30:00.960
It's what's the upside, what's the downside.
00:30:01.200 --> 00:30:12.000
So, you know, it's gonna be much more likely that someone's gonna want to lower or their dosages that they might say, like, hey, you know, look, it's been working for me, but I've been pushing real hard in therapy.
00:30:12.240 --> 00:30:17.839
But like I've gained 15 pounds and and I'm having sexual functioning issues.
00:30:18.079 --> 00:30:19.759
Can we try to get off this?
00:30:20.000 --> 00:30:23.359
There are other people that say, I tolerate this really well.
00:30:23.519 --> 00:30:25.839
I feel good with the combination.
00:30:26.559 --> 00:30:30.319
You know, there's no there's no data to support that it's harmful in any way.
00:30:30.480 --> 00:30:36.799
And, you know, we have a decent amount of data now because Prozac's been out, you know, for 40 plus years.
00:30:37.119 --> 00:30:41.759
Um, and and so, you know, and so it's it's it's everybody's different.
00:30:41.839 --> 00:30:47.359
And again, you could always do a trial and you just do a trial of lowering slowly, and then you see.
00:30:47.759 --> 00:30:54.160
I did want to ask about the long-term effects because, you know, I've wondered myself, am I gonna be on this the rest of my life?
00:30:54.319 --> 00:30:57.519
Is there some point at which maybe it makes sense to wean?
00:30:57.759 --> 00:31:07.599
Um I haven't looked at the research myself, but what does the research say about possible long-term effects of high doses of SSRIs?
00:31:08.160 --> 00:31:14.000
So, you know, I don't think we know as much about long-term effects of high doses of SSRIs, right?
00:31:14.160 --> 00:31:17.039
Just because I don't think it's studied very much for very long.
00:31:17.440 --> 00:31:32.559
But there's nothing in what we've seen, and we have been doing it for a while in the high doses or regular doses of SSRIs that appear to be kind of long-term problematic side effects that lead to, you know, people dying any sooner, being sicker, any any kind of disease process.
00:31:32.799 --> 00:31:38.799
And I think something to remember is, you know, there are things that actually really get in the way of your health.
00:31:39.039 --> 00:31:45.440
Anybody who does this stuff or anything will tell you that stress, cortisol, all of those things aren't good for us.
00:31:45.680 --> 00:31:53.279
So, you know, not only is it doesn't it appear to be harmful, but I think in a lot of cases we might find, again, that it's actually helpful, right?
00:31:53.440 --> 00:32:01.279
That that it's decreasing stress, you know, it's decreasing anxiety, it's decreasing things that actually we do know for sure are destructive for your health.
00:32:01.440 --> 00:32:04.799
Remember, we've had people on Prozac now for 40 years.
00:32:05.039 --> 00:32:10.319
There doesn't seem to be any kind of signs that there's any long-term effects at this point.
00:32:10.720 --> 00:32:10.960
Yeah.
00:32:11.039 --> 00:32:17.279
I mean, if you have an imbalance and your body needs it and you are, you know, better on the medication.
00:32:17.359 --> 00:32:18.960
I mean, it's like people with diabetes.
00:32:19.039 --> 00:32:23.119
If you need insulin, it's a that's what your body needs because it's not producing it on its own.
00:32:23.279 --> 00:32:33.119
And therefore, you yeah, I guess for me, knowing that it's OCD related, my depression and anxiety was probably a result of my OCD.
00:32:33.200 --> 00:32:35.039
I don't want to be on medication forever.
00:32:35.200 --> 00:32:40.160
So I am, you know, I am worried about weaning myself off.
00:32:40.720 --> 00:32:41.599
But yeah, I don't know.
00:32:41.680 --> 00:32:42.160
It's tough.
00:32:42.559 --> 00:32:52.720
That's why you want to, that's why you want to be doing this with a professional that actually knows what they're doing and, you know, and explains everything to you so you know what they're doing.
00:32:52.880 --> 00:32:53.119
Right.
00:32:53.279 --> 00:32:53.519
Yeah.
00:32:53.759 --> 00:32:58.960
And and, you know, and that's, you know, that's again, you know, there there are ways you know, there are ways to do things.
00:32:59.039 --> 00:33:01.119
There's ways to get people off medicine.
00:33:01.279 --> 00:33:08.319
Um, one of them is making sure you're doing it unbelievably slowly so that if there are problems, right, you catch them early.
00:33:08.480 --> 00:33:14.400
You don't, you know, do it so quickly that suddenly the patient goes from here and suddenly a week later they're they're in the floor.
00:33:14.559 --> 00:33:20.400
So Well, that and and the medication convinces us that we're better, that we can get off of it.
00:33:20.480 --> 00:33:23.759
But you're like, no, that's actually the medication making you feel better.
00:33:24.160 --> 00:33:25.839
But like you say, you don't know, right?
00:33:25.920 --> 00:33:28.000
You don't know for sure, especially when you're in therapy.
00:33:28.079 --> 00:33:29.279
Like, what's doing what it is?
00:33:29.599 --> 00:33:31.440
You know, it's very hard for people to tell.
00:33:31.599 --> 00:33:42.720
You know, I'll I ask people all the time when they come see me, um, you know, when I'm seeing them for the first time and they're on medicine or they've been on certain medicine, then I'll ask them, like, did you find this helpful or not?
00:33:42.880 --> 00:33:46.559
And I'm not sure is a completely legitimate answer to any question.
00:33:46.880 --> 00:33:48.240
Because sometimes people aren't.
00:33:48.319 --> 00:33:49.440
They're just like, I don't know.
00:33:49.519 --> 00:33:52.960
I was helped maybe at the beginning, and then I don't know if it was helping.
00:33:53.039 --> 00:33:59.119
And also my life circumstances got better, and you know, admin therapy, and it's hard to know.
00:33:59.279 --> 00:34:04.000
There's lots of variables, and so I don't know that anybody could always know for sure what's doing what.
00:34:04.079 --> 00:34:07.680
And again, sometimes the only way to figure that out is to changing something.
00:34:07.839 --> 00:34:12.159
But when you change something, you change it slowly, you watch carefully.
00:34:12.400 --> 00:34:14.320
That's the way you make changes, right?
00:34:14.400 --> 00:34:15.599
And in a safe manner.
00:34:16.000 --> 00:34:25.199
I want to ask you a little bit about alternatives to the SSRIs and kind of pharmaceutical medication.
00:34:26.239 --> 00:34:33.840
And you might not have any uh you know background on this, so feel free to say, you know, you just don't feel qualified to talk about it.
00:34:34.079 --> 00:34:48.639
But there is growing uh chatter online in OCD communities about psilocybin for potentially OCD treatment, depression, anxiety.
00:34:49.360 --> 00:34:51.840
I thought you were gonna say inocital.
00:34:52.960 --> 00:34:53.760
Inositol.
00:34:56.559 --> 00:34:57.679
Oh, psicodin.
00:34:58.079 --> 00:35:01.920
Magnesium, nope, Liam's going straight to the mushrooms.
00:35:02.639 --> 00:35:03.840
Straight to the hard stuff.
00:35:04.079 --> 00:35:04.239
Yeah.
00:35:04.320 --> 00:35:07.119
So I try not to I try to preface it, but I try not to think of my thoughts.
00:35:07.199 --> 00:35:09.679
I try to tell people what the actual research shows.
00:35:10.000 --> 00:35:15.199
And so, you know, uh the psilocybin study is being done by Christopher Pittinger at Yale.
00:35:15.440 --> 00:35:18.320
Um, and his group has been looking at psilocybin.
00:35:18.719 --> 00:35:22.719
Um I think they have some nice preliminary data.
00:35:22.800 --> 00:35:24.079
Um, and I think Dr.
00:35:24.159 --> 00:35:29.280
Pittinger would tell everybody nobody should be taking psilocybin for OCD right now.
00:35:29.440 --> 00:35:33.280
Nobody should be doing it on their own, nobody should be seeing anybody.
00:35:33.440 --> 00:35:34.960
We don't know enough yet.
00:35:35.199 --> 00:35:46.400
We are we are not there as far as how to dose it, what the scenario has to be, how often uh it's uh the patient population that works for and does it.
00:35:46.559 --> 00:35:56.239
So again, you know, part of the problem is with this stuff is people look at it and they get ahead of the curve, and then people just start saying, all right, I'm gonna get psilocybin from somebody.
00:35:56.400 --> 00:35:59.840
I'm gonna go to the are there people or clinics or whatever.
00:36:00.079 --> 00:36:01.039
And they do it.
00:36:01.119 --> 00:36:07.599
And, you know, as we know, like these aren't medicines that literally don't have negative effects.
00:36:07.760 --> 00:36:10.960
People can have really horrible experiences of psilocybin.
00:36:11.360 --> 00:36:15.840
So I think it looks like it's promising for a bunch of things in OCD.
00:36:15.920 --> 00:36:17.920
I think again, um, my guess is Dr.
00:36:18.000 --> 00:36:22.239
Pittinger will probably talk about it at the OCD conference this summer and where they're at.
00:36:22.480 --> 00:36:22.800
Oh.
00:36:23.840 --> 00:36:25.199
You know, he always does.
00:36:25.280 --> 00:36:28.880
Um brings some to to hand out to the audience, Liam.
00:36:29.280 --> 00:36:36.320
Let everyone just imagine a bunch of people with OCD on Sil Simon at an event.
00:36:39.199 --> 00:36:43.679
It is, it, it is, there is a record of people saying they have short-term relief, right?
00:36:43.840 --> 00:36:48.800
But the long-term effects of it and what are they supposed to microdose every day to feel good?
00:36:48.880 --> 00:36:50.960
And and I mean, that's just opening up a whole bunch.
00:36:51.199 --> 00:36:52.639
There's also stories for every everything, right?
00:36:52.800 --> 00:36:57.280
I mean, look, yeah, there are plenty of people who tell you when they drink, they always see these better in the short term.
00:36:57.599 --> 00:36:57.760
Right.
00:36:58.239 --> 00:37:01.039
You know, and so again, this, and again, this is why we have research.
00:37:01.440 --> 00:37:11.039
On the research question, I'm curious what the setting is or kind of what it is that they are researching.
00:37:11.199 --> 00:37:16.639
Are they researching macrodoses where you are with a clinician during your experience?
00:37:16.960 --> 00:37:21.519
Are they researching microdoses that you're taking daily or semi-regularly?
00:37:21.760 --> 00:37:25.119
And no real data to support microdosing.
00:37:25.519 --> 00:37:32.400
Um, you know, it doesn't actually look like it it does very much, despite, again, the chatter on the internet and things like that.
00:37:32.639 --> 00:37:34.960
So I don't know the exact dosages they use.
00:37:35.119 --> 00:37:45.679
I know pretty much as I remember that people are getting a dosage and then they stay there for a while, and they're kind of getting seen daily, and they're and they're doing it with a team and a therapist.
00:37:45.920 --> 00:37:50.480
These are not people that are giving you psilocybin and sending you home and saying come back in a week.
00:37:50.719 --> 00:37:54.880
So it's a fairly controlled setting at this point in time.
00:37:55.280 --> 00:37:58.639
Again, I I don't want to overspeak because I'm doing this from memory.
00:37:58.800 --> 00:38:07.920
But as I remember, I think they were there for a few days, sometimes four or five days after the dose, um, and kind of you know being monitored.
00:38:08.000 --> 00:38:20.719
And so again, it's just it's something, again, uh, you know, the problem is is people get a whiff of this stuff, and then a bunch of people just start doing it way before we know how to do it safely, how well it works.
00:38:20.960 --> 00:38:25.119
Um and and you know, that's always that's always a scary thing.
00:38:25.360 --> 00:38:27.599
Yeah, something to confess, Liam.
00:38:28.159 --> 00:38:28.880
No, no.
00:38:30.960 --> 00:38:32.320
Nothing to confess.
00:38:32.639 --> 00:38:36.639
Um I wanted to ask the same question about MDMA.
00:38:36.800 --> 00:38:39.519
Um, we've seen that specifically with PTSD.
00:38:39.599 --> 00:38:41.760
I know there's a lot of research into PTSD.
00:38:42.320 --> 00:38:46.400
Is there any research that you know of happening as it relates to OCD?
00:38:46.719 --> 00:38:51.679
Yeah, I think Caroline Rodriguez's group at Stanford is looking at it, if I'm not mistaken.
00:38:51.840 --> 00:38:53.920
Um I don't know where they are with it.
00:38:54.079 --> 00:38:58.639
Again, I could be wrong, but I'm pretty sure again Caroline will be at the conference as well.
00:38:58.880 --> 00:39:06.480
Um, you know, it's funny, we do a we do uh uh every year we do an Ask the Experts panel um about medicine.
00:39:06.880 --> 00:39:14.400
And every year, the uh you know, there are a million questions, but there's so many questions about psychedelics.
00:39:14.559 --> 00:39:19.280
Um so you know, if anybody's gonna come to the conference, I those questions will be asked.
00:39:19.360 --> 00:39:21.360
Um and you'll have really the best people.
00:39:23.039 --> 00:39:26.159
I'm gonna be in the audience asking every question.
00:39:28.559 --> 00:39:41.360
You know what I think it is, is that OCD is such a miserable experience that people are desperate for a fix, right?
00:39:41.440 --> 00:39:46.880
And and you know, askest RIs definitely have provided for me a lot of relief.
00:39:47.119 --> 00:39:50.559
Um they got me, I would say, 50% of the way there, somewhere around there.
00:39:50.639 --> 00:39:53.599
And then therapy has gotten me a long ways as well.
00:39:53.760 --> 00:39:59.440
Um, I've been in ERP for the last, I don't know, how long has it been, at least four or five months?
00:39:59.679 --> 00:40:02.559
And I've definitely had relief from that as well.
00:40:02.719 --> 00:40:10.000
But I, you know, if if you can find, I think that that appeal of some natural solution.
00:40:10.159 --> 00:40:14.719
Now I take this and it's fun, and I take it and I can learn something about myself.
00:40:14.880 --> 00:40:19.280
And then I wake up the next morning and maybe my OCD isn't there or not as strong.
00:40:19.440 --> 00:40:21.280
Like that's super, super appealing.
00:40:21.360 --> 00:40:30.239
And that's why I imagine people showing up at the conference going, let me talk to the person researching MDMA or psilocybin, like, yeah, sign me up.
00:40:30.880 --> 00:40:33.599
That's what leads to addiction, Liam.
00:40:35.920 --> 00:40:36.559
Valid.
00:40:36.800 --> 00:40:37.280
Valid.
00:40:37.519 --> 00:40:41.679
That's why people with ADHD drink alcohol because it gives them the relief.
00:40:41.840 --> 00:40:44.079
That doesn't mean that that's the solution.
00:40:44.480 --> 00:40:47.679
But I think I think this is a right, you know, this is always tough, right?
00:40:47.840 --> 00:40:52.559
Because first of all, I think people's vision of how this would work and how it works are different.
00:40:52.719 --> 00:41:07.519
I I think people hear the stories about people who are you know hardcore drug addicts and they go to the Amazon and they have one experience, and after the experience, it's just gone, and and and I'm sure that happens.
00:41:07.679 --> 00:41:09.920
It's not typically the way these things work.
00:41:10.239 --> 00:41:15.840
So it's also kind of the dream of how it would work is very appealing, right?
00:41:16.079 --> 00:41:19.679
Um definitely I I think we don't really know that.
00:41:19.760 --> 00:41:35.760
And I also just am very careful with, you know, when people start using the word natural, um I I um um I think it's an odd, you know, again, remember, there are places where you can go into the woods and eat these very pretty berries and they kill you.
00:41:36.000 --> 00:41:42.880
So just natural has the this this kind of thing that somehow safety and natural go together.
00:41:46.800 --> 00:41:59.840
Okay, so sum up for our listeners, your top three recommendations for OCD medications and then your absolutely stay away from like well butrin, had I known, I wish I would have.
00:42:00.159 --> 00:42:02.559
What are your top three recommendations for OCD?
00:42:02.880 --> 00:42:12.320
So again, I would say, you know, look, if you have OCD, you know, you know, the there's pretty, you know, you should be on a serotonergic reuptake inhibitor, which are the SSRIs.
00:42:12.400 --> 00:42:15.840
If they don't work, sometimes we try another SRI, which isn't an SSRI.
00:42:15.920 --> 00:42:19.760
It's an what's called a tricyclic, which is called clamipramine or anaphronil.
00:42:20.000 --> 00:42:30.719
Um and so, you know, if you're being treated pharmacologically, you should always, that should always, again, if there's unless there's something happening where you have bipolar disorder as well, but generally people should be started at an SRI.
00:42:30.880 --> 00:42:36.639
And you want to make sure that the dose is high enough and that you're on it for a long enough period of time to judge it, right?
00:42:36.800 --> 00:42:40.800
Because there are time, again, there are tons of people on them, but the dose isn't high enough.
00:42:41.039 --> 00:42:54.320
Um I think, you know, I think the other thing is again, is there are some augmentation strategies, but again, they shouldn't be tried until you've kind of been maximized on an SSRI.
00:42:54.480 --> 00:43:06.639
Often people will give low doses of an SSRI that's not helping, and they start adding other drugs that have more side effects like antipsychotics before they've really actually done what they're supposed to do.
00:43:06.960 --> 00:43:12.559
Is the dosage based on the severity of the OCD or the symptoms that they're coming to you with?
00:43:12.719 --> 00:43:16.800
Because we just upped mine and I don't love the way that I feel.
00:43:16.960 --> 00:43:24.880
So how long, how long should I deal with the new side effects before I realize that maybe the dose was too high and I go back down?
00:43:25.199 --> 00:43:29.280
Well it depends again, you know, it has to know in particular what side effects we're talking about, right?
00:43:29.440 --> 00:43:32.960
Different some side effects people get better with some don't.
00:43:33.199 --> 00:43:35.679
Um, some do get better and some don't.
00:43:36.239 --> 00:43:44.000
And so just monitoring that and you know, but I think, you know, uh again, I think there's no relationship to severity and dosage.
00:43:44.239 --> 00:43:49.840
It's not that people need higher dosage if their OCD is more severe, that that's that there's no relationship.
00:43:50.000 --> 00:44:03.119
There's no relationship to even if somebody somewhat what we'd call has low insight needing needing a different dose, it's just not, it's just some people because of the Their brains, their bodies, they need a little higher than somebody else.
00:44:03.280 --> 00:44:05.039
We all break things down differently.
00:44:05.599 --> 00:44:16.559
Um, and you know, I think I think making sure that like kind of those things are intact, but I think also like to me, the biggest thing is making sure that you understand everything.
00:44:16.800 --> 00:44:26.639
If a doctor's not explaining things to you in a way that you can understand and you don't have all your questions answered, this isn't a good doctor for you.
00:44:26.880 --> 00:44:36.159
And I again I think, you know, and and that's really important, you know, to make sure you feel comfortable, you understand things, you know.
00:44:36.320 --> 00:44:52.639
And again, I think the other most important thing I would say, because I think it's important when you're talking about this stuff, and I know you guys have have dealt with these things and brought up, is it's also remember if a medicine's not working for OCD, sometimes the reason is because they have other comorbid disorders that are being treated.
00:44:52.880 --> 00:45:00.159
So with ADHD, I can do everything I want for the OCD, but until I treat the ADHD, it's hard to get under control.
00:45:00.639 --> 00:45:02.719
Other people might have bipolar illness.
00:45:02.800 --> 00:45:12.800
So sometimes you, you know, you I see patients and they say the refractory OCD patients, nothing working, and then I see them and I say, Yeah, but did anybody else tell you you have this and that you have this?
00:45:13.039 --> 00:45:17.280
So that's another reason patients might not be responding the way you expect.
00:45:17.360 --> 00:45:31.039
And so really making sure sometimes people come in and say, I have OCD, and they just go from there as opposed to you need a full diagnostic interview, everybody consultation to see what else could be going on.
00:45:31.280 --> 00:45:35.119
Um, you know, because I also have to check people are they taking drugs, right?
00:45:35.199 --> 00:45:42.559
There are some people that if they're smoking pot every day, I can do whatever I want, and the needle doesn't move.
00:45:42.800 --> 00:45:44.239
So you Oh really?
00:45:44.480 --> 00:45:55.199
You really have to know the whole picture, what they're taking, what what other diagnoses they have, what other medical stuff, because often the reason people don't succeed is because there are other things going on.
00:45:56.079 --> 00:45:56.320
Right.
00:45:56.400 --> 00:45:58.880
That just touched off so many questions for me.
00:45:59.039 --> 00:46:07.760
One, how many so the THD, I I used to use THC maybe like twice a week.
00:46:07.920 --> 00:46:11.119
Um, and I was like, oh, this is cutting the edge for me at night.
00:46:11.360 --> 00:46:21.519
It was uh, especially like during COVID, I want to say I was using it a fair amount, just because boy, life was boring and and so you'd spice it up a little bit, take the edge off.
00:46:21.760 --> 00:46:25.760
Then over time I found I was waking up the next day, I was much more anxious.
00:46:26.000 --> 00:46:29.599
At least that was how I believed I was reacting to it.
00:46:29.679 --> 00:46:31.119
And so I stopped using it.
00:46:31.360 --> 00:46:38.079
Are you saying that that can inhibit the impact of an SSRI?
00:46:38.719 --> 00:46:44.639
I think that I there are tons of patients, and again, what the dosage is, it's hard to know, right?
00:46:44.719 --> 00:46:49.840
Is is once a month not a problem, but once a week is, or is once a week not a problem?
00:46:50.079 --> 00:47:08.320
I can just tell you that, you know, I continually have seen that when you try to treat people, whether it's for depression, anxiety, OCD with SSRIs, and they're regular pot smokers, the the amount of times you get a response is significantly less.
00:47:08.880 --> 00:47:09.360
Wow.
00:47:09.679 --> 00:47:12.400
So then do you recommend that they quit smoking pot?
00:47:12.480 --> 00:47:18.800
I mean, that person's probably so dependent thinking that was helpful, and now they have to go through the withdrawals of that and then start a new medication.
00:47:18.880 --> 00:47:19.360
What do you do?
00:47:19.679 --> 00:47:23.840
They often tend to not even do anything else until they're off of the pot.
00:47:24.000 --> 00:47:24.159
Yeah.
00:47:24.400 --> 00:47:26.800
Because I don't know who that person is.
00:47:27.039 --> 00:47:29.519
I know who that person on pot is.
00:47:29.679 --> 00:47:29.920
Right.
00:47:30.239 --> 00:47:33.519
So even being able to judge what their symptoms are and everything.
00:47:33.599 --> 00:47:38.639
And remember, one of the problems with cannabis is people use it slowly over years.
00:47:38.719 --> 00:47:41.599
And if you ask them, is it affecting you negatively?
00:47:41.840 --> 00:47:43.280
They will often say no.
00:47:43.760 --> 00:47:50.159
But once you do a trial of getting off it and they're off it for a couple of months, they will say, I sleep better.
00:47:50.400 --> 00:47:53.599
I have more energy, uh, my mood is better.
00:47:53.760 --> 00:47:56.880
And so it's one of those things that I think sneaks up on people.
00:47:56.960 --> 00:48:00.719
So they don't know the effects that cannabis is having on them.
00:48:01.039 --> 00:48:02.079
Yeah, really interesting.
00:48:02.320 --> 00:48:07.039
The other, the other thing you mentioned was uh ADHD and OCD.
00:48:07.199 --> 00:48:11.840
So we've had this conversation a few times on this podcast, but I think it's worth revisiting.
00:48:12.079 --> 00:48:17.039
Alicia and I are both diagnosed with both ADHD and OCD.
00:48:17.280 --> 00:48:44.079
And since being diagnosed with OCD, I've often wondered if actually I'm not ADHD at all, and that the attention deficit stuff that was showing up for me was much more a result of the fact that I was in my head constantly with horrible intrusive thoughts and ruminations and mental compulsions, and that I, as a result of that, appeared distracted and would miss things, which I still do.
00:48:44.239 --> 00:48:45.760
I still miss things now.
00:48:46.159 --> 00:48:51.440
But I don't know that I actually have ADHD anymore.
00:48:51.519 --> 00:48:53.599
Like I've met other people with ADHD.
00:48:53.679 --> 00:49:00.320
I have a very good friend who has ADHD and I see her functioning in the world, and I'm like, I don't know if I have ADHD.
00:49:00.400 --> 00:49:03.920
This person is way beyond my level of attention deficit.
00:49:04.079 --> 00:49:05.840
So anyway, what are your thoughts on that?
00:49:05.920 --> 00:49:13.440
That's that some people are being diagnosed with both of these things, and maybe the OCD is causing what looks like ADHD.
00:49:13.760 --> 00:49:19.280
Well, I think, look, I think one of the problems with ADHD is the diagnosis has the word attention in it.
00:49:19.440 --> 00:49:22.880
So the second people have attention issues, people are like, oh, you must have ADHD.
00:49:23.119 --> 00:49:28.480
The problem is almost every psychiatric disorder, one of the symptoms is inattention, right?
00:49:28.639 --> 00:49:41.440
One of the diagnostic criteria for depression is poor attention in bipolar disorder of distractability, um, in generalized anxiety, poor concentration and focus.
00:49:41.679 --> 00:49:49.519
And so I think you know, you have to be careful, you know, that just somebody having some saying I have inattention does not mean they have ADHD.
00:49:49.679 --> 00:49:49.920
Right.
00:49:50.079 --> 00:49:54.239
And so you really need to do a full diagnostic of ADHD.
00:49:54.320 --> 00:49:56.480
And you also need to ask them questions, right?
00:49:56.559 --> 00:49:59.360
Like, well, tell me what's going on in those periods of time.
00:49:59.599 --> 00:50:05.039
You know, is it because you're lost in your head going over a thought or kind of doing this stuff?
00:50:05.280 --> 00:50:14.159
Um, so I think it's, yeah, I think, you know, people sometimes, and I think ADHD is something that is both over-diagnosed and underdiagnosed.
00:50:14.559 --> 00:50:20.159
I think I think there are plenty of people that don't have ADHD but have given the diagnosis.
00:50:20.320 --> 00:50:24.400
And I think there are plenty of people that have ADHD that have never been diagnosed.
00:50:24.639 --> 00:50:28.000
And so I think something people talk about is this over or under?
00:50:28.239 --> 00:50:29.679
Things can be both.
00:50:30.000 --> 00:50:38.159
And and so, you know, a lot of people that I've treated for OCD that don't respond, it's because they also had ADHD.
00:50:38.239 --> 00:50:44.159
And if you think about it, right, if you have ADHD and one of the symptoms is impulsivity, right?
00:50:44.320 --> 00:50:49.199
So it's hard for you to not give into impulses, how would you be able to resist compulsions?
00:50:49.760 --> 00:50:50.639
Yeah, yeah, yeah, yeah.
00:50:52.079 --> 00:50:55.679
Like yelling and screaming in class, how is he going to resist a compulsion?
00:50:55.840 --> 00:51:04.000
And if somebody's got ADHD and their thoughts are already disorganized, how are they gonna get be able to step back from the OCD in any way?
00:51:04.239 --> 00:51:13.760
And so often you'll see if you treat the ADHD, even if you treat it first and do nothing else, you find some of the OCD just improves from that.
00:51:14.639 --> 00:51:16.880
How do they treat uh uh ADHD?
00:51:17.280 --> 00:51:23.039
So ADHD is, you know, the the you know, the the kind of standard has always been stimulants.
00:51:23.199 --> 00:51:25.920
Um stimulants come in basically two flavors, right?
00:51:26.000 --> 00:51:34.880
They are either amphetamine-based, and those are things like dextoamphetamine, adderall, adderall XR, vivants, or they're Ritalin-based.
00:51:34.960 --> 00:51:37.840
And Ritalin is called also is known as methylphenidate.
00:51:38.000 --> 00:51:43.360
So there's short-acting Ritalin, a little Ritalin LA, long-acting Ritalin, which is concerta.
00:51:43.679 --> 00:51:46.239
And so both treat, you know, both are stimulants.
00:51:46.320 --> 00:51:49.280
There's not a lot of evidence that one's better than the other.
00:51:49.440 --> 00:51:51.360
And so those are the standard treatments.
00:51:51.519 --> 00:51:53.360
Not everybody tolerates those.
00:51:53.519 --> 00:51:57.039
Um, either sometimes it does make somebody's anxiety worse.
00:51:57.119 --> 00:52:01.360
Every now and then you I was just gonna ask, couldn't couldn't a stimulant make your OCD worse?
00:52:01.519 --> 00:52:02.559
I I I've worried about that.
00:52:02.960 --> 00:52:03.440
Yeah, yeah.
00:52:03.599 --> 00:52:07.840
It used to be that people would say that like almost like it was a fact.
00:52:08.000 --> 00:52:10.800
Um, it there are definitely cases where it can make people worse.
00:52:10.960 --> 00:52:17.840
We've also used done studies on stimulants in people with OCD without ADHD, just for OCD that have been successful.
00:52:18.000 --> 00:52:21.679
Lauren Corinne did studies years ago.
00:52:21.920 --> 00:52:30.719
And, you know, not a lot of people followed up on them, but there have been several studies just using stimulants for OCD.
00:52:30.880 --> 00:52:34.320
And I think at ADHD, OCD, they're often really helpful.
00:52:34.480 --> 00:52:41.039
There's always going to be, there is a small cohort who have like OCD or ticks, and then sometimes they just make them worse.
00:52:41.199 --> 00:52:45.840
Um, but it depends also, sometimes if I'm treating them with an SSRI as well.
00:52:46.000 --> 00:52:58.159
Um, but again, you know, and so if people can't tolerate stimulants, we have other treatments, non-stimulant treatments, things like Stratera, well, butrin, um, both can work for AHD.
00:52:58.239 --> 00:53:05.039
They're not as strong as the stimulants are, but they tend to sometimes be a little bit more side effect friendly.
00:53:05.280 --> 00:53:07.360
Um depending on the case.
00:53:07.840 --> 00:53:11.119
Do you think psychiatric meds are overly prescribed?
00:53:11.599 --> 00:53:14.480
Again, I'm gonna probably give you the boring same answer.
00:53:14.719 --> 00:53:17.360
I think they're over-prescribed and under prescribed.
00:53:17.599 --> 00:53:25.840
I think there are people that are on them that don't need to be, and I think there are tons of people whose lives are being destroyed because they're not on them.
00:53:26.239 --> 00:53:30.719
And I think I think it just I think it it goes both ways.
00:53:30.880 --> 00:53:37.760
Um I think, you know, and and that's why, you know, we have like kind of criteria for which we're supposed to be prescribing things.
00:53:38.000 --> 00:53:40.320
And not everybody follows those.
00:53:40.559 --> 00:53:45.519
And, you know, some people just anytime somebody feels an emotion, we'll throw a pill at them.
00:53:45.760 --> 00:53:47.199
And, you know, having normal.
00:53:47.599 --> 00:53:51.599
Or in my experience, trust a doctor who isn't aware of what OCD actually is.
00:53:51.679 --> 00:53:55.840
And when I tell him I have OCD and he prescribes bulbran, we have a problem.
00:53:56.239 --> 00:53:56.400
Yeah.
00:53:56.480 --> 00:54:05.840
Well, and again, I think this is just another thing that people don't do enough, which is it's okay as a doctor to say at some point, this falls out of my area.
00:54:06.159 --> 00:54:12.320
I'm willing to, because you came to me, I'm gonna find you the person that's better to deal with this than I am.
00:54:12.559 --> 00:54:17.920
And sometimes doctors just try to do stuff that they don't know at the expense of the patient.
00:54:18.079 --> 00:54:21.599
And I don't want a doctor practicing on my family.
00:54:21.840 --> 00:54:24.239
And you know, let the ego go.
00:54:24.480 --> 00:54:24.639
Yeah.
00:54:24.719 --> 00:54:31.840
So when there are things that I'm not the best at treating, or people come, I will help them and I will find them somebody to go see and things like that.
00:54:32.000 --> 00:54:34.159
But unfortunately, I don't think that's done enough.
00:54:34.800 --> 00:54:35.119
Dr.
00:54:35.360 --> 00:54:39.039
Poscar uh famously does do heart surgeries, though.
00:54:41.840 --> 00:54:44.159
It's really a hobby, and nothing of friends and family.
00:54:44.880 --> 00:54:45.679
It's a hobby.
00:54:45.920 --> 00:54:48.320
Some do woodworking and heart surgery.
00:54:48.559 --> 00:54:52.320
Um I as kind of a last question because we've taken up a lot of your time.
00:54:52.559 --> 00:55:01.760
Um some people still really feel shame about being medicated for OCD or any number of mental health issues.
00:55:02.079 --> 00:55:08.400
Why do you think medication still carries that stigma even within the mental health community?
00:55:08.559 --> 00:55:15.760
You'll hear from people who are like, no, I was able to do it with therapy, you should just do it with therapy, or, you know, exercise more, eat better, drink more water.
00:55:16.000 --> 00:55:17.280
You hear all these things.
00:55:17.360 --> 00:55:21.840
And I've certainly felt the shame around it, whether that's internal or external.
00:55:22.000 --> 00:55:23.840
So what are your thoughts on that?
00:55:24.480 --> 00:55:25.599
Well, I think a few things.
00:55:25.760 --> 00:55:28.559
I think, you know, we have to take one step further back, right?
00:55:28.639 --> 00:55:33.199
And say, not why is it a shame of medicine, but why is it a shame of mental illness?
00:55:33.440 --> 00:55:41.199
And I think one of the problems with mental illness, in my opinion, is that they sound like things that other people experience.
00:55:41.360 --> 00:55:45.360
So people would say, you know, ah, I have depression, I'm on medicine.
00:55:45.440 --> 00:55:49.679
And somebody will say, you know, I was depressed and down for a while, but I just kind of pushed through.
00:55:49.840 --> 00:55:55.119
And they're comparing being sad and down to major depressive disorder.
00:55:55.360 --> 00:55:57.199
They're not the same thing, right?
00:55:57.360 --> 00:56:07.440
Or somebody saying, you know, hey, you know, I'm anxious and I just kind of pushed through it, but that's not the same thing as having OCD or generalized anxiety disorder or panic disorder.
00:56:07.679 --> 00:56:14.079
So I think because people talk like that, I think then patients think, oh, this is a weakness, right?
00:56:14.239 --> 00:56:17.760
I'm just not strong doing, I'm not pushing enough.
00:56:18.000 --> 00:56:24.239
And I think, you know, and so I think, you know, patients realizing this this is a medical disorder of the brain.
00:56:24.480 --> 00:56:32.400
You know, why, you know, would people feel, you know, kind of shame about taking medicines for migraine headaches, right?
00:56:32.719 --> 00:56:37.360
And and again, it's just this somehow that these have been thought of as this separate category.
00:56:37.599 --> 00:56:40.159
But, you know, like you said, I don't know.
00:56:40.239 --> 00:56:46.159
There are some people with high cholesterol and and high blood pressure that can do diet and exercise and it works.
00:56:46.480 --> 00:56:53.679
I hope people don't feel shame if they have, if it doesn't, that doesn't do it alone and they need blood pressure medicine or cholesterol medicine.
00:56:53.920 --> 00:57:03.760
And so, you know, I think, I think again, I think, you know, I I just to me this, I don't look at these as any different than any other medical disorder.
00:57:04.000 --> 00:57:08.800
And I think when you do, then you start kind of thinking about medicine differently.
00:57:09.039 --> 00:57:26.159
But again, and and that doesn't mean again, it's, you know, you know, part of also, you know, I think part of the problem is it's good, it's a lot of people can do therapy alone, but it's the responsibility of a therapist or anybody you go see for OCD to tell you what the full treatments are, right?
00:57:26.400 --> 00:57:28.239
So to let you know, and vice versa, right?
00:57:28.320 --> 00:57:29.599
This happens in medicine all the time.
00:57:29.760 --> 00:57:32.559
Most psychiatrists don't even know what exposure therapy is.
00:57:32.800 --> 00:57:38.960
You can say you have OCD and if they they'll give you an SSRI and they'll never tell you that.
00:57:39.199 --> 00:57:40.639
Well, it's both on both sides.
00:57:40.719 --> 00:57:48.239
It's your responsibility to give informed consent, which is what you want, what the treatments are, what the what the downsides are.
00:57:48.639 --> 00:57:55.760
And I think that's you know, really important and not to put your own stuff into that when you're treating a patient.
00:57:57.039 --> 00:57:58.239
That is really important.
00:57:58.559 --> 00:58:06.000
If someone listening right now feels hopeless because medications haven't worked for them, what is something that you would like for them to hear?
00:58:06.400 --> 00:58:19.199
So I think that most people who medications haven't worked for, they're often just haven't been given the kind of, you know, type of medication treatment that can help.
00:58:19.440 --> 00:58:24.320
You know, most people that come to me, I rarely see people that, you know, have never been on meds before.
00:58:24.400 --> 00:58:25.519
I do occasionally.
00:58:25.760 --> 00:58:30.079
Most of the cases I see are people that have been on multiple meds, they haven't worked.
00:58:30.239 --> 00:58:33.360
And usually, you know, we can do something to get them better.
00:58:33.599 --> 00:58:37.679
So I think, and that's and that is where you want to maybe go see a specialist, right?
00:58:37.760 --> 00:58:41.039
That, you know, you get to a point, generalist is fine for things.
00:58:41.199 --> 00:58:48.639
But when it gets to a level that goes beyond that, that's the point you might want to find somebody that really does OCD, you know, work full time.
00:58:49.039 --> 00:58:49.519
Well, Dr.
00:58:49.599 --> 00:58:59.760
Stephen Poskar of OCD NYC, thank you so much for putting up with our foolishness for an hour and uh humoring us, you know, even with our crazy questions.
00:59:00.239 --> 00:59:01.679
Yeah, that was really good.
00:59:02.000 --> 00:59:05.039
It's been a pleasure, and thank you guys so much for doing this cast.
00:59:05.199 --> 00:59:16.159
I mean, it's a huge thing for people to know they're not alone and to see people that are smart and funny and have great, you know, full lives um, despite their their OCDs.
00:59:16.239 --> 00:59:17.280
So thanks so much for doing this.
00:59:17.519 --> 00:59:18.719
We'll see you in Seattle.
00:59:18.960 --> 00:59:20.320
See you in Seattle.
00:59:23.280 --> 00:59:29.920
I'm in the thick of this move, which by the way, you guys listening, if you've been following along this journey, we made a decision.
00:59:30.079 --> 00:59:34.480
My family is moving to Kansas City from Southern California.
00:59:35.039 --> 00:59:48.639
And to to say I am facing the most uncertain time of my life uh would be an understatement because we are blowing up our life as we know it in a good way and restarting.
00:59:48.800 --> 00:59:58.719
So we're gonna pivot and lean into to some other opportunities out there and be with our family and have that support and raise our kids with my in-laws and cousins and uncles and all the things.
00:59:58.800 --> 00:59:59.760
So we're very excited.
00:59:59.840 --> 01:00:08.079
Now that the decision fatigue is over and we can lean into that decision confidently, I'm feeling really good about it.
01:00:08.480 --> 01:00:18.880
And for people who've been following along, Alicia and Spence had been looking for houses in the area in Southern California where they are, and it was just insane.
01:00:19.039 --> 01:00:22.400
It was like a million dollars for a shithole.
01:00:22.800 --> 01:00:26.079
1.2 million will get you nothing out here.
01:00:26.239 --> 01:00:30.559
And at some point you have to just say, okay, like I'm done with the rat race.
01:00:30.639 --> 01:00:38.079
There's a lot of things I love about where we live, and there's a lot of things I'm really excited to not experience anymore.
01:00:38.159 --> 01:00:40.800
So yeah, it's wild though.
01:00:40.880 --> 01:00:47.599
I've been in I've been in LA, I've been in Hermosa for 13 years, in California for over 20.
01:00:47.920 --> 01:00:48.960
So my god.
01:00:51.039 --> 01:00:55.280
I don't even own a I don't know how to function in the in the cold.
01:00:55.440 --> 01:00:56.480
It's wild.
01:00:56.639 --> 01:00:59.760
Um but there's so many things to look forward to.
01:00:59.840 --> 01:01:04.800
So I'm just focusing on the positive and trying not to worry because we all know where that gets us.
01:01:04.960 --> 01:01:08.960
Um if I said that there wasn't a lot of those popping up.
01:01:09.119 --> 01:01:13.440
Um, I think I shared before that you can't you can't play God.
01:01:13.679 --> 01:01:20.159
You just have to make the decision and go with it and not think about worst case scenario.
01:01:20.239 --> 01:01:20.800
So that's what I'm doing.
01:01:21.119 --> 01:01:32.880
Yeah, your fear is that in making this decision, you have now somehow set in motion a chain of events that will lead to the death of one of your children, for instance.
01:01:33.039 --> 01:01:35.039
That like because you're moving to Kansas.
01:01:40.639 --> 01:01:44.800
Oh, so now I have to say it, and you need to sit with the distress.
01:01:45.199 --> 01:01:50.400
You know how I want to reframe that is if I stay in California, then maybe something would happen.
01:01:50.559 --> 01:01:53.119
I'm I'm leaving because I'm up, you know.
01:01:53.679 --> 01:01:54.400
We don't know.
01:01:54.639 --> 01:01:55.280
We don't know.
01:01:55.440 --> 01:02:00.400
And I'm gonna be okay with that because that is life, and life is full of uncertainty and change.
01:02:00.480 --> 01:02:01.920
And so there we have it.
01:02:04.320 --> 01:02:07.440
Thanks for listening to another episode of the OCD Confessional.
01:02:07.519 --> 01:02:10.239
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01:02:10.400 --> 01:02:16.159
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