OCD in Adults

00:59:47
https://www.youtube.com/watch?v=WArhJ1zufFg

Résumé

TLDRDr. Adams, a professor at the University of Calgary, delivered an in-depth presentation on obsessive-compulsive disorder (OCD). She clarified the difference between obsessive traits and OCD, explaining that while obsessive characteristics can be adaptive, OCD is a disorder that severely impacts daily life. The talk highlighted the genetic basis of OCD, citing research that indicates a significant heritable component. Comorbidity with other disorders such as depression and ADHD is common. Dr. Adams emphasized traditional treatments including the combination of high-dose SSRIs with Cognitive Behavioral Therapy (CBT), specifically exposure response prevention (ERP), which is crucial for effective management. She also discussed promising alternative treatments focused on glutamate pathways and innovative methods like Magnetic Resonance-guided focused ultrasound for severe, treatment-resistant cases. This advanced procedure targets the brain loops causing OCD, showing substantial potential in improving patients' quality of life. Additionally, the role of serotonin and other neurotransmitters in OCD was examined, supported by brain imaging research. Overall, the presentation underscored the complexity of OCD, the necessity of a comprehensive treatment strategy integrating pharmacology with behavioral therapy, and the importance of ongoing research into novel treatments.

A retenir

  • 🧠 OCD is a brain disorder, not just a behavior issue.
  • 🧬 There is a substantial genetic component to OCD.
  • 🧪 Combining SSRIs with CBT, specifically ERP, is the gold standard in treatment.
  • 🩺 Treatment-resistant OCD may benefit from Magnetic Resonance-guided focused ultrasound.
  • ⚙️ It's crucial to differentiate between obsessive traits and disorder.
  • 🔍 Insight is usually present in OCD unlike delusional disorders.
  • 📈 High doses of SSRIs are necessary for effective OCD management.
  • 🔄 Alternative treatments are exploring glutamate pathways and innovative technology.
  • 📝 Co-morbidities make treatment challenging but targeting them is essential.
  • 💡 Education about OCD's complex nature can aid in better diagnosis and treatment.

Chronologie

  • 00:00:00 - 00:05:00

    Dr. Adams, Vice Dean at the University of Calgary's Cumming School of Medicine, discusses her focus on obsessive-compulsive disorder (OCD). The institution has initiated a wellness hub and a prison health program. Dr. Adams also researches focused ultrasound for OCD treatment.

  • 00:05:00 - 00:10:00

    The discussion transitions to acknowledging the traditional territories of Treaty 7. Dr. Adams expresses gratitude for engaging in these lands and highlights disparities within the healthcare system that must be addressed.

  • 00:10:00 - 00:15:00

    The presentation introduces OCD using Howard Hughes as an example. It discusses the intensity of OCD, differentiating it from typical obsessive personality traits, and how extreme obsessions can impact daily functioning.

  • 00:15:00 - 00:20:00

    Dr. Adams elaborates on the onset and prevalence of OCD, noting its early symptoms can start in childhood. Treatments do not often result in full remission; however, therapy combined with medication shows promise in managing symptoms.

  • 00:20:00 - 00:25:00

    Genetic factors significantly contribute to OCD, with heritability estimates ranging from 27-65%. OCD commonly coexists with disorders like depression and ADHD. Dr. Adams underscores the importance of personalized medication due to varied responses.

  • 00:25:00 - 00:30:00

    Dr. Adams describes OCD symptom clusters, including contamination fears leading to excessive washing and checking rituals driven by doubt. Pure obsessions encompass repetitive intrusive thoughts, while obsessional slowness impacts task completion.

  • 00:30:00 - 00:35:00

    OCD affects individuals through obsessions that cause distress and compulsions designed to alleviate anxiety. Treatment aims for symptom management; however, resistance to the initial drug is common.

  • 00:35:00 - 00:40:00

    The presentation outlines the Y-BOCS tool for measuring obsession and compulsion severity, explaining different levels of time investment, interference, distress, and control related to OCD symptoms.

  • 00:40:00 - 00:45:00

    Neuroscientific understanding of OCD highlights serotonin imbalances and brain activity loops, particularly in the orbitofrontal cortex and striatum, resulting in compulsive and obsessional behavior.

  • 00:45:00 - 00:50:00

    Dr. Adams presents a comprehensive OCD treatment strategy: high-dose SSRIs and cognitive-behavioral therapy (CBT). Alternative options are explored for resistant cases, emphasizing structured medication trials and the utility of the Y-BOCS scale.

  • 00:50:00 - 00:59:47

    Emerging treatments targeting glutamate, such as riluzole, ketamine, and MR-guided focused ultrasound, are discussed. These are for severely resistant OCD cases, and promising results are reported in ongoing University of Calgary research.

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Carte mentale

Vidéo Q&R

  • What is the difference between obsessional traits and obsessive-compulsive disorder?

    Obsessional traits can be adaptive and involve being organized, whereas obsessive-compulsive disorder significantly interferes with a person's life, work, and relationships.

  • What is the genetic contribution to OCD?

    OCD has a significant genetic component, with heritability in adults being 27-47% and in children 45-65%.

  • What are common comorbid disorders with OCD?

    Common comorbid disorders with OCD include depression, anxiety disorders, ADHD, and eating disorders.

  • How is OCD typically treated?

    OCD is commonly treated with a combination of high-dose SSRIs and Cognitive Behavioral Therapy, particularly with exposure response prevention (ERP).

  • What is exposure response prevention (ERP)?

    ERP is a type of cognitive-behavioral therapy where individuals confront anxious stimuli and refrain from ritualistic behavior, leading to reduction in OCD symptoms.

  • What are the signs of severe OCD?

    Severe OCD is characterized by spending more than eight hours a day on obsessions and compulsions, significant distress, and impairment in daily functioning.

  • What alternative treatments are being explored for OCD?

    Alternative treatments include agents targeting glutamate and innovative methods like Magnetic Resonance-guided focused ultrasound for treatment-resistant cases.

  • What is the role of serotonin in OCD?

    The serotonin hypothesis is a key explanation for OCD's neurochemical basis, supported by success in serotonergic drug treatments and brain imaging studies.

  • Can genetic testing assist in OCD treatment?

    Yes, pharmacogenomic testing can guide drug selection based on an individual's specific response and side effect profile.

  • What is the relevance of Magnetic Resonance-guided focused ultrasound in OCD treatment?

    This non-invasive procedure targets specific brain loops responsible for OCD symptoms and has shown promising results in treatment-resistant cases.

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  • 00:00:00
    Dr Adams is a professor in the
  • 00:00:01
    department of Psychiatry and the vice
  • 00:00:03
    dean of the coming school of medicine at
  • 00:00:05
    the University of Calgary uh prior to
  • 00:00:07
    becoming the vice Dean Dr Adams served
  • 00:00:09
    numerous senior leadership POS positions
  • 00:00:12
    with the cing school of medicine during
  • 00:00:14
    her tenure the coming School of Medicine
  • 00:00:16
    opened its student advocacy and wellness
  • 00:00:18
    Hub to all Learners in the faculty for
  • 00:00:20
    counseling on academics career planning
  • 00:00:21
    and mental health the trans disciplinary
  • 00:00:24
    prision health program also launched
  • 00:00:26
    advancing professional development of
  • 00:00:28
    current and Future Care practitioners
  • 00:00:30
    across Canada and internationally Dr
  • 00:00:33
    Adams continues to practice Psychiatry
  • 00:00:35
    and co-leads research on the use of
  • 00:00:37
    magnetic resonance guided focused
  • 00:00:39
    ultrasound to treat resistance obsessive
  • 00:00:42
    compulsive
  • 00:00:44
    disorder um and I'll hand it to you Dr
  • 00:00:48
    Adams thank you so much Julian and uh
  • 00:00:51
    welcome everyone and thank you so much
  • 00:00:53
    for joining me this morning um to talk
  • 00:00:55
    about one of my uh areas of Interest
  • 00:00:57
    which is obsessive compulsive disorder
  • 00:01:00
    um uh next slide Julian thank
  • 00:01:03
    you I'd like to start by acknowledging
  • 00:01:06
    the traditional territories of the
  • 00:01:08
    treaty 7 region of Southern Alberta um
  • 00:01:10
    Calgary is also home to the mate nation
  • 00:01:13
    of Alberta districts five and six and
  • 00:01:16
    I'm especially grateful to be on these
  • 00:01:18
    lands today and and present this webinar
  • 00:01:21
    to you and someone was speaking earlier
  • 00:01:22
    about what's happening in the South uh
  • 00:01:24
    south of us and so again very grateful
  • 00:01:27
    to be on these lands and to um
  • 00:01:30
    acknowledge some of the disparity that's
  • 00:01:32
    occurred in in healthcare um over many
  • 00:01:35
    years and uh a commitment to reconcile U
  • 00:01:39
    some of those disparities and this
  • 00:01:42
    lovely mural is up in the atrium of the
  • 00:01:44
    medical school and um I'd encourage you
  • 00:01:46
    all to to take a look at it if you're
  • 00:01:48
    ever wandering through uh next slide
  • 00:01:51
    thank you so much okay
  • 00:01:53
    so OCD it's always helpful if you have a
  • 00:01:56
    celebrity uh supporting the you know
  • 00:01:59
    this topic and so I don't know if any of
  • 00:02:01
    you saw the movie The Aviator but it's
  • 00:02:03
    uh kind of speaks to the very severe
  • 00:02:06
    nature that OCD can can uh be and it's
  • 00:02:09
    it's really about Howard Hughes and he
  • 00:02:11
    did suffer from OCD a very severe form
  • 00:02:13
    of OCD and so again um The Aviator sort
  • 00:02:17
    of speaks to that as well as this book
  • 00:02:19
    on the LIF leged and Madness of of
  • 00:02:21
    Howard Hughes and what's so interesting
  • 00:02:23
    is that people get so absorbed in their
  • 00:02:26
    obsessions and and rituals that their
  • 00:02:28
    hygiene can very much deteriorate
  • 00:02:31
    because of the length of time that they
  • 00:02:33
    spend in those routines and I think
  • 00:02:35
    that's very much exemplified in the life
  • 00:02:37
    of of Howard Hughes maybe I'm just
  • 00:02:39
    showing my age anyway next
  • 00:02:42
    slide okay general information so I got
  • 00:02:45
    interested in this is a resident which
  • 00:02:46
    was also u a long time ago and I think
  • 00:02:49
    it's a disorder that's really been
  • 00:02:51
    misunderstood a lot of people talk about
  • 00:02:53
    oh I'm I'm obsessive and and many of us
  • 00:02:56
    have obsessive traits which means that
  • 00:02:58
    you know we're organized and it can be
  • 00:03:00
    adaptive that's not what we mean by the
  • 00:03:02
    disorder the disorder is very much where
  • 00:03:05
    it um affects your life and actually
  • 00:03:08
    interferes with your ability to to work
  • 00:03:10
    and have normal relationships and so
  • 00:03:12
    that's the difference between an
  • 00:03:14
    obsessive personality which can be
  • 00:03:15
    adaptive versus the disorder and that
  • 00:03:18
    what we're going to talk about today is
  • 00:03:20
    the disorder which is very different um
  • 00:03:23
    really bothers me when people say oh
  • 00:03:25
    it's my OCD I like a clean house not the
  • 00:03:28
    same thing anyway anyway enough so it
  • 00:03:31
    affects about 2% of the general
  • 00:03:33
    population me mean age of onset is 20
  • 00:03:36
    plus 9 but you know when I asked my
  • 00:03:39
    patients uh when it started it really
  • 00:03:41
    can start in childhood and they remember
  • 00:03:44
    things as as a kid you know worrying
  • 00:03:46
    about cleanliness which is the most
  • 00:03:48
    common form of OCD and and worrying
  • 00:03:50
    about their toys being clean and or
  • 00:03:52
    lining their toys up in a certain
  • 00:03:54
    fashion and sometimes it can disappear
  • 00:03:57
    and then come back at a later date and
  • 00:03:59
    so so I would um argue about when the
  • 00:04:01
    mean age of onset is but we you
  • 00:04:03
    certainly if you ask you can see um some
  • 00:04:06
    form of it in childhood so again most
  • 00:04:09
    have the uh the symptoms before the age
  • 00:04:12
    of of
  • 00:04:14
    25 um it's unfortunate because we don't
  • 00:04:17
    uh despite all our our efforts not a lot
  • 00:04:20
    of people get um 100% remission and so
  • 00:04:24
    most have a progressive deteriorating
  • 00:04:26
    course now I think that's changing with
  • 00:04:28
    time and if if you use the medications
  • 00:04:30
    along with therapy um I think that we
  • 00:04:34
    can amarate that and I think we're doing
  • 00:04:35
    a better job with it if people are are
  • 00:04:38
    um compliant and and understand why both
  • 00:04:41
    medication as well as Erp or cognitive
  • 00:04:44
    behavioral therapy is important um it's
  • 00:04:47
    important to recognize that there's a
  • 00:04:49
    significant genetic contribution to OCD
  • 00:04:51
    our own Dr Paul Arnold who we recruited
  • 00:04:53
    to Calgary Works in this domain the
  • 00:04:56
    genetic heritability of OCD and it can
  • 00:04:59
    be and adults 27 to 47% can have a a
  • 00:05:02
    heritable u cause and kids 45 to 65% so
  • 00:05:06
    there is a significant genetic
  • 00:05:08
    contribution I don't know that we've
  • 00:05:10
    established everything completely but we
  • 00:05:12
    are are much further along in
  • 00:05:14
    understanding that it it can run in
  • 00:05:15
    families and there is a a
  • 00:05:18
    heritability also want don't want you to
  • 00:05:20
    forget that there can be comorbid
  • 00:05:22
    disorders associated with OCD so the
  • 00:05:25
    most common ones are depression um other
  • 00:05:27
    anxiety disorders like panic social
  • 00:05:30
    phobia ADHD is really um um seems to be
  • 00:05:34
    coming into the four there's a lot more
  • 00:05:35
    diagnosis of adult ADHD and it can often
  • 00:05:39
    be comorbid with with OCD Eating
  • 00:05:42
    Disorders also overlap because there can
  • 00:05:45
    be obsessions and compulsions around
  • 00:05:47
    food but again a little bit different uh
  • 00:05:49
    phenotype but there can be some overlap
  • 00:05:52
    with OCD and as I've mentioned the ocpd
  • 00:05:56
    or personality disorder which is very
  • 00:05:58
    different than and the actual Disorder
  • 00:06:01
    so personality traits versus having the
  • 00:06:04
    actual disorder are quite different and
  • 00:06:07
    unfortunately 20% of patients do not
  • 00:06:09
    respond to the first drug prescribed and
  • 00:06:11
    we're going to talk more about the
  • 00:06:13
    medications that we use and and you have
  • 00:06:16
    to try all of them because they're all
  • 00:06:17
    structurally different and so um you
  • 00:06:20
    have to be quite methodical in how you
  • 00:06:21
    approach that um with patients also want
  • 00:06:24
    to mention that there's OCD Related
  • 00:06:27
    Disorders and those can be body
  • 00:06:29
    dysmorphic disorder someone's sort of
  • 00:06:30
    upset with one specific part of their
  • 00:06:33
    face and they'll stare in the mirror for
  • 00:06:35
    hours at their nose and and um be
  • 00:06:38
    consumed by it another common one is
  • 00:06:40
    hoarding which is thought to be
  • 00:06:43
    different than OCD but related um people
  • 00:06:46
    can't throw things away I've had
  • 00:06:48
    patients who they I remember one um
  • 00:06:51
    person who couldn't throw anything away
  • 00:06:53
    that came to them by mail unless they'd
  • 00:06:55
    read it and that was in the days when we
  • 00:06:57
    had all those flyers coming to our house
  • 00:07:00
    magazines and things and they couldn't
  • 00:07:02
    throw it away until they'd read it well
  • 00:07:03
    you can imagine the stacks in in their
  • 00:07:05
    house um trania is another related
  • 00:07:09
    disorder where someone might stare in
  • 00:07:11
    front of a mirror and and pick at the
  • 00:07:13
    the hairs on their scalp or their um
  • 00:07:16
    eyebrows or eyelashes um excoriation
  • 00:07:20
    disorder is another one where people
  • 00:07:21
    will pick at their skin again in an
  • 00:07:23
    obsessive way but it's a little bit
  • 00:07:25
    different in terms of its presentation
  • 00:07:27
    than classic obsessive compuls of
  • 00:07:29
    disorder and tick disorders and
  • 00:07:31
    tourettes obviously can overlap as well
  • 00:07:34
    with
  • 00:07:36
    OCD so um looking at the OCD symptom
  • 00:07:39
    cluster so the the most common one that
  • 00:07:42
    we all think about is contamination by
  • 00:07:44
    dirt and germs and so that is the most
  • 00:07:46
    common Obsession and the accompanying
  • 00:07:49
    compulsion is washing so vigorous
  • 00:07:51
    washing washing several times a day um
  • 00:07:54
    taking up hours in the day using
  • 00:07:57
    excessive amounts of soap sometimes
  • 00:07:59
    counting to a certain number while they
  • 00:08:01
    wash their hands to make sure it's done
  • 00:08:04
    um completely um people describe wanting
  • 00:08:07
    to wash until it feels right and that
  • 00:08:09
    can take hours in a day um that also
  • 00:08:13
    happens in the shower with elaborate
  • 00:08:15
    routines associated with it another
  • 00:08:17
    common symptom cluster is checking so
  • 00:08:20
    the obsession is doubt you know was it
  • 00:08:22
    done correctly did I did I unplug that
  • 00:08:25
    um uh hair dryer uh is that lock
  • 00:08:29
    uh actually bolted those kinds of things
  • 00:08:33
    and so they they ask for reassurance
  • 00:08:35
    from family and friends they go back and
  • 00:08:37
    check a number of times and so as I
  • 00:08:40
    mentioned they might count to a certain
  • 00:08:42
    number and have these repetitive actions
  • 00:08:44
    and very elaborate routines around uh
  • 00:08:47
    checking that their doors are locked
  • 00:08:48
    that their windows are are secured at
  • 00:08:51
    night those kinds of things um another
  • 00:08:54
    common form of OCD which is difficult to
  • 00:08:56
    treat are pure obsessions and so these
  • 00:08:59
    are when there are just intrusive
  • 00:09:00
    thoughts and they go over and over and
  • 00:09:02
    over in your brain and I'll show you
  • 00:09:04
    where that happens um later in my talk
  • 00:09:07
    where it occurs in the brain and they're
  • 00:09:09
    repetitive and they they go over and
  • 00:09:11
    over and they're intrusive and they
  • 00:09:13
    can't get rid of them and often they're
  • 00:09:15
    very ego distonic in other words they're
  • 00:09:18
    reprehensible to The Thinker so they're
  • 00:09:20
    very hard to talk about and if you don't
  • 00:09:22
    ask um they won't tell you about them
  • 00:09:25
    often they can be related to um some
  • 00:09:27
    kind of of illness or a sematic concern
  • 00:09:30
    they're often aggressive or sexual in
  • 00:09:32
    nature and again that's why they're very
  • 00:09:35
    difficult to talk about and again
  • 00:09:36
    they're very reprehensible to The
  • 00:09:38
    Thinker and not in keeping with who they
  • 00:09:40
    are as a person at all the other common
  • 00:09:42
    one is obsessional slowness where things
  • 00:09:45
    take so much time and you often see this
  • 00:09:48
    I I've heard the in kids at school or
  • 00:09:50
    well University students at uh in class
  • 00:09:53
    where you know they'll have an
  • 00:09:55
    assignment and they have to um or
  • 00:09:57
    they're writing a test and they have to
  • 00:09:59
    review what they've written or go over
  • 00:10:02
    that answer again and and you know I
  • 00:10:04
    think we all have that a little bit but
  • 00:10:05
    again this is the disorder where it goes
  • 00:10:07
    over and over in their mind and I've had
  • 00:10:10
    some of my patients who like will get
  • 00:10:13
    rid of their entire assignment and have
  • 00:10:16
    to do it over again repeatedly so you
  • 00:10:18
    can imagine the disruption in their life
  • 00:10:21
    um next Julian
  • 00:10:26
    thanks yeah that's just uh that's the
  • 00:10:29
    sort of classic OCD vigorous uh
  • 00:10:31
    scrubbing and and I guess one of the
  • 00:10:33
    signs as a psychiatrist I look for is
  • 00:10:35
    Red Hands um and that's often very
  • 00:10:38
    telling uh to know how much time they're
  • 00:10:40
    actually spending washing their hands
  • 00:10:41
    it's one of the the things I can look
  • 00:10:43
    for okay
  • 00:10:45
    next um so dsm5 we all hate it but we
  • 00:10:48
    all use it as to understand the disorder
  • 00:10:51
    and and it is helpful it's no longer
  • 00:10:53
    classified as an anxiety disorder
  • 00:10:55
    because it does behave a little bit
  • 00:10:57
    differently and again there's biologic
  • 00:10:59
    underpinnings there's a part in our
  • 00:11:00
    brain that causes these Loops to go over
  • 00:11:03
    and over again and so again what is the
  • 00:11:05
    dsm5 criteria it's recurrent persistent
  • 00:11:09
    thoughts urges or images that are
  • 00:11:10
    intrusive and cause anxiety or distress
  • 00:11:13
    and attempts to ignore or suppress them
  • 00:11:16
    um to neutralize with a thought or
  • 00:11:18
    action and that's the compulsion part so
  • 00:11:20
    when you're very distressed by the
  • 00:11:21
    obsessions you do the compulsive acts to
  • 00:11:24
    try neutralize that very severe anxiety
  • 00:11:27
    that you fear um and that you feel
  • 00:11:31
    next compulsions so repetitive behaviors
  • 00:11:35
    handwashing ordering in a certain uh
  • 00:11:37
    line checking mental acts praying
  • 00:11:40
    counting repeating words silently and
  • 00:11:43
    the person is driven in response to an
  • 00:11:46
    obsession and the behaviors again are
  • 00:11:48
    meant to reduce distress or prevent an
  • 00:11:50
    event yet or connected and people can
  • 00:11:52
    have all sorts of Connections in their
  • 00:11:54
    head that if they don't wash their hands
  • 00:11:56
    a certain number of times or they don't
  • 00:11:58
    count to 10 while they're washing their
  • 00:12:00
    hands something terrible is going to
  • 00:12:02
    happen to their child or to their
  • 00:12:04
    parents and so they make these
  • 00:12:06
    connections um in their brain because of
  • 00:12:09
    these concerns and that's what makes it
  • 00:12:10
    so difficult for them to disengage from
  • 00:12:13
    the rituals because they're so invested
  • 00:12:15
    in something um terrible not happening
  • 00:12:18
    to their family
  • 00:12:19
    members
  • 00:12:21
    next again the obsessions or compulsions
  • 00:12:25
    cause distress so they're time consuming
  • 00:12:27
    at least an hour per day and I'm going
  • 00:12:29
    to tell you about the ybx score that we
  • 00:12:31
    use in terms of the amount of time spent
  • 00:12:34
    in obsessions and compulsions a little
  • 00:12:35
    bit later but to meet the DSM criteria
  • 00:12:38
    it has to be at least an hour a day that
  • 00:12:40
    someone is engaged in these kinds of
  • 00:12:43
    obsessive thoughts and compulsive acts
  • 00:12:45
    and you can imagine how disruptive that
  • 00:12:47
    would be to the person's functioning and
  • 00:12:49
    that's the key to diagnosing this
  • 00:12:51
    disorder and again it can't be
  • 00:12:53
    attributable to a substance use um
  • 00:12:55
    disorder or medical condition and again
  • 00:12:58
    they can't be explained by other things
  • 00:13:00
    like generalized anxiety disorder uh
  • 00:13:02
    body dysmorphic disorder the other um
  • 00:13:05
    OCD Related Disorders that I mentioned U
  • 00:13:08
    but can you you can certainly see them
  • 00:13:09
    along with with OCD symptoms and behave
  • 00:13:12
    in a certain uh kind of a similar
  • 00:13:15
    fashion
  • 00:13:17
    okay
  • 00:13:19
    next and again um what's interesting to
  • 00:13:22
    me is they've they've now specified that
  • 00:13:25
    um so the the Crux of having OCD is that
  • 00:13:28
    you do usually have Insight you do know
  • 00:13:31
    um that this is something that you
  • 00:13:32
    shouldn't worry about you know that it's
  • 00:13:34
    over the top you know that it's
  • 00:13:36
    obsess excessive and obsessive and so
  • 00:13:40
    this is what makes it very different
  • 00:13:42
    from delusional a delusional thinking in
  • 00:13:45
    schizophrenia I've also worked in early
  • 00:13:47
    psychosis and I was very interested in
  • 00:13:48
    that overlap when does an obsession
  • 00:13:50
    become a delusion and so people that
  • 00:13:53
    have OCD they have Insight they know
  • 00:13:55
    that they shouldn't worry about this
  • 00:13:57
    they know that they shouldn't wash their
  • 00:13:58
    hands for the 10th time but they can't
  • 00:14:01
    stop and so again they're they now have
  • 00:14:05
    a classification where OCD can become so
  • 00:14:08
    severe that it's bordering on that uh
  • 00:14:11
    the brink of delusional thinking and so
  • 00:14:14
    that's when you have OCD without insight
  • 00:14:16
    and can have delusional beliefs and I
  • 00:14:18
    was very interested in that that
  • 00:14:20
    intersection of when does an obsession
  • 00:14:22
    actually become a delusion and then you
  • 00:14:24
    can also specify if there's any ticks
  • 00:14:27
    associated with the disorder
  • 00:14:30
    next okay so often I find people are
  • 00:14:33
    very secretive about this and and if you
  • 00:14:35
    don't specifically ask um you won't you
  • 00:14:38
    won't be told they won't tell you about
  • 00:14:41
    their rituals their their mental anguish
  • 00:14:43
    and obsessions that are in their their
  • 00:14:45
    their brain um the compulsive acts that
  • 00:14:49
    they do they can be very embarrassing
  • 00:14:50
    because remember they have Insight they
  • 00:14:52
    know that they shouldn't be doing this
  • 00:14:54
    and they shouldn't worry but they can't
  • 00:14:56
    stop so just remember to ask um um do
  • 00:14:59
    you wash or clean a lot do you check
  • 00:15:02
    things repeatedly again kind of
  • 00:15:03
    open-ended questions so you're not
  • 00:15:05
    leading is there anything that bothers
  • 00:15:07
    you that you can't get rid of in your
  • 00:15:09
    brain but you you can't um how long do
  • 00:15:12
    you take you know to wash your hands or
  • 00:15:14
    how long do you take in the shower is a
  • 00:15:16
    very just a a question that that might
  • 00:15:18
    open the door um again concerned with
  • 00:15:21
    orderliness or symmetry is that
  • 00:15:23
    important and they might seem very
  • 00:15:25
    rudimentary these questions but if you
  • 00:15:27
    don't ask people won't tell you you in
  • 00:15:30
    my
  • 00:15:31
    experience
  • 00:15:32
    next so this is a ybox symptom checklist
  • 00:15:36
    and I it probably hard to read on the
  • 00:15:37
    slide but you are going to get these
  • 00:15:39
    materials that you can look through and
  • 00:15:40
    I find this very helpful because it's a
  • 00:15:43
    list of of um obsessions and and
  • 00:15:46
    compulsions that you may not think about
  • 00:15:48
    asking and so in this list you can see
  • 00:15:50
    there's aggressive sexual religious
  • 00:15:53
    obsessions there's questions about
  • 00:15:54
    hoarding Symmetry exactness and things
  • 00:15:57
    that uh again twig you to ask ask the
  • 00:16:00
    patient once you've determined that they
  • 00:16:02
    have a OCD again they won't always tell
  • 00:16:05
    you about some of the ones that are more
  • 00:16:07
    difficult to talk about um like the
  • 00:16:09
    aggressive obsessions
  • 00:16:12
    next so this is the other part of the
  • 00:16:14
    checklist so again this is the
  • 00:16:15
    compulsions part so cleaning washing um
  • 00:16:18
    repetitive rituals ordering arranging um
  • 00:16:22
    checking compulsions and then if you
  • 00:16:24
    look at the other compulsions again uh
  • 00:16:27
    pathological slowness need to tell ask
  • 00:16:30
    and confess and that's an interesting
  • 00:16:32
    one um I've had U patients who are often
  • 00:16:35
    in a relationship and they they have
  • 00:16:38
    fears about um their spouse having had
  • 00:16:41
    an affair or something like that and
  • 00:16:42
    they have to um confess almost to their
  • 00:16:45
    their partner and and they'll go over
  • 00:16:47
    and over and over it and they'll go back
  • 00:16:49
    and revisit the conversation and um it
  • 00:16:52
    could be again very disruptive in a
  • 00:16:54
    relationship so those are it's a good
  • 00:16:56
    list for you to to go through when
  • 00:16:58
    you're when you're with a patient and so
  • 00:17:00
    you don't miss things okay
  • 00:17:03
    next so this is the ybox scale again
  • 00:17:06
    you'll be getting these materials and so
  • 00:17:09
    um the Y box score is a Yale Brown
  • 00:17:11
    obsessive compulsive scale and it um it
  • 00:17:14
    deals with things looking at time spent
  • 00:17:17
    on obsessions so as I said for the DSM
  • 00:17:20
    criteria you need at least an hour but
  • 00:17:22
    when we look at the ybox scores and and
  • 00:17:25
    what would be considered mild moderate
  • 00:17:27
    or severe we look at the time spent and
  • 00:17:30
    so people can spend between 1 and 3
  • 00:17:33
    hours or 3 to 8 hours and it's it's a
  • 00:17:36
    big jump in that domain and so anyone
  • 00:17:39
    with a score of 26 to 34 would be
  • 00:17:42
    considered moderate to severe and anyone
  • 00:17:44
    between 35 and 40 would be severe so
  • 00:17:48
    these are the domains that you look at
  • 00:17:50
    when you're scoring this time spent on
  • 00:17:53
    obsessions one hour a day 1 to three
  • 00:17:55
    hours a day 3 to eight hours a day and
  • 00:17:58
    and they people actually do spend that
  • 00:18:01
    amount of time and they'll say it's like
  • 00:18:03
    the whole day and they never get any
  • 00:18:05
    relief from it um interference from
  • 00:18:08
    obsessions so again is it definite but
  • 00:18:11
    manageable um is there really impairment
  • 00:18:14
    in in their lives or is it
  • 00:18:15
    incapacitating and for some patients it
  • 00:18:18
    can be
  • 00:18:19
    incapacitating and then the associated
  • 00:18:21
    distress with the obsessions or the
  • 00:18:24
    compulsions again is it manageable or is
  • 00:18:27
    it really disabling and and for that for
  • 00:18:30
    those patients that have very severe uh
  • 00:18:32
    symptoms it really can disrupt their
  • 00:18:34
    life completely and again does does the
  • 00:18:37
    client try to resist um the obsessions
  • 00:18:40
    that's an important factor because some
  • 00:18:42
    people just let it happen and um because
  • 00:18:45
    of the ties to magical thinking about
  • 00:18:47
    things that might happen they'll just
  • 00:18:50
    give in they'll give in to the
  • 00:18:51
    obsessions they'll give in to the
  • 00:18:53
    compulsions and so the question is about
  • 00:18:56
    resist do you try not to wash for the
  • 00:18:59
    third time or do you try not to check
  • 00:19:01
    for that that extra time and so being
  • 00:19:04
    able to resist is is really important
  • 00:19:06
    and and it's an important part of
  • 00:19:08
    treatment going forward and then control
  • 00:19:11
    over the obsessions again how much
  • 00:19:13
    control do they feel they have um can
  • 00:19:15
    they distract themselves can they go
  • 00:19:17
    watch Netflix and you know not be
  • 00:19:20
    focused on what their concern is or or
  • 00:19:22
    do they have no control and they're just
  • 00:19:24
    flooded by these thoughts and then uh
  • 00:19:27
    corating compul of Acts with it and so
  • 00:19:30
    again this scale is what I use
  • 00:19:32
    clinically and also in our research
  • 00:19:34
    protocol that I'll tell you a bit about
  • 00:19:36
    and it um is very helpful just in terms
  • 00:19:39
    understanding the magnitude of the
  • 00:19:41
    disorder okay so I hope that's helpful
  • 00:19:44
    and it's got the at the bottom of the uh
  • 00:19:46
    the ybx scale it does tell you what is
  • 00:19:49
    considered moderate severe and what is
  • 00:19:52
    Extreme
  • 00:19:54
    okay
  • 00:19:57
    next so what is the pathophysiology of
  • 00:20:00
    OCD and this is really important because
  • 00:20:02
    this um leads to how we treat it and so
  • 00:20:06
    again you know when I started in
  • 00:20:07
    Psychiatry we were talking about Freud
  • 00:20:09
    and you know blaming mothers and I don't
  • 00:20:12
    mean that but I kind of do anyway this
  • 00:20:15
    is actually a brain illness this is
  • 00:20:16
    something that is is in our brain and
  • 00:20:18
    and we have evidence for it and so if
  • 00:20:21
    people could stop this they would
  • 00:20:23
    because they do have Insight they know
  • 00:20:25
    they shouldn't worry but they can't stop
  • 00:20:28
    it so why does this happen so again in
  • 00:20:30
    Psychiatry we tend to like to say it's
  • 00:20:32
    everything serotonin related but it is
  • 00:20:34
    true in this case the serotonin
  • 00:20:35
    hypothesis is the current explanation
  • 00:20:38
    for the neurochemical basis for OCD and
  • 00:20:40
    there's lots of of evidence in terms of
  • 00:20:43
    using serotonergic drugs that we'll talk
  • 00:20:45
    about and also it's it's uh supported by
  • 00:20:48
    brain Imaging studies and this is what
  • 00:20:50
    got me interested in Psychiatry it was
  • 00:20:51
    the decade of the brain when we were
  • 00:20:53
    getting into functional brain Imaging um
  • 00:20:56
    structure is fine functioning is not
  • 00:20:59
    and now we're looking at dopamine and
  • 00:21:00
    glutamate that are also important
  • 00:21:02
    modulators in the brain the brain is
  • 00:21:05
    never simple um it's never just
  • 00:21:07
    serotonin it's also dopamine and
  • 00:21:09
    glutamate and that is supporting some of
  • 00:21:11
    our more novel treatments to
  • 00:21:14
    date
  • 00:21:16
    next again so where are these Loops
  • 00:21:18
    these are these Loops that go on in the
  • 00:21:20
    orbital frontal area the cortical St sto
  • 00:21:23
    thalamic Loop and that's where it goes
  • 00:21:25
    over and over and over in your brain and
  • 00:21:27
    I'll show you the next picture
  • 00:21:29
    because you have to see it where it is
  • 00:21:30
    in the brain so it's the pink area the
  • 00:21:33
    CATE nucle nucleus paman Globus padus so
  • 00:21:36
    it's the basil ganglia so you don't have
  • 00:21:38
    to know about the anatomy of the brain
  • 00:21:40
    all you can see is the pink part that's
  • 00:21:42
    the part we're talking about so they're
  • 00:21:44
    very deep structures um where these
  • 00:21:46
    Loops go over and over and over in the
  • 00:21:50
    brain uh
  • 00:21:52
    next again I'm a practical person so I
  • 00:21:55
    like to understand how this happens so
  • 00:21:57
    if you look at left side of the photo so
  • 00:22:00
    where the paman interacts with the motor
  • 00:22:02
    cortex that's where you would have ticks
  • 00:22:04
    and chronic multiple motor ticks and
  • 00:22:06
    I've got us uh the next slide shows
  • 00:22:09
    don't Advance it yet Julian but it will
  • 00:22:11
    explain all of this to you because I
  • 00:22:13
    think you have to know where it occurs
  • 00:22:14
    in the brain so that's where chronic
  • 00:22:16
    multiple motor ticks occur without
  • 00:22:18
    emotional or cognitive system so that's
  • 00:22:20
    on the left side of this diagram my left
  • 00:22:24
    um if you have pure obsessional disorder
  • 00:22:27
    without any motor symp symptoms so no um
  • 00:22:31
    nothing related just the pure obsessions
  • 00:22:33
    that's the ventromedial part of the CATE
  • 00:22:36
    interacting with the lyic cortex and
  • 00:22:39
    then if you have typical OCD it's the
  • 00:22:42
    dorsal lateral part of the codic nucleus
  • 00:22:44
    interacting with the uh motor the
  • 00:22:46
    premotor and Association neocortex
  • 00:22:48
    that's where you get the typical OCD
  • 00:22:50
    because you have to understand in the
  • 00:22:51
    brain how is it that we can have ticks
  • 00:22:53
    that are associated with OCD how do
  • 00:22:56
    these obsessions work where are they and
  • 00:22:58
    and and why can't they be stopped and
  • 00:23:00
    then if you get all of it together where
  • 00:23:03
    does that occur in the brain so I I hope
  • 00:23:05
    this is helpful um
  • 00:23:07
    next this is the explanation that you
  • 00:23:10
    can read later and it was what I was
  • 00:23:12
    just talking about um to understand why
  • 00:23:14
    some people have ticks some people have
  • 00:23:16
    pure obsessions without the rest and
  • 00:23:19
    then some have typical OCD where you've
  • 00:23:21
    got complex cognitive and motor
  • 00:23:24
    behaviors um in addition so you've got
  • 00:23:26
    obsessions and compulsions
  • 00:23:29
    and then um I think I hope it explains
  • 00:23:31
    it a little bit more to understand some
  • 00:23:33
    of the um very Innovative I think Mr
  • 00:23:36
    guided fuss that we're doing to treat uh
  • 00:23:38
    treatment resistant
  • 00:23:40
    OCD okay next let's get on to the
  • 00:23:45
    treatment so mild to moderate severity
  • 00:23:49
    you can consider cognitive behavioral
  • 00:23:51
    therapy which is the exposure response
  • 00:23:53
    prevention alone and that's often what
  • 00:23:56
    uh we do with kids not that I treat kids
  • 00:23:58
    but Dr Dr Paul Arnold does at the
  • 00:23:59
    Children's Hospital and they'll often
  • 00:24:01
    start with cognitive behavioral therapy
  • 00:24:03
    very important and there there is
  • 00:24:06
    evidence to suggest that Erp or
  • 00:24:08
    cognitive behavioral therapy alone can
  • 00:24:10
    achieve what medication can do but
  • 00:24:12
    probably it's best to have both together
  • 00:24:15
    in moderate severe cases we would do
  • 00:24:17
    both so it's always best and the gold
  • 00:24:19
    standard is really to have high does SSR
  • 00:24:23
    that's well tolerated that doesn't give
  • 00:24:24
    side effects along with cognitive
  • 00:24:27
    behavioral therapy so the two together
  • 00:24:29
    are very
  • 00:24:31
    important
  • 00:24:33
    next so here's the medications that we
  • 00:24:36
    use so there's a whole list um and again
  • 00:24:40
    as I mentioned they're all structurally
  • 00:24:42
    different with different uh dose ranges
  • 00:24:45
    and different side effects and I think
  • 00:24:47
    the the failure for treatment is not
  • 00:24:50
    approaching this methodically using a
  • 00:24:52
    medication for a long enough period of
  • 00:24:55
    time at a high enough dose um to see to
  • 00:24:59
    before you decide if it's effective or
  • 00:25:01
    not so a good clinical trial of a
  • 00:25:03
    medication is 6 to8 weeks and some of
  • 00:25:06
    the OCD literature would suggest even 10
  • 00:25:08
    to 12 weeks so you have to be patient
  • 00:25:11
    start with one agent start it at a lower
  • 00:25:14
    dose increase it incrementally pay
  • 00:25:16
    attention to side effects but make sure
  • 00:25:19
    it's a high enough dose for a long
  • 00:25:21
    enough period of time before you say
  • 00:25:23
    it's not working and you can see the
  • 00:25:25
    dose ranges on the slide so
  • 00:25:28
    we often get anti-depressant uh effects
  • 00:25:31
    because these are all anti-depressant
  • 00:25:32
    medications and you get the
  • 00:25:34
    anti-depressive effects at the lower
  • 00:25:36
    dose but if you want the anti anxiety
  • 00:25:40
    and to have the effect on the obsessions
  • 00:25:42
    and compulsions you need to go higher so
  • 00:25:46
    the higher doses of ssris is really what
  • 00:25:49
    we're targeting and again you have to do
  • 00:25:51
    it methodically you do it as a partner
  • 00:25:54
    with your patient and you understand um
  • 00:25:57
    what their experiencing and I learned a
  • 00:25:59
    very good thing from a nurse I used to
  • 00:26:01
    work with and she would always say did
  • 00:26:04
    you take your medication every day and
  • 00:26:06
    they'd say oh yes and then she'd say um
  • 00:26:09
    did you ever miss a few you know maybe
  • 00:26:11
    two or three days well maybe I missed
  • 00:26:13
    three or four and it's like okay um so
  • 00:26:16
    you're actually not getting it every day
  • 00:26:18
    of the week so I really learned a lot
  • 00:26:19
    from from her and I I do ask a lot about
  • 00:26:23
    uh compliance and maybe that's not the
  • 00:26:25
    right word but um understanding if if
  • 00:26:28
    patients are actually taking what you
  • 00:26:30
    what you think they are and I learned uh
  • 00:26:32
    early on that that's not always the case
  • 00:26:35
    so you don't want to be increasing the
  • 00:26:37
    dose if the uh patient is not actually
  • 00:26:39
    taking the medication regularly so some
  • 00:26:43
    some points to consider so looking at
  • 00:26:45
    you know how do we decide which one to
  • 00:26:47
    to use and so what I'll often do is ask
  • 00:26:50
    if there's a family history of OCD so if
  • 00:26:52
    there's a first-degree relative that has
  • 00:26:55
    done well on an SSRI medication that's
  • 00:26:58
    what I would go with I also have the
  • 00:27:00
    privilege of of um working with Dr Chad
  • 00:27:03
    boozman who does a um has a research
  • 00:27:06
    protocol around pharmacogenomic testing
  • 00:27:11
    for SSRI agents and so um it's it's
  • 00:27:14
    great I email him he sends a spit test
  • 00:27:16
    to the patient they spit in the the
  • 00:27:19
    little vial and send it back to him and
  • 00:27:21
    I get this tremendous report which
  • 00:27:23
    doesn't actually tell me which one is
  • 00:27:24
    going to work but it gives me guidance
  • 00:27:27
    to know um what side effects the patient
  • 00:27:29
    might experience on specific SSRI so get
  • 00:27:32
    it's a bit of a guideline as to which
  • 00:27:35
    one to choose which has been very
  • 00:27:37
    helpful there's if you read the
  • 00:27:38
    literature around pharmacogenomic
  • 00:27:40
    testing that some variability of of uh
  • 00:27:43
    it being useful or not but I think we
  • 00:27:45
    just haven't quite um understood the
  • 00:27:48
    importance of it and I certainly find it
  • 00:27:50
    very useful clinically um to understand
  • 00:27:53
    especially if someone has had a number
  • 00:27:56
    of Trials and they've had a number of
  • 00:27:58
    side effects it will give me guidance
  • 00:28:00
    for that so which one do I start with I
  • 00:28:04
    often will start with fluvoxamine which
  • 00:28:06
    has a lot of evidence in the literature
  • 00:28:08
    or cerrine um those are two very anti-er
  • 00:28:12
    energic agents again going up to a high
  • 00:28:14
    enough dose so you can see the range up
  • 00:28:16
    to 300 for Lou Vox up to 200 for
  • 00:28:20
    ceraline um other agents like fluoxitine
  • 00:28:22
    which was one of the first ssris to come
  • 00:28:25
    out um which probably got a bad
  • 00:28:27
    reputation because of that it can be
  • 00:28:29
    very useful in OCD and um peroxin is
  • 00:28:33
    another useful agent and in terms of
  • 00:28:36
    side effects the biggest ones are um
  • 00:28:39
    sexual dysfunction or low libido and
  • 00:28:42
    sometimes a headache when you first
  • 00:28:43
    start them but really they're generally
  • 00:28:46
    much more um Toler tolerable than the
  • 00:28:49
    old tricyclics now one of the
  • 00:28:52
    medications on this list is chamine
  • 00:28:54
    which is a tricyclic anti-depressant and
  • 00:28:57
    it can cause weight gain and sedation it
  • 00:29:00
    still was known as the gold standard for
  • 00:29:02
    treating OCD and so what I will often do
  • 00:29:05
    is start a a medication like
  • 00:29:08
    fluvoxamine titrate it up to a high
  • 00:29:10
    enough dose and then add lowd dose
  • 00:29:13
    clomipramine at bedtime because sleep is
  • 00:29:16
    often a problem and so the sedation if
  • 00:29:18
    it occurs at night is when you want it
  • 00:29:20
    to to happen and and start with you know
  • 00:29:23
    even 50 75 milligrams and see how it's
  • 00:29:26
    tolerated and you don't necessarily have
  • 00:29:28
    to go as High um with that medication if
  • 00:29:32
    the person isn't tolerating it so you
  • 00:29:34
    always need to to uh have a dialogue and
  • 00:29:37
    understand what kind of side effects are
  • 00:29:39
    occurring in order to uh have effective
  • 00:29:42
    treatment the other thing I tend to add
  • 00:29:45
    with Lou Vox and clomipramine is
  • 00:29:48
    aiol and that's a bifi and I usually go
  • 00:29:51
    one to 2 milligrams only and this is a
  • 00:29:54
    better choice than something like
  • 00:29:56
    resperidone um because ridone can cause
  • 00:29:59
    an elevation in prolactin and other
  • 00:30:02
    complications and so I tend to use aiol
  • 00:30:05
    it's not listed on this slide but it's a
  • 00:30:08
    Abilify and it's to get it that dopamine
  • 00:30:10
    part um for treatment so you have the
  • 00:30:14
    serotonergic agents which are these
  • 00:30:16
    primary anti- Obsession agents on this
  • 00:30:19
    slide and then I add a tincture of
  • 00:30:21
    dopamine which is aeropol is my choice
  • 00:30:25
    Abilify people have used respirat
  • 00:30:28
    olanzapine but again sedation weight
  • 00:30:31
    gain um increased prolactin with ridone
  • 00:30:34
    you need to be careful with those kinds
  • 00:30:36
    of of side
  • 00:30:37
    effects um again with Citalopram we used
  • 00:30:40
    to go higher with the dose but again you
  • 00:30:42
    have to be careful of QTC prolongation
  • 00:30:45
    if you go uh above 20 milligrams of Si
  • 00:30:48
    talopram or cyx I've not seen that a lot
  • 00:30:52
    clinically but it is a a sign to warn
  • 00:30:54
    and I believe it's one of your questions
  • 00:30:56
    anyway um so these are the the primary
  • 00:31:00
    anti- obsessions agents that I use and
  • 00:31:03
    again use them
  • 00:31:04
    appropriately titrate them start low
  • 00:31:08
    titrate them to a high enough dose for a
  • 00:31:10
    long enough period of time
  • 00:31:21
    next again okay so I'm fear of being
  • 00:31:24
    repetitive here we go so SSRI Max
  • 00:31:27
    maximize the dose is tolerated and again
  • 00:31:30
    at least 6 to 8 weeks and 10 to 12 is
  • 00:31:33
    even better what do you do if the first
  • 00:31:36
    one doesn't work you choose another one
  • 00:31:38
    and repeat if you've got pharmacogenomic
  • 00:31:41
    testing even better but if you don't
  • 00:31:43
    move to the next agent um taper one and
  • 00:31:46
    start the other and and repeat again as
  • 00:31:50
    described if two to three of the primary
  • 00:31:53
    drugs aren't effective then I consider
  • 00:31:56
    combinations or augment M ation I'm not
  • 00:31:58
    a fan of poly Pharmacy but I think if
  • 00:32:01
    the primary agent isn't working in OCD
  • 00:32:04
    it can be very beneficial to use some
  • 00:32:06
    combinations that I described or to
  • 00:32:09
    augment so um fluvoxamine with chamine
  • 00:32:13
    as I just mentioned is a very useful
  • 00:32:15
    combination again start with the
  • 00:32:16
    fluvoxamine first titrate It Up Add lowd
  • 00:32:20
    do chamine at bedtime and then I do add
  • 00:32:23
    aeropol um that's in 6 augmenting with
  • 00:32:27
    with other agents and my choice in is
  • 00:32:30
    the aapip resole that's listed in in
  • 00:32:32
    number six um others use respiron lopine
  • 00:32:36
    but I've mentioned some of the concerns
  • 00:32:38
    um that are associated with those
  • 00:32:40
    medications second line agents are
  • 00:32:43
    mortaz upine now mapine is excellent for
  • 00:32:46
    anxiety but it causes um sedation and
  • 00:32:49
    weight gain so it's not uh favored by by
  • 00:32:52
    patients other second line agents would
  • 00:32:55
    be then lexine duotine so they work both
  • 00:32:58
    on serotonin and
  • 00:32:59
    norepinephrine and they can be um useful
  • 00:33:03
    in treating OCD so again you have to
  • 00:33:06
    look at your armamentarium start with
  • 00:33:08
    ssris but know how to use these
  • 00:33:10
    medications appropriately or you've lost
  • 00:33:14
    your patient um if you don't stay in
  • 00:33:16
    constant um uh dialogue with them about
  • 00:33:19
    what they're
  • 00:33:21
    experiencing
  • 00:33:25
    next cognitive behavioral therapy very
  • 00:33:28
    important I imagine many of you probably
  • 00:33:30
    practice it uh listening to this webinar
  • 00:33:32
    and so the main state of treatment is
  • 00:33:35
    Erp exposure response prevention and I I
  • 00:33:39
    worry because sometimes um clients will
  • 00:33:41
    tell me that they've got they've had
  • 00:33:43
    therapy and it's not working but if it's
  • 00:33:45
    not evidence-based and it's specific for
  • 00:33:48
    OCD it won't be helpful so the gold
  • 00:33:52
    standard of treatment is a highd does
  • 00:33:54
    SSRI that's well tolerated along with
  • 00:33:57
    cognitive behavioral therapy
  • 00:33:59
    specifically exposure response
  • 00:34:02
    prevention so again it's where you
  • 00:34:04
    confront fearful stimuli and you become
  • 00:34:08
    habituated to it so you kind of let the
  • 00:34:09
    anxiety dissipate and then eventually it
  • 00:34:13
    it goes away and that's what patients
  • 00:34:15
    finally feel uh a relief and will
  • 00:34:17
    sometimes abandon their rituals it it's
  • 00:34:20
    so um rewarding when patients feel that
  • 00:34:23
    relief where they actually are can you
  • 00:34:25
    know focus on something else in their
  • 00:34:27
    life and can actually leave the the
  • 00:34:29
    handwashing and and not spend so much
  • 00:34:32
    time of their day in it um it's
  • 00:34:34
    suggested that you could make a list of
  • 00:34:36
    the patients fears and rituals and kind
  • 00:34:38
    of arrange them according to difficulty
  • 00:34:40
    some therapists will say you start at
  • 00:34:42
    the easiest ones and have the patient
  • 00:34:44
    conquer those I've heard other
  • 00:34:46
    therapists say that they start with some
  • 00:34:48
    of the hardest ones and then all the
  • 00:34:50
    other ones tend to to disappear I think
  • 00:34:52
    you have to again work with the patient
  • 00:34:54
    and understand what would work for them
  • 00:34:57
    and I think they you know you also have
  • 00:34:59
    to explain what is normal behavior
  • 00:35:01
    because it it gets lost um they feel
  • 00:35:05
    that you know washing their hands that
  • 00:35:07
    many times a day is is um is perfectly
  • 00:35:11
    normal and it's not um again you know
  • 00:35:13
    again you have to be realistic if you've
  • 00:35:15
    touched raw chicken and you're cooking
  • 00:35:17
    of course you wash your hands but you
  • 00:35:18
    have to educate the patient about what
  • 00:35:20
    is uh normal behavior and what is
  • 00:35:23
    acceptable in terms of handwashing a lot
  • 00:35:26
    of people ask me how are my patients
  • 00:35:28
    during covid um but interestingly a lot
  • 00:35:31
    of them um coped quite well and and some
  • 00:35:35
    of them felt uh some validation and that
  • 00:35:37
    you know maybe they it was okay to wash
  • 00:35:39
    their hands um but again it's a very
  • 00:35:41
    different uh mode of thinking Some
  • 00:35:45
    people got uh some of my patients got a
  • 00:35:47
    lot worse during covid um because of
  • 00:35:50
    their fears being realized so it was a
  • 00:35:53
    very interesting time but I'd say a bit
  • 00:35:55
    of a mixed bag in terms of people doing
  • 00:35:57
    very well or or not doing well at all so
  • 00:36:01
    again just remember to educate what's
  • 00:36:03
    what's normal um next slide 24 is uh
  • 00:36:08
    yeah cognitive selft talk so I think
  • 00:36:10
    while the patient is attempting the
  • 00:36:12
    exposure um therapists would encourage
  • 00:36:15
    them themselves talk did I think it was
  • 00:36:16
    a problem before did anyone ever tell me
  • 00:36:18
    to worry about this why am I worrying
  • 00:36:20
    about this and then sometimes um if
  • 00:36:23
    they're just unable to engage in therapy
  • 00:36:26
    at that time some sometimes they might
  • 00:36:28
    imagine the
  • 00:36:30
    exposure uh as a form of of The Next
  • 00:36:32
    Step maybe they'll be able to take in
  • 00:36:34
    terms of the Erp so if they can't
  • 00:36:36
    actually do it in real real life they
  • 00:36:39
    might imagine the exposure before they
  • 00:36:41
    actually engage in it um and again
  • 00:36:44
    important to educate the family I've
  • 00:36:45
    seen lots of my patients where the
  • 00:36:47
    family gets incorporated into the
  • 00:36:50
    rituals um somebody you know having a
  • 00:36:52
    shower won't allow anyone else in the
  • 00:36:54
    family to run any other appliances while
  • 00:36:56
    they're in the shower hour as an example
  • 00:36:59
    uh very disruptive to um to family life
  • 00:37:03
    and and and actually doesn't help the
  • 00:37:04
    patient at all it just reinforces the
  • 00:37:07
    the obsessions and and compulsions so
  • 00:37:10
    it's very important to um to remember to
  • 00:37:13
    do
  • 00:37:14
    that
  • 00:37:16
    next so because we have such great
  • 00:37:19
    therapists they're in high demand and
  • 00:37:21
    often there's a weight list so uh I've
  • 00:37:24
    been told that this OCD workbook is very
  • 00:37:26
    helpful and it kind of kind of explains
  • 00:37:28
    um why the patient may be thinking the
  • 00:37:30
    way they do why do the obsessions happen
  • 00:37:34
    um what can they do while they're
  • 00:37:35
    waiting for a therapist in their of
  • 00:37:38
    their own accord in terms of managing
  • 00:37:40
    some of the Erp or even trying some of
  • 00:37:42
    the exposure response prevention at home
  • 00:37:46
    um while they're waiting for for
  • 00:37:47
    treatment so uh this can be quite a
  • 00:37:50
    helpful workbook if if your patient is
  • 00:37:52
    so
  • 00:37:53
    inclined next
  • 00:37:58
    so reasons for treatment failure I you
  • 00:38:00
    wouldn't think a diagnosis would be that
  • 00:38:02
    tough but um I've seen uh patients
  • 00:38:05
    admitted to inpatient uh WS where
  • 00:38:09
    patients are called psychotic and
  • 00:38:11
    they're not psychotic and they if you
  • 00:38:13
    speak to them they um still have insight
  • 00:38:16
    to know that this is um over the toop
  • 00:38:19
    unnecessary but they're so anxious they
  • 00:38:21
    can't stop and and I understand some of
  • 00:38:24
    the confusion because of that close link
  • 00:38:26
    with delusional thinking when does an
  • 00:38:28
    obsession become a delusion as I
  • 00:38:31
    expressed before but if you don't
  • 00:38:34
    understand that you're dealing with OCD
  • 00:38:36
    you may think it's a generalized anxiety
  • 00:38:38
    disorder or worse yet something that's
  • 00:38:40
    in the psychotic domain and then you'd
  • 00:38:42
    only use antis psychotics which would
  • 00:38:45
    not be helpful for a patient with OCD um
  • 00:38:48
    solely on their own and again the most
  • 00:38:52
    important part of treatment failure is
  • 00:38:54
    inadequate treatment so an inappropriate
  • 00:38:56
    or an ineffective medic medication you
  • 00:38:58
    haven't tried the next one as I said
  • 00:39:00
    they're all structurally different so
  • 00:39:02
    you need to try all of them um before
  • 00:39:04
    you deem it to be a treatment failure
  • 00:39:07
    and then again the trial being too short
  • 00:39:11
    or the dose being too low so it's very
  • 00:39:13
    fundamental principles around medication
  • 00:39:16
    use and the other important part is no
  • 00:39:19
    behavioral therapy associated with using
  • 00:39:21
    the medications so um there's been no
  • 00:39:24
    CBT or Erp um as part of the treatment
  • 00:39:27
    picture and that can result in failure
  • 00:39:30
    or compliance again I hate to always
  • 00:39:33
    talk about compliance it's not only a
  • 00:39:35
    patient Factor there's many other
  • 00:39:37
    factors that that can be part of this
  • 00:39:39
    and so uh maybe they don't understand
  • 00:39:42
    the illness and or very helpful family
  • 00:39:44
    members who always have an opinion about
  • 00:39:46
    mental illness which really gets my goat
  • 00:39:49
    I don't think you need those medications
  • 00:39:51
    you know just pull up your socks and
  • 00:39:53
    stop worrying um really helpful
  • 00:39:56
    suggestions like that from family can
  • 00:39:58
    result in patients stopping their
  • 00:40:00
    medication the the other thing I see
  • 00:40:02
    which is a tragedy is that patients are
  • 00:40:05
    actually better um they actually have
  • 00:40:07
    relief for the first time in their life
  • 00:40:08
    around their obsessions and compulsions
  • 00:40:11
    so they stop their medication and it's
  • 00:40:13
    like okay here we go again um and so
  • 00:40:17
    that's one of the uh common reasons for
  • 00:40:19
    for um treatment failure is that they'll
  • 00:40:21
    actually stop their medications and for
  • 00:40:24
    some reason when you go back to the same
  • 00:40:26
    SSRI it doesn't always work I I don't
  • 00:40:29
    know why that is the brain is a complex
  • 00:40:31
    organ and so even though it's worked in
  • 00:40:33
    the past if you've had a Hiatus in
  • 00:40:36
    treatment where they've been off it for
  • 00:40:38
    several months even you go back and use
  • 00:40:40
    the same agent and it doesn't work and
  • 00:40:42
    I'm not sure why that is I'm sure
  • 00:40:45
    someone smarter than I might know why
  • 00:40:46
    that is um anyway and then again the
  • 00:40:49
    unrecognized cognitive impairment I
  • 00:40:51
    think just understanding that people are
  • 00:40:54
    so consumed by the obsessions and and
  • 00:40:57
    they can't focus they can't attend they
  • 00:41:00
    can't concentrate on even what they they
  • 00:41:02
    need to be doing so another thing to to
  • 00:41:04
    think about
  • 00:41:07
    next alternative treatments so again an
  • 00:41:09
    exciting time um in OCD all of these
  • 00:41:12
    agents work on glutamate and so we
  • 00:41:15
    currently have a biohaven study looking
  • 00:41:17
    at ruol as an add-on for medication so
  • 00:41:20
    patients will be on their same
  • 00:41:22
    medications and then we add real usol um
  • 00:41:25
    again looking at the the glutamates
  • 00:41:27
    story or the the contribution that it
  • 00:41:29
    makes to the pathophysiology of OCD
  • 00:41:32
    ketamine lrene and cycloserine also work
  • 00:41:34
    on glutamate cycloserine is a an
  • 00:41:37
    antibiotic and one of our researchers Dr
  • 00:41:40
    Alex mcar did a recent study using
  • 00:41:42
    cyclos sering with rtms or repetitive
  • 00:41:46
    transmagnetic stimulation which I'll
  • 00:41:48
    also tell you a little bit about and
  • 00:41:50
    again found some promising results in uh
  • 00:41:54
    treating OCD so again always looking for
  • 00:41:57
    for new treatments and that's why I
  • 00:41:58
    think clinical trials are so important
  • 00:42:01
    especially in Psychiatry so we come up
  • 00:42:02
    with evidence-based treatments um for
  • 00:42:05
    these brain
  • 00:42:07
    disorders
  • 00:42:09
    next okay something I really want to
  • 00:42:11
    tell you about is a protocol we're doing
  • 00:42:13
    uh in Calgary and if you look down this
  • 00:42:15
    list of neuros stimulation methods it's
  • 00:42:18
    Mr guided focused ultrasound and it's a
  • 00:42:22
    a very Innovative and novel and
  • 00:42:25
    non-invasive way of treating very severe
  • 00:42:28
    treatment resistant OCD so this is a
  • 00:42:31
    nice table if you're trying to
  • 00:42:32
    understand all these new ways of of
  • 00:42:35
    brain stimulation and and what is
  • 00:42:37
    helpful in mental illness at the top you
  • 00:42:39
    see repetitive transmagnetic stimulation
  • 00:42:42
    again that's outside of the scalp it's
  • 00:42:44
    not invasive it's used as a treatment
  • 00:42:47
    for depression and if you go with a deep
  • 00:42:49
    coil there are um there is treatment for
  • 00:42:52
    OCD in that regard and the one I just
  • 00:42:54
    mentioned with Dr mcar with deep TMS as
  • 00:42:57
    well as adding cycloserine I won't go
  • 00:43:00
    through all of these um you can read
  • 00:43:02
    about them because it's helpful when a
  • 00:43:03
    patient might mention that they'd had a
  • 00:43:06
    gamma knife uh in the States you know
  • 00:43:08
    years ago you can understand what that
  • 00:43:10
    might mean but I wanted to focus on the
  • 00:43:13
    Mr guided Focus ultrasound which is
  • 00:43:15
    second from the bottom so it's a
  • 00:43:17
    protocol we're doing in Calgary they've
  • 00:43:19
    also done it at Sunny Brook and Toronto
  • 00:43:21
    and there's um a number of centers
  • 00:43:23
    around the world that also use this
  • 00:43:25
    method of treating treatment resistant
  • 00:43:27
    OCD um lots of it lots of it is in South
  • 00:43:30
    Korea as a start but what's important
  • 00:43:33
    about this is that it's for treatment
  • 00:43:35
    resistant OCD so if you've exhausted the
  • 00:43:40
    ssris the augmentation with ariol other
  • 00:43:44
    um agents if you've tried um Erp
  • 00:43:48
    endlessly and so these are for patients
  • 00:43:51
    where they're consumed by their
  • 00:43:53
    obsessions and compulsions they are
  • 00:43:54
    spending over 8 hours a day
  • 00:43:57
    um in their in these with these concerns
  • 00:44:00
    these are the patients that are
  • 00:44:02
    treatment deemed treatment resistant and
  • 00:44:04
    who we are using as subjects in this
  • 00:44:08
    protocol um we've done six patients so
  • 00:44:10
    far in the midst of doing our seventh
  • 00:44:12
    and the results are amazing and what's
  • 00:44:15
    important to know is this technique is
  • 00:44:17
    the same one that they use for treating
  • 00:44:19
    uh Tremor so there's amazing um videos
  • 00:44:24
    of people being using the same form of
  • 00:44:27
    of treatment for Tremor and you can see
  • 00:44:29
    the the hand kind of shaking before the
  • 00:44:32
    procedure after the procedure their hand
  • 00:44:34
    is steady and they can drink water it's
  • 00:44:36
    it's quite remarkable the hbi has lots
  • 00:44:39
    of these videos um to demonstrate it and
  • 00:44:42
    so it's the same technique but it's used
  • 00:44:45
    to treat treatment resistant OCD and
  • 00:44:48
    that's why I showed you the brain and
  • 00:44:50
    where that that pink area was that's
  • 00:44:52
    where this treatment works and so what
  • 00:44:55
    they do is they use the MRI to know
  • 00:44:58
    exactly where they are in the brain and
  • 00:44:59
    this is being done here by Dr Zelma Kish
  • 00:45:02
    is the functional neurosurgeon and Dr
  • 00:45:04
    Bruce Pike and Conrad roal who look
  • 00:45:07
    after the MRI side of the of the
  • 00:45:10
    procedure so they know exactly where
  • 00:45:12
    they are in the brain the brain is
  • 00:45:14
    heated up um to you can see the the
  • 00:45:17
    degrees 51 to 56 degrees C and they kind
  • 00:45:20
    of create tiny pinpoint lesions in that
  • 00:45:23
    specific area of the brain that I showed
  • 00:45:25
    you and that targets those loops that go
  • 00:45:27
    over and over and over and it's um
  • 00:45:31
    fascinating and um very
  • 00:45:34
    exciting next I'll otherwise I'll go on
  • 00:45:37
    and on so this is kind of what it looks
  • 00:45:38
    like um looks scary but it's not it
  • 00:45:42
    again
  • 00:45:43
    noninvasive they know exactly where they
  • 00:45:45
    are in the brain there's people around
  • 00:45:47
    all the time usually they can do
  • 00:45:49
    bilateral uh so both sides of the brain
  • 00:45:51
    in one treatment and there's um
  • 00:45:54
    medication provided you know people
  • 00:45:57
    there making sure that the patient is
  • 00:45:59
    okay and they make those tiny pinpoint
  • 00:46:01
    lesions I'll just show you some
  • 00:46:03
    preliminary data the next slide which
  • 00:46:06
    shows the Y boox scores over time so
  • 00:46:08
    remember that checklist that I or that
  • 00:46:11
    uh score that I showed you that we use
  • 00:46:12
    clinically that would be um severe or or
  • 00:46:16
    moderate to severe and looking at the Y
  • 00:46:19
    box scores over time so I I vet the
  • 00:46:22
    patients and um deem whether they're
  • 00:46:25
    treatment resistant or not a second
  • 00:46:26
    psychiatrist also sees the patient to
  • 00:46:29
    understand um and be sure about the
  • 00:46:31
    diagnosis uh which is very obvious but
  • 00:46:35
    also that it is treatment resistant that
  • 00:46:37
    they've exhausted all of the
  • 00:46:39
    pharmacology all all the medications
  • 00:46:41
    have been tried with augmentation
  • 00:46:43
    strategies with CBT and Erp and they're
  • 00:46:46
    deemed treatment resistant and so we do
  • 00:46:49
    the ybx score before and I see them a
  • 00:46:52
    week post procedure a month 3 months 6
  • 00:46:55
    months and a year and all the patients
  • 00:46:57
    that we've done are so much better it's
  • 00:47:00
    um it's a small end so we've we're still
  • 00:47:03
    looking to do more patients but the
  • 00:47:06
    results are quite remarkable and and I
  • 00:47:08
    think what's most important is that it's
  • 00:47:10
    about quality of life so that their
  • 00:47:13
    relationships are better they're working
  • 00:47:15
    again they're not so focused on the
  • 00:47:18
    obsessions and compulsive acts it's
  • 00:47:20
    never gone completely but they're not
  • 00:47:23
    having to pay so much attention to it um
  • 00:47:26
    they're not f focused on it they're not
  • 00:47:27
    spending 8 hours a day in it so this is
  • 00:47:30
    quite promising and I'm very excited to
  • 00:47:33
    be part of the the research here at the
  • 00:47:35
    uh through the hbi and the University of
  • 00:47:37
    Calgary and I will stop
  • 00:47:45
    there thank you uh Dr Adams that was
  • 00:47:49
    excellent thank you I'm was going to
  • 00:47:50
    stop sharing and
  • 00:47:54
    um me to do I'm just going to before we
  • 00:47:58
    just um look at the chat and questions
  • 00:48:01
    I'm just going to launch uh the post
  • 00:48:04
    webinar
  • 00:48:06
    [Music]
  • 00:48:07
    valuation is this
  • 00:48:10
    one
  • 00:48:13
    okay and we'll go to
  • 00:48:19
    chat ha all these blank screens I'm a
  • 00:48:22
    people person so I like to see faces but
  • 00:48:25
    I know this is the new way
  • 00:48:30
    ah yes people oh
  • 00:48:35
    good oh thank you so much it's nice to
  • 00:48:39
    see your
  • 00:48:42
    faces okay um Dr Adams I'm going to read
  • 00:48:45
    out the questions as as they came in
  • 00:48:48
    order and the first one is from Kelsey
  • 00:48:50
    are the results from rtms being shown to
  • 00:48:53
    be just as effective as the
  • 00:48:54
    pharmacological combined with py therapy
  • 00:48:57
    approach um I wouldn't say not not yet
  • 00:49:00
    um I think an rtms alone I don't think
  • 00:49:04
    would be as effective so still the gold
  • 00:49:06
    standard is a highd does SSRI along with
  • 00:49:09
    Erp that is still the best form of
  • 00:49:11
    treatment for OCD I think we're looking
  • 00:49:14
    at different protocols for repetitive
  • 00:49:16
    transmagnetic stimulation but you have
  • 00:49:18
    to make sure it's deep coil I showed you
  • 00:49:20
    in the brain how deep those structures
  • 00:49:22
    are and so you have to make sure it's
  • 00:49:25
    it's the right kind of coil for rtms and
  • 00:49:28
    maybe an agent like Dr mcir was using
  • 00:49:31
    where you add a glutamate agent like
  • 00:49:33
    cycloserine there might be some
  • 00:49:35
    opportunity that it would supersede um
  • 00:49:38
    how well you get uh uh treatment
  • 00:49:40
    Effectiveness with ssris and Erp but
  • 00:49:43
    we're not there
  • 00:49:45
    yet okay um question from Ashley lock I
  • 00:49:48
    wondered what Dr Adams thinks about
  • 00:49:50
    trinic for treating OCD I believe it is
  • 00:49:53
    considered off label use for OCD yes so
  • 00:49:56
    VOR otine um I have used it I I tend to
  • 00:50:00
    not I do not meet with pharmaceutical
  • 00:50:02
    companies I was a former program
  • 00:50:04
    director for Psychiatry and I I um tend
  • 00:50:07
    not to use the latest and greatest
  • 00:50:09
    because they come and tell you about it
  • 00:50:11
    but having said that um there is some
  • 00:50:13
    evidence for vortioxetine and I always
  • 00:50:15
    use the generic name which is trellix
  • 00:50:18
    and so um I do have a few patients on it
  • 00:50:22
    and I hope no one were is concerned that
  • 00:50:24
    I call my patients patients because I
  • 00:50:26
    have a deep respect for them and it's
  • 00:50:28
    always a dialogue I know some people say
  • 00:50:30
    client but I hope you understand my my
  • 00:50:33
    deep respect for patients so yes it has
  • 00:50:36
    been shown to be helpful in OCD I don't
  • 00:50:39
    know if it has as much evidence as some
  • 00:50:41
    of the other
  • 00:50:42
    ssris um interestingly it it um can be
  • 00:50:46
    useful with effects on cognition and so
  • 00:50:49
    it might be one that I'm starting to use
  • 00:50:51
    a little more a little more regularly
  • 00:50:53
    some of my patients will also say that
  • 00:50:55
    it has fewer sexual side effects and so
  • 00:50:57
    that might be important um depending
  • 00:51:00
    again uh speaking to your patient and
  • 00:51:02
    what might be important to them so I do
  • 00:51:05
    use it I don't know that there's enough
  • 00:51:07
    evidence for it and and as you say it is
  • 00:51:09
    um off label use but often that's how
  • 00:51:12
    things start right as off label worth a
  • 00:51:15
    try okay Amber Fleming I know several
  • 00:51:18
    pts taking CX 40 to 50 milligrams what
  • 00:51:22
    you say 10 to 20
  • 00:51:24
    milligrams yeah and you know that's what
  • 00:51:26
    the the literature will say 10 to 20 and
  • 00:51:29
    uh another useful agent is caloan which
  • 00:51:32
    is Celexa which is the parent compound
  • 00:51:34
    for scy talopram and so we used to go up
  • 00:51:37
    to 80 milligrams with that but again um
  • 00:51:40
    they shut that down and it's often
  • 00:51:42
    perhaps a patient that might be elderly
  • 00:51:44
    who suffered some um uh effects because
  • 00:51:47
    of of the higher Doses and so they've
  • 00:51:49
    limited the dose I do go higher with
  • 00:51:52
    sialo pramit again these are patients
  • 00:51:55
    that are very um debilitated by their
  • 00:51:58
    symptoms and so I do go higher 30 40
  • 00:52:01
    milligrams of Si tpra and there's been
  • 00:52:04
    no issue with QTC prolongation so I do
  • 00:52:07
    go higher um I tend to go higher with a
  • 00:52:10
    lot of these medications I do have a
  • 00:52:13
    long-term patient on 300 of fluvoxamine
  • 00:52:16
    300 of chamine and 2 milligrams of
  • 00:52:19
    aeropol so you have to be bold but
  • 00:52:22
    cautious in terms of using these
  • 00:52:24
    medications appropriately
  • 00:52:27
    okay uh question from Dr preim have you
  • 00:52:30
    ever referred treatment refractory
  • 00:52:32
    patients to the program at Sunny Brook
  • 00:52:34
    Hospital in Toronto I've tried even
  • 00:52:36
    though Peggy RoR is a colleague she does
  • 00:52:40
    we have a lot of trouble getting people
  • 00:52:41
    in because we're out of Province
  • 00:52:43
    obviously and so they're very lucky that
  • 00:52:45
    they have the only inpatient um
  • 00:52:48
    Treatment Center in Canada and so it is
  • 00:52:51
    I've tried it is very challenging to um
  • 00:52:54
    get someone admitted uh to the Brook
  • 00:52:57
    Center unfortunately again they are
  • 00:52:59
    doing this or have done the same
  • 00:53:01
    protocol that we've done in Mr fuss and
  • 00:53:04
    so we have a lot of uh a good
  • 00:53:05
    relationship with with that group but
  • 00:53:07
    they still won't let our patients in
  • 00:53:09
    considered out of
  • 00:53:11
    Province question from Rebecca Ponting
  • 00:53:14
    in terms of severe to moderate OCD can
  • 00:53:16
    patients medications be managed with
  • 00:53:18
    their GP or would specialist psychiatric
  • 00:53:20
    treatment be essential you know I think
  • 00:53:23
    an initial consultation with a
  • 00:53:25
    psychiatrist who
  • 00:53:27
    un and and not all psychiatrists do
  • 00:53:30
    understand how to use if I'm honest use
  • 00:53:32
    medications appropriately with a high
  • 00:53:35
    enough dose and so I think an initial
  • 00:53:37
    consultation would be really helpful and
  • 00:53:40
    um that's what often I'll do I have an
  • 00:53:42
    anxiety or I'm work in the anxiety
  • 00:53:44
    disorders clinic at the Foothills
  • 00:53:46
    Hospital here and so uh what I'll do is
  • 00:53:49
    manage the medications and then Lea with
  • 00:53:51
    the family doctor and and so they feel
  • 00:53:53
    comfortable with the higher Doses and I
  • 00:53:55
    I understand if you're a family doctor
  • 00:53:57
    you're not always comfortable with
  • 00:53:59
    pushing the dose and so I find an
  • 00:54:02
    initial consultation with Psychiatry is
  • 00:54:04
    really
  • 00:54:06
    helpful the right
  • 00:54:09
    psychiatrist any thoughts about OCD
  • 00:54:11
    versus ocpd and how treatment approaches
  • 00:54:15
    differ yes and so you know we struggle
  • 00:54:17
    with that um you know thinking about
  • 00:54:19
    myself do I have a bit of ocpd probably
  • 00:54:23
    um so again what is what is personality
  • 00:54:26
    and is adaptive versus what is a
  • 00:54:29
    disorder and so I always try to
  • 00:54:31
    understand um that difference and so if
  • 00:54:34
    it really is impacting their life and
  • 00:54:36
    it's disruptive both at work and in
  • 00:54:39
    relationships then I would consider that
  • 00:54:41
    to be the disorder and that's how I
  • 00:54:44
    would approach what we've talked about
  • 00:54:46
    today if someone is more on the
  • 00:54:48
    personality side and is you know
  • 00:54:51
    fastidious I guess is the word we use or
  • 00:54:54
    you know different things we use to
  • 00:54:55
    describe people people perhaps some
  • 00:54:58
    cognitive behavioral therapy along those
  • 00:54:59
    lines might be more appropriate um maybe
  • 00:55:02
    issues around control might be part of
  • 00:55:05
    it as well in on the personality side
  • 00:55:07
    which I think would be different than
  • 00:55:09
    the than the
  • 00:55:10
    disorder okay and there's a another
  • 00:55:13
    question by a direct message to me are
  • 00:55:14
    there any ethical concerns regarding
  • 00:55:16
    utilizing Erp with clients who have
  • 00:55:19
    sexual pedophilia obsessions how should
  • 00:55:21
    one navigate this so you know what I
  • 00:55:24
    think is a tragedy is people not
  • 00:55:27
    understanding um the obsessions related
  • 00:55:30
    to OCD especially when they're
  • 00:55:32
    moralistic or reprehensible so sexual
  • 00:55:36
    aggressive I have a Cadre of of patients
  • 00:55:39
    of young females they're you know
  • 00:55:42
    they're in their 20s and they have
  • 00:55:45
    obsessions about being
  • 00:55:47
    pedophiles now how absurd is that right
  • 00:55:51
    and so they can't babysit they worry
  • 00:55:54
    that they're going to harm the child in
  • 00:55:56
    some way not educating the family is
  • 00:55:59
    critical because parents jump in and
  • 00:56:01
    think oh my God this is terrible we've
  • 00:56:04
    got to get this person help this is uh
  • 00:56:07
    you know pedophilia and so I just
  • 00:56:10
    caution you to make sure and that's why
  • 00:56:12
    history and talking to people is so
  • 00:56:14
    important because you have to understand
  • 00:56:16
    what it is they're worried about they
  • 00:56:19
    and and understand that in these
  • 00:56:22
    obsessions they never act on them so
  • 00:56:25
    they worry about it another common one
  • 00:56:27
    is self harm and that's a tough one to
  • 00:56:30
    distinguish are they actually going to
  • 00:56:31
    harm themselves are they actually going
  • 00:56:33
    to commit suicide no but they worry
  • 00:56:36
    about it and so those obsessions go over
  • 00:56:38
    and over and I've seen unfortunate
  • 00:56:41
    patients being
  • 00:56:42
    admitted and then they're on suicide
  • 00:56:44
    watch well they would never commit
  • 00:56:46
    suicide it's the furthest thing from
  • 00:56:48
    their mind but if you only tick the box
  • 00:56:49
    and say suicidal yep that's what happens
  • 00:56:53
    so they obsess about it but they would
  • 00:56:55
    never act on it so the same thing with
  • 00:56:57
    sexual disorders pedophilia they obsess
  • 00:57:00
    about it the patients that I treat that
  • 00:57:02
    have OCD do not act on
  • 00:57:05
    it next one I'm working an early
  • 00:57:07
    psychosis program and we have a few
  • 00:57:09
    patients who we suspect have antis
  • 00:57:11
    psychotic induced OCD symptoms would the
  • 00:57:14
    treatment differ very good question so
  • 00:57:17
    when I came to uh Calgary I started
  • 00:57:19
    working in the early psychosis program
  • 00:57:21
    having come from Edmonton treating
  • 00:57:23
    everybody with OCD and so you're
  • 00:57:25
    absolutely right our antipsychotic
  • 00:57:27
    agents induce serotonin uh because they
  • 00:57:30
    block serotonin can cause OCD symptoms
  • 00:57:33
    it's very common it's very challenging
  • 00:57:35
    to treat and the the treatment is the
  • 00:57:38
    same so you still use a uh an SSRI I I
  • 00:57:42
    often start with ceraline um in the in
  • 00:57:44
    the patients who have psychosis and
  • 00:57:47
    again titrate up accordingly it can be
  • 00:57:49
    very difficult to treat because of the
  • 00:57:52
    dopamine blockade with your novel antis
  • 00:57:54
    psychotic so when I was in early in
  • 00:57:57
    training we we didn't use some of the
  • 00:57:59
    newer antipsychotic agents and with the
  • 00:58:01
    Advent of those you do see serotonin
  • 00:58:04
    blockade and the emergence of OCD
  • 00:58:06
    symptoms I have a Cadre of those
  • 00:58:08
    patients as well so same treatment
  • 00:58:11
    profile um very resistant and so often
  • 00:58:15
    again Erp can be
  • 00:58:18
    useful okay I'm just very quickly I'm
  • 00:58:20
    wondering about distinguishing between
  • 00:58:22
    when intrusive thoughts move from normal
  • 00:58:23
    to being OCD related I'm thinking the
  • 00:58:26
    distinguisher would be the score on the
  • 00:58:27
    Y box and whether the intrusive thoughts
  • 00:58:29
    are occurring
  • 00:58:31
    constantly and uh
  • 00:58:33
    distressing absolutely right yeah and
  • 00:58:35
    that's the distinction because sometimes
  • 00:58:37
    you know you say I I can't get that out
  • 00:58:38
    of my head that's different um than
  • 00:58:42
    hours spent in obsessions and
  • 00:58:44
    compulsions and and the YB score will
  • 00:58:47
    tell you one to three hours a day 3 to8
  • 00:58:50
    hours a day imagine that very
  • 00:58:53
    distressing very disruptive to their
  • 00:58:55
    life and that would be the distinction
  • 00:58:58
    correct you answered your own question
  • 00:59:01
    sorry last question there are you
  • 00:59:03
    noticing an increase of ASD with OCD
  • 00:59:05
    patients is the treatment the
  • 00:59:07
    same um I I think we have to be careful
  • 00:59:12
    and and speak to just treating what what
  • 00:59:14
    is OCD um so I think I think I'd like to
  • 00:59:18
    stick to the definition of what OCD is
  • 00:59:21
    so that you know there's distinct
  • 00:59:22
    obsessions compulsions associated with
  • 00:59:25
    it and stick to the the very defined
  • 00:59:28
    nature of OCD there's a number of
  • 00:59:30
    disorders that can be comorbid that
  • 00:59:32
    overlap and I think making those
  • 00:59:34
    distinctions is important so um if there
  • 00:59:37
    are OCD symptoms as I've described
  • 00:59:40
    obsessions compulsions to the degrees
  • 00:59:43
    we've been describing then I would treat
  • 00:59:45
    accordingly
Tags
  • OCD
  • treatment
  • CBT
  • SSRIs
  • genetics
  • neurotransmitters
  • ERP
  • focused ultrasound
  • mental health
  • psychiatry