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Dr. Jordan Bawks: [00:01:21] So welcome to PsychEd, the Psychiatry Education Podcast for Medical Learners by medical Learners. Today we'll be talking about OCD, obsessive compulsive disorder. The objectives for today's podcast are that we want listeners to be able to recognise the clinical features of OCD and diagnose it using DSM-five criteria. We want listeners to be able to appreciate the differential diagnosis and how to conduct assessments to help guide clinical judgement. And we want to talk about the bio-psychosocial treatments for OCD. Today we're joined by Dr. Nick Grujich, a staff psychiatrist at Sunnybrook Health Sciences Centre and a part of the Frederic W. Thompson Anxiety Disorder Centre. Dr. Grujich is an award-winning educator of both medical students and residents at the University of Toronto, and we're very happy to have him on the show.
Dr. Nick Grujich: [00:02:12] Thank you, Jordan. Happy to be here.
Dr. Jordan Bawks: [00:02:14] Dr. Grujich, why don't you start by telling us a little bit about your involvement with the Thompson Anxiety Disorder Centre and your interest in anxiety disorders?
Dr. Nick Grujich: [00:02:22] Sure. It happened kind of organically. When I applied for my job here. There was an opening in OCD clinical work. I guess I was working with Dr. Peggy Richter and not long after we started seeing.. Well, not long after I started seeing OCD patients, she had a tremendous donation that was offered and that's what allowed us to start the Frederick Thompson Anxiety Disorders Program.
Dr. Jordan Bawks: [00:02:50] Great. So we you know, one thing that I'm always conscious of when I'm teaching medical students is that there seems to be a common mistake when people in kind of the lay public talk about OCD, like, "oh, my friend is so OCD." Usually they're actually talking about OCPD, which we'll talk about later. But Dr. Grujich, can you give us like a plain language summary of OCD to set the frame for today's podcast?
Dr. Nick Grujich: [00:03:17] Sure. So obsessive compulsive disorder is an anxiety disorder and the symptoms are marked by a intrusive or persistent image that that gets stuck in someone's mind. And as a consequence of that, they feel anxiety and distress related to it, and they typically find some sort of compulsive behaviour or mental ritual that they engage in to try and alleviate the anxiety caused by the obsession.
Dr. Jordan Bawks: [00:03:43] Okay. It's pretty plain language to me and we'll get deeper into the DSM five criteria shortly before we do. Aarti, do you want to actually we should formally introduce you to the show. This is Arthur's first podcast. Why don't you introduce yourself, Artie?
Dr. Aarti Rana: [00:03:58] Yeah, Thank you. Jordan. My name is Aarti Rana, and I'm a PGY one in psychiatry, just starting my residency and learning all about OCD today.
Dr. Nick Grujich: [00:04:07] Fantastic.
Dr. Jordan Bawks: [00:04:08] And I forgot to introduce myself too. I'm Jordan Bawks. Maybe you recognise my voice from the previous episodes. I'm a PGY-2 in psychiatry, currently working at Mount Sinai Hospital in Toronto. So Aarti, why don't you tell us a bit about the epidemiology of OCD?
Dr. Aarti Rana: [00:04:23] Yeah.So as we know, OCD is seen with equal frequency in both men and women, and the mean age of onset is around 20 years old. It has a chronic course and it tends to be highly familial. So 10% prevalence rates in the first degree. Relatives of those with OCD, if you have a relative 10% likely to have OCD, there's a high degree of shame related to the contents of obsessions of OCD, which we'll probably dig a little bit further into.
Dr. Jordan Bawks: [00:04:53] Yeah, I mean, I think that's something that you think about when you're seeing a patient who's like young and they're quite anxious and you feel like something's missing because the contents of the obsessions can be pretty upsetting to people and it can be hard for them to talk about it. Dr. Grujich, any thoughts on kind of like the the typical ages or the types of patients that you tend to really start to suspect OCD early on just based on?
Dr. Nick Grujich: [00:05:20] Yeah. So generally speaking, OCD starts in adolescence or early 20s. I've seen OCD in very young people as young as five, six, 7 or 8 years old. But OCD can also start later in life. But the mean age of onset is usually in one's 20s. Once you have a diagnosis of OCD or you have the symptoms of OCD, they tend to persist over the course of one's life. What people tend to describe is a waxing and waning of symptoms, which are generally in proportion to stressors and life events that are going on around the same time.
Dr. Jordan Bawks: [00:05:56] Okay, so why don't we clearly flesh out the DSM five criteria for Ocd? So first this is one that I actually find tricky still to this day. It's the the presence of obsessions, compulsions or both. So you actually don't need obsessions and compulsions to have OCD, so.
Dr. Nick Grujich: [00:06:17] That's correct. Now, having said that, the vast. The majority, upwards of 90% of people who have one will have the other. So the typical pattern we'll talk about this is that an obsession is followed by a compulsion, and that happens in over 90% of individuals. Now, correct. As per DSM strictly, you don't need to have both. But the vast majority of people that you'll come across will have both.
Dr. Jordan Bawks: [00:06:41] Okay. And when the DSM five, like when psychiatrists talk about obsessions, we're talking about persistent unwanted thoughts, images or impulses. So these are kind of felt by patients to be intrusive, uncontrollable. They tend to provoke anxiety because they're distressing and they often result in an attempt to ignore or suppress them, which is where we get to the compulsions.
Dr. Nick Grujich: [00:07:07] Absolutely.
Dr. Jordan Bawks: [00:07:07] So when we talk about compulsions in the DSM five lingo, we're talking about repetitive behaviours or mental acts. And that was one that I always kind of forget to ask about with patients. But that compulsions don't just have to be physical behaviours. They can be like counting or reciting kind of mantras.
Dr. Nick Grujich: [00:07:28] Is that right? Yeah.
Dr. Nick Grujich: [00:07:29] So we call those mental rituals.
Dr. Jordan Bawks: [00:07:30] Mental rituals. And they're sort of performed, as you said, They follow obsessions. They're performed in response to obsessions, often in kind of a ritualistic, patterned fashion.
Dr. Jordan Bawks: [00:07:40] And the intention, the kind of the use of them is to reduce the distress that's associated with the obsessions.
Dr. Nick Grujich: [00:07:46] Exactly is the point. Now, they're not always connected. I mean, we'll talk about specific phenotypes of OCD, but sometimes the compulsion can have no connection with the nature of the obsession.
Dr. Jordan Bawks: [00:07:57] Okay. So it's not always as clear as fear of contamination and hand-washing.
Dr. Nick Grujich: [00:08:02] Exactly.
Dr. Jordan Bawks: [00:08:03] And as per usual in the DSM five, the symptoms must cause distress and significant functional impairment. And the specifier they use in the OCD is that they, the symptoms must take up over an hour of the day. Is that something that you find?
Dr. Nick Grujich: [00:08:19] So that's an important one because some degree of checking and and cleanliness, if you will, or cleaning behaviour, that's all normal. It's all well within the normal scope of human experience. Ocd becomes pathological or quote unquote diagnostic meeting diagnostic criteria when it becomes functionally impairing and when it actually starts chewing up more than an hour per day.
Dr. Jordan Bawks: [00:08:43] Okay. And the DSM also has some specifiers. So talking about patients with or noting patients with good or fair or poor insight and sometimes absent insight and almost a delusional level like a quality to them.
Dr. Nick Grujich: [00:09:01] Exactly. So that was the DSM five edition.
Dr. Jordan Bawks: [00:09:04] Okay.
Dr. Aarti Rana: [00:09:06] Yeah. Dr. Grujich, I'm curious. Sometimes you have patients that say, of course, I checked the door five times every night before I go to bed. How do you actually ask the right questions to get at whether or not this is really OCD? What are the screening questions that you're asking people when you have a high suspicion?
Dr. Nick Grujich: [00:09:21] That's a very good question. Ocd can have many different phases, and for that reason, it's often missed. Primary care physicians and even psychiatrists will often mis misinterpret people's symptoms as a different anxiety disorder or some other illness. So maybe we'll take a moment at this point to talk about different types of OCD or different phenotypes. So the first one that we often see in the media and that people usually ascribe to OCD are obsessions around contamination. So this can be a fear of having HIV or things being dirty or unclean. And that thought gets stuck in one's mind and causes distress. And so the compulsion that's typically associated with that are compulsions around cleaning. So maybe it's undressing when you come into the home and having to wash all the clothes, hand-washing, excessive showering routines and so on. Second common OCD theme is around doubt. So it's obsessional doubt. Did I lock the door? Did I not lock the door? Did I say the right thing when I was speaking to this friend? Is this email correct? Is it going to be misconstrued? And so there's often catastrophic thinking that's associated with doubt, obsessions. And of course, the typical compulsion that would follow would be checking behaviour. So checking doors, checking locks, appliances, checking, rechecking emails, checking and double checking thoughts or reviewing narratives of discussions with friends that's associated with OCD thinking. The third one is a bit of a grab bag where it's a need for orderliness or things to feel just right.
Dr. Nick Grujich: [00:11:04] And so this is where symmetry counting, superstitious numbers, odds and evens these things can all be part of that grab bag of symptoms. And then the last one, which is very common and often the most distressing, but the one that's typically associated with the most shame are what are called intrusive thoughts that tend to be of violent, religious or sexual themes. So if someone identifies as heterosexual, they might have an image of homosexual act and they can't get that thought out of their mind and it tends to cause a lot of distress. So again, when someone has these types of obsessions, they will come up with all kinds of potential rituals, be them behavioural or mental in nature, to try and reduce that distress. So let me come back to your point actually, in typical, when I see a patient with an anxiety disorder, I'll ask them if they ever get thoughts stuck in their head that caused them distress and that they typically engage in some sort of repetitive behaviour or some thought process to try and alleviate that anxiety and distress. If my index of suspicion is higher, then I might go into specific examples like the themes that we talked about. So I might ask about contamination, doubt, intrusive thoughts or things needing to feel just right type of obsessions.
Dr. Jordan Bawks: [00:12:31] Okay. I think that Segways pretty nicely into the next set of questions we were hoping to ask you, which is around differentiating like OCD from other common kind of mimickers like the common kind of differential diagnoses that are tricky to tease apart. So for example, someone with like really severe generalised anxiety disorder, what kind of questions or features might you try and find to tease those apart?
Dr. Nick Grujich: [00:12:58] Good question. So I think right off the bat, like all of our mental health diagnosis, they typically flock together. Rarely will you see someone with pure OCD without a comorbid anxiety disorder or mood disorder or substance use disorder or so on. So I think that we want to try our best to distinguish between the symptoms that are being presented and how to understand the diagnosis. But it's not uncommon for people to have multiple different disorders happening concurrently. So with GAD specifically, there's often this sense of rumination or quote unquote obsessional thinking. But what's different is with GAD, it's more of a broad free flowing type of worry. And the worries are typically around normal, everyday events. So a worry about finances. A worry about relationship. A worry about one's personal health. And they tend to move around and be free flowing. And the worries are kind of consistent with the person's belief they want to be problem solving. And so they see their worrying on some level as advantageous to prevent surprise or to plan and prepare. They also don't describe compulsive behaviours the way someone with OCD might. So, again, it can be difficult to distinguish, For example, if somebody is concerned about where their partner is, they might start checking their phone in a compulsive fashion. Curious when they're going to get a text from that loved one to say that I'm okay. But again, you distinguish that because they see that behaviour as reasonable and rational and it's unique to that one situation that's related to an everyday type of event. With OCD, the patient again, in the with the exception of the low insight OCD symptoms, they typically have a good sense that their worries or their obsessions are irrational.
Dr. Aarti Rana: [00:15:01] Okay. And how about eating disorders? I mean, that's an instance where someone has a particular kind of obsession and a compulsion response to that, which is to change their eating habits. But we don't call that OCD. Right.
Dr. Nick Grujich: [00:15:15] So in the DSM, they talk about what is the best fit for the symptom criteria. If all of the obsessional thinking and compulsive behaviour is exclusively related to eating behaviour, then you'd be more appropriately diagnosing an eating disorder rather than an OCD disorder. Now, having said that, people who work in eating disorders populations will be the first to say that OCD is typically a comorbid illness and the two often flock together.
Dr. Aarti Rana: [00:15:47] Okay. And you had mentioned one of the new DSM five criteria was kind of a psychotic component to the OCD. How do you distinguish it generally from psychotic disorders that might have an obsessive component to them?
Dr. Nick Grujich: [00:16:01] Right. So again, that could be tricky. Like all things in mental health, we talk about spectrums and continuums. And so there's folks who struggle with OCD that have good insight and can appreciate that their obsessions are irrational, although they continue to engage in the compulsion because that's what relieves the anxiety. But as you move along that continuum towards less insight, that's when it can start feeling delusional. When you look at psychotic disorders, I guess you look at clusters of symptoms. So if someone has schizophrenia, you look for things like negative symptoms, prodrome family history and other components, whereas with OCD, you might not see some of the other associated symptoms that typically come with primary psychotic illnesses. The other thing obviously, is that with OCD, there's the compensatory compulsions, whereas with psychotic disorders related to primary psychotic illnesses, you don't typically see as clear of an association.
Dr. Jordan Bawks: [00:17:00] Yeah, that makes me think a little bit about like depression. Like sometimes if I'm screening, like I've found somebody who is. I'm working with somebody who has depressive symptoms, feel pretty good about that. And then I'm moving kind of into an Anxiety disorder screen and I let myself slip a little bit and I'll sort of say something, a screening question like, "Do you have any obsessions? Like, do you tend to obsess about things?" Then people will kind of like volunteer in the colloquial sense, like, yeah, I'm obsessing about and sometimes it's in depression. It tends to be like about a loss or about a personal inadequacy. And in those situations, like you don't see the there's no compulsion to fix that. It's just kind of a rumination as opposed to an actual like obsession in the way. Good point. We think about it.
Dr. Jordan Bawks: [00:17:48] I wanted to quickly talk about tic disorders, trichotillomania, body dysmorphia, hoarding.
Dr. Nick Grujich: [00:17:56] Sure. So in DSM for OCD, PTSD and and the classical anxiety disorders were in one chapter called the Anxiety Disorders in DSM five. They pluck them out because there was a number of orphan disorders that didn't really have a home. And they had a lot of overlapping components with OCD and of course, with PTSD and trauma-related disorders. So from my understanding, the folks who put together the DSM five purposefully put OCD close to the Anxiety disorders chapter to convey their connection. Yet OCD is now in an independent chapter called Obsessive Compulsive and Related Disorders. So we'll go over the different diagnoses that fall in this chapter. So OCD, of course, hoarding disorder, skin picking disorder, hair pulling disorder and body dysmorphic disorder. So tic disorders are not actually there. Tic related is a specifier as part of OCD because people who have OCD and tic disorders have a different phenotype than other types of OCD. So those are the different related disorders. I guess I don't know how much detail you want to go into them. Theoretically, we could do a whole podcast on each of those independently, but if you can look at them all individually, they all have some degree of fixation on something or some sort of obsessionality with some sort of repetitive behaviours. Again, they're all quite different, but those are the themes that connect them.
Dr. Aarti Rana: [00:19:37] One way to understand that better for me at least, would be to go back to this distinction between obsession and compulsion, which I always struggle with, especially when it comes to like mental acts. So you can have an obsession that's mental, but you can have acts or compulsions that are also mental. Can you clarify that distinction a little bit?
Dr. Nick Grujich: [00:19:59] Sure. Yeah. Yeah. So. So let's take, um, let's take someone who has a violent, intrusive thought. So I have a young child at home and I have this horrible graphic image of me hurting the child. So specifically, let's say it's an image of stabbing my child. Now, I have no wish to do that. Obviously, I love my child. And when that thought comes into my mind, it's very, very, very distressing and anxiety provoking. And I question whether I'm going to do it or not, even though I know I'm not. There's this gnawing question that happens and the distress goes up. You can imagine how a parent might feel if they have that and some of the shame that's associated with that. So I think we'll talk about this later, but it's not consistent with my beliefs. And the term egodystonic comes up. I'll talk about that later. But when I have that thought, I will scramble to try and figure out a way to get rid of that thought. And so if I figure out a mental ritual that I can engage in that alleviates the thought, then that might become a paired compulsion. So a mental ritual might be where I would go in over in my head every time I've interacted with a child and I've not hurt the child or these kinds of reviewing of of mantras or saying things to oneself or reviewing evidence in one's mind. So these are different types. Some people will engage in mental rituals like counting over and over and over again as a way of alleviating the distress related to the obsession.
Dr. Jordan Bawks: [00:21:43] One of the common differentials that I know medical students often get pimped on that we haven't gotten to yet is differentiating OCD with OCPD.
Dr. Nick Grujich: [00:21:52] And are they the same thing?
Dr. Jordan Bawks: [00:21:55] Not quite the same thing.
Dr. Aarti Rana: [00:21:57] Ocd. Aren't we supposed to all be OCD? .
Dr. Jordan Bawks: [00:21:59] All medical students have OCD? Yeah. So this is sort of what I was alluding to earlier. And again, not that we have kind of the time today to really go into OCPD, but that's OCPD Obsessive Compulsive Personality Disorder is really unfortunately named because it shares three of the same syllables. And in some respects you can see some of the similarities, like in terms of the tendency to kind of like obsess in the more like colloquial sense to be very detail-oriented to be perfectionistic, to be moralistic, to be rigid, to want to sort of alleviate anxiety through control. That's kind of what I think about when I think about OCPD as a personality disorder.
Dr. Aarti Rana: [00:22:49] Yeah, kind description of medical students.
Dr. Jordan Bawks: [00:22:53] Well, we all have traits. And, you know, without this is the interesting thing about personality disorders, which is a soapbox for another time, but is that, everybody has a personality, right? Everybody has personality traits and we in the DSM five, we really characterise a disorder by marked functional impairment. So by that stretch, the majority of medical students, by the fact that they got into medical school by the fact that they continue to attend medical school, don't have ocpd full on, but probably something that a little bit of the traits helps them study for tests and get those bonus marks.
Dr. Nick Grujich: [00:23:24] I'll give you one clinical example which highlights it. So the patient who comes in and you ask them about cleaning and they say, I clean for two hours a day. So is that OCD cleaning or is it OCPD cleaning? So when you ask them what motivates the behaviour, they'll tell you that they enjoy having a clean house. They like to do this. This is consistent with what their beliefs are and what they want. Whereas the person with OCD will say, I know that this is excessive and ridiculous, but it's the only way that I can get rid of these intrusive thoughts around germs being in my house so they can see the behaviour as problematic. But they can't stop the behaviour because if they don't do the behaviour then they have the painful anxiety, whereas the OCPD is kind of a rigid, fixed, perfectionistic need to be done my way and this is the way I like things done.
Dr. Jordan Bawks: [00:24:20] And that's where the buzzwords that come in from medical students who are looking to score on their exams and impress their supervisors comes in Egodystonic versus Egosyntonic, which you kind of mentioned earlier. So ego kind of meaning like mind your conscious mind in this sense, it's something that's egosyntonic is something that you feel is consistent with your values. It's something that doesn't cause you like active distress versus Egodystonic is something that feels like foreign to your own mind, something that, yeah, it feels kind of intrusive and upsetting.
Dr. Aarti Rana: [00:24:52] Let's say this patient has been referred to your office by their GP and the GP suspects they have OCD. Is there anything else in the history that you want to cover that we should be asking about that we haven't touched on yet?
Dr. Nick Grujich: [00:25:05] You know, without going into too much detail, I think you screened for comorbidity, obviously special populations like youth pregnancy, geriatrics, if there's a bipolar mood disorder, if there's an active substance use disorder, these are all factors that we always think about that might impact our treatment suggestions. You want to look at severity, you want to look at supports, you want to look at whether the person has the capacity to engage in psychotherapy or medications. And you want to start looking at the patient in terms of your bio psychosocial formulation to identify treatments that are appropriate.
Dr. Aarti Rana: [00:25:43] And speaking of special populations options, what if you have a youth who recently had a throat infection? Oh.
Dr. Jordan Bawks: [00:25:51] Pandas. Yeah.
Dr. Nick Grujich: [00:25:52] So which one of you champs wants to talk about that one?
Dr. Jordan Bawks: [00:25:55] We try to talk about it in the hall before we came in, and I think I botched it, so.
Dr. Aarti Rana: [00:26:00] Couldn't remember the acronym, to tell you the truth.
Dr. Nick Grujich: [00:26:03] So there is this this idea that strep infections can cause OCD and there's a very real and and and observed phenomenon around that. I work with adults and so I don't typically screen for that. Sometimes adults will ask me to prescribe them antibiotics because they've heard on TV news programs that antibiotics can treat OCD. However, there is no evidence in the adult literature. It's not in the guidelines that antibiotics are a viable treatment for adults with OCD.
Dr. Jordan Bawks: [00:26:40] All right. So for listeners who want to go read up about that because they're working with paediatric populations. They can Google paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. And the Wikipedia article looks pretty comprehensive to me right now. I think that the PANDAS acronym there is quite helpful. Lastly, before we wrap up kind of diagnosis and move into treatment. Is there anything that you kind of look for or comment on as part of your mental status exam in patients who have OCD?
Dr. Nick Grujich: [00:27:16] So sometimes it's obvious, but most of the time it's not. So when I say obvious, I mean someone that engages in rituals when they're sitting in your chair. So if before they talk, they have to engage in a pattern of rituals or before they engage in movements. I mean, these are the kinds of things that are obvious. I remember one patient before they would start talking, they would have to look at all four corners of the room before they could start talking. And so I guess on mental status exam, you keep your eyes open and you look for things, but oftentimes they're subtle. And if they're mental in nature, you'll never get them. So I think that on mental status, the patient with OCD will often come across as globally a bit anxious or apprehensive. But if they do have rich rituals that you can observe, then that's something you obviously comment on.
Dr. Jordan Bawks: [00:28:07] All right. So let's take a second to pause and summarise what we've talked about so far. We talked about the epidemiology of OCD. We talked a little bit about its natural course. We've talked about the nature of obsessions, that they're intrusive, upsetting thoughts, images or impulses, and we've talked about compulsions which are repetitive behaviours or mental acts that are usually done to reduce the anxiety associated with obsessions. And we also talked a lot about the differential diagnosis and how to distinguish different psychiatric syndromes from OCD using kind of screening questions and thinking about course and of course, family history factors in there too.
Dr. Jordan Bawks: [00:28:51] And we spent a little bit of time talking particularly about OCPD, because it's such a common question for medical students and junior residents. So now we'll move on to the treatment of OCD. Dr. Grujich, can you give us an overview of the treatment of the what are the treatment pptions for OCD and how do we choose between them?
Dr. Nick Grujich: [00:29:12] So your options would be psychotherapy or pharmacotherapy? We'll talk later on about research based or somatic treatments for OCD, but predominantly at this point, the guidelines would recommend either psychotherapy, which is a cognitive behavioural therapy informed CBT model or sorry, a cognitive behavioural therapy model for OCD or medications or a combination of the two.
Dr. Jordan Bawks: [00:29:39] Okay. My understanding is that psychotherapy is the gold standard treatment for OCD and has like frank superiority over pharmacology alone.
Dr. Nick Grujich: [00:29:50] So I would agree with that. I think one of the challenges is how does one access good evidence based psychotherapy? If someone is reliant on a public system, they might be subject to extremely long wait lists or just frankly, not find someone available who can provide therapy. Also, issues like language barrier or availability to participate in CBT. The other thing is that CBT is hard work and so not all of our patients are well enough to engage in CBT. So for I guess all of those reasons, the vast majority of patients who have OCD and anxiety disorders will get treated with medications with regards to the medications. Suffice to say that OCD responds to serotonergic drugs and so the guidelines will emphasise specific drugs based on clinical trials and whatnot. But I think that you're in the right ballpark if you start medications with a serotonergic drug. And so for ease of of tolerance and tolerability, we typically start with the SSRI or selective serotonin re-uptake medications, and then we go from there.
Dr. Aarti Rana: [00:31:02] And how does treatment with SSRIs in OCD differ from depression or anxiety?
Dr. Nick Grujich: [00:31:07] So with OCD, it tends to respond more to higher doses, and trials often take longer. So in our CANMAT guidelines for depression, they talk about 2 to 4 week trials for depression, for OCD. Those trials can be up to three months and sometimes even longer. So if you are a prescriber working with someone with OCD, you need to be patient and you need to understand that the trials will take time. So that's the first issue. And the second issue is that with anxiety disorders and depression, we start at the lowest dose and we give it time to see whether we've achieved full remission. If there's a partial response, then we would optimise for OCD. We tend to push the medications to higher doses quicker because there is evidence that suggests that higher dosing can be more effective. And oftentimes with OCD, we'll try supra-threshold dose. So, for example, sertraline above 200mg may confer more benefit.
Dr. Jordan Bawks: [00:32:11] And after we exhaust some of our first line options, what are the second line options that we might bring in? Pharmacologically.
Dr. Nick Grujich: [00:32:19] So my algorithm follows the Canadian guidelines, which is I'll try one SSRI. If that fails due to lack of efficacy or tolerability issues, then I'll try a second SSRI. And if that also fails, then we got a couple of options. We could try an SNRI, a further SSRI, or we can go to Clomipramine.
Dr. Jordan Bawks: [00:32:40] Okay. And sometimes I've seen augmentation with antipsychotics. When do you start to think about involving an atypical antipsychotic in the treatment of OCD?
Dr. Nick Grujich: [00:32:52] That's a good question. Globally, the way I approach psychiatric illness is less is more when it comes to medications. And so I would rather stick with one medication and optimise it as much as possible to try and get as much benefit. If the person still has residual symptoms and has functional impairments as a consequence of residual symptoms or distress, then that's when you consider augmentation. Now, augmentation also includes therapy, so don't forget about that option. But the most evidence in terms of augmentation strategies is adding atypical antipsychotics and Risperidone and Aripiprazole have the most evidence from that standpoint. Now, there's an interesting research that's going on in looking at glutaminergic drugs. And so there are a bunch of interesting third-line agents that in the coming years there'll be more research. But these are drugs like Ketamine or Memantine or Topiramate. So these are interesting things. N-acetylcysteine is another one. So again, it's a serotonergic drug, whether it's an SSRI, SNRI or Clomipramine, there is some evidence for addition of Mirtazapine. And you could think about atypical antipsychotics and then glutaminergic drugs is an option that would be further down.
Dr. Jordan Bawks: [00:34:08] Okay, so it sounds like there are quite a few well-established pharmacologic options and an algorithm to work through with patients, but it's important to be patient exactly with that process. Now, we talked about exposure and response prevention as being kind of like A CBT Protocol. That's kind of the gold standard of OCD. Can you walk us through some of the underlying psychological factors in OCD and why it makes ERP exposure response prevention so effective?
Dr. Nick Grujich: [00:34:41] Sure. So let me give you an example. So let's say I'm struggling with doubt obsessions and I leave my house in the morning to get to work and I lock the door. And as I'm walking to the car, the obsession creeps in. Did you lock the door? Did you not lock the door? If you didn't lock the door, someone's going to break into the home and and light your house on fire. Whatever these catastrophic, irrational obsessions are. By the time I get in the car and I'm sitting in the car, there's a high degree of distress because this obsession is unrelenting. And so in the interest of alleviating the anxiety, I'll just say, you know what? Let me just double check. So I'll get up, I'll get out of the car. I'll walk to the door. I'll lock the door again. I'll check it, and then I'll start walking back to the car. Now, we've all done that at some point in our lives, and that's totally fine and totally normal. But when it's OCD, that intrusive thought will creep back. So as I'm walking back to the car, the obsession returns and it causes me the same distress. And so then how am I going to get to work? Because I'll be worrying about this the whole day. So maybe it's just easier if I get up and check. Now you can see that if I do this over and over and over again, this is going to potentially impact my ability to get to work on time or to complete tasks and so on. So the CBT approach which you alluded to, is the behavioural interventions called exposure response prevention.
Dr. Nick Grujich: [00:36:03] So the therapist and the patient will start identifying all of their obsessions and their compulsive behaviours and they'll rank them in a hierarchy in terms of their capacity to not engage in the compulsion and what the subjective units of distress would be if they don't do the compulsion. Once you've ranked them all in a hierarchy, then you want to start knocking things off the list. So if we're going to use this same example through the lens of exposure response prevention protocol, what I would say is you lock the door, you're mindful about the fact that you lock the door as you're walking to the car once the obsession starts, rather than engaging in the compulsion and reinforcing this pattern, I'm going to say to myself, No, I check the door. I'm not going to double check. So what tends to happen is the anxiety level goes up and up and up, but it reaches a maximum. So the good news is anxiety does not go to infinity. It reaches a peak. At some point it'll plateau off and then eventually we will habituate to that uncomfortable experience and it will go back down to normal. The analogy that I use for my patients, I find it helpful is if you put your foot in a hot tub, your reflex is to pull it out. But if you leave your foot there, your foot will get hotter and hotter, but eventually you get used to it. And then the warm temperature doesn't bother you anymore.
Dr. Aarti Rana: [00:37:25] And what happens if you've tried pharmacology, you've tried psychotherapy with patients and they're still refractory to treatment? Is there any other options for patients who still have OCD?
Dr. Nick Grujich: [00:37:40] So usually between the two, you're going to get some benefit. You're absolutely going to get some benefit. I like working with anxiety disorders because I feel like on some level, everyone is going to get a little bit better. Even just psychoeducation is enough to get people feeling better. Now there are people who have problematic compulsions, perhaps even dangerous compulsions that might involve self-injurious behaviour and and real severe functional impairment if that person is really unable to benefit from the first and second-line therapies and psychotherapy, then that's when you might think of somatic treatments. Most of these interventions are experimental in nature, but to name a few are RTMs. There's some trials looking at RTMs, there are ultrasound guided focus interventions. We're doing studies at Sunnybrook looking at that. There's psychosurgery, which is something that was practised a long time ago but is now coming back because we're able to really localise treatment. And so that would include deep brain stimulation for OCD. So again, these are these are all very much experimental interventions, but there is promise in terms of using these types of somatic treatments.
Dr. Aarti Rana: [00:39:03] So psychosurgery is one of the options that kind of begs the question of whether there's a particular part of the brain or parts of the brain that are implicated in OCD.
Dr. Nick Grujich: [00:39:12] So research trucks on. But I think at this point we would say orbitofrontal cortex and anterior cingulate cortex and the head of the nucleus. The caudate nucleus.
Dr. Jordan Bawks: [00:39:25] Okay. So. At this stage. We've talked about epidemiology, we've talked about phenomenology, diagnosis, differential diagnosis, mental status, treatments, psychotherapy, pharmacology, psychosurgery. Dr. Grujich at this stage, is there anything else that you want to talk about to OCD? Think it's important for medical students, junior trainees, anyone else who might be listening?
Dr. Nick Grujich: [00:39:53] So I'm glad that you pursued this topic. It's fairly niche, but it's not all that, um, um, prevalent, I guess you could say. And I think OCD is one of those illnesses that often gets missed and people who have OCD tend to struggle with it for their whole life in the absence of good treatment. And so I'm glad that you're bringing more light and attention to this disorder.
Dr. Jordan Bawks: [00:40:17] Yeah, that's certainly our hope with the podcast that we can encourage students to pursue psychiatry, facilitate learners, recognising psychiatric illnesses no matter where they practice. And for the lay public also to learn about mental illness in a way that we hope destigmatizes it and encourages people to seek treatment or help loved ones.
Speaker4: [00:40:41] So thanks so much, Dr. Grujich, for joining us today. A pleasure as always. Aarti any thoughts after your first episode?
Dr. Aarti Rana: [00:40:50] No, I think I learned a fair bit about OCD that I probably should already have known. And that's it.
Dr. Jordan Bawks: [00:40:57] That's the beauty of medicine. We keep learning, keep learning and keep learning. So as always, thanks for tuning in to PsychEd. Feel free to get in touch with us at Psychedpodcast.org or leave a comment on our iTunes page. We welcome any and all feedback. We are actively trying to improve our product. In fact, we actually are launching a survey soon. So if you see that survey link, it should be on our website. Please take the five minutes to fill it out. It will help us create a better product for you, our listeners. The only way we can give the people what they want is if you get those fingers or thumbs in action on the keyboard. This episode of Psyched was written and produced by Dr. Jordan Bawks, Dr. Bruce Fage and Dr. Aarti Rana. Our theme song is Working Solutions by Olive Musique. We would especially like to extend another thank you to Dr. Nick Grujich for making time to help us out with this episode and for providing clinical resources to help write the script. This podcast is made possible by support from the Department of Psychiatry at the University of Toronto and is produced in affiliation with the Canadian Psychiatric Association. The views expressed in this episode do not necessarily reflect those of the Canadian Psychiatric Association or the Department of Psychiatry of the University of Toronto. Another thank you to all the people behind the scenes who make the Psyched Podcast a reality. All of our medical students, residents and staff mentors. Thanks. Catch you soon!