Understanding OCD with Dr. Scott Bea

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host Nada Youssef and you're listening to Health Essentials podcast by Cleveland Clinic. Today we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio and we're here with Dr. Scott Bea. So happy to have you back.

Dr. Scott Bea:    Thanks for having me back, Nada, I had fun the last time.

Nada Youssef:   And Dr. Bea is a practitioner of cognitive behavioral psychotherapy and concentrates his clinical practice on anxiety and mood disorders. Dr. Bea is also a psychotherapy trainer and supervisor in the adult psychiatric residency training program here at Cleveland Clinic. Today we are talking about obsessive compulsive disorder, OCD. Please remember this is for informational purposes only and it's not intended to replace your own physician's advice. So before we talk about OCD, I'm just going to ask you some questions again. So just get to know you on a personal level.

Dr. Scott Bea:    Sure.

Nada Youssef:   A little deeper this time. So if you could have any superpower you want, what would that be?

Dr. Scott Bea:    If I think about that very much, I might get into trouble, but at this point I say I'd love to be able to fly.

Nada Youssef:   Flying, okay.

Dr. Scott Bea:    I think that's the ambition we all had when we were kids. It'd be beautiful to fly and be something sweet to see the world from that vantage point, I think. And transport yourself more quickly.

Nada Youssef:   Yes, absolutely.

Dr. Scott Bea:    Wouldn't have to take the bus home.

Nada Youssef:   That's right. No traffic. So if in 20 years, or whenever, people started migrating to Mars, would you go or stay behind? And why?

Dr. Scott Bea:    I think I'm sticking.

Nada Youssef:   You're sticking, yeah?

Dr. Scott Bea:    You know, it's interesting. I actually had a class on space colonies when I was a college student and I really thought we'd be in space, colonizing space, have space stations much more enormously than we have now. But at this point I like the food and the feeling of mother Earth a little too much. I've gotten older. My risk assessment has changed as I've gotten older.

Nada Youssef:   I think physically and mentally we're meant to be home with the trees and the water.

Dr. Scott Bea:    That's right. There you go. Right?

Nada Youssef:   Yeah. Okay, so if after we die we become animals, what animal would you want to be, or would you be?

Dr. Scott Bea:    I've kept a lot of cats in my life. I've got a fondness for dogs, but something tells me a panda bear. They seem awfully cute and cuddly and they get lots of affection, I think somehow.

Nada Youssef:   Or a bird, so you can fly.

Dr. Scott Bea:    There you go. either of those.

Nada Youssef:   There you go, okay. Excellent. Thank you so much. All right, so millions of people are affected by obsessive compulsive disorder. The International OCD Foundation says that in the US alone as many as one in a hundred adults and one in 200 children have OCD. That's roughly two to three million adults and a half a million kids. And when you look at a lot of times at movies and shows, they seem to portray OCD almost as a lighthearted, funny thing, but it is not a funny thing. It's one of the biggest myths about OCD. It is a disorder and it's very distressing for the people that have it. So I want to begin with today's discussion with the definition of what is OCD.

Dr. Scott Bea:    It really is a tough condition. As you said, it gets tossed around flippantly in our culture where we minimize the suffering that people go through. It's an anxiety disorder. It's very real. It involves either obsessions, which are intrusive, unwanted thoughts that are producing very high levels of distress or discomfort and/or compulsions, which are actions or mental acts that are designed to neutralize the feelings of anxiety, ward off potential harm. Sometimes devoted to suppressing or neutralizing the tension that obsessions are producing. Takes up an awful lot of time in one's life, more than one hour a day. Some have it very pervasively. The compulsive acts are performed in very ritualized ways according to specific rules, and again, designed to be neutralizing. It can range in terms of the interference it creates. People can be more or less insightful about the irrational aspects of OCD, but it creates an awful lot of suffering for an awful lot of people.

Nada Youssef:   Now, where does it stem from? Is it something that is internal? When you say anxiety, I'm thinking of internal. I'm not thinking of something that triggered it, or it could be. Where does it stem from?

Dr. Scott Bea:    It's coming from our brain. We know the brains of people with OCD are functioning differently. We'd say they're hypermetabolic. They are working real hard up here. If we image the brain in sophisticated ways, we can see that the brain of somebody diagnosed with OCD is actually functioning differently than somebody that's not experiencing it. If they're treated effectively, that brain area starts to look more ordinary and we know the circuits in the brain that seem to be associated with OCD probably better than any other psychiatric conditions. So we know a lot, but there's still a lot more to find out. It is a brain concern. It's not that somebody did something wrong to acquire it, or was parented in the wrong way. It's really happening in the brain.

Nada Youssef:   Okay, that's very good to know. Now, does any repetitive or obsessive behavior qualify as OCD? How do I know it's OCD?

Dr. Scott Bea:    We have lots of repetitive behaviors. Might tap your foot, tap a pencil, might check your cellphone an awful lot. I will say most repetitive behaviors are probably reducing tension at some level, but the repetitive behaviors of OCD are very purposeful. They're very much designed to get to a particular feeling state to rid a person of a feeling of anxiety or to ward off a sense that harm could come to themselves or somebody if this is not performed. It also has to do with the interference. Somebody tapping their foot or you know, tapping a pencil or looking repeatedly at their cell phone is really distressed by it. There are some other distressing, repetitive conditions, I would say. Things like compulsive gambling or compulsive shopping. Other things that are more impulse control problems, video game addictions, things like that. But those aren't OCD.

Nada Youssef:   Yeah. Okay, that makes sense. So is OCD defined by the repetitive action only or also the repetitive thought in my head that keeps going on and on if I don't act it out? Is that not OCD?

Dr. Scott Bea:    It's interesting. I mean OCD comes in all sorts of forms and varieties. So there a condition within OCD that some call pure obsessions in which a person is having distressing thoughts and the only action they're taking is actually a mental action. They may be praying, they may be counting in their head, they may be doing other mental acts. Those are still compulsions. I mean that is an action. They're doing it purposefully and again to get to some goal to some sense of relief and that sense of relief for human beings is wildly powerful. Just about anything that produces that feeling in us attracts us back to it.

It's interesting, in OCD we actually call this negative reinforcement. It sounds like punishment, but it's not. If you can get rid of an uncomfortable or unpleasant condition, you're motivated to repeat that in order to get to that feeling of relief. You could think of the snooze alarm, it's like an instance of negative reinforcement. The alarm goes off in the morning, it wakes you up. You don't like the sound of it or the idea that you have to get up. So you hit the snooze alarm, gets rid of the aversive condition. You can rest again. When it goes off, you're motivated to use the snooze alarm. So people that use the snooze alarm tend to use it a lot, because it's very rewarding.

Nada Youssef:   Every morning.

Dr. Scott Bea:    That's right to get rid of that sound, to get rid of that feeling.

Nada Youssef:   We live in a loop of life. Our days are very similar, even though they're different. We're very habitual beings. So is OCD almost easy to come by? If I could be doing something habitual that to me, I do it every day. But how do I know the difference between, I'm just doing repetitive behavior that I do everyday versus this is a mental condition?

Dr. Scott Bea:    I love the question. Human beings are ritualized. We're creatures of habit. Nobody in our audience probably showered in a wildly different way this morning. I'm going to start at my toes and work on up. Right? I mean, we do these things and habits actually keep us from being as tense. If we had to think through, "What do I do about showering everyday?" Or, "How do I make this left hand turn in my car?" It would create a lot of complications. So these habits exist in a deep spot in our brain called the basal ganglia. In many cases it just makes our life easier. OCD is not something that you just happen on. We don't really cultivate that. It comes on us, generally as a result of something going on in our brain. So even though we're all creatures of habit and we may be more or less habit driven, most of that's not OCD.

Nada Youssef:   Okay. Does OCD start from childhood or is it something that only adults can get?

Dr. Scott Bea:    We definitely see it in children. I mean for boys, we see it in a little bit earlier stages. Eight, nine, 10 not uncommon for a boys. For females a little bit later. Sometimes people may have bits of it, but it hasn't created tremendous interference yet. There are instances in an adult's life where they'd say, "I never had OCD before." But something changes, a period of stress. After the birth of a child. It's not uncommon that OCD might really flare up for certain women right after the birth of a child. And so it catches some people by surprise, but we often see it, the early parts of it, in childhood.

Nada Youssef:   Okay. So environmental factors could be a trigger or something of that sort?

Dr. Scott Bea:    Definitely. People with OCD will tell you in a climate of stress, their condition worsens. It gets harder to resist performing their ritualized compulsions. And certain life stressors, as I say, or events can trigger the illness itself.

Nada Youssef:   Sure. Okay. Now I want to talk about two things. OCD a lot of times is confused with perfectionism. Can we talk about the different ... Because a lot of people are like, "Oh, they're very OCD. They're very organized and perfectionist." But what is the difference? Let's talk about that.

Dr. Scott Bea:    That's where our culture kind of gets it wrong. Where people say, "Oh, I'm so OCD." That's definitely-

Nada Youssef:   Yeah, you hear that one a lot.

Dr. Scott Bea:    Perfectionism is not OCD. And again, it kind of injures people who are suffering with the illness because it minimizes it. Perfectionists are going to be able to justify their perfectionistic strivings. They're going to say, "Hey, it really helps me out. I'm a better student." Or, "My home stays in good shape." Or, "I'm really organized when it comes to bill paying, or decorating or those sorts of things." There's usually a rationalization for it. It's not seen as an irrational act. They may know that they pay a bit of a consequence for it.

There's also a condition known as obsessive compulsive personality disorder, which is a little bit more defined by perfectionistic strivings, orderliness, trying to control the environment, but that is distinct from OCD. It has to do with how rational the acts are. A lot of people with OCD will tell you, "I know this is silly." Or they'll label it as stupid or irrational, and yet they can't help themselves. Perfectionists kind of know what they're doing. They have a justification for it and they're striving to get to this feeling of closure, completion or perfection. Although we say perfectionism is an imperfect pursuit.

Nada Youssef:   Correct. Yes. All right, very good. So many people tend to think of OCD as a fear of germs or repeating something over and over, like maybe locking the door over and over or turning off the oven. Can you give us more examples of what we might not know are considered OCD?

Dr. Scott Bea:    Yeah, sure. I think some of the most common obsessions and compulsions center around harm, or we call them harming obsessions. Harming another person. I mean, as odd as it sounds, a fear that I might stab somebody, a passer-by. Even though I don't have a sharp object on me. Or injure somebody with my words, that I might utter a verbalization or say something that is a racially insensitive out of one's awareness. Having thoughts of self harm. A person could have a thought of suicide go through their mind and become alarmed by the thought and then go into rituals to try and reassure themselves about suicidality. Then there's something we call scrupulosity, which is a real debate over right and wrong. Is this a right or wrong thought, right or wrong behavior? Did I look at that person too seductively or lustfully?

Those people sometimes feel a need to go confess that to their partners. That would be the compulsion. The obsession was, "Oh my gosh, did I look at them in a way that was wrong?" They might engage in confessing behaviors, a very common compulsion in order to reduce their tension. It's brutal to their partner, of course, but they're trying to correct something in their brain. Also, obsessions about sexuality, about one sexual identity, sexual orientation, or even whether or not they could be a sexual predator or pedophile. Those are actually relatively common sorts of obsessions that afflict people and it takes all sorts of forms. These days I've been treating people who obsess about getting bedbugs. And so this is on their mind consistently. They're checking consistently. They avoid going into certain public environments, stores, come home and put all their clothes in the dryer to ward off any chance that they might get bed bugs. So this is something that's emerged more recently.

Nada Youssef:   Why do you think that emerged more? Is it because it's in the media? People are reading about it?

Dr. Scott Bea:    It's in the media and it's one of those things that you can't absolutely control. And yet people want to exert control. The imagery in their head creates such tension that this would be intolerable. In a case or two, it's actually happened to them before, but they'll still see that as an intolerable consequence. And they spend lots and lots of time thinking about it and trying to ward off the danger of it, and just avoiding being out in public. There are people that might not want to sit in our waiting room because there are upholstered chairs. I've been advised to not ... Or if I ride the bus to go home and immediately put my clothes in the dryer, having been on public transportation. So it takes all sorts of forms and shapes and varieties. The things that can really shake up our brains can be kind of grist for the OCD mill.

Nada Youssef:   Yeah, and just like you mentioned it is in the brain. Would you consider that to be a little bit of maybe overthinking?

Dr. Scott Bea:    There's no question that people with OCD are overthinking. We know their brains are working really, really hard. It's very interesting when we're really engaged or when we're busy, our brains get kind of quiet and when we're a little still, our brains get kind of active. People with OCD will be overthinkers and they will also tend to have a tendency to think in black and white terms. All or none, good or bad. And they'll generally admit to this that they have a hard time seeing the grays in the world. They'll go quickly to the good or bad. They'll say I had a bad thought. So they experience thoughts as bad, or a good thought. So we try to encourage them to think of thoughts as just thoughts. But in some ways OCD is kind of having a phobic response to thinking experience.

Nada Youssef:   Yeah, to yourself. Okay. So you can't have OCD without realizing it, because you mentioned a few times, people that have OCD, they know very well that, "This may be silly, but I have to do this."

Dr. Scott Bea:    Well not everybody knows. I mean there are people that can go through long periods of their life and they'll tell you when you interview them that I never knew this was OCD. I thought everybody's brain worked this way. I thought everybody did that. And we've seen people get into their late fifties and sixties before ever being identified professionally as having OCD. I mean they may have known this was odd or not right, but not known it was OCD necessarily.

Nada Youssef:   Very interesting. That's very interesting. So we talked about it deriving from anxiety. Correct. So how is it diagnosed?

Dr. Scott Bea:    Generally you'll be diagnosed in a clinical interview with a psychiatrist, psychologist or counselor. Sometimes really helps to be with somebody who's seen OCD before because there are some subtleties people might miss. I think it's just a matter of worry or not get the distress or ritualization that's involved. Even in a way a person might think. There's also a scale called the Yale-Brown Obsessive Compulsive Scale that helps kind of categorize how severe the condition could be. And when we're treating somebody, we might like to use this scale occasionally to track progress. Sometimes for certain treatments it's required that you'd be particularly severely afflicted. So we might use that scale in those instances.

Nada Youssef:   So then treatments includes cognitive behavioral therapy as well?

Dr. Scott Bea:    Definitely. I mean there is a known behavioral treatment for OCD called exposure and response prevention. It's been around since 1975. It's nothing new under the sun. It's just really, really uncomfortable. And so it's a treatment that works. We know it works. We know it changes the brain biologically, yet it's tough for people to endure exposure. Put people in situations in which they're exposed to the very thoughts or scenes that create the upset of OCD. Response prevention or what we might call ritual prevention is then preventing the rituals. This is like going through behavioral withdrawal. And people do get kind of addicted to the rituals. It produces relief, so they're strongly motivated. So we expose them. In a case of contamination you might say, "Well, Nada here's a concoction of dirt and hair of unknown origin. I'm just going to put that on your lap for the next 50 minutes and then we're going to require that you don't touch water for the next 24 hours."

That's exposure and ritual prevention. Of course the brain does not like this, and it's going to respond with a lot of tension anxiety. Yet if you can stay in that circumstance, the brain starts to quiet itself and it seems like it's not going to, but anxiety can only go so far and then it's gonna start to come down. As it starts to come down, your brain is learning an emotional lesson that it can't learn any other way and the human being is learning also that I can recover without the ritual. It's tough. I call it bootcamp for the brain. It works, but not everybody wants to volunteer for being that uncomfortable and we do it in compassionate ways. We actually create hierarchies of these experience from the least threatening to the most threatening. We work up the hierarchy with that individual so that they can acquire higher levels of skill and tolerate higher levels of tension across a period of time.

Nada Youssef:   So that example that you just gave me, is that something that you actually would do?

Dr. Scott Bea:    Absolutely. I've done that, and some wild things with patients across time. Really. Yeah. I mean, I've had patients hold knives to my wrist. I can recall other loud exposure events we did to help with harming obsessions. YouTube is great for exposing people to lots of things or scenes that they don't really like to see. So yeah, the technology has emerged in a way that helps with exposures these days too.

Nada Youssef:   Does that ever backfire? I mean, do they ever get into an anxiety attack from having everything in front of them that they fear?

Dr. Scott Bea:    Exposures have to be done right. I mean, you have to keep a person in an exposure situation preventing the ritual we'd say long enough until at least half of the distress they're feeling dissipates. Okay, because then they're learning something critical. Distress passes even with inaction. If you do the exposure but you don't recover, then it just sensitizes that person. "Oh Geez, this really shakes me up. I'll never recover from this."

Nada Youssef:   Is there a safe word? Get me out.

Dr. Scott Bea:    Yeah, that's right. Yeah, give me a safe word. That would just sensitize you. So it has to be done in really systematic ways, so the person is actually experiencing tension reduction in that circumstance.

Nada Youssef:   Okay, great. That's good to know. Is there medication? Like actual medication that we take for OCD?

Dr. Scott Bea:    Absolutely. I mean there are medicines that are known to work and the medicines are going to be offering quick relief. A person that's experiencing OCD is suffering and they may not be able to function well. And so medicines can create pretty quick relief. Although we use anti-depressant medicines often called SSRIs, Selective Serotonin Reuptake Inhibitors. It's a fancy name. But if the medicine works, it tends to produce a decline in the symptoms of OCD. It takes a little bit longer than the treatment of depression. In depression it might take four weeks to see if a medicine is going to start being effective. In OCD, it tends to take a little longer, maybe up to 10 weeks. There's some research that suggests that people with OCD need higher doses of the medicine than those that might be just experiencing depression. It does work. We do see brain changes. Again, the images that we can get from the brain when it's effective, same brain changes that we see with behavioral treatments.

So both are biological treatments. We say the medicines offer quick relief, the behavioral changes offer more lasting relief. Often you'll see them in combination, because sometimes it's really difficult to do these exposures when you're in the height of distress. I say, you can probably learn calculus in a room that's 120 degrees, but it's great if you could just turn it down to 70. Learning something hard is just a lot easier in a cooler room. So we're trying to cool off the climate with the medicines. And then hope that a person has a willingness to do the behavioral treatments because they produce more lasting effects.

Nada Youssef:   So I'm very curious, how does the medicine neurologically work on the patient that has OCD? Because it seems like a very mental thing. What does the medicine do?

Dr. Scott Bea:    We're not exactly sure. There is a circuit in the brain that seems to be implicated in OCD pretty clearly. And we think that this circuit maybe modified by the serotonin. What you notice clinically when you ask somebody what has changed, they might have the same thought or obsession, but it doesn't create the same anxiety reflex. It kind of caps it a little bit. Hits a ceiling. So it doesn't produce as much distress. In that climate of relatively less distress, they may not feel the strong urge to engage in repetitive compulsions. Although the compulsions have some habit strength, I mean they've become a habit. And so there's generally a little bit less distress before we start seeing some of the habits fall off. But we do. People tell you they don't feel the distress in the face of the same thought.

Nada Youssef:   Yeah. So they were able to deal with the reaction. Okay, great. So are there other conditions that may coexist with OCD?

Dr. Scott Bea:    Definitely depression. It's funny because the antidepressants are probably treating depression too. It gets easier for people to manage compulsive acts and be less distressed with obsessions. But depression is very common because people have been suffering and they've been suffering for a long time and so they lapse into a sense of helplessness, that this condition has them and they can't quite escape it. So depression is common. Other forms of anxiety, like generalized anxiety, which is kind of chronic worry or anticipation of negative events in the future and kind of high arousal in our body would be very common. Then you have all these other offshoots that we think are related to OCD a little bit. People that believe there's something really wrong with their body, with their nose, the shape of their face, their figure, their symmetry. Call that body dysmorphic disorder. We have these other habit disorders.

Hoarding was originally thought to be a some offshoot of OCD. We think it's a little distinct now. What's interesting about hoarding people that collect things and have a hard time throwing them out. Medicines don't treat that very well. People that have hoarding problems almost never come to treatment on their own. People with OCD will. Hoarders generally are dragged in by family members with a bunch of pictures to display what the problem is. But they will not be able to see it in the same way. We know they have a specific problem in making a decision. "What do I do with this object?" Which is a little different than OCD. Although you will see these things coexisting.

Then a couple other things that people might not be familiar with. Illness anxiety disorder. People might have lots of distress about having acquired an illness, so they'll spend lots of time googling different illnesses. Or repetitive doctor visits to gain reassurance. Hair pulling, which is called trichotillomania. Skin picking disorder.

Nada Youssef:   Nailbiting.

Dr. Scott Bea:    Nailbiting. All this little offshoots. In the case of hair pulling or skin picking, oftentimes a person touches their scalp or a spot on their skin and it feels imperfect and it creates some tension state and they will often try to correct that to some criteria that reduces the discomfort of that imperfection. Often in kind of trance-like state, often in the same spot or in the same circumstance in their own home. They'll suppress it in front of other people. They can do that.

Nada Youssef:   Right, oh it's very, very interesting.

Dr. Scott Bea:    People with OCD will also suppress compulsions when they need to, so they're not embarrassed by them.

Nada Youssef:   And if you have one of these nail biting, hair picking, skin pulling, that's not a form of OCD, right? Just to clarify. It doesn't mean that you absolutely have OCD, but it usually coexists?

Dr. Scott Bea:    Not at all. You could have OCD and have these conditions as well. I've certainly seen those coexist. You could have that distinct from a diagnosis of OCD. The other condition that is pretty commonly associated with OCD is Tourette's syndrome and individuals with Tourette's, these are tics. These are repetitive physical movements, eye twitches, other movements or gestures, and at least one vocalization or vocal tic, as we would call it. Those people very commonly get diagnosed with OCD. The majority of people with Tourette's also have OCD at least 60%. And about 50% of people with OCD had some tics in their childhood. So the tics and OCD have some commonality.

Nada Youssef:   That's very interesting about Tourette's. I always thought it was just like a speech impediment, but now that you say that my own tutor and my school has it. And he did have a lot of ... He had to turn a certain way and walk a certain way. But that's very interesting, it comes with OCD.

Dr. Scott Bea:    Again, they'll be trying to suppress that, but this urge to move in a certain way, or blink, or make a verbalization or vocalization kind of gains on them and it feels the only way to get rid of that urge is to engage in the tic behavior.

Nada Youssef:   Sure. Now when children have this disorder, can they outgrow it as they become adults? And the opposite, can you develop it when you're older? I know you mentioned someone much older that ... Did they develop it or did they just notice they have OCD? Can it come and go?

Dr. Scott Bea:    With respect to children, I think children are highly ritualized in their play. If you're with young children, they'll often ask you to repeat certain behaviors. "You come through my shopping line and checkout." Over and over and over, they're gratified by that. We don't know if children really outgrow OCD. The real course of OCD is that it tends to worsen over time. And I'll try and describe it this way. Anything that, again reduces tension, almost in a drug-like way is very rewarding and we'll tend to repeat it. The more we repeat it, the less effective those behaviors become. So just like drugs across time, you need more of that in order to get desired relief. So if the condition is not being treated, it often has a worsening course across time and often people will come to treatment when it's gotten so severe that it's creating interference. There are some that suggest that OCD may remit or go away in some cases, but more often you're going to see worsening courses across time.

Nada Youssef:   That's very interesting. So could it be genetic? Is it genetic?

Dr. Scott Bea:    Well it's interesting. We do know that about 25% of people with OCD have a close biological relative that's also diagnosed with OCD. And there've been some twin studies that suggest about 40 to 65% of the risk associated with acquiring OCD is genetic. So we think there is a powerful component there. It may not be the only thing, but it is a thing.

Nada Youssef:   Okay, very, very good to know. Now we talked about stressful events triggering OCD. Are these called flareups? Like when someone starts having the ritual more than usual, is that a flare up?

Dr. Scott Bea:    They'll actually speak of it as a flare up of their condition or their symptoms. They may say, "Oh my gosh, I really was terrible this week." "I had this stressor in my work life and I've just been counting more or pacing more." I mean the number of behaviors is probably beyond what people would imagine and could constitute OCD. But yes, in times of stress, people struggle more with their symptoms. They're more effected by the thoughts and they tend to perform the rituals more.

You can imagine if a brain is experiencing greater stress and it's used to using ritualized efforts and reassurances, then that's going to get worsened when there is stress. And by the way, reassurance seeking that is the greatest compulsion. And so people will seek reassurance in all sorts of ways. People actually come into psychotherapy and they may spend most of that session trying to get reassurance from their therapist on a number of matters. Good therapists know how to resist that, and that reassurance is not a good thing. In an odd way, and it's not to equate the two, but it does have this characteristic of almost drug-seeking behavior. They want that relief. Again, when a person is trying to change the condition, they will experience it as almost withdrawal from the feeling of reassurance and it's painful.

Nada Youssef:   Now do you think, because you mentioned something like hoarders, they don't want to go see a physician or want to be seen for it. Do you think people with OCD, they don't have the same feeling where like I'd rather do my ritual and feel good then go through, dirty hair in front of them and not touching water. Do you think that could be something where they could not be coming to the doctor for?

Dr. Scott Bea:    I think not. It's real human to go through a cost benefit analysis. How much am I willing to suffer to get to a better spot? And you can't make that decision for a person. I mean they have to make that decision for themselves. It's one of the things that makes treating hoarders tough, it's because they're really ... Don't want to make this decision but in a social way they may not be able to do this without harming people around them. And so that sometimes compels them to treatment. I've seen people that simply are not going to do exposure and response prevention and you have to respect that. I mean that person has to make a choice themselves. It is common that people try to find a comfortable way to do it. I always say there is no comfortable way, this is boot camp.

There is no comfortable way through bootcamp and there are some people who do extraordinary courageous things to get to a better spot. Yeah, it's inspiring. When people get better and it's really lasting, I mean they can take all the credit for it, because it was really through their effort. And it is bootcamp. I've heard it said in bootcamp, "They tear you down to build you up." That's not true. They just tear you down for 13 solid weeks and you know what?

Nada Youssef:   Leave it up to you.

Dr. Scott Bea:    Hey, what happens there is the thing that made you so uncomfortable, the first day of bootcamp by the 13th week doesn't make you uncomfortable anymore. It's really changing the brain. That's what military training is about. I didn't realize that early on. So we speak about it in that way that the ... You're going to be uncomfortable anyway. You might as well devote the discomfort to get into a better spot rather than standing still.

Nada Youssef:   Very good point. So it's about 13 weeks long? Is that? Or is it depending?

Dr. Scott Bea:    Oh, that's bootcamp. Oh, I will tell you. So it takes a little bit longer for OCD because of the requirement to be uncomfortable. Some people can make some dramatic turnarounds if they're strongly motivated and can tolerate the stress. Others can spend an awful long time trying to develop the courage to really do pretty powerful exposures and prevent the rituals. So it runs the gamut. And I will say this, even people who are well-treated and who are not experiencing interference from those symptoms significantly anymore, less than an hour a day, will still have a brain that has the capacity to reflexively over respond to a thought.

Nada Youssef:   Sure, sure. I can only imagine. Now I read that reassurance actually feeds OCD, so I want to know if that is true.

Dr. Scott Bea:    Absolutely. I was trying to allude to that a moment ago that reassurance is the greatest ritual and it seems compassionate when somebody you know is suffering with a worry or obsessional distress to reassure them that everything is going to be okay. And everybody likes to hear that everything is going to be okay, but nobody believes that. It feels good for a second or two or maybe 20 seconds. I would say it's like a bandaid with no adhesive. It feels good going on, but it falls right off. Then you have to put the bandaid on again and again because it creates that feeling of low tension that humans love. There's a tendency to want more and more of that and the more you use it, the more you're going to need it. I mean there are all sorts of things like this, nicotine, caffeine, heroin. These are drugs that get in our system quickly and effectively but leave quickly and so you need more and more of it. Reassurance works the same way.

Nada Youssef:   Okay, so I was thinking when you talk about reassurance that you're talking about as a therapist, that's what they want from you to tell them that it's okay, but what do you suggest to our audience that maybe personally know loved ones that have OCD, how to be there for someone, how to ... Besides drag them to you.

Dr. Scott Bea:    It's a tough matter because again, you can notice their suffering and your impulse is going to be to want to take the suffering away and yet that is not particularly helpful for them. It's good to ask permission or to notice. "Boy, it looks like you're suffering a lot. I wonder what thoughts you have about what you could do about that?" Would it be okay if I make some suggestions? One thing you want to stay away from is just offering reassurances. You see somebody who's really in the throes of anxiety. You really want to extinguish that fire. But you could say, "I can tell you're really anxious right now." And if a person is asking you for reassurance, you could say, "I can tell you're really anxious but I can't help you with that." Or "I don't know anything about that. I wondered if you'd be willing to go see somebody who does?" Try to keep making offers of that sort of assistance without using the reassurance.

Some relationships get developed around reassurance. If you know somebody, you develop a relationship with them that you know they have OCD. You've probably fallen in the trap of reassuring them. It's hard to step out of that. Sometimes a professional can even help family members figure out a new way of responding rather than engaging in compulsions. I mean, there are people that will. They'll go check the door over and over again for their loved one rather than saying, "I know you're anxious about that, but I can't help you." Which doesn't sound compassionate, but really is. It's offering a path for a person to get better.

Nada Youssef:   Yeah. It's actually helping more than harming. Great.

Dr. Scott Bea:    Yeah, and there's lots of help out there. Look, there are some new technologies happening for people with really, really severe OCD. In some cases there are neurosurgical procedures, something called deep brain stimulation, which is used in other conditions as well, but has been used with some positive effect in people with OCD. Now that's a brain surgery and an extensive surgery and we'd like to avoid that if we can. So some of these other things that we know work, we try to use those, absolutely first.

Nada Youssef:   So come see Dr. Bea right?

Dr. Scott Bea:    Come see Dr. Bea, yeah. Come on along.

Nada Youssef:   Thank you so much for joining us, it was a pleasure again.

Dr. Scott Bea:    Nada, a real pleasure. Always fun talking with you. Thanks for having me back.

Nada Youssef:   Thank you so much and thanks again for our listeners for joining us today. We hope you enjoyed this podcast. If you'd like to make an appointment with a specialist in the center for Behavioral Health, you can call (216) 636-5860 and to listen to more of our Health Essentials podcast from Cleveland Clinic experts, make sure you go to clevelandclinic.org/hepodcast, or you can subscribe on iTunes. And for more health tips and information from Cleveland Clinic, make sure you're following us on Facebook, Twitter, Snapchat, and Instagram @ClevelandClinic, just one word. Thank you. We'll see you again.