The Neurobiology of OCD with Neuroscientist Uma Chatterjee

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Hello, welcome back to BookSlux and the Lobotomies. Today is a special episode because I get to learn more about why the fuck my brain does what it does. I have OCD and that's what we're going to be chatting about today, but I also live with CPTSD and anxiety. And we get to have a neuroscientist on who is going to talk about the neurobiology of OCD and some mental illnesses. If you too are curious about OCD and the brain, then you're really in for a treat. Uma Chatterjee is a neuroscientist currently earning her PhD in neuroscience studying the neurobiology of OCD and mental illnesses. She hosts the Mental Health Science Communication and Advocacy podcast called a chat with Uma. Is president of OCD Wisconsin and serves on one mind's lived experience council. Uma is also a good friend of mine and Uma has such a tremendous story and is using her lived experience to help others. And by sharing her story and doing the work that she does, she's really one of the bravest, most wonderful people that I know. And I'm so excited that you all get to learn from her today. Welcome, Uma, to books, looks, and the bottomies. I'm so excited to have you here. I'm so excited to be here. I'm so excited to have you here today because understanding the brain and its impact on OCD and understanding the body and its impact on OCD is so important to me. I have a million or one questions for you about this, but the first question that I want to ask is, have you a neuroscientist ever wanted a lobotomy? You're like, "Girl, I'm getting one." Well, I can say that I've like, in some ways legitimately done them on not humans, but animals. So like, in that, yes, also probably not at this stage of life, but I fantasized about lobotomies and just about like, cut my brain in half, take half out of it. Can this even exist? I remember Patrick McGrath asked me this question of, he was like, "Could you just clone yourself?" So like, you can do all things you want to do. I was like, "Nobody needs to suffer with this brain like more than one person." Right. You're like, "Honey." So yes, I would want a lobotomy if only it worked. I know that some people do psychocirgery for OCD is the last resort. It wouldn't technically be a lobotomy, probably, but have you, like, do you research that area of science where cutting into the brain might actually help with mental health? Directly no, but indirectly yes, and that I study the specific brain areas that contribute to OCD that which we're going to get into. And part of why we care about that is how can we intervene in those brain regions, not includes things like deep brain simulation or even lesions that can be done physically or chemically, meaning sort of a lobotomy kind of. So yes, in many ways. You're researching essentially to find things other than the knife. Ideally. Iconic. And could you share with our listeners before we get into more specific questions? Your lived experience with OCD and mental health and what really got you into pursuing this kind of research as a neuroscientist? Absolutely. I, according to my clinicians and myself, was born with OCD. I cannot remember a day of my existence where I have not clinically met diagnostic criteria for OCD. It has been what has governed my life in combination with other fun illnesses. We all have comorbidities, or almost all of us comorbidities, so fun, right? But OCD has been something that has shaped the way I've existed. In my earliest ages of life, I remember just feeling like if I didn't do certain compulsions, which obviously I didn't know what obsessions or compulsions were, I thought this was just how you live. But I was consumed by the fear that if I didn't do these prayers, my parents would die, or that I was responsible for literally everything bad that happened in the world. I had endless magical thinking, thought action fusion. And I was able to, in some ways, mask it because I was still functional at that earliest ages of my life, like probably 21 or 12. I was really, really struggling. I was debilitated, but I was especially coming from an immigrant household where mental illness wasn't real. I mean, they barely bought into physical illness being real or the Western medicine world being real. I was just kind of labeled as, you know, I just was causing problems. And how dare I have any problems when my family came here and struggled to go through so much in both and, right? But I internalized so much shame about just the way I existed and felt like all of my thoughts were real. And I had been abused most of my life, but going through chronic sexual abuse as a child, and when I was 12 years old, that set me on a very quick downward spiral where I was just consumed by PTSD, by very, very severe OCD that started latching on to all the harm themes, all the taboo themes, especially sexual obsessions. It became pedophilic obsessions. And I also appreciate I can just say that without having to explain what those are to you because pretty much any other time I talk about this, I have to add like a 50 year long preamble about harm themes. So thank you for you. And I was barely holding on. I again was really abused and there was a lot going on. So I thought I just needed to escape my household by the time I was 18 and then my life would be okay. And turns out that's not what happened. I was pretty independent financially by the time I was 16 just because I had no options. But even when I escaped my house, it got to the point where I could barely get up or get out of bed. I could barely leave my home. I couldn't turn the lights on at night because I was somehow afraid that I was going to cause myself and everyone I knew to be homeless. I was so so sick. I was admitted to different inpatient hospitalizations due to, you know, trying to kill myself many times. And nobody identified OCD. I was diagnosed pretty early on with depression and anxiety and panic disorder. No one really found the PTSD because I didn't know how to verbalize what was actually going on and also no one in my house believed me. But most importantly for OCD, like nobody identified it. I went 25 years with like 22 different clinicians who misdiagnosed it all the way from, you know, therapist to psychologist, psychiatrist. I was just told to stop thinking about it. I didn't even know how to verbalize. At that point, the horrible taboo and truth of thoughts I was having and the only things that were sort of coming out was like, oh, I couldn't leave a grocery store for eight hours because I was so afraid of making the wrong decision and ruined everyone's life. I totaled multiple cars because I couldn't stop checking my blind spots. I was so afraid if I didn't look at the blind spot the exact proper time, I was going to cause a car crash. And of course, I still cause car crashes because that's how OCD goes, right? But at least no one else was harmed just me. But even with all that, I was eventually a 22 diagnosed with OCD, but that was only because someone handed me the DSM and was like, oh, do you fit that? I was like, yeah, I guess. And they're like, okay, let's start psychodynamic therapy where we try to find the root cause of all your intrusive thoughts, which is the most horrible thing when you're having ego-destonic intrusive thoughts that you don't identify with. And so I had been told my whole life that I had nothing wrong with me. Then I sort of believed in mental illness because of depression and anxiety. I was in treatment and nothing was helping me. I was just getting worse and all that told my brain was that I am actually a monster. And this therapy, this treatment, these medications were supposed to help me in nothing's doing anything. So it's obviously that I am the problem. And that fueled obviously my suicidal ideation. I was hanging on by a thread. I dropped out of college at 20 with the 1.83 GPA. Like I said, I could barely leave my house. And the only part that sort of pushed me toward eventually getting treatment was one, I started living with my now husband, Zach, and living with someone and seeing how differently function compared to them really shows you what's that there's something very, very wrong with you. You're like babe, everyone's not like this. No, not everyone is counting every single paper towel you're using and thinking that if you use more one more extra that like the whole world's going to implode and it's going to be my fault, like that's kind of fucking weird. But at my worst, like I literally just was waiting to die at every moment. And then I was diagnosed with cancer almost exactly to the day six years ago. And what was so scary about that was that on the one hand, I had the primal instinct kick in of like, oh, I need to treat me and I need to like live. And then there was another part of me that was like dang, this this might be what finally takes me out. Thank God, I failed suicide before like this might be it. And that is a horrific place to be in in life. And I wish that that had finally gotten me the answer as it didn't, but at least showed me that there's something. between the treatment I'm getting that's not working and whatever the hell is going on with me. And yeah, maybe I'm a monster, but someone needs to finally name that for me. And eventually at 24 to 25 years old, I found your Instagram that literally taught me not just what was like I had been diagnosed, but I had no idea what actual themes of OCD were, especially again, the taboo themes that absolutely no professional had ever brought up. I didn't know what mental compulsions were, which I had physical compulsions, but compared to like the entirety of my life, that they were probably about 5%. They were so severe that I was still diagnosed, but like, the rep I was just ruminating all day long, seeking reassurance all day long, checking my memory, recording things, checking if anything actually happened. I didn't believe anything was real. So I learned about that. I learned about what ERP was, which I'd never heard of in my whole life. I then googled it to confirm because I was like, this must be a joke, right? Like how do I go this many years with not a single professional giving me the actual treatment that's at least first line for OCD? But I bought into treatment to try it once and I was like, I'll just die if this doesn't work. And it's been a long road. I have been in recovery, I guess, for like five years. I am still doing ERP today because there's a lot I have to do to untangle so much of what my brain has done to me my whole life, but it completely fucking turned my life around. I, for the first time, learned that not all my thoughts are real. I learned that I did not have to indeed do behaviors all day long to try to figure out my thoughts that were never going to be figured out. I learned that they weren't my fault, even though it's still hard for me to believe that sometimes. And that freedom just completely, completely turned me around because I never thought I would be like, I'm about to turn 29. Like I can never imagine life past like 16 to 18 years old every day that I lived was just like a coincidence that I was alive. And I never imagined a future. I again had dropped out of college. I could barely function or leave the house or like clean myself. I couldn't take showers. Like it was horrific. And because of treatment, I was able to go back to school. I went from a complete failure to earning all A's in all my classes. I really just wanted to understand what the fuck mental illness was and what was going on in our minds and our brains. And I started off as a college major. And then I quickly learned that I kept being annoying in class and asking, but why, but why, but why? And realized that actually I wanted to answer questions from a biological standpoint. I got my master's neuroscience and doing my PhD in neuroscience now. And I'm just super fucking passionate about raising awareness for what the fuck this condition is. It's so misunderstood. You know this. You deal with this every single day. Like on every single day, I count at least like 10 times or someone misuses OCD. And there's just such devastating downstream consequences as a result. And I want to understand what's going in our brains because hardly anyone is studying the specific disorder because of how misunderstood it is. So in a nutshell, that's why I'm here. I am so grateful, A, that you just shared your story, but B, that you are doing what you do, because I think so often I want to know why too. I want to know why I have OCD. And I know that we probably don't have that exact answer. But I think sometimes what I've heard from clinicians is, well, those are really matter why you have it. We just need to treat the symptoms and I get that. I really do because the symptoms are what we have right now. But something that has altered my life and your life so tremendously, I want to know why that happened. And I think we as humans want to know that. And the fact that you are doing this kind of research to help us get to that place is incredible. And hopefully one day will lead to, I mean, maybe this is too big of thinking, but will lead to, I don't know, us figuring out how to stop OCD perhaps. I have a question that might be a little bit taboo. No, nothing's off limits. I have heard people say, and this is going to be different for each person. But I have actually come across quite a few people who have said that their OCD experience was worse than their cancer experience, not that we are comparing one or the other, but just to show how deeply impactful OCD can be because I think a lot of the time people think it's this quirk and it's like a little personality trait that doesn't really impact people. Can you speak to that? Absolutely. I'm like, what is the use of having cancer if I can't speak to that fucking question that's so morbid to say? But like literally, I talk about this all the time because the way I was treated in cancer treatment and still to this day I'm treated when I talk about the fact that I live with cancer because for me, it wasn't cured or taken away. I'm on treatment for the rest of my life to make sure it stays suppressed, which really sucks and is great for health OCD. But anyway, but the way that I'm treated talking about that, the compassion I'm treated with versus when I talk about the vast majority of my time I spend talking about and researching mental illness. I've even been asked, why would you care about studying OCD, what you could study cancer as if there's some sort of moral high ground that cancer matters more? And it's just their completely different experiences. For cancer, it's a very clear cut. This is what's happening. This is what's treatable. And yes, it is life threatening. And I can never take that away from my experience. But OCD has tortured me my whole fucking life. OCD is something that I can't just make go away. And I know a lot of people find so much meaningful relief from treatment and it can become subclinical. And yet, it can rear its ugly head at any given moment because of so many biological and environmental factors that we're probably going to get into today. But OCD just like literally attacked every fast and my being and getting back to what I said when I was diagnosed with cancer. The fact that I was like, well, maybe that will be relief from I didn't know it at the time. But OCD, this thing that has been torturing me and ruining my whole life and making me feel like I am unworthy of living. Like it has almost taken my life. And I say this, you know, this is really hard to say, but like by choice. Like obviously I'm so grateful I'm alive now. But like in my worst and when things flare really badly, I always have it on the table to end my life. And that's very different than cancer just taking it without you willing it. So yeah, I it's a nuanced thing to talk about. I also feel like it's taboo because other people might feel differently. But for me, OCD is so fucking devastating. It is so yeah, it can and it has taken so many lives of people I know. And that that's what kills me. I'm so glad that you're here. And thank you for your willingness to answer that. I have never had cancer. So I can't speak to that experience. But what I can't speak to is when my OCD was really, really debilitating. I was on the phone with my friend. And I remember saying to her, I wish that I had cancer. And that might sound unbelievable to somebody listening to this. Like why would you wish that you would cancer? But my thing was, if I had cancer, then maybe there would be a cause. There would be treatment. I could possibly get rid of this. Whereas I felt like my brain was just with me 24/7. There was no fix for that. I didn't know what was happening. There wasn't a cause at the time. I wasn't diagnosed with OCD. And I genuinely believed that having cancer would have been an easier experience in terms of getting better. And then also cancer would not have attacked my identity in the way that POCD did. And it sounds sick. I do recognize that that I was suffering so much that I wished for a cancer that could possibly kill me. But like you said, I was also extremely suicidal with OCD. I was hospitalized once. Like OCD almost killed me time and time again. And I wanted to die a lot of the time to escape OCD. So then when people say to me, now when I talk about that, like cancer can kill you. It's like, well, OCD almost killed me 100 million times. This is not to compare one or the other. I just think it's a really interesting thing to talk about considering that you've dealt with both. Yeah. And I also want to add that with OCD for both of us and for probably most people we know, like we, especially when we don't know we have OCD or like we're we lack insight, we identify with what's happening in our brain. Like we feel like we are our OCD, which we know we're not. And it's in large part because of our brain and how our relationship to our thoughts and we're not necessarily taught. Like, you know, we're not our thoughts, right? And like biologically, we are adapted to give meeting to our thoughts. So anyway, we identify with all the torture and the distress that is OCD versus with cancer. It's like, Oh, this is this thing growing in me. And or this is something by this organ that is not me. Well, guess what? Our brains are also an organ. It's by far the most complex organ in our body, but it's also still an organ in our body doing some random ass shit, causing a disorder, but it's hard to see that. So it makes total sense that one would want something that they can externalize that they can fix on the side that's not them. Might kill them, but it's not them versus this thing that they feel like is them. And in the spirit of lobotomies and talking to a neuroscientist, I thought, you know, there are cures for cancer. How do I get rid of what's happening in my brain? And obviously, there's therapy that can change the brain. Neuroplasticity really does exist. But that was my thought process back then too was like, this is my brain. There's nothing I'm going to do to fix it at this point, whereas cancer, I thought I could. Yeah. Moving on to our next question that kind of speaks to this, our mental illness is biological, psychological, or both. And is there a difference? No, there is no difference. And that's my take. That's the take of anyone who I respect in the field who does this work, especially when we're working with the brain and we're manipulating actual behavior. People separate our brain from our mind all the time. And I kind of don't get why other than perhaps like we forget that our brain is an organ that generates everything about our experience, it generates our thoughts, our feelings, how we interpret the world. And our brain, like everything we conceptualize as our mind, everything we conceptualize as psychological is driven by biology. And conversely, the thing people also forget is, is our experiences change the brain right back. So that doesn't take away from the idea that it's, you know, brain versus my, it's all the same thing. So my answer is mental illnesses are biological. That's how I conceptualize them. Most people I know. And the psychological aspect of it is the part that we're able to consciously experience and thus treat, but it's still treating the brain biologically, especially when we're doing psychotherapy. Like why would psychotherapy work in any form, especially for example, ERP for OCD, like, I guess if people think the brain isn't driving OCD, which we're gonna debunk today. - Thank you, because I'm like, girl, I know that there are some people who are like, oh, it's a reasoning disorder. You just reason your way into it or whatever it might be. And I'm like, it's this fucking brain up here. Okay, there's something going on in this brain in this body that is malfunctioning to say the least. So is OCD a brain-based condition, meaning can brain differences cause OCD? That's a nuanced answer. The short answer is yes, but in, well, I'm gonna say that for everything. Like science and the brain is so fucking complex, but this is how I would most accurately address this in a simple way. At this point in time, we are unable to diagnose OCD by looking at someone's brain. And that's in large part because of a lack of technology. So our, so imaging studies like, there's a reason that nobody goes to like a psychiatrist or a psychologist and they get a brain scan to determine if they have OCD. That's because we don't have that technology at all. If you look at an individual's brain with OCD or with anything, you're not able to just look at it and be like, oh, they probably have OCD. And rare instances maybe if they have like a very weird brain, but that's usually not the case. I'm like, honey, that would have been me. They would have been like, early, early, calm, we have the case of OCD over here. But what has been established in science for decades at this point, actually far longer biologically than more like how much we've known psychologically about how to treat OCD, which is quite interesting to me. But biologically, we've looked at brains via different technologies of brain scanning. And in group sizes, we're able to see distinct differences between a group of people who have OCD and a group of people who don't have OCD. And that's also because the brain is so complex that the differences are quite subtle, but the subtle differences are extremely powerful in what they end up generating in people. So in some, all imaging modalities are showing this hyperactivity in the circuit that we're going to talk about. And generally speaking, successful treatment, whether that's through psychotherapy or medication or both, are when people respond to treatment meaningfully, we're able to generally in groups of people with OCD versus people without see that normalizing or that lessening of that activity, at least while they're experiencing relief. And a lot of people relapse, and that's a whole other conversation, but we're able to see that later on. And lastly, when we, to your earlier point, when we go into human brains and we manipulate parts of the OCD circuit that we talk about in terms of deep brain simulation, otherwise we see meaningful results. And like, how would that be possible if there were a difference? So the big answer is yes, but not in the way most people think where like you can get scanned and individually, you can see if you have OCD or not. I always get these comments on my Instagram about OCD brains and people are like, I'm too afraid to get one because if it didn't show that I had OCD, then I feel like that's like a whole triggering thing for people. But I often hear that we don't know if it's the chicken or the egg. So when I talk about the differences in the brain of someone with OCD, sometimes clinicians will say, well, that might be because somebody has been performing compulsions for a while. The compulsions caused the brain differences as opposed to their being brain differences in the first place that led to compulsions. Can you speak to the chicken or the egg and what research shows us about that? My first question to those people is why are people doing compulsions? Like if we have billions of people on this planet, why are they at least to our understanding, like around 3% of the population doing these compulsions that result in clinically diagnostic OCD. Like explain that to me, right? And that the bigger answer to that question will be probably answered when we talk about the neurobiology of OCD. But long story short, we don't have the, there's almost no way to collect the data right now of like when someone is born, what their brain looks like in exactly how it develops like every week, every month, every year until the point where they're potentially diagnosed with OCD, even people like me, where I was born with OCD, like one, no one was scanning me too. Like, no, why would they scan me? Like it's not like they know, like we don't have the technology this time to think like this person might have OCD, right? And third, our brain is like changing and developing clearly throughout many periods of our life. So at what point do we decide that it's the right time to start measuring for what's going on? So we don't in the causal way have the evidence to say that someone is born with a different brain, which again, makes no sense 'cause like your brain's changing all the time. So how are you born with a different brain on its own, right? But I guess more accurately, we don't have a way to say they were born with a brain that was for sure going to develop OCD, however, but that's the case for literally anything. We don't have a way to say this person's going to be born with cancer or this person's going to be born with diabetes. That is a mean cancer or diabetes aren't real or biological disorder. So that makes it really bothers me when people have that argument. But also when we talk about the development of a condition and what predisposes someone to it and how our brains are forming and at what point it becomes a mental illness, I'm going to remind everyone again that the brain is by far the most complex organ in our body. It is something we hardly understand. Even with our limit understanding, we know that certain genes inform how our brain is developing and it changes the way it literally builds our brain. It builds our body. Genes are, they work together in the case of OCD is probably like 500 different genes that are working together to mold every single form and part of our brain, every single cell. How are cells look? How they act with each other? How many synapses are on them? How sensitive they are to different chemicals and different modulators and neurotransmitters? How they eventually become a region that is communicating with another one? So by that definition, genes are forming our brain. Some people have a far higher likelihood of developing a brain that will probably at some point clinically crossover to diagnostic OCD. A lot of people have that predisposition, which we can't even find at this point, but we will eventually, because by all these complex, but they might not develop it. That's because they weren't under the proper circumstances, stress-wise or some sort of immunological trigger or whatever that was going to set off that loop that's going to start hyperactivating, even though they are sort of prying to have it. So there is a really complex answer once it's got. It's so complex. And I think a lot of the answers here are like we have information but maybe not the full answer. Like even what causes OCD, my understanding is, right now there's some research that shows possibly genes, possibly biology like a biological predisposition that can be influenced by environment. Is that kind of how you see it? - It is and people say that all the time, it's like genes and environment and like genes are the gun that's loaded and environment is a trigger that pulls it and yes, there's so much more to flesh out about that, which is why I'm doing this episode, because there's a lot more data than just like, maybe genes, maybe environment, but from a genetic standpoint, which genes or what drives biology, so they're the same thing to me. It's a, we have established it is probably around 40 to 50% genetic for OCD, which is huge, by the way. - No, it makes so much sense. My brother has OCD. - Wow. - I definitely have seen it in another family member. It's wild to think about, like there has to be some kind of genetic component for sure. - That being said though, the familial thing, a lot of people use the opposite of like, oh well I'm the only one who has it. Like it's probably not genetic. Denova mutations are a thing. Like you're literally born with, so genes aren't exactly the right word, but it's the easiest thing to say. We're mostly talking about exactly how the gene looks in someone's body. Almost everyone has the same set of genes. It's more like how they express in different people. And sometimes those are inherited. Sometimes those, you're just born with the mutation that nobody in your family has for God knows what reason and that results in something totally different. Sometimes only because your two parents made it, did that mutation actually happen. There's so many nuances. So when we say genetic, a lot of times people conflate that with familial and yes and also like a lot of it is not necessarily heritable so much as just obfucked up. - Girl snap snap. What's coming back to me is unfortunately, I didn't like science class, but I do remember it's like the big X and then the little X or like the big A and the little N like all of those combinations would be, I would get these questions in science class. Like could this daughter have blonde hair? And I think that's kind of what you're speaking to is like, you could have two parents with brown hair and then the child has blonde hair. So like just because the parents have brown hair or the parents will say don't have OCD doesn't mean that the kid doesn't have OCD. - That's true and in exactly that line of thinking, I wanna add even more complexity in that there are, you know, genes and very singular things that can determine things like your traits that can determine the way you look, all those things, right? For things as complex as a psychiatric disorder where you know, yes we live by diagnoses we live by like the DSM because that's the best way we're able to label a set of symptoms and a set of dysfunctions and then most importantly figure out how to treat that because of course, different disorders eat specialized treatment, listen all therapists who don't know that. But in actuality and looking at it from a biological standpoint for no mental illnesses are there one gene probably, maybe with autism which is a neurodevelopmental condition there have been like a few genes that are implicated vast majority of people with certain expressions of autism spectrum disorder. But in the cases of complex psychiatric disorders, it's not one gene or a few genes. It's like, again, like I said for OCD, like probably four to five hundred. That come together. They're all upping the risk factor. And at a certain point, they all work together to create this like fucked up loop in your brain. That does a whole bunch of shit. How lucky are we? Those four hundred to five hundred said bitch. And you're getting it. We're so special. You're getting it. I'm like, could those four hundred or five hundred not have? Okay, that is very hopeful. What is neurobiology just for people who don't know? And then can you walk us through what research shows about the neurobiology of OCD? Absolutely. So most people are familiar with the term neuroscience and it means the science of the brain, right? But the brain can be studied at so many levels of inquiry, which we mostly think about. Like people mostly assume that I'm like putting people in a scanner and I'm looking at humans and actually know I'm studying the biological substrate. It's like the biological driving aspects of what the brain looks like. And so neuroscience encompasses things like cognitive neuroscience, psychological neuroscience interactions with people. And then you break it down even more. You're scanning people in a scanner and you're looking more at like how their brains operate. But we can barely see anything other than what's lit up and how much they're connected to each other. And maybe like density of certain receptors and things like that. But in order to get even deeper into the mechanistic, well, what's actually happening? Like why is there more blood in that area? Like why is it more active? Like we have to look at the cellular level, the molecular level. And that's what neurobiology is. It's looking at the biology of how the brain works. And that's a more subset specific part of neuroscience. Wow. And so talking about the neurobiology of OCD, my favorite topic, I'm going to break it down into a few levels. I'm going to start with the most broad level, which is the systems one, which means the circuit in our brain. And that's when different regions of the brain are talking to each other. And based on potentially overactivity or underactivity, it can change the way if someone's brain works from being quote unquote normal. So I'm going to start with the first part of the circuit that it's called the cortical stridal, the lamic cortical loop. The first part is the cortex. Most people have heard of things like the prefrontal cortex. We talk about it in terms of being very evolved. And it's part of our brain that's developed later as we've evolved as humans. We have a part of the cortex called the OFC, the orbital front of cortex. It's right in the front of our forehead. And on a high level, it's at least in the context of OCD, it's assigning things like salience and telling us like what's important and detects threat in OCD. People can most likely guess that this region is over detecting threats and it's exaggerating potential things like for example, an intrusive thought pops in your head of like what if I stab my dog every single person on this planet Earth has intrusive thoughts. And most people are able to have that thought and they're like, that's fucking weird. I hate it. Oh, moving on. People with OCD latch onto that thought. Sure, it's really relatable to most people listening who have it. Yeah, I'm like girl. And they're over assigning value to that thought. There's also another part of the cortex called the carrier Singular cortex, the ACC. And that's a monitoring conflict and error. And it's really hyperactive when people with OCD telling us that something's wrong. So it's in normal people, they're able to figure out is there is this something worth looking at? Is this something that makes sense and they're able to more cognitively get out of it? And people with OCD that feeling of something's wrong, something's off like crisis. Whoa, it fuels whatever form of distress someone's experiencing. We talk about anxiety all the time. There's also disgust, shame, just rightness, whatever that urgent need is to take that feeling away. And so those cortical areas then talk to a deeper structure in our brain called the stratum. And that area of the brain does a lot of things. But what's relevant to OCD is that it's modulating our behavior and our habits. So our OFC is talking to our stratum and telling it that there's a thought that's happening. And those thoughts usually then tell our brain to take action. And so we have this direct pathway in the stratum that's telling us to do stuff. And simultaneously, we have the indirect pathway that's supposed to suppress behavior. And there's it's not one or the other. It's both and they're acting together at the exact same time. And in healthy people, that's able to help us figure out when we should take action. And when we should not take action in the case of OCD, the stratum ends up being stuck in gear and driving repetitive behaviors that could be physical or mental. Once the OFC calls something salient, like again, that thought that I'm going to stab my dog or that the door knob is contaminated or whatever the interests of thought is. It really doesn't discriminate and it doesn't matter, which I really appreciate in the context of understanding neurobiology because people again tend to think OCD looks like a certain thing, but it literally can be any behavior, any thought, right? So so that there's an imbalance in the go, no go pathways at the stratum is then creating these habits or purporting these habits that we really don't need to be engaging in. And those are essentially compulsions. That projects to an even deeper structure in our brain called the thalamus. And the thalamus gates our senses and it relays and kind of takes everything together and creates physiological feelings of arousal. So, you know, OCD isn't just like all in our head in that like we're just thinking about stuff and we're doing stuff like we're feeling so fucking real. Exactly. The worst parts of it. Exactly. So over activation or the poor gate, poor gating here can cause us to have like horrible heart racing, panic, adrenaline, all of that stuff. And it's basically doing that to signal to our brain that the thought was real and important. The behaviors that we did in response to that thought mattered. And thus that should happen again and again and again. So that thalamus then projects back to the cortex, telling it all of that, which then means the next time we have a thought, we'll do the same thing again. I think what you're talking about and correct me if I'm wrong, there's a study out of I think it's the University of Michigan and it's called stuck in a loop of wrongness or something like that. And it kind of I think talks about this exact experience where something in the brain, I'm going to butcher it. So I'm not even going to pretend like I know what what that is. But is like the breaks essentially aren't working in the brain of someone with OCD like they are in someone without OCD. However, they look at it through the lens of compulsion. So it's really hard for someone, let's say if we're using the stereotypical contamination to stop washing their hands like the breaks aren't working as much. How does that though relate to intrusive thoughts? Because for me, it was less like I absolutely performed mental compulsions and I avoided like I had compulsions. But OCD for me was more like if I looked at the letters of OCD, it was like big O tiny C because my brain can get stuck on a thought and then I swear to God it can loop 400 million times. Like it'll be the same phrase. Like let's say like I don't know what pussy or something that's like I just don't want to be fucking thinking about. And then it's boom boom boom boom boom. 400 million times. And no matter what I do, it's like the record player is broken and it just repeats nonstop or it could be a mental image like that. Is that the same the brain stuck in a loop of rawness or not? Because I feel like we only talk about it with compulsions and then I'm like wait, but what's happening that I keep having this thought? Like what's happening in my brain? Well, just on a systems level because we still have a lot of deeper levels to go. I mean, you're like, we got to dissect all the levels of your brain. But that's literally it. Like that's why I started with the OFC and that is the beginning of the cortical stride olphalamic loop. Thoughts are generated up in front over here or you know, we're associating something or we're seeing something or whatever. And our brain is overactive in that way. So it's literally just like making it louder and louder. And then like you were talking about the big O little C, but like even in relation to that, like you have that thought and you're like, what? What? Oh my gosh. Like what? Like you have a response to that thought, right? We talk about that, right? That is a behavior. That's a behavior. You're then feeling the panic and you know, the thalamus is like creating those physiological signals to tell your brain that you should feel like what the fuck to that thought, which again is a behavior. If you're like giving it attention, we talk about that all the time, right? And that's reinforcing the loop. So like I think a huge macep in the field generally is like the compulsion aspect. Yes, is super important. But one, people tend to look at physical far more than mental and two, they tend to forget that like the compulsion is related to the obsession. And that really translates to so much of the research that's been done or lack thereof where I was going to talk to this later. But like typically when they're looking at behavioral models and like animal models, this is a kind of work I do. I look at human brains like tissue as well. But in terms of animal models, people are looking at like, Oh, if we manipulate this gene or we do this like medication for like an OCD animal model, what do they do behaviorally? And that's probably because it's hard to like gauge the thoughts of an animal. However, there is a lot of things we can do to gauge to for me, like what I've been doing is like, I'm watching the behavior in response to inducing like the closest thing. It's hard to do like disgust or just right this with an animal, but you can do anxiety or fear. And that's what I do. And then I watch their response to that stimulus as opposed to just generating repetitive behaviors that are not in response to anything. And a lot of times people study OCD and autism together as if they're the same thing because of that repetitive behavior concept. And like, that's not accurate. I really appreciate you paying attention to the obsessions piece two because for me with OCD, like, yes, of course, there was a part of me that was like, wait, could I be a pedophile? Could I be attracted to animals or my parents? But that was because I was having 800 million intrusive thoughts and images. And I think some people think if you can just know that you're not that thing, then OCD kind of falls away. But for me, like a lot of the time I knew I wasn't a pedophile, what I was bothered by more was the relentlessness of my brain and the unrelenting thoughts and images all fucking day long. So it wasn't always that I thought I was this pedophile. A lot of the times it was I don't want to have these thoughts. I don't want to be around kids because I already know that my brain is going to loop on a thought about one of them. And I think that we have to talk about that too because it's not just I perform this compulsion to figure out whether or not I'm this thing. It could also be I'm performing this compulsion or I'm behaving in a way to try and get rid of this thought that is looping. Exactly. And that what I love about biology is there's an explanation. There's a biological explanation for your brain, the front part of your brain literally just being hyperactive, which is in many ways like the beginning of that cycle or in that circuit in the brain. Now, there's also questions of like what was hyperactive to begin with that cause that cycle to continue? That's like a huge question. And perhaps in different people, it started in different parts of that circuit to where that's why people respond differently to treatment, which we can get into later. But all that to say, the end result of it all is that circuit is hyperactive and the front part of your brain is generating those thoughts over and over and to your point earlier. Like, it doesn't matter logically what we know. It feels real. It feels real. And even if we don't believe it and we know it's not true, we're still experiencing it. It's a horrible fucking experience. Right. That's more so how it will show up for me now. I'll have a lapse like once every six months and it's usually like a two week lapse. And it's not that I don't know what this is. I know that this is OCD. I am just like, why the fuck do I have to have this same phrase repeat in my brain 400 million times? Yep. And I've gotten so good at mindfulness and the art of acceptance and it's like it's still there. So I guess a question I have to follow up with that is even when I'm not behaviorally doing anything toward the thought, it's just like boom, boom, boom, boom. Why is that? Because unfortunately, we do not have a cure for OCD. You're like bitch because you're not cured. That's why. No, nobody's cured. You can be subclinical and that's the most beautiful thing ever. And that just means that at this moment in time, that circuit because of whatever interventions you've done and then more deeply the cells that are driving those circuits, the molecules that are interacting with those cells, like all of those are less active right now, but they can come back up for any fucking reason. And it's like whack them all. Like yes, you can lessen the likelihood of it becoming louder by a whole host of practices to take care of yourself, blah, blah, blah. But at the end of the day, we're humans. We live in a world that causes stress. We, that's like pouring gasoline on a fire that's already there. Even if the fire is really quiet, it's still there. That's unfortunate. And that doesn't mean, I don't mean that to take away. I hope for anyone. Obviously, there's so much hope for recovery and healing and living a far better life. I mean, my life is like completely 1 million percent different. Yet my fucking brain runs and like it gets loud often. The differences at least were always me to get it on an upward spiral. You know the so well as a clinician, obviously, and a survivor of like you're always meeting it with at least you've met with it before and you know what it is, even if it feels real. So definitely. Is there anything else related to neurobiology and kind of the circuits of the brain that causes sessions and compulsions that people should know about? Yeah, I just wanted to give more context to brain regions and systems really fast. We don't have to go into the nitty gritty. That's for my thesis. But, but in terms of like the systems in the brain regions, right? Like what makes up those regions and what's doing all that work? It sells. There are many cells that are driving these parts of the brain. And so I just wanted to talk about the fact that different cell types and different parts of the brain play different roles and just to illustrate how complex this is and why there's so much work that needs to be done to dissect this on every level mechanistically. And for example, in the front part of the brain, we have cells that are called pyramidal neurons and it will completely different from the cells that are in the codic pitamins, the stridal area that are called medium spiny neurons and they express different types of receptors and are activated to different things. And then we have different types of cells that are not even neurons, like I said, called astrocytes that for example are sort of cleaning up all the chemicals that are being spilled out and they're taking away cells that are dead and just doing so many things. So there's so much nuance and complexity within these regions. It's so hard to simplify it down. And also like in terms of calling regions different things, we didn't talk about the amygdala because that's not part of the circuit. But people say the amygdala all the time. There's like 12 parts of the amygdala. Wait, that's wild. Because like do here people say like OCD is, you know, art is an overactive amygdala. Okay. So why is that a myth then? Tell me. I say this 50,000 times the brain is so complex, right? So we talked about the circuit, this canonical circuit of the cortical stridal of the lemic loop. All of those brain regions also talk to like a bazillion other brain regions, including for example, some of them talk to the amygdala, right? And so you can imagine that if a brain region is, you know, acting up too much or not acting up enough, then everything that their cells are projecting to are going to act differently in response as well. And so the amygdala can be one of those. And namely, you know, we talked about with OCD, it shows up in different ways for so many different people. A lot of people experience fear or anxiety. Some people don't experience that at all. And they experience disgust or they experience just rightness and they, like, nothing ever feels complete. Most of that is all reconciled by the cortical stridal the lemic loop, but the downstream experience of how that's experienced emotionally in the brain and in the body can be explained by other brain regions. Yes, the amygdala, just like many other parts of the brain can be involved, but it's not always and it's also not part of the circuit that is both driving OCD and also conversely is being used to treat OCD. Some of the best evidence for that is the amygdala does jack shit for deep in DBS treatments. Like if you try to, like, no matter even if your OCD is largely anxiety, fear based, like they've done many trials looking at different targets to target with deep brain simulation surgery either because it's directly, this is a good distinction to make. The pathophysiology of an illness is what is driving the illness and then you can still harness other mechanisms in the brain to treat something. For example, like me taking chemo for cancer doesn't mean that like I got cancer because of the chemo deficiency, right? Or like me taking antibiotic for like something doesn't mean that I had an antibiotic deficiency that caused the infection. So in the same way, like you can stimulate a different part of the brain and it can help with the disorder even if it's not part of what caused or drove the illness in the first place. Either case though, the amygdala doesn't do anything. So that's a common myth. People like to justify that OCD is an amygdala disorder. It's not and I will lastly say I'm very passionate about this myth. The last thing I'll say is that people talk all the time about like OCD versus anxiety and conflating the two and that's incorrect for many reasons, but particularly in the DSM, the thing we use to diagnose and treat illnesses, used to be in the same category and then as of the DSM-5, they were split into different categories and one of the main reasons is because OCD neurobiologically is a different disorder. It's an anxiety and they're not treated the same in terms of biological treatments or sometimes people use ERP, but that's a different story. The point is, biologically, medication for one does not treat the other and if we kept it in the same category, then most pharma companies or scientists would just study anxiety and also label it as OCD treatment and they're not. So in order to incentivize people to study and treat OCD differently than anxiety, they put it into different categories. So that's just more evidence to debunk the idea that OCD is just anxiety or a form of anxiety or it's a spectrum. Yes, the only validity to that is that, like I said, we use the words, like disorders to distinguish different conditions right now to figure out how to treat them, but at the end of the day, this brain is so complex, that's why so many of us have so many comorbid disorders. There's circuit level impacts that sell you over impacts that contribute to a whole host of symptoms that might be one disorder, it might be five, like you and me. Right. Definitely. Yeah. I'm like, pick one. What is it? One today. What do we got? Okay. So how are anxiety and OCD different in the brain? Anxiety is mostly involved with the amygdala and different subnucleid the amygdala that are talking to different parts of the brain, including the cortex because the cortex is involved in literally everything, but it is primarily a fear anxiety experience disorder as opposed to like OCD. It's primarily the over salience of thought meets the behaviors and then the physiological response that then projects back to the thought and that the experience of anxiety can help feel that circuit, but it's not the circuit itself that drives the disorder. Brilliant. This podcast is made possible by no CD. No CD offers effective, affordable and convenient OCD therapy. No CD therapists are trained in exposure and response prevention therapy, the gold standard treatment for OCD. With no CD, you can do virtual live face-to-face video sessions with one of their licensed specialty trained therapists from anywhere in the U.S. No CD therapy goes beyond sessions. It includes in-between session support where you can message your therapist any time, access therapeutic tools. and get support from a community of peers who are overcoming OCD right in the OCD platform. Is it noCD.com today and book a free 15-minute call with their care team? Many of whom have personal experiences with OCD. Is it noCD.com today? We know that with OCD, compulsions reinforce obsessions. Can you talk about the, I guess, neurobiology with that? What is happening in the brain when someone performs a compulsion gets temporary relief and then ultimately feels the urge to do that compulsion again and again? Absolutely. So when someone does that compulsion, what I love about this circuit conversation is that the circuit of the cortical striatatholabic loop almost perfectly aligns with the obsession compulsion cycle loop, which is really great biology is awesome. In the case of compulsions, what we talked about earlier is that the dorsal striatum, the conate mutamen, the go and no go is very off balance and is thus causing these behaviors. In the context of what's signaled in the dorsal striatum, namely those medium spiny neurons are talking using dopamine and people talk all the time about dopamine being like this, you know, fun reward chemical. It's like a high whatever. In the case of OCD, it's simply just causing that over signaling that then provides that temporary relief that then tells the brain like do this more and you're going to keep experiencing that relief when you do this behavior and your brain is learned to look for that relief because we were adaptive humans were trying not to feel like shit. So that's then reinforcing that habit circuitry, which then is telling our cortex again to like look at that thought importantly so that we can do those behaviors again. I appreciate that you are differentiating between OCD and anxiety because I think that's part of the problem with medication and OCD and why some psychiatrists don't know that it can take a higher dose to treat OCD. Isn't that a lot of the research that is done with SSRIs is based on treating depression? And then psychiatrists think well if this works for depression, this is also going to work for OCD, but depression or no CD are probably different in the brain too. Yeah, of course they're completely different in the brain. We also don't understand so much of depression. Like we have like at this point, we're trying to understand if there's like eight different versions of depression because like they look so different in different people and it's such a broad term to answer one part of the question. In terms of serotonin, I mean, we're already talking about neurotransmitters. So serotonin, like most people know is associated with like mood regulation and feeling good. Actually serotonins involved in so much more than that. It's involved in so many parts of our body and our breathing and how we function. And in the case of the brain really, it's more so associated with how strongly cells are communicating with each other. And in the case of OCD and this circuit, how strongly these signals are getting passed in the loop. I kind of look at it like a volume knob that's being turned up or down in terms of making things more active or less active. And that ends up resulting in things like mood regulation and many other things that keep us alive. People tend to think of the mood side of it, right? And so for what's interesting about depression and and SSRIs is that like for most psychiatric illnesses, especially the ones we've just discussed, the treatments of them came by accident in that SSRIs. I believe we're discovered because they were being used to look at malaria and like people ended up just feeling better on them and they're like the fuck. They're like, honey, I have malaria, but I'm happy. But I am happy today. Exactly. And so in the same way for OCD, SSRIs were found to be helpful in OCD, but it's not because in any causal way SSRIs are acting on specifically what's going on in the brain for people with OCD. It's kind of again like using chemo to treat cancer. Like that doesn't mean again, you would like a chemo deficiency. It means you can use chemo to attack a thing that was growing for some other reason. We don't we can't definitively say either way that like serotonin plays a huge role in why someone develops OCD in the first place in terms of signaling. However, we can harness the therapeutic benefits of serotonin being something that helps induce plasticity in the brain and change the way the cells communicate. Because I said it turns the knob on up and down, that's in part also why you might need a much higher dose because there's a lot going on dysfunctionally in the case of OCD, but it's important to say that it's not attacking the pathophysiology. And that's why we need treatments that are actually targeting what's going on in the brain rather than just like finding some random ass other mechanism that helps treat the dysfunction while the dysfunction is still happening. I really hate when people say, well, the serotonin myth has been debunked and then essentially use that to say that SSRIs don't work in treating OCD or depression. And I love what you're speaking to. Maybe a serotonin imbalance isn't causing OCD. That does not mean that SSRIs do not work to treat OCD. Like Prozac has changed my fucking life. It has changed my brain. It has turned down the volume. Like that's really it. It is turned down the volume of thoughts in that loop that used to be 24/7. Yeah. Just isn't. Absolutely. I think that is so important to say. And people have this logical fallacy where I've heard this by people so often where they're like, oh, we haven't found a gene for OCD. That means it's not real. It's not a disorder when like literally do you remember the tyrate I went on earlier of like, well, actually, we haven't even talked about why we haven't found the genes yet. That's because we don't have enough people in the studies, which we'll get to later. But like just because we haven't found it doesn't mean it's not there. And actually we have found a lot more people think. But people love to make this logical fallacy because we don't know something for certain now that it means it's not true. And that there's like so much it's so much more complicated. Yes. Okay. It reminds me of. And by the way, I love pure and I love her work with OCD, but it reminds me of Rose Cart. And I think she came out with that book, The Maps We Carry. And I haven't read the book. So I will say I might be getting this wrong, but I think her argument was kind of that like if there aren't biomarkers that show that OCD exists, then kind of this is environmental and we can heal and community. And it's like girl, yes, I believe that environment can contribute to the onset of mental health conditions, but it's not just environmental. So I feel like it was almost like a, how do I say this? Let's debunk it. There is no biological basis that has been found for OCD. The only thing we cannot say, like I said in the beginning is like we're able to track someone from birth and see exactly when they developed it and did the brain, you know, change in a certain way that caused the obsessions or then and then the compulsions or did someone have the obsession and then they did compulsions that have changed the brain. But obviously, like if 3% of the population is developing this, like this is not a thing that if you just happen to do a behavior often, it turns into OCD. Like that makes no sense whatsoever. Number two, the predisposition to OCD because it's just trauma. Like I've heard that myth not only from that argument, but from so many people where they like to say that OCD is just a form of PTSD and it's trauma and thus it can be treated in the same way as trauma is. That makes no sense at all because by that definition, everyone who has PTSD would have OCD, which is not true. And also just in general, like as humans, almost everybody experiences some form of an extremely stressful life event if not trauma and even those who experience like whatever you want to call it, a capital T trauma or something that constitutes the diagnosis of PTSD or CPATSD, only one out of 10 people develop the diagnosis. That doesn't even track for PTSD, let alone for OCD. And there are so many things that have been found in the literature and in data to exacerbate the onset of or relapse for OCD, including stress, including trauma. But that is meeting a brain that is primed with that circuit with the many, many complex variables that no one is talking about in the pseudoscience world. That prime, essentially, your circuit to be ready to be overactive. And you can, any stressor can cause that, including hormonal changes that sometimes people develop OCD when they're going through menopause and people develop it after they give birth. Like there are hormonal changes that can any sort of stressor like that or moving or a bad relationship or trauma. Like that can all onset or exacerbate OCD. But that's not causing OCD. That just doesn't even make logical sense and then getting to the biomarker point. The term biomarker is overused in a way to de-legitimize illnesses or legitimize them so often and is extremely frustrating because our technology is not like we like to think we're so technologically advanced as humans in terms of the brain and the body, but especially the brain. Like we aren't able to even look at someone's brain and see like what cells exactly are activated in a certain situation. That's why we have to use animal models and we have to like be able to open their brains up and do brain surgery and then turn their neurons on with light. Like that shit's magical. It's so cool. We can't do that in humans. We don't have the technology to see anything with specificity. We don't have the technology to have a biomarker that causally defines OCD at this time. That's not because it's on a biological disorder. It's because it's so complex that we haven't developed the technology to identify it yet. But that logical fallacy of we don't have this, it's not real. That's just not critical thinking. Yeah, and I think it it felt harmful to me because I understand the need for community and I also understand the need to look at environment and trauma and life stressors. Like if we're ignoring those things, we might be ignoring a piece of the puzzle. But I don't believe that treating trauma or life stressors is going to cure OCD. And that's where I found that article to be a bit problematic. Like if we heal in community and if we did it, that's not enough when somebody has clinical OCD. Like we also have to treat the symptoms and we also have to look at what is going on in the brain and body. - No amount of processing the capital T traumas I've been through and I say that just to like illustrate a greater point. I think there's many versions of trauma that are valid beyond capital T, but just to illustrate the point, like I went through chronic sexual abuse. I was in a cult for seven years. I was physically emotionally abused at home. Like I was, I met diagnostic criteria for PTSD and CPATSD by the time I was fucking eight years old. I have been in treatment for that. That didn't do shit for my OCD. The only thing it did was potentially, like in terms of treatment, it's helping me have an open window of tolerance for my exposures because I was so traumatized and it's helping me with the insight of like just because something actually happened to me doesn't mean like it's gonna happen to me every single time, but there's a very distinct difference between, they're two different diagnoses also driven by different parts of the brain. Yes, they intersect and overlap, but yeah, it's not the same thing and it does not at all address the whole point of the episode. The biological crux of OCD that then manifests psychologically in our distress and our illness as an obviously environmental triggers and trauma make a huge difference for not just OCD, but literally any version of distress. So it's categorically misinformation. I'm so curious about, I guess, the onset of OCD because for me it happened in point two seconds. Like I was standing at work one day and then boom, I had a thought like what if you have sex with her about a child and then it was downhill 24/7 unwanted thoughts and images and it was, I literally felt in my moment, this is how I, in that moment, this is how I describe it is like my brain broke. I really felt like something happened in my brain that just totally fucking broke. And then I hear from people that it's more of a gradual onset or like you, you're born with it per se. Like you just can't ever remember a time without it. What can explain the differences in onset? - There are a lot of things that can go into it in terms of like people who were born with it like me, like perhaps like my circuit developed so early to be prized plus I was like cooked in trauma and that could have played a role in it. Or even if there are many people who have no trauma in their life that were born very early on with like very severe pediatric OCD, that could just be that like their genetic predisposition was far higher, which then informed the way their brain was developed early on and how their cells were overfiring early on and there you go for early, right? And also importantly, there's different periods of our life when there's a lot of plasticity going on. For example, the most obvious one is when we're growing up our brain is forming. So there's a lot that can get crossed and a lot of shit that can go wrong in that point of life. Then you have more of the teen area in your life where different critical periods are opening for the first time. You're way more susceptible, for example, to like social influence and that's because of your brain. Most people don't know that. And another huge thing associated with that period is puberty and all of the hormones that are then changing the way your neurochemicals are activated and how they're then causing your cells to, I'm trying to build like the levels of how these things are working. So those chemicals inform yourselves and should form the region's blah, blah, right? And then in adulthood, there are different periods of extreme stress. There's periods of people like pregnancy. That's why there's a whole postpartum side of OCD that happens, menopause. Generally speaking, I've heard a lot from when people leave their home that was very traumatizing and they enter the world and they're living alone. That's like ages 18, 19-ish. They're experiencing a whole new version of life that is extremely destabilizing even though technically you're free. Like I was and maybe you were as well. But you're starting to face with the actual world is that can be extremely stressful. There are things like comorbid conditions. I know both of us have struggled with severe eating disorders. I had bulimia, you had anorexia. That can be a huge onset trigger. I'm like, I was literally just thinking about that as you're talking. I'm like, yeah, it was probs, the anorexia. It was probs because at 18 I was so severely malnourished. I had such horrible undiagnosed anorexia and I went right from extreme anorexia into her CD. I'm often like bitch, if you wanted to eat, no, I probably would have had it at some point, but I do feel like, or maybe I wouldn't have had it as bad, but at this point, what could I do? I can't go back in time, you know? But it's interesting to think about, right? The fact that you can pinpoint a stressor that put your body into survival mode, that will probably do it to onset. What you were already predisposed to, that your brain was primed for. And also there's a lot of overlap in terms of like anorexia and OCD, they're different disorders, but also they have a lot of overlap with cognitive flexibility and rigidity. And like obviously they give rise to both. So there's things like that to basically stress, like the big answer, but I was trying to make that more specific. And then lastly, let's talk about pants pandas real quick. I was gonna ask about pants pandas because I also wonder if that accounts for my sudden onset because my anorexia was a pretty sudden onset too. What do we know about pants pandas and autoimmune conditions and their role in mental health symptoms? So just to briefly define pants pandas for anyone who doesn't know, they are two versions of essentially if someone experiences a virus or an infection that just generally impacts their brain or body. The idea behind pants pandas is that those infections or viruses depending on if it's pants or pandas. And typically the P is pediatric, but we can get into adult real fast. In any case, those infect you and then they cause the, they cause that circuit, the base, they call it basal ganglia and cephalitis, which now we know the basal ganglia is the Codaputein, the stradum that part that we were talking about. That gets damaged essentially. And then it's damaged because of the infection or virus in the idea of pants pandas is that when the virus slash infection is active, then it's causing that circuit to be overactive. But when it's not active, it's not causing that. And so that's super important to talk about because there's also the version of that that's not pants pandas, but people send a conflate with it where for whatever reason your brain got damaged because of a virus or illness and then it left it damaged and then you just have it. And people call that pants pandas all the time and that's not it. Like that's not the same thing. When it's only pants pandas when it's correlated to and then presumably causated with when the virus or infection is active. And in many cases, so I have many autoimmune conditions. I also have chronic Episcene Bar of Iris. And I will never, I don't know the full answer for this for me. But that would basically be like my OCD is really bad when my Epstein Bar is really bad. And it's not bad when it's not active. And it's which is on and off in my body. Mine stays bad and Epstein Bar is not always active and had it tested. So that's not the case for me. I had people conflate that like, oh, they hear about pants pandas and they're like, oh, well, I could have, maybe I did have a virus or infection or I could have. And then that must be the answer. Like, no, it's way more, it can cause damage that then keeps your brain damaged. And that doesn't mean you have OCD for the rest of your life like at 100% all the time. But just like anyone else with OCD, which by the way, another cause of OCD could possibly be that at some point your brain got damaged. Girl, my brain came out damaged. It was damaged in the womb, incidentally. I hate to break a sea of it. We're gonna have a hard life. Okay, buckle up. But I did want to clarify that because there's such a misconception people learn about pants pandas, which is super important to learn about. But they then run with it thinking that at some point I had an illness and thus it's pants pandas. Like it is only that if it correlates to your actual symptoms. And the last piece is like people talk about it being pediatric 'cause it's been found so often and studied in pediatric populations. It doesn't mean that you can't be an adult who had that infection as a kid and that keeps staying active in your body. And so that's a misconception and it can happen in adults. There's a lot less data looking at what it looks like in adults from an onset standpoint. But from a persistent standpoint, obviously if it's in your brain and body and you can't treat it, then it's gonna stay active. When I read "Brain on Fire" when I was in the middle of my debilitating OCD, I related so much to it because Susanna Cahalen had that just like sudden onset of mental health symptoms. And I really thought to myself, could this be me? Like my brain did feel like it was on fire. And I've never been tested for pants pandas or other autoimmune stuff, which part of me is like maybe I should and to just check it out. But I don't like what explains that brain on fire feeling? In the most simplistic way, like your brain is on fire, it's overactive. Like I sometimes I feel like a lot of pressure in the front of my brain. It could be placebo, I don't know. But like that's literally my brain. You know what I mean? We're the same person. I'm writing about this in my memoir, but I will give a little sneak peek. I was on the phone with my fucking therapist in the McDonald's line. This was literally, I don't know, fucking eight years ago. And I was begging her. I was like, I feel pressure in my head. My brain fucking hurts. There's something wrong with my brain. You have to get me to a neurologist and she was just like, no, like, "This is OCD." And I was like, there's something wrong with my fucking brain. And then I would put her on mute and be like, "Thank you for the diet, Cug." Like literally having a fucking breakdown in the McDonald's line, but that was it. Like I could feel my brain pulsing when my OCD was so bad. - What makes me sad? I don't, I'm by no means putting your therapist on blast 'cause that's just what happened. And like, you know, most people are not scientifically informed in this way, but like that was incorrect. Like your brain literally is involved. Like your brain is generating exactly that. Some people can actually feel it. Like calling it your OCD, I mean, like it is your OCD. Like your brain is experiencing OCD. Like no shit. - Right. - Is that where something like brain surgery could have helped me? Like what would have happened if I went to a neurologist, let's say? It would have been like bitch get out. What are you doing here? - Well, no, in that a lobotomy, I mean, I know you're joking, but not really. In that brain surgery, that's part of what in the worst treatment or factory cases of OCD, like brain surgery helps 50% of people. Like again, those are people who know it is. - Yeah. - Not even yet. - Yeah. - It's really sad that that's, and if anything that illustrates how debilitating horrific and severe OCD is, but once people go through the entire treatment algorithm of they've tried every first line, second line, third line medication, in combination with first line, second line, third line, experimental psychotherapies, blah, blah, blah, even like ketamine and whatever things, of those treatment or factory patients who literally nothing else works for surgery in different parts of that circuit, especially the straight-up, literally relieves OCD. So yes. Does it stop OCD? Like if I would have gotten that surgery, let's say at 22 years old, like would that have cured me of it? - I don't know of anyone who has ever reported that, like I said, we don't have a cure, but by basically deep brain simulation, it's one of the only treatments we have that directly, causally changes the way that circuit works by like literally either activating or not activating a part of the brain, right? So in that case, it's helping that loop be less active, but some people have a lot more relief early on, some people it takes up to a year, but mostly everybody has to do ERP to like, actually, because it doesn't just change, like changing the way your brain functions just from a pharmacological or biological standpoint is sort of in some ways a myth in that, like because OCD is such a complex disorder where it's not one brain region that's causing it, it's a combination of multiple that's talking to each other, like it's still governing your thoughts, like it's not changing like how many thoughts you had in this part of the brain, right? But it can make you far more able to actually do treatment and malleable to it and it can cause your brain to be able to change itself and to speak differently to each other. So it wouldn't have made it go away probably, but it made it, it would have maybe if treatment wasn't gonna work for you, like made it work a lot faster and make you feel better earlier. That's a last resort. - That makes so much sense. And we've talked about SSRIs and how they can positively impact OCD symptoms for some people. Why do some respond to SSRIs? And others do not. Or I should just say any medication. - Part of it is getting, but to that point, that SSRIs are not targeting the actual drivers of OCD. It's harnessing a different mechanism to our understanding that helps your brain change itself and feel different and communicate differently as opposed to directly impacting, like in a very targeted precise way that's circuit. And for that reason, you know, serotonin receptors are expressed on many different cells, but not all cells and in many different parts of the brain. And when we talk about OCD looking different and different people and treatment looking different and different people, while that circuit is hyperactive in pretty much everyone with OCD, where the overactivity started could impact where treatment needs to interact with that circuit. For example, like if their OFC was more overactive than we can in a dream world where we have precision therapy like this and precision medicine. - That would be amazing. - That's what we're working to. That's what people like me are working to every single day. But like for people where the OFC started at all, like we can target the OFC more. For people where the strideum started it all, we can target the strideum, et cetera, et cetera. And so that probably lends itself to why not everybody responds to treatment and not everyone responds to the same treatment. We are able to just like ERP, like while it does change the brain and is really obviously helpful for so many people, ERP wasn't developed as a result of understanding how the neurobiology of OCD works. And this is a psychotherapy that addresses it. It was like kind of the opposite where like ERP was found and developed off of cognitive theories. And now we're trying to reverse engineer and figure out how does ERP work with the actual pathophysiology of the circuit as opposed to it's like harnessing alternate mechanisms to help the circuit change. So it's so complex. But in terms of treatment in general, the heterogeneity of it, there's also like, like I said, like up to, I don't know, 500 is genes that are related to OCD, but like different people express them differently. That could all end up resulting in someone having OCD. But for certain people, sometimes genes are regulating how exactly chemicals are able to interact with cells in our brain. And some people might not have the ability to even like utilize serotonin in the same way that other people do so the medications wouldn't work in the same way. - Wow. Can you talk a little bit about behavioral change impacting the brain like neuroplasticity and how let's say ERP treatment. So exposure and response prevention might change that brain circuit. - Absolutely. So we'll start with defining neuroplasticity because it's a term everyone uses. It's kind of a buzzword and I appreciate that. However, it's true that it means your brain can change itself, but that's such an easy thing to say as opposed to understanding on a very granular level what that means. And the easiest example for me to talk about this is in everyday life, we're meeting new people. Like you and I are having a conversation we've never had before and that's literally every conversation we do, right? We drive the new places all the time. We do new things, we learn new things at every age. People learn a lot of things easier when they're children and that's because their plasticity is upregulated because that's adaptive, but even as adults we're able to learn things that myth has been debunked that we can't learn things because our brain is able to change. And so in an adaptive way, our brain is changing every single day and what that means on a granular level is that the cells in our brain are responding to different things and they're learning how to generate associations and they change their literal morphology. Like you can look at a cell, like I look at cells under microscopes from brain areas, like and I'm looking at how different synapses are showing up and how they're the way they look changes and thus how they're communicating with new cells. Like your brain is changing all the time in every given moment and sometimes it's changing a lot and sometimes it's changing very, very subtly, either way it's changing. So anything you do is going to change your brain, anything you experience is going to change your brain. That's why if you cross the street and you almost hit by a car, you're probably going to check when you're crossing the street about getting hit by a car again because your brain, the cells have learned to tell you to do that, right? So much more complex than that, but essentially your brain is changing all the time. So obviously when you're doing exposure and response prevention or any sort of therapy, it's changing the way your brain's working because you're interrupting that circuit. It's you're learning to not do behaviors and response of those thoughts or to lessen them. And then that's thus showing your brain. It doesn't need to immediately or automatically do a behavior to be able to tolerate the distress of a thought essentially. And that's changing your brain. That doesn't mean we're curing OCD. I told you we don't have a cure and Nord, do we know what causes it in the same way? But we're able to change how we respond and we're able to tune things down. And so therapy is doing that medication in a different way is doing that. Like I said, currently our first line medications of SSRIs are kind of globally doing that. And that's another point of why SSRIs may not work for everyone. Like when we take a drug, it goes everywhere. Like they're called dirty drugs because like they target the serotonin receptors all across your brain. There's also like a bunch of different types of serotonin receptors and only some matter and some don't, but yet you're targeting all of them. And so in that way, we're globally changing the brain through SSRIs. Through behavior, it's more targeted in the way that we're only changing the behaviors that actually matter in the context of OCD. But either way, it's changing our brain. And I wanted to name synaptic plasticity as specifically what we're talking about with neuroplasticity. It's not just this like ambiguous concept. Devol, your brain can change. And you can be a different person, like literally on a molecular cellular level, your brain is changing. And I love that. That's so fabulous. And it provides so much hope for people with OCD. I feel like I'm 95 to 97% better and different than I was during my debilitating OCD. Like that's how much quieter the thoughts are. It's something I don't get them. I still get an interest of thought or a couple of interest of thoughts every day. But my brain has changed. I can absolutely see that. Yeah. And that's why we are developing novel medications and interventions related to being able to not only change the brain, but change the brain in the way that's specific to OCD. And there's so much hope. And where we are right now, like, already with the treatments that were not developed based on neurobiology, we're already at 60% to 70% which is incredible. We're not at 100. And there's people that suffer very, very unnecessarily or are able to treatment to persist in. And the hope I want to offer is that by continuing to do the work that we do, we are going to get to precision medicine. We are going to be able to target exactly what's going on in your brain. So there's only more hope than there than we are now. Absolutely. You are so amazing and so fucking brilliant. I feel like you're going to be the Ruth Bader Ginsburg of this field. Like, you're going to change so much. And I just can feel and see how passionate you are. And that's what we need. That is what this field needs. So I'm so grateful for you being here and for turning everything that you've been through into this career path. And I hate when people say things like OCD is a superpower or your trauma made you stronger. Like, I don't believe that whatsoever. I'm just proud of you for using strength and everything within you to live with all of that and to do something with that. It just speaks volumes to you as a person. And we're so lucky to have you in this field. That means the world to me. And I just thank you for being-- I don't want to make you feel uncomfortable, but I'm sure you get this lot. But I just want to say as a human, thank you for normalizing talking about the-- deepest darkest ways that OCD shows up in the world because I As I as I entered especially my academic and research career and showing up professionally in all these ways I have always been open about lived experience But there's something about knowing that the language for especially the most like horrific themes in terms of stigma and Chame like that exists You giving the words to it has helped me like it's so wild but like in these conversations I'm like yeah like pedophilia and necrophilia and BCLity like that's my YouTube and literally people's faces like I I just appreciate you Normalizing that and I also appreciate what you said about The way I show up in the world because it's I feel like an imposter all the time Because of my OCD but also because my field like I Talked being in neurobiology and neuroscience and being an academia generally like it is still so stigmatized To ever disclose that you have a mental illness like the only other real person I know in STEM is Kyle King who talks about it out loud and that's really really unfortunate and It's kind of wild that I've made it this far because usually they discriminate against us and I've been open So I I just appreciate you seeing the passion and Helping uplift the perspective of someone who has lived experience who does this work because you almost never see it at all Who else is better to study the brain and neurobiology than someone who has lived with it? I I agree So I'm available to me. That's so fuck it's wild but like literally the people who like treat and study these conditions like Neuroscientist and psychiatrist who study mental illness for a living when they hear you have it They automatically look at you like you're less worthy or capable and that's what I've thought Upward against my my whole career. So I really appreciate you seeing it as a strength than not a weakness Yeah, no you are so much more capable I feel like then people who haven't gone through what you've went through and I feel like that about therapists too When people are worried that if they disclose let's say on social media or whatever that they have a mental health condition that It's going to impact their ability to see clients and I have found as someone who has publicly disclosed your CD That that has just helped my practice and it's helped my clients. Yeah, because people want to know that you get it Yeah exactly you get it from the inside out exactly and in the context of research like I said so So much of the research has been done on stuff that's important and validated yet There's so much that's been missed especially in the context of who we're talking about rodent studies Not looking at the obsession part of OCD like I this is kind of a secret But I'm I'm actually like pioneering and developing a new like behavioral test to look at the obsession part of OCD and pathological doubt and OCD Which like is wild to me that that's ever been done? It's because no one thought about it because but I do because I have it so yeah Yeah This is so wow. I feel like we're gonna have to have you on like once every five years to talk about all of the updates But this has been amazing. Where can people find you? I am on social media everywhere at Ooma R chatter G I host a podcast called the chat with Ooma It's the intersection of research and lived experience where I normalize conversations of Survivorship while also talking about cutting edge research across mental illness and treatment and all of the things but making it understandable and digestible and By websites Ooma R chatter G. Thank you so much Ooma. This has been wonderful