Dr. Andrew Huberman, Ph.D. is a Professor of Neurobiology and Ophthalmology at Stanford University School of Medicine. His lab focuses on neural regeneration, neuroplasticity, and brain states such as stress, focus, fear, and optimal performance.
In this episode, Andrew Huberman takes a deep dive into obsessive-compulsive disorder (OCD). He explains the biology and psychology of OCD, the mechanism and efficacy of treatments, behavioral and pharmaceutical approaches, and so much more.
Host: Andrew Huberman (@hubermanlab)
OCD is a combination of thoughts (obsessions) and actions (compulsions), often linked in a way where the obsessions lead to the compulsions
OCD is characterized by intrusive obsessions, meaning the person doesn’t want to have them – and compulsions that provide brief relief to the obsession but reinforce or strengthen the obsession
OCD is extremely common: around 2.5-4% of people have true OCD – a wide range because it is likely underreported as some people may learn to blunt or hide their actions out of shame or embarrassment
True OCD is extremely debilitating, ranking #7 among illnesses (all illnesses, not just mental health)
  • Debilitating traits of OCD: compulsive actions, the consumption of brain energy and focus, time (mentally and physically),
Categories of OCD fall into 3 bins: (1) checking (e.g., checking locks or stove); (2) repetitions (e.g., counting numbers or repetitions); (3) order (e.g., symmetry, alignment, needing completeness, germaphobia)
Substance abuse is high in people with OCD because of anxiety and damaging thought patterns
Most people with OCD do not seek treatment likely because of stigma or shame
The underlying binding of OCD is anxiety
Anxiety: bodily fear response without clear and present danger in the environment
OCD sharpens and narrows your focus toward the very thing the obsession is directed toward
Up to 70% of people with OCD have been diagnosed with anxiety or depression – but we should use caution in saying which came first
Heritability: about 40-50% of cases have inherited or genetic component
The brain’s two main functions: (1) make sure biological systems are working properly; (2) predict what’s going to happen next based on knowledge of past
Cortico-striatal thalamic loop: the Circuits and loops active in OCD as identified by imaging studies – cortex (involved in perception and understanding what’s happening), striatum (involved in action selection and go-no-go behavior), thalamus (relays and filters information from the environment to the brain)
Drug therapies (detailed below) are targeted at the cortico-striatal thalamic loop
Activation of the cortico-striatal thalamic loop in rats without OCD actually generates persistent OCD-like behavior
There is evidence of elevated cortisol and DHEA in women with OCD
Males with OCD have increased cortisol and reductions in testosterone (cortisol and testosterone compete)
Cortisol is either reflective of or causative of increased anxiety
DHEA, cortisol, and testosterone are related through GABA – for example, DHEA is an inhibitor of Gaba transmission (associated with lower levels of anxiety and increased balance in circuits), leading to overall excitation of the brain (remember the cortico-striatal thalamic loop)
Manipulations of these hormones (cortisol, DHEA, and testosterone) may prove fruitful for the treatment of OCD by restoring the function GABA system
The most common diagnostic is the Yale Brown Obsessive-Compulsive Scale (Y-BOCS)
 It’s important to identify or define precisely what the obsession relates to, beyond a general way
Y-BOCS is designed to get at the fear driving the compulsion: Y-BOCS asks questions to get beneath the surface of OCD traits and explore the cognitive dimension of the exact fear the person experiences if they don’t act on the compulsion
Cognitive-behavioral therapy (CBT) for OCD identifies underlying fear, maybe even a fear unbeknownst to the patient
Cognitive-behavioral therapy will purposely invoke more anxiety in attempts to intervene in neural circuit and relief that happens with compulsion
The goal of cognitive-behavioral therapy in the context of OCD is to get the patient to tolerate, not relieve the anxiety
CBT directs people to feel the anxiety at the max then tolerate and reroute the compulsive urge
The compulsion to avoid anxiety is a powerful driver of OCD – CBT directs the patient to live with the anxiety and see that nothing bad will happen as a result
Clinician home visits are common in OCD treatment to identify the environmental context of anxiety onset – patterns can be so deeply ingrained, that patients may not know they do certain activities
CBT is the most effective therapy for OCD – even as compared to SSRIs, unless the patient adds CBT to an existing SSRI regimen
Thoughts are not as bad as actions: it’s important to convey to OCD patients that thoughts are just thoughts and it’s ok for someone to have weird or disturbing thoughts sometimes – it will pass, but actions are more damaging
SSRIs keep more serotonin in the synapse so that more serotonin can be used instead of being taken back up
All drugs have side effects: SSRIs are known to impair appetite, reduce libido, indigestion, etc.
While SSRIs may reduce symptoms of OCD, there is no indication that OCD itself impairs the serotonin pathway
Low serotonin has been shown to impact cognitive flexibility/inflexibility – challenges in task switching, cognitive domain switching, etc.
It should be noted, that not everyone with OCD responds to SSRI or pharmaceutical treatment
Cannabis: there is clinical evidence cannabis may reduce anxiety (remember, we patients with OCD should lean into anxiety) – but seems to have little ameliorative effects on OCD
Ketamine & psilocybin are being explored but the jury is still out
Transcranial magnetic stimulation (TMS): if done while the patient is having intrusive thoughts, the stimulation can disrupt the compulsive behavior during and after treatment by intervening with the automatic nature of OCD
  • There’s a lot of excitement about TMS in combination with SSRIs or CBT but it’s still the early days
Mindfulness meditation: increases the ability to focus but helps if in conjunction with CBT and allows the patient to focus on CBT and CBT homework
Obsessive-compulsive personality disorder: delayed gratification people want or enjoy because it allows them to function better and or in line with how they would like to present themselves
OCPD does not have intrusive features – people don’t mind or might even like the obsessive thoughts
People with OCPD are good at delaying gratification and can concentrate and perform in ways that instill order (unlike OCD which is intrusive and disrupts function in life)
Repeated cortico-striatal stimulation generates persistent OCD-like behavior (Science)
Implicit and explicit memory in obsessive-compulsive disorder (Journal of Anxiety Disorders)
Patient adherence to cognitive-behavioral therapy predicts long-term outcome in obsessive-compulsive disorder (The Journal of Clinical Psychiatry)
Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder (The American Journal of Psychiatry)
Pharmacotherapeutic Strategies and New Targets in OCD (Current Topics in Behavioral Neurosciences)
Acute effects of cannabinoids on symptoms of obsessive-compulsive disorder: A human laboratory study (Depression and Anxiety)
Neurosteroid Levels in Patients with Obsessive-Compulsive Disorder (Psychiatry Investigation)
Nutraceuticals in the treatment of obsessive compulsive disorder (OCD): a review of mechanistic and clinical evidence (Progress in Neuro-Psychopharmacology and Biological Psychiatry)
Capacity to delay reward differentiates obsessive-compulsive disorder and obsessive-compulsive personality disorder (Biological Psychiatry)