Episode 165: Finding Success with OCD Treatment

John Tsilimiparis : Thank you for having me, Jackie.

Jackie Pack: Yeah, it’s great to have you on. So why don’t we start with kind of a definition of OCD and a brief overview or what you find is important when you’re starting with clients who are dealing with this.

John Tsilimiparis : Sure. So OCD is an anxiety disorder. Sometimes people try to distinguish one from the other, but it is an anxiety disorder, and anxiety disorders are the most popular disorder, psychiatric condition in the United States, but OCD specifically is considered a psychiatric neurobiological illness that is linked to problems in the regulation of the brain’s chemical serotonin. It seems to be some imbalance there. Serotonin as we all know is really important because it plays a critical role in the control of moods and subsequent behaviors. OCD can be influenced greatly by life events such as trauma, loss, chronic illness, financial problems, relationships, discord, issues from the past, so its origin is usually a nexus of both genetics and the environment, so you can have panic disorder or generalized anxiety disorder or just be a general worrier throughout your life, and then you have one of these adverse events in your life, and suddenly you have these very specific OCD symptoms, and then your anxiety changes, so it’s actually not as common as generalized anxiety disorder or the other types of anxieties that we see more often, but the numbers are according to the CDC, 3% of the population of the United States, roughly 6 million Americans suffer from OCD at some point in their lives.

Jackie Pack: And so would somebody… let’s say somebody has like a more generalized anxiety disorder that they have been dealing with and then they have one of these adverse events happen, would they notice the shift? What would they notice or what would people around them start to notice?

John Tsilimiparis : So they would notice that they’re probably going to have a combination of two things. Obsessive compulsive disorder is really two things. It’s obsessions, which are defines as these repetitive thoughts, ideas, or mental images, or impulses that an individual experiences that are really, really intrusive, sometimes inappropriate and scary. And then coupled with that, they see compulsions. Compulsions are defined as these also-repetitive but very ritualistic behaviors that an individual feels compelled to perform in an effort to avoid or decrease the anxiety that is created by the obsessions. So you’ll se a big different where instead of just having excessive worry about things, your worry will be kicked up a notch, and these worries will be obsessive and you might start performing things. Like for example, if you develop basically these days people are developing phobias because of the coronavirus, so if you obsessively worry about the coronavirus and you have OCD diagnosis, you might be obsessing about it so much more where you are constantly checking, you’re Googling symptoms, you’re constantly checking the news, you’re constantly checking your throat or your nose or seeing if you have headaches and wondering if you have a cold yourself, and you do it so much that it interrupts your day. That would be obsessing about the coronavirus and listing these control strategies to make sure that you don’t get it, so you’d see that but it would be in an obsessive way where again, your world, your life is interrupted and you’re seeing some kind of impairment in your day. You’re unable to go to work or you’re unable to take care of your kids. Things like that.

Jackie Pack: Okay, and it’s going to be, from what you’re describing, it’s going to be like a specific obsession or it’s not more generalized.

John Tsilimiparis : Yeah, it’s usually a little more specific. People tend to have… the most popular is germaphobia, so catching an illness, getting sick, getting food poisoning, but it’s mainly catching something and getting sick, so that means people do a lot of checking. They do a lot of repetitive, ritualistic behaviors in hopes of averting disaster. So remember, nobody does something compulsively for no reasons at all. You and I could speak for days, and you wouldn’t be able to come up with something that you do or that you worry about that doesn’t give you a benefit, so worry is the same thing. Worry gives us benefit. Worry says if I worry enough about something, bad things won’t happen, so the obsessing is always justified by I’m doing everything in my power to feel safe. So that’s a little part of that. Now the obsessions are not always exaggerated fears about real life situations and not always connect to commonplace problems such as relationships and financial concerns. In fact individuals with OCD are quite often very distressed precisely because they recognize that their unwanted thoughts are excessive, and they notice that they’re irrational, so they sometimes start obsessing about having those thoughts. In other words it’s not just that I feel scared that I touched a doorknob and a public toilet, but they start to feel scared that they’re going to start obsessing about touching the doorknob and the toilet for the next couple of weeks.

Jackie Pack: Okay.

John Tsilimiparis : So it’s generalized obsessing, but it’s also obsessing about obsessing, which is kind of hard to explain. I don’t know if that made sense.

Jackie Pack: Right, kind of like with panic attacks, you can have a panic attack about having a panic attack.

John Tsilimiparis : Exactly. People with panic disorder of course are shocked and scared and completely overwhelmed by the panic attack, but then most of the time they’re afraid of having another one, so they end up staying home and they get agoraphobic because those symptoms were horrible, so with OCD, the symptoms of being caught, the brain lock of being caught in my thoughts, is as scary as catching the disease.

Jackie Pack: And does there seem to be like an age, or does this occur for children or is it more with adults? Is there anything about that?

John Tsilimiparis : There are cases with kids being very young and having this, but usually it starts to blossom… blossom is probably the wrong word, mushroom I guess, age 10, 11, and on, kids start becoming much more aware of the world and they’re out of the magical thinking of being a child. They start worrying about their looks or they start working about… you know, just being much more aware of what’s out there, so there are many, many different types of OCD that we see with young people as well as adults, germaphobia being number one, but there are also the types of checking OCD, people that fear always disasters, so there are people that have long rituals before they leave their homes, before they go to work, they have to check appliances that are off, they have to check windows, doors, locks, making sure everything is in order and in doing that, that takes up a lot of time. Sometimes it takes hours for them to leave their homes, and then there are other people that really like and need the concept of symmetry. They need to have things in order. Groceries need to be stacked in order. The closets need to be either alphabetical or by color, and so the rest of their day has to be that way too. If there’s any digression in their days, it starts to make them anxious.

Jackie Pack: Okay, and that’s also it sounds like if this is going on for an individual and they’re in a relationship where they live with somebody, other people are going to be able to see this.

John Tsilimiparis : Yes, and that’s another thing is a lot of people come in with their partners, and the partners usually complain and ask how is it that I can help my spouse, my partner? And so yeah, the other person is as affected as the person with OCD. They don’t suffer as much because they’re not going through the mental machinations of needing all of that, but they do suffer, and so everyone’s affected. Everyone is touched by this illness. Other types of obsessions are as I mentioned contamination, needing complete safety and security at home, symmetry at home, sometimes people also have fears of accidentally or purposely committing an act which one considers to be violent or harmful to others, they have what’s called harm OCD, where they start to fear that with one single act or impulse they could hurt others and/or they could hurt themselves, and 99.9% of the time nobody ever really does that. Let’s see, we have people also what’s called scrupulosity. This is a kind of excessive fear that involves your faith and involves feeling like you’ve done something sinful, immoral, something sacrilegious, so they have a constant preoccupation with their acts and the things that they say, and compulsions that result in that… well, if you go back to contamination, the most common one we see is washing. We know that people wash or shower excessively using antibacterial cleaning products to kind of eradicate potential contaminants. That we see very often. But if you have that sense of needing control all day long, there’s going to be other things in your life that you’re gonna do the same, so if I wash excessively, if I fear something and I basically bend and feel vulnerable to my obsession, I’m going to do that throughout my day in other areas too. I leave no stone unturned at work. I have to make sure my car’s always gassed, everything’s fine, things like that.

Jackie Pack: Okay, say a little bit more about the scrupulosity.

John Tsilimiparis : Well it’s very common actually. This is for people who have basically grown up with religion in their lives and sometimes we call it a little magical thinking when you think that there can be a supernatural force that can have influence on your life in a negative way. I know a lot of people believe that to be in a positive way, but these people take it in a negative way, so there’s a constant monitoring that they are being watched and they basically are not allowed to make mistakes, not allowed to sin, not allowed to like things that they think they shouldn’t like. They have a lot of guilt, so they’re not only answering to let’s say family values and family positions, they’re also answering to some kind of higher up authority and if you have OCD and you have that kind of thinking, it’s kind of dangerous because it creates so much wonder and so much worry because anything can happen. There’s nothing specific. Psychotherapy is not an exact science. Well for many people, faith is not necessarily an exact science. It’s much more of a feeling, though it’s hard to distinguish that, and that causes people a lot of distress. Why do you ask? Do you have people that have some scrupulosity in your practice?

Jackie Pack: We do get that, and I’ve also… I was just thinking coming from that, like a religious background, it might not be as obvious as maybe like the handwashing or the checking or different things like that. You may be able to describe this person as just really orthodox or like a very religious person instead of maybe having OCD.

Right, and I’m glad you brought that up. Right, but the difference is somebody with OCD and that kind of religion has an excessive worry and an excessive obsessing about that, and that I’m pretty sure is not correct, I mean not that it’s not correct, but it’s not normal in terms of somebody who’s just your basic religious, church-going believer.

Jackie Pack: Okay, so it would be…

John Tsilimiparis : This is excessive. I’m sorry, say that again.

Jackie Pack: You would think that it would still maybe stand out in the congregation or that person would still maybe go above and beyond what the congregation is doing.

John Tsilimiparis : Yes, this would stand out. This would be a lot more. This would be a constant fear, a constant obsessive worry that they are going to be struck down by the almighty or lightning or something bad is going to happen to them. I had a patient years ago who came from a religious family, and she got an abortion at 21 with her boyfriend, which she very much regretted and felt bad that she had to do that, obviously went against her religion, and 2 years later the boyfriend unfortunately died of cancer and passed away, and so she naturally took that to mean that she was punished because of that, she was punished because of the abortion, that she didn’t have the child and went against her beliefs, and so it took a long time to help unravel that for her, and that’s an example of that, so from age 24 until I saw her at 38, she suffered greatly because of the OCD around that.

Jackie Pack: Right, so let’s talk about, first before we get into treatment modalities, do you find co-existing mental health disorders that package with OCD?

John Tsilimiparis : Ah, great question. Yes, so other anxiety disorders as well, like you see people with social anxiety and OCD, you see people with as I mentioned before generalized anxiety disorder, panic attacks are a big part of that, but I think the one that you see the most together with that is major depressive disorder, and it’s either because people have been anxious for so long and suffering from OCD that they get depressed about it, or they just concurrently go together because there’s that imbalance in the brain and sometimes it’s a fine line between anxiety and depression, so either way the serotonin is not firing right, but I would say that depression, which is the second-most popular mental health condition in the United States, those two are probably the most popular that you’ll see together.

Jackie Pack: Okay, and so when you’re treating somebody with OCD, what are the various treatment modalities?

John Tsilimiparis : Well, the first one, and first and foremost most important one is cognitive behavioral therapy.

Jackie Pack: Okay.

John Tsilimiparis : That’s where we use, I’m sure you know and your listeners probably know, but just to go over it, it’s a restructuring of thought patterns, restructuring of negative thought patterns and the breaking down of faulty belief systems, which is really the lynchpin that keeps the OCD, obsessing together because you believe them whole-heartedly, and so this type of therapy helps you challenge those thoughts. It’s also about identifying and changing the automatic thoughts we have from the negative stimuli, helping people improve their impulse control so you don’t act out so quickly from those thoughts, and then separating rational thoughts from irrational thoughts, so the best thing that people start to do is the excessive need for control is really part of the lynchpin that I just mentioned that keeps OCD together. In other words, if I’m an excessively controlling person, and I don’t mean that in a critical way, I just mean that’s the way my thinking is, that means I don’t like uncertainty. I want guarantees in my life, and I want to know the outcome of everything. So as we know, there are no guarantees in life except maybe death and taxes and things like that, and breaking the law. If you break the law, there’s a good chance you’re going to pay for it in some way. Some people get away with it, some don’t. So CBT is helping people to break down the excessive need for control and try to sit better with the uncertainty of a negative thought. People with OCD tend to be really impulsive. They have a negative thought and say, “Oh my God, I just touched something that could have been contaminated. I have to go wash my hands.” So we try to have them sit a little bit with the discomfort before they wash their hands. That leads to the second form of treatment, which is exposure therapy. Exposure therapy is literally exposing you to the stimuli which is in this case a thought that you’re now contaminated, so that each time you expose yourself and you wait and you delay doing the compulsion, you start to habituate to it, and then it starts to dilute the charge, and you feel less of an urge to do it so quickly. Does that make sense?

Jackie Pack: Yeah, it does. How long would that take, though? I mean that’s not immediate obviously.

John Tsilimiparis : Good question. It all depends on the person’s threshold for tolerance and pain. Some people have a high threshold, and I don’t mean that critically at all, some people have a low threshold, so it’s exposing you to feared situations, but it’s all very, very, very incrementally, so it’s using what’s called systematic desensitization, and I would take the smallest thing. Let’s say you were afraid that you just got contaminated and you had to go wash your hands. I wouldn’t make you wait 30 minutes or an hour to wash your hands. I would make you wait about a minute, and then I’d let you wash your hands, when usually they can’t even wait a minute. So it’s very, very, very incremental, and that works very effectively, because after a while they start to see that naturally my anxiety came down before I washed my hands, and that starts to build self-reliance and it starts to build confidence.

Jackie Pack: Right, okay.

John Tsilimiparis : But it’s a slow process, so it’s a very good question. The third one..

Jackie Pack: The therapist working with that client is going to be pretty sensitive to the anxiety that that creates for them and move at a pace that they can…

John Tsilimiparis : Absolutely. You have to customize it to each person. You don’t want to use what’s called flooding. Let’s say if you were afraid of snakes, I throw you in a room of snakes and let you stay there for an hour and lock the door. That’s barbaric. We don’t do that. But yes, you have to… and again, another good question. You have to customize the movement and the progress of the treatment according to that person. Everybody’s going to be different, but most of them are so eager to do it that they kind of willingly do it. I just do it very, very slowly.

Jackie Pack: Yeah.

John Tsilimiparis : Because another part of treatment that works too which is using mindfulness and self-regulation, and I’m sure you know mindfulness is a different kind of therapy. It’s helping you develop a different relationship with discomfort. It’s teaching you that just because you have a negative thought and you have discomfort doesn’t necessarily mean that something is wrong, so the ability to manage disruptive emotions and impulses and learn how to soothe and calm your body’s reaction to stress. It’s also a way to interrupt the threat response while fully engaged in daily living, so every time you feel scared, every time I feel scared, there’s a threat response that comes up, and that’s your fight or flight or freeze response. Learning how to sooth that threat response sets you up much better for the exposure.

Jackie Pack: Yeah, and just overall probably increases just an awareness for the person and gaining some insight as they calm their body.

John Tsilimiparis : Yes, and most of them have never tried to do that because whenever they feel the impulse to go and perform a compulsion as soon as they get triggered, they do it immediately, and so they never tried to do that because frankly it’s uncomfortable. You know, mindfulness, all of this is uncomfortable, but mindfulness really takes a lot of effort to try to teach the body to self-soothe and most people with OCD because the obsessions are so uncomfortable they’ve never given themselves a chance to actually sit in that, so they can do these, all of these exercises on their own, but it’s better with a therapist, so I have them do it in the office with me. It’s like going to the gym, Jackie. If you go to the gym and you do a 3-hour workout, you’ll probably do fine, but if you go and do a 3-hour workout with a coach or a trainer, you’re going to do a much better job and it’s going to be more effective, much more effective.

Jackie Pack: So let me ask you this. Do you find with clients as you’re working with them on their OCD issues, does it also treat the generalized anxiety that may have preceded the OCD?

John Tsilimiparis : It does. It does because… yeah, because generalized anxiety will inspire negative thinking and negative thinking patterns. It’s also going to benefit from the mindfulness because generalized anxiety again is excessive worry, it’s just not necessarily obsessive and compulsive, but there’s definitely worry, so these 3 modalities that I just mentioned are good for any kind of anxiety disorder. Obviously you’d probably use exposure a little bit less, but exposure works well too even if you have mild anxiety, you know to be with those thoughts as opposed to needing to control or correct those thoughts.

Jackie Pack: Right, so is there a… do we know like a success rate or…?

John Tsilimiparis : For CBT?

Jackie Pack: For OCD? Yeah.

John Tsilimiparis : You mean a success rate for working with these modalities?

Jackie Pack: Right.

John Tsilimiparis : I don’t know the numbers, but if you look up evidence-based psychotherapy for OCD and all anxiety disorders, cognitive behavioral therapy is at the top, and a close second is going to be mindfulness, it’s going to be DBT, dialectical behavior therapy, then you’ve got all kinds of other ones that also work very well, too, they’re just not as universal as CBT. You have EMDR, you have lots of trauma treatment therapies which are vastly different, but most of them are going to use some form of cognitive behavioral therapy, as well as the self-regulation skills, just another way of calling it mindfulness.

Jackie Pack: Right, and so people who are suffering with OCD and having their life interrupted, they can find healing and they can find relief.

John Tsilimiparis : They can. Another thing that does help, and I know a lot of people are squeamish about it, but medication helps too.

Jackie Pack: Okay.

John Tsilimiparis : There’s a lot of good SSRI types of medications, these are antidepressants that work well on anxiety. There’s a few that work specifically for OCD, and we’ve helped people that don’t want to be on medication, but we find that when you are on an SSRI or you’re using some kind of sedative like a Klonopin, Ativan, Xanax, it makes it much easier to do the exposures because it builds so much confidence that little by little you don’t need the sedatives anymore because your brain has habituated the fact that you have actually gone through it and that it did not destroy you. Remember, along with control is also what’s called excessive need for control is also a kind of all-or-nothing thinking that goes along with OCD thoughts, which is I’m either safe or I’m unsafe. In other words, I’m having an okay day, I’m hanging out at the gym getting my workout, and all of a sudden I have a thought that maybe I touched something that contaminated me and I go from “I’m okay” to “I’m going to die”, and so that is very debilitating for people.

Jackie Pack: Right.

John Tsilimiparis : So excessive need for control and that kind of awareness of all-or-nothing thinking helps people a lot, and right off the bat, that helps whether you take medication or not. So to answer your question, sorry that was a long answer to an easy question, treatment works extremely well and we’ve had very good numbers for people that come in and immediately, as soon as you heighten their awareness the fact that if they start doing these things they feel better, they do pretty quickly.

Jackie Pack: That’s awesome. So anything that we haven’t covered thus far that you wanted to get to or that you think is important for listeners to understand about OCD?

John Tsilimiparis : Well when you think of mindfulness, people take for granted when they hear mindfulness. When they hear mindfulness, they generally hear, oh that’s meditation, and I can’t do meditation. Well it’s actually a lot deeper than that. Mindfulness is again gaining a general awareness of things, from starting to accept thoughts merely as events, events that cross over my horizon as a cloud from horizon to horizon and I basically see these thoughts as events, nothing more, nothing less, and in doing that, I’m using my diaphragmatic breathing, which as we know slows down the anxiety in general and puts the neocortex, the executive brain back online, especially when you do the exhale, and also progressive muscle relaxation. We have people do all of those things before they do exposures, and you can just see them much more relaxed when they do that, medication or not, so it’s quite holistic if you really think about it, but one has to do it with a coach or therapist. Doing it alone is very difficult to teach somebody to slow down that threat response.

Jackie Pack: Right, and yet the other good thing about mindfulness I think is that it can be practiced without other people really knowing what you’re doing, so you could be sitting in a work meeting and practicing your diaphragmatic breathing and kind of lessening muscle tension and nobody is necessarily aware of what you’re doing.

John Tsilimiparis : That’s exactly right. You could do it in a meeting, you could do it driving in your car, you can do it anywhere. You can always flex and stress muscles. I had people do a regimen. They wake up in the morning, and I have them do stretching first, we’d go over it together, lie down in my office, or we’d do it sitting in a chair, then we do a kind of guided meditation and they can go to one of the podcasts or they can go even on YouTube, you can just put in 5-minute guided mediations. There’s thousands of them. And then they do that and set themselves up for the day and/or an exposure, and you’re basically leaving your home with a completely different mindset than you do if you don’t do that. If you don’t do that, you are back into automatic thinking, automatic pilot, so these exercises help you to disengage from the automatic pilot, which is always the fearful, fight-or-flight, survival mode pilot, and it’s there for a reason, there for a reason. It’s also there because it’s a failsafe. Remember God, the universe, evolution would not have given you a survival system unless it’s failsafe. In other words, cavemen didn’t have time to say, hmm, should I move away from this charging sabertooth tiger, or should I just stand here and be eaten? So when the fight-or-flight or freeze response is enacted, you have to run, and that’s what the body tells you to do, so it’s failsafe. The problem with the failsafe system is that it doesn’t know how to distinguish between a real fear and an imagined fear, so with OCD, if I fear that I’m contaminated, the failsafe system says if you don’t go wash your hands right now, you’re going to die. That’s how it works. That’s how the body is put together. Maybe that’s why human beings have survived this long. Otherwise you would have been hit by a car a long time ago because you wouldn’t have cared. You would never had gone to the doctor if you got sick, so on and so forth.

Jackie Pack: Yeah, that’s great. So tell us a little bit more, where can people find the Mindfulness for the Soul podcast?

John Tsilimiparis : So you can find it on Apple podcasts, iTunes, you can find it on Spotify, you can find it on other ones, too. I think that if you just Google it, it will tell you where you can see it, but it’s… another one called Anchor, another one called Stitcher, but the main ones are Apple podcasts and Spotify.

Jackie Pack: Okay, awesome, thank you so much, John, for being on today and letting us know about OCD and the fact that people can heal from it.

John Tsilimiparis : Thank you so much for having me. You asked a lot of great questions. You were an excellent interviewer.

Jackie Pack: Thank you.