Adam Dayan, Esq.
Curious Incident Podcast Episode 14: Managing Obsessive-Compulsive Disorder
About This Episode
In this episode hosted by NYC Special Education Attorney Adam Dayan with guest Dr. Dean McKay, a Board Certified Psychologist and Professor of Psychology at Fordham University as well as President of the Society for a Science of Clinical Psychology, sheds light on Obsessive-Compulsive Disorder (OCD).
Dr. McKay addresses various forms that OCD can take in both children and adults while dispelling myths and stereotypes.
Dr. McKay also explains symptoms of OCD and how it can affect daily life, as well as methods to manage the disorder through evidence-supported cognitive behavioral therapy (CBT).
(LISTEN) The Curious Incident Podcast Episode 14: Managing Obsessive-Compulsive Disorder
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Speaker 1: This is Curious Incident, a podcast for special needs families and your window into the world of special education. Special needs parenting can be challenging and we want to make it easier by providing you with the resources you need to help your child. Let's delve deep into the world of learning differently with your host, special education attorney Adam Dayan.
Adam Dayan: I'm excited to present my next guest on this podcast, Dr. Dean McKay. Today Dean is going to be speaking with us about Obsessive Compulsive Disorder. This subject is close to my heart because I struggled with OCD as a kid and I was fortunate to get the tools I needed to manage it successfully. Dr. Dean McKay is professor of Psychology at Fordham University. He's also president of the Society for a Science of Clinical Psychology and past president of the Association for Behavioral and Cognitive Therapies. He has published over 200 peer-reviewed articles and book chapters, and is the editor or co-editor of 19 books. He is board certified in clinical and cognitive behavioral Psychology from the American Board of Professional Psychology. In addition, Dr. McKay co-directs the Institute for Cognitive Behavior Therapy and Research, a private group psychological practice in White Plains. Dean is also on the board of advisors and a consultant for Better Living Center for Behavioral Health, an intensive outpatient and partial hospital center in Dallas, Texas, that specializes in OCD, anxiety and trauma. Dean, welcome to the show.
Dr. Dean McKay: Thanks. It's a pleasure to be here this morning.
Adam Dayan: A pleasure to have you. Tell me a little more about you. What makes your approach or outlook unique given your particular background, skills and experiences?
Dr. Dean McKay: My training is in clinical psychology and the program where I earned my doctorate emphasized cognitive behavioral approaches to treatment. Briefly, cognitive behavior therapy is a structured approach to therapy. It's considered collaborative with clients and in the context of anxiety disorders in OCD, one of the primary approaches is to really help people get closer to things that they ordinarily avoid, which in turn often is a source of difficulty in their lives. So as the avoidance is reduced then the anxiety that's associated with it is reduced and then people feel a great deal of relief.
Adam Dayan: And I'm looking forward to unpacking that with you further, especially the part about avoidance. Before we go any further, let me ask you to define obsessive compulsive disorder.
Dr. Dean McKay: In the current diagnostic manual, which is a tool that mental health practitioners rely on, OCD is defined as an intrusive set of thoughts or images that the individual finds distressing and those may or may not be accompanied by specific behaviors that are designed to nullify them. That's in a nutshell how it's defined. Now, research has suggested that OCD emanates from certain circuits in the brain that are misfiring, if you will, and sending a signal to suggest certain thoughts and images are potentially dangerous or potentially more likely to be acted on, even though the OCD sufferer has no desire to act on those thoughts or images.
Adam Dayan: So an alarm is sending a signal to the person's brain that there's danger when there's not actually danger objectively?
Dr. Dean McKay: I guess to highlight and elaborate a little bit, there's a conflict between a portion of the brain that's suggesting that there is actually danger present and the other part of the brain that can objectively appraise that and say that's not true. And so those two lie in conflict, but because the part that's misfiring is the part of the older area of the brain, we tend to listen to that and it goes to emotional areas of our brain that are a little harder to, I guess ignore or step aside from.
Adam Dayan: Okay. So can you give an example of what might be an intrusive and unwanted thought and the type of behavior that a person with OCD might engage in in response to that thought?
Dr. Dean McKay: Sure. There are some that are pretty controversial by the way. Some of these intrusive thoughts have been the subject of some misunderstandings in the public eye, but a common one that we can look at is intrusive thoughts of harming others or themselves. An example where this might come up is the person who struggles with a thought like this is sitting at a dinner table and they have a steak knife there and they have family members that are there as well. And the thought that suddenly comes to them is, what if I stab someone at the table with my steak knife? Now that thought is objectively of upsetting, but the client has no interest in stabbing anybody at the dinner table. So they can say the higher part of the brain, the more recent and more new parts of the brain evolved, that say, you're not going to stab anybody, you have complete control over yourself, is no danger here.
But that old part of the brain is on, but what if you did? And that starts to shoot out this emotional reaction that drives a lot of anxiety. And then you might have a scenario where that sufferer will want to make sure that they put steak knives away or not have them around, or maybe even ask others around them whether or not they made any moves that were a little bit startling to the other people at the table in order to get some kind of comfort in the idea that there was no hazard that anybody faced as a result of this errant thought.
Adam Dayan: And that's got to be pretty confusing for the person with OCD. Right? Their brain is sending signals that they might do something terrible, but they actually have no intention of doing that terrible thing.
Dr. Dean McKay: Exactly, exactly. And then you could imagine that what ends up happening after that is you live with this for a longer, longer period of time. People start to look at that thought and ask themselves, I wonder if this means something about me. And in our modern understanding of OCD, there's a special name for that, it's called over importance of thoughts. So the OCD sufferer will start to appraise their thoughts and say, these must mean something about me, when in fact they don't. They actually just mean that you're struggling with errant thoughts that many people have. And that becomes the source of considerable anxiety. And then people start to really scrutinize their thoughts. And then you're off to the races, you have all kinds of other thoughts in a typical day that it may involve offending other people or doing something harmful and suddenly it's full on people very avoidant and they struggle mightily with it.
Adam Dayan: So in your example with the knives, the person might be saying to themself, I must be a terrible person because I might stab somebody or I'm thinking about stabbing somebody with these knives. Is that correct?
Dr. Dean McKay: That would be right. They may go a step further and ask themselves the question, what does it mean about me that I could sit at the dinner table and even entertain for a second the idea of stabbing my family and loved ones.
Adam Dayan: Okay. And what is the behavior that accompanies that? Right? The person is having these thoughts that appear to be dangerous, and then what sort of behavior are they engaging in in response to that?
Dr. Dean McKay: There are a lot of different options. One might be avoidance and avoidance might be kind of small where they could say, I don't need a steak knife, please just give me a butter knife or one of those just serrated edged ones that you might use, that have no risk of harming anybody with. It could evolve to the point where that person would avoid eating meals with family loved ones in order to exert an abundance of caution and to ensure that they're not going to stab anybody. They might go a step further than that even. And I've heard of people where they'll say at bedtime, got to lock up all the knives, everything that's in the kitchen, the kitchen is filled with potentially deadly implements. And so they have to be locked away in order that maybe I'm going to get up in the middle of the night even and I'm going to be sleepwalking and half conscious and I'm going to grab a steak knife and I'm going to go into all the bedrooms and stab everybody. There's a lot of ways in which this can suddenly be really disabling.
Adam Dayan: Thank you for clarifying that. So that's one category of presentation, harm to oneself or others. Are there other common presentations?
Dr. Dean McKay: Sure. The one that the public most often thinks of with OCD is contamination concerns. And roughly half of all people with OCD have at least some concerns with dirt and contamination. So what that could look like is the individual thinks that they may have come in contact with something that is harmful, that would need to be on their skin or some surface and it needs to be washed off. This could include not just harm to themselves from that contaminant, but also they could become concerned that they're going to harm others, so they're going to contaminate other people, get other people sick. So that's another fairly common and prominent presentation.
Adam Dayan: Okay. So you said 50%, that's pretty high. That's definitely a high number, but it's not everybody, right? It's not everybody who falls into that category. Are there any other categories that you want to mention?
Dr. Dean McKay: Yeah, so right now I've just described two major categories. The one that I started with is pure obsessions. Those are sometimes accompanied by behaviors around avoidance, hiding things and possibly checking. So I'd mentioned checking by way of asking other people if they're okay. There's contamination concerns, which as we know usually is accompanied by washing rituals and that might be hand washing, might be showering and may also involve avoidance once the person has gotten perfectly clean and staying away from things that are sources that they believe are contaminating. And then the third major category involves ordering and arranging. So this is where people get thoughts about things not being symmetrical or not being properly arranged, and then having to go through great effort to rearrange things. And then of course avoidance, which would mean making a point of not using those things so as to not disrupt the perfect arrangement that they may have achieved.
Adam Dayan: And what would you say the fear stems from in that category?
Dr. Dean McKay: Well, in that one it's a little less clear what the fear is. There's not a uniformity of fear states across these three major subtypes of OCD symptoms. And so orderliness and symmetry has been suggested to be more like a just right experience. It's a little bit hard for sufferers to define what they're bothered by except that there's a, shall we say, like a gestalt that's not pleasing. In fact, this made the news a few years ago. You may remember I guess winter of 2018 or so, the entrance to the Holland Tunnel had all these holiday decorations and they were quite asymmetrical in their arrangement on the sign. And there was a person who suffered from OCD related to symmetry who started a petition to try and get the MTA to change the arrangement of the holiday decorations in order that they'd be more symmetrical.
Adam Dayan: Wow.
Dr. Dean McKay: That was in the New York Times actually. It's worth taking a look in the archives, you'll see there's a whole thing about it. They went to great length to talk about the issue around symmetry, and I actually was interviewed for that and we got to talk a little bit about OCD in that context.
Adam Dayan: I don't remember that story, but I'm assuming he didn't have much success.
Dr. Dean McKay: No, it did not go very far.
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Adam Dayan: What are some myths or stereotypes that you would like to disabuse our listeners of?
Dr. Dean McKay: One that is a very popular one, when I speak to people and they ask me what I do and I describe my expertise, it's very typical for people to say things like, I'm a little bit OCD or I think I have that, and I don't believe that that's what they're referring to. When people say, I'm a little bit OCD, what they're referring to is more a self complimentary kind of statement, which is like I'm very fast fastidious, or I'm very orderly, or I'm very neat and clean. Those are not the stereotypic things associated with the disorder as understood by experts in the field. If someone knew what OCD entailed for bonafide sufferers, there is no way anybody would make a comment like that. That's I think probably the most prominent misunderstanding and misconception, is that people will casually refer to themselves as having a little bit of OCD. It's just simply not reflective of what the disorder entails.
Adam Dayan: I think you told me offline that profile of being fastidious or perfectionistic is not typically part of the OCD profile. Is that right?
Dr. Dean McKay: That's right. That's right. The typical OCD sufferer will have elements that are very ritualized and in line with that idea of avoidance and trying to deal with what makes them anxious based on the definition I gave you before. But they are not necessarily going to have excessively neat homes. They're not necessarily going to be excessively concerned with making sure that every object that they handle is clean. In fact, I've worked with people who have contamination concerns whose homes are not necessarily clean at all. If you walked in and you were operating only from that stereotype, you would be surprised and you'd say, oh wow, looks like really any other home.
Adam Dayan: Okay. Any other myths?
Dr. Dean McKay: That's probably the most prominent one. I think the one about people maybe being concerned with excessive cleanliness and washing is probably not completely inaccurate given that roughly half of OCD sufferers do struggle with that. But it's important to know that just like half of them have some of that symptom, there are half that don't. So as stereotypes go, it really misses the mark for a big chunk of sufferers.
Adam Dayan: Okay. I was reading an interview with Lena Dunham, the American writer and actress. She's been open about her experiences with OCD, and this kind of relates to what you said a minute ago. She talks about knowing that the rituals you're doing are ridiculous while you're doing them. Can you speak about this aspect of OCD a little bit more?
Dr. Dean McKay: Sure. The typical sufferer struggles with this conflict between what feels like an overwhelming and intense emotional experience, one that is very difficult to step aside from, versus the objective and more cerebral rational side of the brain where you look at this and go, there's no way that can happen. Or the odds of it are so infinitesimally small that my effort to undo this through a ritual is not going to be particularly meaningful. The problem of course is that if we look at how we've evolved, it's very hard to ignore those emotional sides of our brain. And in fact, we're hardwired to really not ignore it, because emotions exist to protect us. But in people who suffer from OCD, the emotions have kind of run amok.
And so that conflict is a very compelling one, and it's so compelling that it feels like life and death is on the line. I have to take this action. And in fact, the risk is not worth it any longer given how loudly the emotional reaction is, basically yelling at us saying, do this, take care of this.
Adam Dayan: We've talked a little bit about the signs and symptoms.
Dr. Dean McKay: Sure.
Adam Dayan: One that you've mentioned is anxiety. Can you describe what that anxiety spiral or that anxiety moment is like for somebody in the grips of an OCD moment?
Dr. Dean McKay: People experience in a lot of different ways. One is mainly through what I would probably refer to as like a cognitive panic. The thought is so intense that nothing else matters. You may experience this with such strength and to such a distracting degree that there is no way that it would be possible to engage in any other work or any other life activity you wouldn't be able to commit any attention to a loved one or a family member. Now, many people who suffer from anxiety have a range of physiological reactions, and many people with OCD will have that too. This includes heart rate going up really high where it's pounding so hard that you may hear it in your ears and you'll feel it in your neck and your chest. People get sweating in the periphery or numbness, which happens through such intense blood flow that you'll lead to some tingling sensations in the extremities.
People get lightheadedness. So there is a vestibular consequence. People get short of breath. There's a range of these pretty known physical sensations that the sufferer may feel that there's something physically wrong with them and think that maybe they're having a panic attack. So as a result of this cascade of emotional reactions that have physical consequences attached to them, many OCD sufferers do not necessarily seek help from a mental health professional first. They often instead go to their general practitioner.
Adam Dayan: Okay. When they're in the grips of an OCD moment and they engage in ritualistic behaviors, whether it's the hand washing for someone who's got that contamination fear or avoiding the steak knives as we were discussing earlier, those behaviors do bring down the anxiety for that person. Correct?
Dr. Dean McKay: Yes, they do. Yeah. Typically they bring them down and what then maintains that behavior is the relief that it affords. So once you've gotten relief and you found this trick which many people get, then it's likely to persist. Now, of course there's consequence for that trick because things happen that are compromises in one's life or you end up let's say hand washing and there are all kinds of pain that can accompany that through excessive hand washing, it can lead to chap skin and sores and things like that.
Adam Dayan: And that's exactly where I was going to go next regarding the consequences. And so you gave some examples with the hand washing. What about for the avoidance, what are the consequences for someone who is using avoidance to reduce anxiety?
Dr. Dean McKay: Avoidance, obviously what then happens is people's lives get abridged. If you are struggling, let's say, if we start with that example that I had at the beginning, if you were having trouble being in the presence of steak knives, it's not obvious how widely that impacts your life until you start to really think about all the ways in which people have utensils in front of them when they eat. And so that means now you may have trouble going to a restaurant, so you're sitting at the table and someone else at the table orders steak or a duck or whatever dish comes with a sharp knife. And now you may go, I can't go to dinner now. So now that's a big chunk of your life that may get abridged, and then it means going like you can't go to a fair, you can't go to all different kinds of events. And OCD is insidious. As you avoid things more, it will still seek out things that might be dangerous. So let's say the next step for the person who's avoiding steak knives goes to only having the serrated knife at the table. Now they may go, but if I'm strong enough, I might be able to pierce the skin, and if I get to the right spot, the person could bleed to death. The serrated knife is not going to work for me either. And now they're not maybe using knives at all when they're in the presence of other people. And it doesn't take long before the person is not going to a lot of places.
Adam Dayan: Right. Sure. All right. We'll talk more about avoidance when we talk about treatment. Another common sign or symptom, seeking assurance or reassurance from loved ones that different situations will not necessarily cause harm. Can you speak a little bit about that?
Dr. Dean McKay: Sure. One way that people may try to adapt to OCD is basically borrow someone else's brain. There's a recognition that the brain is sending that person a bad set of information, but it's in an emotionally driven set of information. And so they'll look for a verification from someone else. So family members are a perfect source for that. And let's say you're sitting at the dinner table, you're thinking that your steak knife is a potential weapon that you're going to pick up at any moment. And you look around the table and you might ask people, did I look like I was going to use the steak knife for anything other than just cutting my steak? Or they'll ask other subtle questions to see whether or not anyone at the table even for a moment felt that they were at risk. And the benefit of that is they're getting an external verification around the hazard that they may oppose.
The problem with reassurance is twofold. One, it's very short-lived. So you get this reassurance and then the next time you encounter the object that you're concerned about, you need the verification again, and that may happen rather quickly. The second is that as you ask people more and more, first of all, they start out, it's very well-intentioned. Family members will answer these questions. Imagine you're at the table with someone, they don't reveal to you that they have this inner struggle. They just ask a question about their steak knife. You're going to answer them, and you're going to answer them in a way that's in line with what anybody would reasonably say, which would most likely be something like, don't be silly, Dean, you weren't going to grab that steak knife, or you were using it just for your steak, and everything was totally fine. As you ask these questions more and more to the same people, it really becomes very difficult for people to maintain their composure and drives a lot of frustration. And oftentimes by the time people show up for treatment, their families are very frustrated with them and struggling very mightily with how to best answer these questions that they've answered by the time they show up in a mental health practitioner's office literally thousands of times.
Adam Dayan: So let me pick up on that. If you're talking to the family member who's receiving these questions, which you said are well-intentioned. At what point should a signal go up in their heads that these questions, however well-intentioned they may be, might be signs of an inner struggle that the person with OCD is having?
Dr. Dean McKay: It varies for every person. I think many people who go through this as family members probably wonder how long it's going to take for this message to finally penetrate. How long will it take for me to make it clear to this person that they pose no danger or they're clean or whatever level of concern they're expressing and that they're providing reassurance for? So very often when people show up at the office and they're struggling with the reassurance, they'll say things like, I've answered this question a thousand times, I don't understand why they don't understand it or why they can't finally grasp it. And for some people they'll also say, maybe I should say something different. What do you think I should say? Or the alternative is that sometimes people say, you know what, I got so fed up with it, I finally started answering incorrectly.
And it's that last one that connects somewhat to treatment. I don't know, maybe I'm getting ahead of myself with where you want to ask this question, so this will be like a little teaser. And that is that in the course of treatment we do work with families and an important emphasis with families is to rework how to answer those reassurance questions. But usually by the time they've come to treatment, they've gotten so frustrated that they will answer incorrectly for the most extreme feared situation rather than doing it gradually, which is what the therapist would do with the client directly.
Adam Dayan: Okay. And we'll talk about that some more when we get to treatment for sure. Finally, on the subject of signs and symptoms, I know that depression and withdrawal from others can be a sign and symptom of OCD. How do you identify when it is and when it's not?
Dr. Dean McKay: Well, a default assumption is that if people have obsessions and they're intense and obsessions drive a fair bit of depressed mood. And the reason for that is those intrusive thoughts or experience is uncontrollable. And generally anything that's aversive in our lives that's uncontrollable leads to some depressed mood. It's a fair assumption that depression will be what we call secondary to OCD. So if somebody shows up for treatment for OCD, at least for me, my baseline assumption is that they are having some depressed mood that is a direct consequence of having intrusive thoughts that are uncontrollable, and where their efforts to manage it with the external world is of modest benefit. So that's an important consideration.
To what extent other kinds of psychological conditions may or may not occur with OCD? That's an open question. So some people with OCD may have depression that has nothing to do with their OCD, and that presents a unique complication, probably a little bit of a longer discussion than we have time for today. That'll be our cliffhanger, if you will, for people that are on the edge of their seats.
Adam Dayan: All right. So as far as conditions that co-occur with OCD, you just talked about depression, we've spoken about anxiety, and there's generalized anxiety. Any other OCD related disorders that are common for people who are struggling with OCD?
Dr. Dean McKay: Well, right now the way that OCD is diagnosed, it's part of a broader category called the OC related disorder. So OCD is the central disorder in that category, and then there are several other ones that are in that group. One is body dysmorphic disorder, which involves a distorted perception of one or more body areas but without the presence of an eating disorder. There's trichotillomania, which is repetitive hair pulling. And there's one called excoriation disorder, which involves systematic cutting of oneself without an intention to die by suicide. So those are part of this broader category. The extent that those may be co-occurring with OCD proper is not entirely clear. So those are sometimes present with OCD and sometimes not.
Probably the most frequent co-occurring psychological disorder, if there is one that's going to co-occur with OCD, would be generalized anxiety disorder, which you mentioned a moment ago. And GAD briefly is characterized by excessive worrying, which we distinguish from obsessions in that worries are things that are possible but are still kind of remote. So for example, someone with obsessions about the steak knives that I described before, perhaps they also have excessive worries around their ability to maintain their job. And now that may not be a completely unreasonable worry, but it's not really an obsession because obsessions are things that are just really not going to happen at all, whereas job loss we know does happen.
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Adam Dayan: So Dean, OCD is a condition that sometimes flies under the radar. You can't necessarily tell what's going on inside a child's mind, and sometimes a child is ashamed of the compulsions and performs them in private. What kinds of things do children with a disorder do or say that can point towards an OCD diagnosis? How can one translate how children might be articulating what is happening inside their heads so adults can figure out what condition they are suffering from?
Dr. Dean McKay: Sure. There's two things for this first. So one is that there's a small band of young children, roughly around age three or so, that developmental psychologists have identified as being normative for there to be repetitive behaviors that would look like OCD. It's really important that parents know that. So young children, toddlers and preschool-aged kids have a period of time where you might see repetitive behaviors and some other kinds of things that seem like OCD, that are not necessarily disordered. So our temptation to overpathologize is why I'm highlighting that. The second part is that the age of onset for most kids with OCD is if it's in young children, is around age seven or so.
And so when you start to see things that involve repetitive questioning of let's say safety or kids who do certain behaviors around bedtime that seem a little bit more than excessive, they include things that are frankly kind of random. It might be turning light switches on and off, or we see with children bedtime rituals suddenly becoming quite elaborate. Those might be some behavioral signs that something's going on. As far as verbal behaviors, children will ask questions and they'll ask questions that are designed to try and provide them some reassurance based relief. So children land on the idea of reassurance pretty early in the course of the illness if they have OCD. So those are the two major things to watch for.
Now, if you think that this is happening, there actually is a good screening measure, a very brief measure that will give you a feel for whether or not further evaluation is necessary. It's a five item scale and it's called the obsessive compulsive inventory, children's version, five item version. And what's nice about that is it could be administered by a pediatrician or by some other specialist like a GP, and that will give you a hint as to whether a further evaluation needs to be done.
Adam Dayan: I'm assuming that for the screening, a parent would have to report to the pediatrician, hey, this is what's going on with my child, I want to do this screening. Is that correct? Dr. Dean McKay: Yeah, that's right.
Adam Dayan: And just getting back to what you said about overpathologizing, so that window that you were talking about where it's normal for children of a certain age to be demonstrating some repetitive behaviors, was that zero to seven, birth to seven?
Dr. Dean McKay: Generally it starts around age two and it'll probably go to around five. And then between five and seven, the incidence of OCD is fairly low. So the average age of onset for young children is around seven ish. They say that OCD has what they call a bimodal age of onset. So there's a subset of sufferers for whom the age of onset is around seven ish, and then there's a subset of sufferers for whom the age of onset is in, mid-teen years, so 15, 16. So those are the two major times where you might see it come about. I would argue actually that it's more difficult to detect in teens because teens are naturally disinclined to report things to their parents.
Adam Dayan: What is it that's happening in the brain or life of the seven-year-old or the mid-teen that is making those periods common times for diagnosis?
Dr. Dean McKay: The brain goes through a lot of development over the ages from birth up till mid 20s. So by most developmental psychologists and developmental neuroscientist perspective right now, your brain is fully developed roughly by age 25. And one of the things that's happening is as different brain areas are emerging and becoming more active and more mature, the older parts of the brain, these parts that signal OCD symptoms start to send out these bad signals. There's this kind of neural dysfunction that may start. In the seat of OCD according to neuroscientists right now, is considered to be the basal ganglia, which is an area responsible for repetitive action and also for suppressing some things that might be not tolerated well in society at large.
So the steak knife example really is a good through line for this discussion, because society says if you're sitting at a dinner table with people, you wouldn't think or even consider acting on an urge to stab anybody with a steak knife. That's off the table as an idea. So society would frown on you even saying it as a joke. OCD then goes, we're not supposed to say that? Let's worry about and maybe present to this individual the possibility that it's going to be said out loud and then the conflict emerge. Now, in a developing brain, we start to learn about what things are societally frowned on. And as we learn about those things, then if there's any dysfunction in those areas of the brain, that's where things become problematic.
Adam Dayan: Okay. If a parent goes to the pediatrician, does this obsessive compulsive inventory child version and it is flagged, in other words the child meets the criteria. What's the next step? Is there further assessment? Is a recommendation made for a counselor or a professional? What happens right after that?
Dr. Dean McKay: After that there should be further assessment. So that screening tool is like any other where the question would be raised whether or not there are enough symptoms present that this would warrant actual treatment, and so we should treat that like any other screening test, just like any other health professional, if you had a blood test and it showed that you had high cholesterol, hopefully your healthcare provider would say, okay, we need to do a few more tests to see whether or not some action has to be taken beyond just dietary changes. And we should really look at some of the mental health measures in the same way. And so this measure is intended to just serve as a gateway. Maybe at the end of the day, further evaluation will determine that nothing needs to be done and that we should look at that as this kind of a red herring or maybe it needs to be treated. OCD is very frequently misdiagnosed or as we started out in this discussion and fly under the radar, and this is a way to help put it on the radar. So many people go a very long time before they actually get diagnosed.
Adam Dayan: Okay, thank you for clarifying that. Dean, talk a little bit more about how OCD usually impacts an individual's day-to-day functioning.
Dr. Dean McKay: The avoidance ends up being really I think where the greatest impact lies. Once you start avoiding different situations, and if you're a child, this can then spill into school related activities. It may involve things at home that includes engagement with your family, and all of those things that you end up avoiding if you're a child, things that you do socially and out in the world leads to and facilitates development. And so this ends up abridging someone's development and puts things behind as it goes on longer and longer. Actually it's a really important condition to get on top of because the ability to learn new social engagement skills and strategies for navigating the world at large becomes compromised. And then there's a lot of catching up that has to be done when treatment ends up being finally implemented.
Adam Dayan: And then if you're stuck at home doing ritualized behaviors instead of socializing with your friends, you're probably getting to places late and also winding up in a negative mood as a result of that. Would you agree?
Dr. Dean McKay: Absolutely. Lateness is a fairly common problem for people with OCD because the rituals abridge their ability to get anywhere on time, and people get frustrated with that too, too. The social consequences downstream include people not inviting you to things as frequently because most people don't understand or you've not communicated to them that you're suffering from OC symptoms. Well, people just will make other conclusions and they're not particularly socially favorable.
Adam Dayan: Right. All right, let's move the conversation toward getting help. How much does it have to be interfering in one's life for a person to say, okay, I can't function like this, I'm seeking professional help?
Dr. Dean McKay: Well, that's a matter of personal preference I guess. And so one would have to look to see how much they would like to do in their daily lives and then ask the follow-up question of how much are these symptoms stopping me from doing things? And to be really fair, most people have some things that look like OCD symptoms in a very small way. I know that conflicts with what I said earlier, but really the more accurate conveyance is that every now and then for every person, there will be times where you get an intrusive thought where you'll go, I don't like that. What if that happened? That's a fairly typical kind of thing. Or people engage in orderliness that is idiosyncratic and excessive. And so we have to ask the question of whether or not our life goals are being met. And if they're not, then treatment's probably worth pursuing.
Now, parents may ask this question in relation to what they see in their child as suffering, and that's a little harder to determine. Some kids will specifically ask for treatment. We've had in the practice that I co-own many children who have gone to their parents and said, I need help with this, because they were concealing it so successfully and they were not asking for reassurance, that the parents had no idea this was happening. It's not so typical, but it does happen. In other ways if you see your child really suffering with symptoms, then you may bring them to someone for treatment, and then it's a matter of the therapist engaging the kid in treatment and coming up with strategies together to tackle it.
Adam Dayan: I was just about to ask you what suggestions you have for parents, and I'm curious to hear some more. Your advice to parents might be different, as you said, if their kids are seeking reassurance from them versus if their kids are not seeking reassurance and it's harder to detect that there's potentially a problem. So what other suggestions do you have for parents whose children are struggling with OCD?
Dr. Dean McKay: Usually the first thing is if the child is not specifically asking for treatment, which again, there are some kids who will, then the other thing would be for the parent to talk to the child about ways that they could feel less uncomfortable. That's probably going to be the easier and more non-threatening way of going about it. So this would be the kind of thing where if it's evident that the child is asking a lot of questions, it's evident that the child is also being frustrated at bedtime or at other times of the day where there are these routines that become out of control because of OC symptoms. It's worth having a discussion about ways that this could be alleviated. And to be aware that if they find a good OCD specialist, treatment is not a long-term endeavor. Relief can be usually had relatively quickly. The question for treatment providers and for clients, parents and children alike is, how much further beyond just relief of symptoms do we need to go? And that's a goal setting question that's usually set out in the course of treatment.
Adam Dayan: Let's talk about finding a good OCD specialist. What qualifications should parents be looking for to determine that they found a good OCD specialist?
Dr. Dean McKay: There are a couple of things. One would be familiarity with exposure with response prevention as a specific approach to treatment. That is currently the most empirically supported treatment for the disorder. It's been known to be effective for at least 40 years, so it's not new, but what's interesting is that there are a lot of mental health professionals to this day who are not necessarily very familiar with it. It's worth asking about that specific procedure if the clinician is familiar with how to implement it. And in addition to that, to what extent are they familiar with other what we call cognitive dimensions associated with OCD? I mentioned one earlier that was the idea that the person with the steak knife obsession will also look at their thought and go, this thought is really an important one. And so that's a cognitive dimension called over importance of thoughts.
There are several others. So one is also intolerance of uncertainty, which is typical for many people with anxiety disorders and it's also relevant for OCD, which is the degree that somebody feels they need to have absolute certainty that there is no risk for whatever they're concerned about happening. There's what we call inflated responsibility, which is the extent that one feels that their actions are going to have more implications for people around them. So that includes things like what we call thought action fusion, which is, if I think it, does it increase the odds of it happening? And then also what we call overestimation of threat.
So the overestimation of threat would be, let's say if you are sitting there with a steak knife and you're holding it in your hand about to cut your steak, you might think, well, the threat now that I could stab somebody is even greater because I'm actually holding the knife, it's not just on the table. And so those are examples of cognitive dimensions that are worth asking clinicians if they're familiar with.
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Adam Dayan: Okay, so parents are doing their homework. They're looking at various criteria and qualifications for the providers. They're also looking for more resources so they can educate themselves and understand OCD better. Where can they turn to get more resources and information?
Dr. Dean McKay: The best source by far, in my view, is the International Obsessive Compulsive Disorder Foundation. They have a very thorough website that has resources listed there for parents. They also run a nationwide training program to ensure that there is a larger pool of clinicians who are familiar with exposure with response prevention and other evidence-based treatments. And they also run an ongoing consultation program for people who are experts in the area or for people who are emerging experts. I would start there for sure. The other source, there are resources on the Anxiety and Depression Association of America webpage. I think that's adaa.org. And the other one is the Association for Behavioral and Cognitive Therapies, where there are also resources that are available for adults and parents of children with OCD.
Adam Dayan: Are there any books that you can recommend that describe OCD in kid friendly ways?
Dr. Dean McKay: It's available still in print. There's one that a friend of mine wrote years ago. It's called Blink, Blink, Clop, Clop: Why Do We Do Things We Can't Stop? It's written by someone named Katia Moritz, and I believe it is still available on Amazon. It's a children's book, and it's about farm animals who develop OCD and how they end up managing it. It's adorable and it's very kid friendly. Beyond that resource that comes to mind offhand, there are a number of good books about OCD that have been written other than the one that really put OCD on the map more than 30 years ago was one called, The Child Who Couldn't Stop Washing by Judith Rapoport. But there are several others that are very good. One by Edna Foa, called Stop Obsessing. There's one by Gail Steketee, and the coworkers last name is White, and I'm blanking on the name of it. There's that one. There are several that are out there that are kind of self-help guides that enumerate how treatment is conducted. They're not recent books, but the approach to treatment remains effectively the same.
Adam Dayan: Excellent. Thank you. It's commonly said that OCD is a bully. Do you agree with that characterization? In what ways is OCD a bully?
Dr. Dean McKay: It's a useful way for clients to think of OCD when they're feeling like it's a struggle to battle it with the approach to treatment that's recommended. And that is to suggest that OCD is this uninvited aggressor, and once you stand up to OCD like a bully on the playground, OCD will back down. It's a fair characterization as a metaphor that can be really inspiring for clients, particularly for children who may be familiar with the phenomenon of dealing with bullies in their daily lives. And so I think that that's a fair statement.
Adam Dayan: How can people with OCD whose brains are sending out danger signals, distinguish between actual danger and a fearful but harmless thought?
Dr. Dean McKay: I love that question. I think that's something that we struggle with all the time. How do we know whether or not I should pay attention to this? I guess one of them, as people get better and their symptoms improve, the shorthand that we often ask ourselves is, what would a reasonable person do? And so the flip on that would be what would a person who doesn't have an OCD bully in their head do? And I think that that's probably the easiest trend for how to think about this. The standards vary from person to person though. In this era right now as we're speaking with the COVID pandemic coming to an end, we know that what counts as reasonable is highly variable. And so people have to come up with their own standards. They're also local conditions that I think are worth keeping in mind.
I like to use the example with contamination fear that if you were getting treatment for contamination and you are in the Northeast, there are a lot of places you might go and encounter things that are potentially dirty without any really concern for infection of any kind. If you're in the southeast and southwest rather, and you're going into dry dusty areas, especially enclosed dry dusty areas, you probably don't want to stir up the dust that much, because there are certain viruses that you might get that from a local norm condition would be unwise, and a reasonable person would not take those risks there. The variations are kind of local, and I guess we have to come to some conclusions about those for ourselves on an individual basis.
Adam Dayan: Okay. Let's talk a little bit more about the treatments for OCD. You mentioned exposure and response prevention. Talk a little bit more about how that works.
Dr. Dean McKay: Sure. Exposure with response prevention is where the client and the clinician come up with a list from least fearful to most fearful related to things that are avoided in the service of keeping the obsessions at bay. And then in collaboration, you start with some of the things that are more manageable and practice coming in contact with them. And then the response prevention part is where the ritual is not engaged in. So let's stick with the steak knife example because I think it's such an easy shorthand and it's a useful one that many people struggle with. The person who's worried about steak knives at the dinner table, they may start out with a simple exercise where they have the steak knife on the table, and maybe rather than even being in the presence of any actual people, there's just some photos of their loved ones at the table.
And the person may have said at the beginning, okay, that's not terribly fear producing. And you say, okay, well great, let's practice that. You sit at the table with the steak knives and pictures of your loved ones out right there. And then you build up to more intense scenarios where they ultimately are able to sit at the table with that steak knife present and using it for cutting their steak. Now in fully addressing that symptom, while the person is sitting there, you might also have them practice actively having that thought of stabbing people. And that's where people get really uncomfortable. But it's important to remember that you're allowed to have whatever thought you wish, as long as you take no action.
And so at least when I do this, I practice and remind people that you can have whatever thought you want, whenever you want, as long as if it doesn't translate into any action. And so having people practice this is the important additional element. And then again, no rituals attached to it. And in this case, also practice not asking questions of others for reassurance.
Adam Dayan: What are some other examples of treatments for OCD?
Dr. Dean McKay: Other than what I just described with exposure with response prevention, there are some practitioners who adhere to only cognitive therapy approaches, which there is a body of research that suggests that it can be done. And that is to address the notions around over importance of thoughts, overestimation of threat, piece of intolerance, uncertainty, and the like, and try to come up with ways to challenge those things. They usually include what we call behavioral experiments, which look a lot like exposure. So that's another major psychosocial treatment. And then of course many sufferers also will seek out medication. I'm not a medical expert on this, but I do know that the class of medications that are most frequently prescribed for OCD are the selective serotonin reuptake inhibitors or SSRIs.
These include medications that many people have heard about that have been in the public eye for decades now, like Prozac, Zoloft. It includes some newer ones and newer stills within the last 10 or 12 years like Lexapro. So those medications are commonly prescribed for OCD in addition to the psychological treatments that I mentioned.
Adam Dayan: Do you get resistance towards the concept that exposing someone to situations that make them anxious can be beneficial? And if so, how do you overcome that resistance?
Dr. Dean McKay: Oftentimes when people come into treatment and they've read about exposure, they've read information that makes it sound quite scary. I think that that's what leads to some resistance when people set foot in the office for the first time. And that is that the expectation is that in the course of doing this treatment, I'm going to as a clinician provoke an overwhelming amount of anxiety. And the modern notions around exposure, and what I mean by modern is within the last eight or nine years, deemphasizes that. It actually emphasizes that so long as you engage in this activity that you have previously avoided, even if you don't feel anxious doing it because the clinician has guided you there, or you had a different emotional reaction because of the way it was presented, that that will be an alleviating way of engaging in the treatment. This falls in this category of what we call inhibitory learning. Inhibitory learning is the idea that because you did this thing that you previously avoided, no matter how you practiced it, that will lead to changes in the experience. And so that makes it much less scary for people. And I usually make a point of explaining it to people that way, that I adhere to the inhibitory learning model. And I know a lot of other people do too, by the way. I've done a bunch of trainings on how to implement the inhibitory learning approach for OCD of late. And so I know more and more people are practicing that way.
Adam Dayan: I imagine it requires establishing trust with the person first. How do you establish that trust?
Dr. Dean McKay: Yeah, you're right, establishing trust is critical. And one way to establish that trust is obviously having expert knowledge. The other is by starting with some things that you are confident will be manageable and that the person finds success with. So the clinician is putting a lot on the line when they first do the first few exposure exercises in helping the person find some relief. And once you get a few of those, especially ones that are not too intense, then usually people will find it to be more acceptable.
Adam Dayan: I know you told me that you like to make it comical sometimes to help reduce the anxiety that's involved. Can you give an example or talk a little bit more about how you make it comical?
Dr. Dean McKay: Sure. And I want to be clear that the comical is also while being attentive to being respectful to the person's symptoms. And so that balance is a tightrope that I do walk with clients. But one way, for example, that's pretty common because people harbor these thoughts that if I think it increases the odds of it happening, thought-action fusion, I will do things with people where I will say, okay, look, let's practice this together. I want you to wish for something bad to happen to me in the next 10 minutes. And we could pick something that's fairly nondramatic. Or sometimes when I've been seeing people in the office, which I only see people remotely now, but in the office, I would say, let's wish for the garbage can to burst into flames. It's so absurd and frankly silly and comical that people tend to laugh at it rather than react with any fear. So those kinds of things are fairly typical.
Adam Dayan: How do you help people deal with the shame and guilt associated with OCD?
Dr. Dean McKay: Well, one way that many sufferers find some relief from that is through community of other OCD sufferers. The knowledge that they're not alone, many times when people show up at the office for treatment, they think, how can I have this thought? This is terrible. And that over importance of thought concept starts to lead to people drawing conclusions about themselves that are inaccurate, and then they'll feel guilty and shameful for just the mere fact that they had the thought. Once they're connected with other communities where this happens routinely, so that's where that resource, the International OCD Foundation, they I think provide great solace for people who may feel that kind of shame and guilt around the experience.
The other that I tell people, and I've been really impressed by this statement, and I wish I knew where I got this quote, but I heard it recently. And that is that our brains have evolved to keep us alive, not happy. And so thinking about obsessions as a consequence of a part of our brain that was evolved to engage in emotional reactivity, and even though the modern world leads to running a muck a bit, knowing that this is because of something that was evolved, protect us from something, can sometimes be really very relieving for people.
Adam Dayan: I can see how that would be helpful. I know you've done research on the ways that disgust plays a unique role in OCD, particularly for contamination fear. Can you talk about that?
Dr. Dean McKay: Yeah. So disgust is an underappreciated and under-researched emotional state. And just like every emotion it is designed to protect us. Disgust at its core is designed to help us not ingest something that will be poisonous or harmful in some way. And so our defenses against things that might be disgusting begin with fairly basic things like being able to readily identify rotting food, that's one. Which includes by the way the ability to identify rotting food even for foods that we're unfamiliar with. That's one part. The other way though, again, if we think of the evolution as an overcorrection, and that is that we also tend to react with disgust to unfamiliar foods. So that's the main way in which disgust really initially emerged.
Now where it goes from there includes though knowledge that we generally have, that our skin is a potential place where infections and other illnesses might penetrate. And so people who struggle with contamination fear are more likely to, it's not just fear, but it's the unique combination of fear and disgust, because of the concern of pathogens penetrating the skin. And the more recent research literature on this actually gives us a special name. It's called, the chills. And the chills is emerging as a pretty important emotional reaction that is present among people with contamination fear.
Adam Dayan: Dean, for your patients who may require intensive treatment and who have concerns about the time commitment and financial cost, how do you broach that subject with them?
Dr. Dean McKay: Well, the time commitment is an easy one because the question is, well, is your life worth it? And if this is really destroying your life, well, would you commit the same amount of time if it was a medical illness? And if the answer is yes, then it's worth pursuing because your life will be measurably better if you're able to get to the other side. The cost is a little bit of a more difficult issue, and I understand, and I recognize that in many regions where specialized care might be available, it also may be a little bit cost prohibitive. There are some specialty centers that have sliding scale options available and different ways to address the client's needs without it being cost prohibitive. And so you'll want to look to see whether or not if they have trainees, to what extent are they also getting good supervision from someone who's also an expert in treating OCD. That's an important consideration.
The other one that's less well known, but many people are surprised to hear about is that most states in the country have mental health parity acts, and those mental health parity acts require that insurance companies cover specialized care for OCD. So this means that some reasonable effort has to be made by the insurance company to provide coverage or reimbursement for experts who are not in network. And so sometimes this is something that clients may need to be apprised of by clinicians. And actually as I'm talking about this now, if clinicians are listening to this, check into what mental health parity acts are on the books in your state and whether or not OCD is listed as one of the conditions that is mandated for specialized care. This is the case in New York and Connecticut, and I believe it's true in a bunch of other states as well.
Adam Dayan: Are there any differences in approaches when working with children versus working with adults with OCD?
Dr. Dean McKay: With kids you have to really kind of make it fun more than with adults. If you think about the typical child when they come into therapy, they need to know that it's going to be an activity and it has to be engaged in with the clinician in a way that's going to be enjoyable. As I say to my students, if you want to have a lot of free time on your hand, treat children with OCD and scare them during the first session, your schedule will be clear. So I make a point, if we're doing exposure therapy for kids, it has to become a game, it has to become fun, and it's actually completely in line with that approach of treatment I described before called the inhibitory learning model, where the emphasis is on learning and not necessarily on fear activation.
Adam Dayan: What does recovery mean from your professional standpoint? Can someone overcome their OCD or is it something they will always have to manage?
Dr. Dean McKay: So most sufferers, I look at this as something where you get good at self-regulation so that you're constantly able to manage it and snuff out little warning signals that may be arising, that would potentially be indicators that OCD is returning. And I think really a way that I've tried to explain it to people is with dentistry as an example. We all know that we have a burden to care for our teeth for our entire lives. We would never go to the dentist and say, hey, doc, am I cured of cavities? We know instead though that there are things that you can do to minimize the number of cavities you may get, and you also know that every now and then you may need to go to get a filling. So OCD may be sort of the same way. For someone who may suffer from OCD, they may need to look at the clinician as the equivalent to a dentist.
When first getting treated, you go to the clinician, you get this under control, and then afterwards you learn, here are some things I need to do to make sure that I keep it at bay. But we know that over one's life, maybe there's going to be some new concerns that'll all emerge, and you'll need to go back to the clinician and go, hey, you know what, I started to get these intrusive thoughts about this new thing. I knew how to handle it before with exposure, but I'm not quite sure how to approach this now. And then you deal with it and then you move on again.
Adam Dayan: I think that's a great analogy. Can a person with OCD rewire their brain? And I'm thinking about some of the reassurance questions that we spoke about earlier. I'm thinking about the intrusive, unwanted thoughts that we've discussed. In your opinion, can a person rewire their brain to eliminate those unwanted intrusive thoughts and reduce or extinguish the need for reassurance?
Dr. Dean McKay: The literature on this suggests that, through brain imaging studies, that after successfully undergoing treatment there are changes neurally in the brains of OCD sufferers. It is possible to rewire one's brain through behavioral exercises and behavioral activities. So yes, the short answer would be yes, that can be done, the need for reassurance can be diminished as well as the extent and intensity of obsessions.
Adam Dayan: That's encouraging. Thank you.
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Adam Dayan: Before we conclude, I have to ask, what fuels your passion? Why do you do what you do? What drives you to get out of bed and go to work every day?
Dr. Dean McKay: Well, so for me I have found it to be so rewarding when people come into treatment and they get relief, the change is often quite dramatic. I sometimes find it a little disheartening that right now there is a lot of treatment out there that's not great. People come to at least my practice or have reported to me that they've had a long list of other treatments and to know avail. But to me I find that this has been really so inspiring. And I've had people who've said to me that treatment saved their life, and I've heard this from other people as well. And so to me, that's a huge fueler of my passion.
Adam Dayan: That's amazing. That's got to be very rewarding.
Dr. Dean McKay: Yeah.
Adam Dayan: What's one interesting fact about you?
Dr. Dean McKay: I've been pretty candid about this with a lot of people. I was adopted and raised by my grandparents. That was something I learned when I was 19. So that's something most people are unaware of or had not known before. I also enjoy very long and very intense bicycle rides, usually over 50 miles, but this time of year it's sometimes hard to get out on the bike.
Adam Dayan: Where can our listeners get more information about you?
Dr. Dean McKay: Well, I have a webpage for my work at Fordham, so there's my faculty webpage at Fordham University. That's probably the best place to find me. And if you have questions for me from this podcast, just email me. My email address is McKay, email@example.com.
Adam Dayan: Excellent. Thank you, Dean, for the opportunity to speak with you about this topic today. One of my personal and professional missions in life is to help people with OCD get unstuck, and you've provided a wealth of information about how they can do that. You're doing amazing work, and I look forward to keeping in touch with you in the future.
Dr. Dean McKay: Same here. It was a pleasure. Thanks for having me on today.
Adam Dayan: Thanks, Dean. I really appreciate it. Take care.
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