Ep.73: Understanding OCD with Dr. Brady Bradshaw MD and Dr. Robyn Cohen, PhD

In this episode of Insights From the Couch, we’re diving deep into what Obsessive-Compulsive Disorder (OCD) really is—and what it’s not. Forget the casual "I'm so OCD" comment—this conversation is all about the real, often misunderstood experiences of those living with this challenging and complex disorder. We're joined by two of our favorite experts: Dr. Brady Bradshaw, a child, adolescent, and adult psychiatrist, and Dr. Robyn Cohen, a developmental neuropsychologist. Together, we explore the many faces of OCD, from harm OCD to contamination fears, and mental compulsions that happen entirely inside someone’s mind.

We’re also pulling back the curtain on the often-overlooked aspects of OCD like the shame, stigma, and difficulty getting an accurate diagnosis. Whether you’re someone navigating OCD, a therapist wanting to learn more, or a loved one trying to understand what’s going on—this episode offers education, empathy, and evidence-based strategies for healing. Plus, we talk treatment, including exposure and response prevention (ERP), medication, and what real recovery can look like.

Episode Highlights:

[0:26] - Welcome and overview of today’s topic: the real story behind OCD
 [1:31] - Meet Dr. Bradshaw and Dr. Cohen: their roles and experiences with OCD
 [3:02] - What OCD actually is vs. common misconceptions
 [6:10] - Breaking down the subtypes: harm, contamination, symmetry, hoarding, and more
 [8:10] - Mental compulsions explained with powerful real-life examples
 [11:01] - Is OCD just intense anxiety? Exploring how it's neurologically distinct
 [13:20] - The overlap of OCD with ADHD, autism, trichotillomania, and body-focused repetitive behaviors
 [17:42] - The diagnostic challenge: why OCD is often missed or misdiagnosed
 [21:43] - What’s going on in the brain during OCD—and how treatment changes the brain
 [23:44] - Living with OCD: analogies, partner dynamics, and the emotional toll
 [25:27] - The gold standard: treatment options like ERP and when meds are needed
 [28:19] - The importance of working with experienced ERP-trained therapists
 [32:53] - Pushing the limits with exposure—and why it works
 [37:50] - Naming the OCD: why it helps and how it shifts control
 [39:13] - The importance of trust and creativity in therapeutic interventions
 [40:07] - Relationship OCD and health anxiety—subtypes or something else?
 [43:03] - How to support a loved one with OCD (without enabling compulsions)
 [46:35] - Final takeaways: treatment works, and there’s real freedom on the other side
 [47:36

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Transcript

Colette Fehr: 0:44

Marc, welcome to insights from the couch, where real conversations meet real

Laura Bowman: 0:48

life. At midlife, we're Colette and Laura, two therapists and best friends, walking through the journey right alongside you, whether you're feeling stuck, restless or just unsure of what's next. This is a space for honest conversations, messy truths and meaningful change.

Colette Fehr: 1:07

And our midlife master class is now open. If you're looking to level up, get into action and make midlife the best season yet. Go to insights from the couch.org and join our wait list. Now let's dive in. Welcome back to insights from the couch. Everyone. We have a great episode today on OCD and everything you need to know, not the OCD Everyone claims they have when they don't and they just want to clean their room the real deal. We're going to be unpacking it all we have. Dr Brady Bradshaw, our friend who's joined us many times and is one of our favorite guests, and Dr Robin Cohen, who is a neuropsychologist, is that the correct way to say it? Robin? Yes, that's right. Okay, great. So can you guys, first of all, welcome. We're so excited to have you. I have a million questions pinging already. Thanks for being here. And can you just start out by tell us a little bit about you so our audience knows that you guys are, you know how you guys are dialed into this work?

Brady Bradshaw, M.D.: 2:12

Yeah, I can go first. I'm a child and adolescent and adult psychiatrist. I'm a physician. I do diagnostic evaluations, as well as prescribing medications. I also do psychotherapy, psychodynamic psychotherapy, with patients, and I have a private practice in Orlando, in Baldwin Park,

Colette Fehr: 2:33

right across the street from me, actually, and we never see each other, which is so bizarre. And we live around the corner from each other, and we don't see each other there, either, too busy, too busy.

Unknown: 2:45

I know. I know.

Colette Fehr: 2:47

And Robin, how about you?

Dr. Robyn Cohen, PhD: 2:49

So I am actually a developmental neuropsychologist, so I see children, adolescents and young adults. Currently, I do evaluations and private practice in Winter Park. But prior to that, I ran the neuropsychology, pediatric Neuropsychology department at Arnold Palmer hospital. And prior to that, I did do treatment, actually specific and research specifically with OCD.

Laura Bowman: 3:17

Wow, wow. So let's start off. I mean, just what Colette was talking about, people so flippantly refer to their OCD, like, Oh, my God, I like, I am so OCD, I got to clean my room, or I need things just a certain way, like that is not it, right? I mean, can we get, like, a real working definition of what is OCD?

Dr. Robyn Cohen, PhD: 3:42

Basically, when you have clinical levels of obsessive compulsive disorder, it's comprised of obsessions, which are really severe, intrusive thoughts that cause extreme distress, and then the compulsions come in as behaviors that you do to try to relieve the distress of those obsessive thoughts, and that causes significant life impairment in terms of taking hours per day, and can interfere with your relationships, with your working and it's a pretty broad range of severity that you can have, but your your urges to kind of get things the way you want them and order them, you know, is not really what we consider a clinical obsessive compulsive disorder, yeah, how

Colette Fehr: 4:34

did that become a thing that everybody says? Everyone thinks

Brady Bradshaw, M.D.: 4:41

I was just going to add, you know, there's that the prevalence is really not very high. So OCD, the prevalence is like one to 2% of the population. So it's really not very common, exactly as it's talked about. I mean, ADHD is more common. General Anxiety disorders are more common. I think the part that we relate to is the intrusive thoughts, which, you know, Robin and I were talking about this, are not abnormal. You know, everyone can have an intrusive thought of, oh my god, what if I crash into this car, or what if I, you know, or I need to clean this closet. So we all can have an experience of like an intrusive thought. But it's the intensity and the repetitiveness that it just like keeps staying in the mind and causing a lot of distress. These patients are in a lot of inner turmoil. It's usually very what we call ego dystonic so it really feels very bad for them to think. Those things. When we think about, like, you know, the colloquial or just like, casual use of OCD, it's like, oh, did I turn my curling iron off? Like, let me go check I'm so OCD like, that's, that's not OCD like, we might go and check our curling iron, you know, make sure it's unplugged. And then when we do that behavior, our brain says, Okay, done. Check. It's, it's, it's not plugged in. But somebody with OCD doesn't have that inhibition, they don't have that stop sign, and so they, they keep going on that loop over and over. They're not reassured by the checking.

Colette Fehr: 6:19

Yeah, I had a client who the intrusive thought was that this person had run someone over, and she couldn't stop thinking that she had run somebody over, and there was not really an incident or anything that had even happened to suggest that it just was a thought that perpetuated and recycled and recycled, and no amount of checking or reassurance actually quelled that thought, yeah, yeah.

Laura Bowman: 6:50

To that point like there are a bunch of subtypes. I mean, I don't think people understand how many different subtypes of OCD there are. But, I mean, we're talking with that. You're talking about Colette is like a harm OCD, like, fear of causing harm, but there's contamination. There's like a just symmetry, a just right. OCD, like, what other? What is? What falls under the umbrella of all the different clinical subtypes of OCD

Dr. Robyn Cohen, PhD: 7:18

there are, there's various ones. When you look at kind of like cluster studies, and they, when they in research and subtype it out, contamination definitely, is probably the most prevalent, followed by harm, which usually goes along the harm obsessions usually go along with checking as a compulsion. There's the symmetry. There seems to be kind of like a pure obsessional subtype, where you don't see as much compulsions, but maybe they're more like mental compulsions. So they are compulsions, you just can't see them behaviorally, but they're happening inside their head to neutralize the obsessions and then hoarding is also related to OCD as well, right?

Colette Fehr: 8:05

And hoarding can be the OCD type and a non OCD type,

Brady Bradshaw, M.D.: 8:10

right? I do, yes, I do think there can be an OCD type and a non hoarding OCD type. The the OCD is the that fear of discarding things, and so that's part of the compulsive hoarding. But I think hoarding as a symptom can show up in different disorders.

Colette Fehr: 8:27

So when you mentioned this, when it doesn't have a compulsive behavioral component, so I've had clients like that where it's really the intrusive, the repetitive, intrusive thoughts, and then there isn't, they don't do a behavior. But you're saying that that can actually there is a compulsion. It's just mental So can you give an example of what that might

Dr. Robyn Cohen, PhD: 8:50

look like? So I can actually give an example from actually my son, who has OCD and he had mental compulsion, so he would get an intrusive thought that something bad was going to happen to me, that I was going to get killed or die. And so he in his head, then had to say things in a certain order in his head, nobody saw him saying this in order to protect me. And it got so significant that, you know, he really wasn't able to pay attention in class or, you know, because this would take up so much of his time before he got treatment for it. So that is kind of just one example of how it can manifest. But there's many ways it could, it could manifest.

Brady Bradshaw, M.D.: 9:31

Okay, I had a patient one time that would have an intrusive thought of like throwing her baby off of the balcony of her stairs, and so she would do a mental compulsion of a prayer every time that thought would come into her mind. And again, it's so ego, just like this is just like Robin's example with her son, or this patient with her baby. It feels so bad because it's so different from what they normally would feel, you know, like she didn't want to harm her baby. You know, this was like a very terrible feeling for her. And so the prayer, it's often like prayers or like counting sometimes can be a mental compulsion. And I also wanted to say that there are some people who just have obsessions that don't have mental compulsions too, but I think the numbers Robin correct me if I'm wrong, like 90% of people will have both obsessions and compulsions, either mental or behavioral.

Colette Fehr: 10:24

Okay, most people and is it true that, because I don't know where I got this and if it's really clinically accurate, but that OCD is sort of on an anxiety continuum, like a more extreme end, because I have a lot of intrusive thoughts. It's, I don't think that I have OCD and unless maybe I do, and I just don't know, but definitely I don't have, like, the compulsion behavior part, but I will get horrible thoughts about, like, let's say I'm taking a knife out of the drawer. I'll think about how I could, like, stab myself with it, and I'm like, Oh, I mean, I'm not wanting to stab myself with it. And I think the difference is that thought then goes away. I don't continue to think about the fact that I could stab myself with the knife, but I get a lot of horrific worst case, how you could die. What could happen? You know, I'm close to an edge. I could hurl myself off like my brain will think of that. So is there, Is there truth to that, that that's just like OCD is an extreme form of anxiety, or what differentiates this from anxiety, if anything, other than the intrusive thought compulsive behavior aspect, right?

Dr. Robyn Cohen, PhD: 11:42

I mean, it used to be considered, it used to be under the umbrella of anxiety disorders. They've since pulled it out, realizing that there's an OT OCD type of spectrum and disorders that are more neurologically related to that. Yeah, so, but it did used to fall, and anxiety is a huge part. I think that too, when you're experiencing clinical OCD and you get those intrusive thoughts, not only do they feel bad, they cause such extreme anxiety, whereas when we're going through our day experiencing intrusive thoughts just like that, we all have different frequencies of that experience, but we're not getting that debilitating fear coming with it, oh my God, and then trying to find some sort of relief to that fear that's associated with it.

Unknown: 12:33

Gotcha, yeah,

Laura Bowman: 12:36

let me tell you guys about the type of client I'm seeing, because I see a lot of anxiety disorders, and I see a lot of that intersectionality between ADHD, ASD, all the things right, and OCD. And so I have like, maybe four of these types of clients I'll just describe here, who are, like, really bright women, really creative. Some of them are very high functioning. Most of them have, like, really struggle with intrusive thinking, a lot of intrusive thoughts. And they talk about it in terms of, like, their themes are always changing. A lot of it's around good person, like moral scrupulosity, not always because of religious trauma or anything, just because it's like, a lot of feelings of guilt. There's also a lot of like, fear of they're going to find out they're gay, they're going to find out they're actually transgender. They're going to find out something that is going to make them basically unlovable. And every time, and they want relationships very badly, and when they get into relationships, of course, all of this ramps and their themes are always dancing around, and they're also very like, typically, a lot of them meet the criteria for ADHD, and many of them will have, like, a body based, like picking disorder, or, like, hair pulling. I'm seeing this constant. Am I the only one do you have? You had clients like this,

Dr. Robyn Cohen, PhD: 14:01

oh, yeah, yeah, absolutely.

Colette Fehr: 14:05

So, yeah, this is related to OCD. What you're describing,

Laura Bowman: 14:10

like, what's the main thing? Is it all of these things kind of dancing together, or is it OCD this? I don't know. How do you conceptualize that? I think

Brady Bradshaw, M.D.: 14:19

there's a high comorbidity with OCD, which I think is one connection I'm making to what you're describing. And so we see, you know, a higher rate of and people who have tick disorder, we see higher rates of OCD. And then, like trichotillomania, like pulling hair or like skin picking, those types of things, we see higher comorbidity with OCD, but some of what, and then ADHD, or autism spectrum. You know, with ADHD, people with ADHD have higher rates of intrusive thoughts as well. So it's like, really impulsive. Their brains are going really fast. And then it's like, what's something super scary that could happen right now, while I'm pulling the knife out, right, that thrill of that, you know, so there is high comorbidity. And I think the other thing that I was hearing Laura and that, like, you know, patient example that you gave, is possibly like OCPD as well, which is a, you know, we would want to differentiate from OCPD is more of like a personality, what we call a personality disorder, or traits, where there's like, high perfectionism, guilt feelings, high conscientiousness, detail oriented, afraid of making mistakes, and it tends to be like more. Invasive and chronic, then, you know, big intense flares of anxiety and OCD symptoms. So the intensity, I think, is different, and the clinical picture is different, but OCPD is more like of a chronic, you know, developmentally, you might hear it over years of time and more of like, that, intense perfectionism,

Laura Bowman: 16:04

yeah, oh, yeah. I don't know why. I've just, like, associate that with more with men. Maybe I'm like, just see it in men more. Maybe that's my own

Colette Fehr: 16:12

body, and I have talked about that a lot. I mean, I think OCPD is so little known even among therapists, you know, you know, you touch on it for two seconds in the DSM in our pathology class. And I think a lot of times with OCPD, people don't come to therapy unless their relationship is suffering. I see a lot of it in my office, because there are maybe one of the partners has OCPD and they can struggle relationally because of the rigidity and all of that. Yeah, so it's, and it's, it's confusing, because it's obsessive compulsive personality disorder, but it's really nothing like the mood disorder

Brady Bradshaw, M.D.: 16:57

the anxiety disorder, yeah, yeah.

Dr. Robyn Cohen, PhD: 16:59

It's poorly named. Unfortunately, I think it's even slightly more prevalent than OCD. Yeah, OCPD is more prevalent. That's fascinating, but I'm not going to see it like you said, because those people are probably only seeking treatment when they're in a couples or family type, you know, therapeutic. They're not seeking it for themselves,

Colette Fehr: 17:23

because a lot of those qualities are really great in terms of thriving at work. I know I'm not saying anyone who's a workaholic has OCPD, but I do think that those things can go hand in hand, and unless the partner is saying, you know this, and this is a problem. I think rigidity is always difficult, especially on relationships, so that's where it can interfere. But at work, it's like, this works great, right?

Laura Bowman: 17:52

I'll just OCPD is like ego syntonic, right? It's like they think they're great. It's working for them, like the people who come in to therapy for, like, intrusive thinking and and like, they're disturbed, but they're in and what they're really almost shopping for and like, this goes to treatment, which we can talk about in a minute, is almost like reassurance. Yes, um, they're really shopping for reassurance, which is why we can treat this really wrong if, like, if people are improperly trained, this

Colette Fehr: 18:22

can go poorly. Yeah, and I've had so many clients in the past when I used to work with a lot of individuals who were just never diagnosed, and it was very clearly OCD and they were misdiagnosed forever. Is that typical that it's hard to get an accurate diagnosis for a lot of these people?

Dr. Robyn Cohen, PhD: 18:42

I think so. What do you think? Brady, I do.

Brady Bradshaw, M.D.: 18:45

I do hear that from my patients. I think there's a lot of reasons that that might be the case. I mean, one is that people often have a lot of guilt and shame around their symptoms, because the intrusive thoughts can be really terrible, and ego dystonic. So they might be afraid of being labeled as like a sexual predator or deviant or like that they're a bad mother. If they feel that way, you know, like there's so much shame around it that they can be sometimes reluctant to disclose, even to a professional, what they're experiencing. So I do hear that that they either are reluctant to disclose or they get, like, mislabeled for those like intrusive

Colette Fehr: 19:27

thoughts. Okay, so before we get into treatment, let's talk about if someone's listening and they're wondering if they have OCD. I mean, obviously we're defining here the intrusive thoughts and the compulsive the compulsion, the drive to do certain behaviors to reduce the anxiety or relieve the anxiety around those thoughts. What might someone look for and think about if this could be a factor in their life?

Brady Bradshaw, M.D.: 19:54

Well, I think it depends on time spent. That might be one thing I would look for. Okay, so if you're spending a lot of your time going back and checking the door to make sure it's locked, and maybe now you're late for work, like that would be a good sign that this is impairing to the point that it's really becoming a problem. So time, I think, is one thing that I really look for, time and then intensity or level of distress. So is this something that you're quickly like, oh, did I lock the door? Let me check. Did I lock it? Check again. Okay, I'm good. Or is it like, there's hours of going back and checking and thinking about it, and I'm distracted at work because I'm thinking, Did I lock. My door at home?

Dr. Robyn Cohen, PhD: 20:42

Yeah, no, the distraction and the attention. Because a lot of times people think, Oh, well, I just can't pay attention. You know, it's ADHD. I've got a deficit. But really it's that they're attending to these intrusive thoughts and monitoring for them, sometimes even. And so it's, you know, it's something important when somebody comes in with attentional issues to definitely look at and roll out.

Brady Bradshaw, M.D.: 21:07

And I think because the fear sometimes is irrational, and they're able to identify that, that's another reason that they can be sort of like reluctant to disclose, like, you know, I've even had physicians with like health obsessions, and they know, you know logically, that it's not rational, and they will still right. They know it's irrational, but they can't it feels stronger than their rationality,

Colette Fehr: 21:36

right? And then the conundrum is that the compulsion and the behavior actually perpetuates the whole thing and keeps it going. So, and I want to get into the treatment thing, but can you give us a little explanation of what's happening in the brain with this? Because it really, there really is a difference, right? I mean, I think, and I don't know if this is right, but what I learned a million years ago was it's almost like a gear shift getting stuck, like you can't quite shift into another gear. And maybe that's not quite accurate, but what's happening for people with this? Because, like you said, they know that it's not necessarily, maybe on some level, you know, consciously, I didn't run anybody over. I locked the door, but you still can't help but have that thought and the need to check,

Dr. Robyn Cohen, PhD: 22:24

yeah, I think that's a great metaphor. I mean, you know, it's, it's, there's a, there's a lock almost, that happens and a loop, and you can't get out of it. And there's brain structures that look different, just on regular neuro imaging. They're on functional neuroimaging, you can see differences functionally in the brains of people suffering from OCD versus normal controls. So yeah, there's, there's a lot of biological mechanisms that are happening. And then after treatment, as the symptoms remit and treatment is successful, when they go back into a brain scan, their brains look like more of the normal controls. You don't see those brain Yeah, activations that you did when they were suffering. So it's, it's a really fascinating disorder to study from that kind of neurological pinpoint.

Laura Bowman: 23:18

That's fascinating. It's funny, like what I've heard, and the these clients really do suffer. I mean, it is so agonizing to be battling thoughts all the time. And my clients will say it feels like a flock of birds are attacking me, like, and they just aren't able to, like, find the forest for the trees like, it's just, it's so overwhelming coming in on them, and yeah, I just, I have such compassion for what it's like to do. And it's these thinking structures are so tricky, and it always seems to attack people, like on the level of their values, like, the more they care about something, the more the intrusive thinking will attack them, and it's very tricky. So it's always shape shifting. And I just can't say enough about how much compassion I have for how much work it is to live with something like this, and you can't see it. So it's hard for anybody. It's hard for the person to have self compassion, because it's like, is this thing real, or am I just crazy?

Colette Fehr: 24:25

Yeah, yeah. And I think it's hard for people to when I see the partners and therapy, you know, often there's just so much frustration with it, how it also interferes with the partner's life. Then, because we were two hours late, because we had to drive back 25 miles to check the stove again when we had already checked the stove 10 times, a frustration, a difficulty relating to it. Because if this is not something your brain's doing to you, I love that flock of birds analogy. You know, if you're not being attacked by a flock of birds, it's hard to know what it feels like to try to move through daily life being attacked by a flock of birds. So I think it is really important, if somebody has OCD in your life, to understand what's happening, so that you can have some compassion for it, and also that partners don't inadvertently collude with the whole mechanism that perpetuates and exacerbates the OCD, right? We don't want everybody enabling it so that it gets worse. So let's talk about what because there is hope for this to be better. I've seen it a million times. I know. We all have, right? How different it can be. I did not know that it changed how the brain shows up on these scans, which is fascinating to hear. So you know, all I know of is ERP. My understanding is that's the gold standard, exposure response prevention. Is that? So what works? Do we need meds? Does it just depend on the person? Tell us what's the best practice for treating?

Brady Bradshaw, M.D.: 26:08

OCD, yeah. ERP is still recognized as a very helpful treatment as part of cognitive behavioral therapy. CBT, so depending on the severity which most of the people that I'm I see, you know, when they're walking in to see a psychiatrist, the severity is pretty high, it's pretty intense, and so usually it's a combination of medication and therapy. The therapy, CBT with ERP, is hard work for these folks, you know, like exposure response prevention is you're telling me not to do this thing that like feels like it I have to do it, and I have and it soothes my terrible anxiety and distress. So it's not easy to tolerate this type of therapy, and so often medication is needed to help and SSRIs, serotonin, antidepressants are the sort of gold standard Medicaid, gold standard medication that we use to treat OCD like a Zoloft, Zoloft or Prozac. All of the SSRIs have good data for OCD. Chlamypramine, which is a tricyclic antidepressant, also has good data for OCD, but because of side effect profiles, we usually go with SSRIs first, and patients with OCD tend to need higher than the upper limit of the normal doses of those medicines. So Prozac for somebody with anti with depression or anxiety, might we might do 20 or 40, but I've had patients with OCD on 100 milligrams of pro sex. So you sometimes really have to crank the dose up on the medication. But I really want those patients also to be in therapy and getting you really need

Colette Fehr: 27:58

both, right? That makes sense. And in fact, Brady, I think we have shared patients where I did not know. One of the common things I see is that people are getting psychotropic meds from their family practitioner or internist, and let's say OCD is happening. They're getting like, a low dose of Zoloft and saying, Oh, well, it didn't work for me, right? And I had no idea until, I think I had sent somebody to you, Brady, that that that was even a thing that was done, or why that was needed, and that that can be effective. So if this is a factor for somebody listening, it, my opinion, at least, is that it really is worth it to see a psychiatrist,

Brady Bradshaw, M.D.: 28:40

yeah, and a therapist who knows how to do CBT with ERP. I don't know Robin, if you want to speak more to that, but you, Laura, you sort of alluded to supportive therapy that's just colluding with OCD is sometimes more hurtful than helpful. So yeah,

Dr. Robyn Cohen, PhD: 28:59

and it's not easy. It's not easy. It's not an easy therapy to deliver. It's not an easy therapy to receive. It's not, you know, not everyone responds to it, but you know, it does have good effectiveness for a good portion of patients that are especially motivated, patients, speaking from someone who's done it with children, adolescents, it's really important to get family to be educated and how to support at home, because doing the sessions really won't help that much without the carryover into their day to day environment. And also, too your sessions have to be very flexible, because it's not something that can neatly fit into, like a 45 minute session. If you're doing this therapy, you need to have the flexibility. Some therapy sessions might need to be a couple of hours, because ending a session in the middle of doing an exposure when that anxiety has not decreased, could cause more harm than than benefit. So it's just, it's it can be very life changing and effective, but it really needs to be with somebody who has a lot of experience in delivering that, that type of therapy

Colette Fehr: 30:18

you are so right, because there are so many therapists who have absolutely no idea about any of this stuff. There's so many things to focus on and specialize in, that if this is not something you've drilled down on, you know, you just might not even know what would help. So can you guys just give a little explanation? Because we're talking about ERP and CBT. And we said the full names exposure, response prevention, cognitive behavioral therapy, but our listeners mostly don't know what those things are. So can we just give a little like definition of that kind of therapy?

Dr. Robyn Cohen, PhD: 30:54

Sure, absolutely. So the exposure part of exposure and response prevention is eliciting the obsession, or the intrusive thought that's causing distress. So you elicit that in the session, and then that creates a an urge to do the compulsion to neutralize that obsession. And so the therapy is basically stopping, you know, the compulsion, having that anxiety of that obsession, just keep going and keep going, because eventually it has to decrease on its own. Without the compulsion, you cannot stay in a physiologically aroused anxious state when there is no direct threat to you for an extended period of time. And some people could experience that decrease in anxiety in a few minutes, but some might take hours, but eventually you just literally cannot physiologically sustain that. And every time that anxiety goes down without the compulsion is like a step in the right direction,

Unknown: 32:02

learning, yeah, yeah,

Brady Bradshaw, M.D.: 32:03

exactly. Rewiring,

Colette Fehr: 32:06

rewiring and learning that you don't need the compulsion in order to reduce your anxiety, that you can actually ride the wave of the feeling, get to the other side without doing the thing. And that's what starts to help your brain change and know that you don't need those behaviors

Brady Bradshaw, M.D.: 32:25

Exactly. And Robin, I think this is true, but it's usually done in a gradual way, so that you're not flooding the patient's system. So it's not like if they have a contamination fear, you're having them eat food out of the trash, like it's not that fast, but you do

Dr. Robyn Cohen, PhD: 32:43

eventually have to get to that point. So you make the hierarchy of what would be the least fearful thing and then what would be the most fearful thing. But when you're doing the protocol, you really need to get almost, like, above and beyond. So like, I've had kids that had to, like, touch toilet seats in public bathrooms and touch their face. You know, contamination, like taking a french fry and like putting it on the McDonald's table and then eating it. So, you know, you do things that even we would not do normally, but you do need to take it that far to help, like, with with remission, it just seems to be the most effective when you go to that that extreme with it. But you would never do that until you've already had so much success with so many other things, right? So yeah,

Laura Bowman: 33:34

I also like act therapy, which is Acceptance and Commitment, especially with my my clients that have a lot of, like, thinking, intrusive thought based OCD, it's really the tolerance of uncertainty, right, like and and the fact that we can't know for certain if the relationship they're in is ever going to work out. We don't know for certain if they'll fall in love with a member of the same sex, and, like, beginning to tolerate uncertainty and to build the life worth living anyway, like we're always, we're always toggling back between like the life worth living, because that builds the willingness to do the work, right? You know? And I love that model, the ACT model, which is a behavioral based model as well for helping OCD clients, especially my thinking, intrusive thinking based ones. I think the exposure for contamination and just right and all that stuff has to be there. And sometimes exposure for these thinking things has to happen too in a structured way. But I notice how shape shifty it is that as soon as you know you you sees on one they just come up with a new theme, yes, and underlying it all is just like that. You can never be certain about life on any level. And can you tolerate that?

Brady Bradshaw, M.D.: 34:55

I think the fears this may not always be true, but a lot of the patients I see with OCD, the fears that they have are so fantastically bad that to accept it would be intolerable, like throwing your baby or running over a person you know, like it's I think that speaks to the intensity of OCD, and then maybe that's why it got separated out of the anxiety disorders, because it starts to kind of even cross into, like, magical thinking, or like it gets almost bizarre in the fear, right? And they know that. That's why it's not psychotic. They know it's not real, yeah, but it is really a. Um, with stressing,

Colette Fehr: 35:42

yeah, yeah. And that was what I found fascinating about that ERP training was the hierarchy part of, you know, Laura. We remember that with Laura Myers, yeah, where she talked about, like, the scale of 100 and starting with targets that are, say, like, I had a client who's afraid to drive over bridges. So you don't start with, I don't know, I don't know what's the scariest bridge or anything out there, but like a really high bridge that has no guard rail and you're on the edge, you know, you might go over a bridge that's low where you can stay in the center, and even that was intolerable to this client. But it is amazing how, just without OCD. Exposure to things that scare you is the thing that builds confidence, that changes it. So it makes sense that this would work, but also why it's so difficult. Somebody's really got to be willing to do the thing and do the thing repeatedly, and it's very hard to do something that you feel afraid of, it feels counter intuitive, or to not do something that brings you relief. But what seems to be what you guys are suggesting, and what I've seen in my limited therapeutic experience with this, is that this is something that really can change. There's a lot of hope. There's a lot of freedom from this, right?

Brady Bradshaw, M.D.: 37:06

Absolutely. Oh,

Dr. Robyn Cohen, PhD: 37:07

yeah, and the going from living in such distress to the freedom that within, and it's ironic, right? Because there there's a lot of control with OC, you're trying to control a lot, but when you let go and you do this treatment, or you take and you take medicine, then the relief on the other end is so life changing. And I'm sure you know all disorders, obviously, when there's treatment and there's relief, there's a big difference in life change. But for some reason, OCD really sticks out as something that you really can just completely change the trajectory of your life with that treatment.

Brady Bradshaw, M.D.: 37:48

Yeah, which is amazing. Another thing I just wanted to mention that I because I do think it's really helpful and hopeful. And Robin, you and I have talked about this before, but, and I think this is part of a CBT technique, which is to name the OCD as something apart from the person. Yeah, I feel like that is specifically helpful for OCD patients, because it I don't know that it just like creates some space, maybe there's some release of control there, and I think it normalizes and maybe reduces some of the shame and guilt that they feel. So I don't want to throw my baby my OCD is tricking my brain and making me think that. But I don't want to do that. It's not mine. It's my OCD,

Dr. Robyn Cohen, PhD: 38:31

yes, and then at the end, you go from the this perspective change of that was controlling me, and now I'm controlling that. Yes, that's not separate.

Laura Bowman: 38:43

Yeah, you're leading your OCD part. Yeah, yeah. And, you know, it's like what Brady was saying about how scary some of these things are. They are really scary. And I think it's it speaks to that when you you have to have a really well trained therapist, you have to have a lot of trust with your therapist, and the therapist has to be like, really and very often very creative. You're coming up with, like, interventions that are very offbeat, often, like, I was listening to a guy who had this fear that he was going to kill himself. But he was like, it was, it was an ego, dystonic fear. He did not really want to kill himself. He just thought he was going to take a knife and carry to take a knife and kill himself. And literally, the treatment was he had to sit for like an hour a day with a knife to his throat. Like he built up a certain amount of time. But can you imagine, as a therapist, how much trust you'd have to have in your therapist to begin to sit with like a knife to your throat eventually, the upshot of this is he eventually got bored. You know, he was just like, Okay, I guess I don't want to kill me. I like, he wasn't afraid of it anymore. But like, these irreverent treatments, yeah, are scary.

Dr. Robyn Cohen, PhD: 39:54

And as a Thera prior therapist who did this work, we were always in constant consultation with other therapists who also do this work to because when you get creative, you want to bounce these ideas off other people and, oh, yeah, no, I've done that before. Or no, this is this could go wrong with that. So it is very important, from the therapist's perspective, to always have somebody that's also doing the work to be able to work through some any new situations that are going to come your way.

Colette Fehr: 40:21

Okay, so I want to ask too about relationship OCD, right? Is this a real thing? Like, what is it really? Because I had a client come in and say, like, I am diagnosed with relationship OCD, and I had to really, like, look it up and do a deep dive into it. And. I'm still not sure how clinically accurate this is. So where do you guys fall along those lines?

Brady Bradshaw, M.D.: 40:47

I've never, I have not heard of that. I'm interpreting it as an anxious attachment, maybe like an attachment. I would probably use that lens. It's not a DSM diagnosis, right?

Laura Bowman: 41:01

I have a client who would cop to that, and what she describes is something where it's like, she'll get into a relationship, and very quickly, she's looking for evidence that she shouldn't be with this person and that that she's like, am I attracted to him? Do I still like him? Should I break up with him? Are we compatible? If we're not compatible in this and it just keeps proliferating.

Colette Fehr: 41:25

That was similar to the guy that I saw, but it sounds like it's one of those internet diagnoses, you know, like,

Dr. Robyn Cohen, PhD: 41:33

could significant be a significant OCD in that person, and that's just the manifestation their intrusive thoughts are taking. So almost maybe like another, like a subtype, but not its own distinct diagnosis.

Colette Fehr: 41:46

Yeah, right, I guess I wondered if it was a real subtype. But maybe anything can be. I mean, you could be preoccupied with anything,

Dr. Robyn Cohen, PhD: 41:56

yeah, I would think it would fall, that would fall under a subtype of, like a checking kind of thing.

Colette Fehr: 42:04

Okay, yeah, yeah. What

Laura Bowman: 42:06

about health anxiety? Like, can health anxiety get quite have an OCD component? Is that under the same OCD umbrella? I mean, I know, like it can be like in its own category, but I feel like OCD and health anxiety can dance quite a bit.

Brady Bradshaw, M.D.: 42:23

Yeah, I think that would go under the subtype of, like, a fear of harm, you know. So they, like, are really afraid that something's wrong with them, or that there could be something harming them. And so that leads to the compulsive checking, and like, either checking your body, or, like, multiple doctor's appointments, I've definitely seen a health anxiety OCD, that

Colette Fehr: 42:45

for sure, yeah, or I'll have people who are constantly looking things up every day. They're sure they have something new every day.

Laura Bowman: 42:53

And now we have, like, chat GPT to really feel that, which is like, it's very concerning, because you can talk to chat GPT all day long, and it will reassure you endlessly, right?

Colette Fehr: 43:05

One, you've seen the stuff about how chat GPT has also helped people take their own life. I know this is terrifying. Yeah, technology creates new problems.

Laura Bowman: 43:16

How do we support people? If you're in a relationship somebody listening is in a relationship with somebody who is suffering with OCD, or you're a parent and you suspect your child is dealing with OC cd, symptoms like, how is the best way to support besides like medical intervention and getting a psychiatrist on board and treatment just parenting or loving or supporting a person with OCD, what are some of the best practices? Well, I mean,

Dr. Robyn Cohen, PhD: 43:44

obviously getting the professional support is number one. And then that professional will be able to support the caretaker in terms of, you know, giving specific kind of strategies for that specific situation. But, but in general, keeping a framework of this is not who this person is. This is a disease that this person is suffering from and trying to find the best way to straddle being supportive without constantly giving in to you know, like you said earlier, going back 25 miles to check the stove, even though you've already checked it, you know, being able to be comfortable with, you know, we're not doing that, you know, I'm thinking from a parent perspective, obviously, because that's what I primarily deal with. But I don't know, Brady, do you have any adult kind of examples? Yeah.

Brady Bradshaw, M.D.: 44:41

I mean, it does take a lot of compassion. I think if you're if we're thinking about a partner example, because sometimes your partner might be doing behaviors that you can see are really the OCD and not your partner, like you're saying Robin, it feels like it's different from who that person is. And so sometimes I think it can be hard to be patient with that, because it does consume hours that maybe then they're not available to the partner, to the other partner, but to be compassionate and know that it's not as simple as saying, like, you know, we can't vacuum for two hours tonight. Like, we're not gonna, you know, like, you can suggest and encourage and support, but they may not feel like they can help themselves, and that's why you do have to often have a medical piece involved, where they're getting therapy, they're getting medication to support that, because the partner telling the person not to do the behavior that's not really out. Very effective or compassionate. You can encourage like, Hey, do you think do we need to drive back? Like, maybe this is your OCD, like, maybe we could just go, keep going, but they may not be able to, and so being able to accept that and that they are in a lot of distress, I think, is important. I can also just make a comment about the family. Thing is that okay? Can I? Yeah, I think for a family, if a child is suffering, or a teen with OCD, for the parents and the family to be thoughtful about initiating therapy also and making sure that it is a good fit before starting ERP, because I have seen where the parents can't tolerate the hierarchy of exposure and will swoop in and pull the child, and that is really reinforcing the OCD, so try to be thoughtful at the beginning, so that you're not committing to something that you're going to have to swoop in and pull out and make sure that as a parent, you can tolerate the plan before you start

Dr. Robyn Cohen, PhD: 46:44

it. When I was treating children and adolescents, I really maybe older adolescents, I would do some sessions individually, but I always included the parent, because without the buy in from the parent and the motivation from the parent, it's just not going to work, and it's just as important for them to learn this as it is for the child to learn it too. So, you know, I would say it's a pretty big red flag if you have somebody that's just like, oh, you know, I'm just going to work with your kid, and this is what we're going to do, and I'll see you when we're done with our session.

Colette Fehr: 47:15

That's such good advice. Good point. Yeah, yeah. So, okay, really like a takeaway here that we're all saying is this can be so hard to suffer with, and there can be so much shame attached, and when it's happening to you, it's so overwhelming, and it probably feels like you're the only one you're not. But really take the step to get help, because help is so possible. It's out there find a good doctor and a good therapist who have worked with patients and clients that have OCD, so you're going to get the right treatment. And it's amazing how different it can be. On the other side, there is freedom from this, so it's exciting to have something that actually can change and be helped when you know some of the stuff we're challenged with is so seems so fixed and immovable. So as we wrap up here, can you guys let our listeners know how they can find

Brady Bradshaw, M.D.: 48:16

you? Yeah, we're well, we're both in Orlando, and my website is Baldwin Park, med, M, E, d.com,

Dr. Robyn Cohen, PhD: 48:27

and I'm in the Winter Park area, and my website is the neuro code.com

Colette Fehr: 48:32

Wonderful, wonderful. And if you guys are not in this area or in Florida, you know Google and look for look in Psychology Today. You know, ask around if you have a therapist. Really, find somebody who knows what they're doing with this, because it's its own thing, and you want somebody who has additional training for this specific thing, absolutely. Yeah. Thank you so much for being here. Really, I learned a lot, and I know our listeners will have too. And to all of you listening, thanks so much for tuning into another episode of insights from the couch. We hope you got some insights from our couch today, and we'll see you next week. You.