OCD Protocols: A Practical and Evidence Based Manual to Decrease Anxiety, Lower Mental Chatter and Improve Your Quality of Life

I haven’t been on this app since 2023; when I first downloaded this app back in 2019 it was basically in its foundational stages and nothing more than a subreddit filled with people just venting about their experiences. Logging in now and seeing all the updates makes me happy since more people with OCD can connect with each other, connect with psychologists and have a disposal of tools at their hands to help them navigate through this journey. However, when going through and reading some of these posts I still see a lot of catastrophic thinking and general hopelessness among some of us. I am not faulting anyone for having these feelings, as OCD itself is powerful due to many cognitive distortions – “Catastrophizing” and “Emotional Reasoning” being two of the strongest. But I don’t think it’s helpful for the community as a whole to become an echo-chamber of “OCD sucks, my life won’t get better” because that is not true, OCD can be very debilitating. I can attest to this firsthand, but there are many things we can do to improve our quality of life and still live a full and meaningful life despite this disorder. I am writing this because I believe I offer a unique perspective on OCD, I was diagnosed with OCD back when I was 14 and it completely hindered some of my experiences, now that I am older and currently on my way to get my PsyD to become a clinician I want to share my insights and hopefully help everyone who is feeling stuck just as I once was. I am passionate about this because not only do I know what it’s like to have OCD, but I also know what it is like to work with therapists who do not know how to address OCD fully. Many of them know about ERP, mediation/grounding techniques and coping strategies which are all great, helpful and something I will write about here, but they do not dig deeper and for people like me who have struggled with chronic OCD I could do 1000 exposures and still get anxiety or intense rumination. Long before I pursued my doctorate, I began digging deeper and looking into other strategies and alternative paths to better manage my symptoms, but now that I have an academic background in psych and have built connections with real researchers I aim to bring the community more tools, resources and a better understanding of OCD at 0 cost to you all. I hope this post can serve as a guide and starting point for everyone to not only learn about the mechanisms of OCD but also become aware of all the tools and options at your disposal that can help beyond just ERP. However with that being said, please always reach out to your own prescriber, and psychologist to find out what works best for you on your journey and if you find something interesting here that you haven’t talked about with them yet don’t be afraid to bring it up – I have yet to meet someone in this field that doesn’t want to help or learn more. Furthermore, if you would like more clarity on a topic I mentioned don’t hesitate to ask and I will do my best to answer. I have a genuine desire to help as many people as possible without having you pay out of pocket or make a gazillion co-payments to see the improvement you deserve. Now with that long preface out of the way let’s get into the nitty gritty of OCD and get you back into the swing of things. 1. Understanding the OCD brain This section might be a bit boring but it’s important to understand the mechanics behind OCD, I know it’s cliché but I really believe “we fear the things we don’t understand” and that once you have a bit of a grasp on what’s going on in your brain you’ll realize it’s not as “f*cked up” as you might believe. I think this part often gets under-looked in therapy and it amazes me how many people who suffer from OCD don’t know what is going on up there. For your sake and mine I will try to keep this as simple and brief as possible A. The Cortico–Striato–Thalamo–Cortical (CSTC) Loop • This is the core of OCD, this loop leads us stuck in a cycle of error detection, “something feeling off”, self-monitoring and habit formation • Essentially this is why your brain feels like a broken smoke detector that is constantly going off despite there being no fire a. Cortex (OFC/Prefrontal Cortex) Notices something and evaluates it → “Is something wrong?” b. Striatum (Caudate Nucleus) Filters the thought → “Should we let this go or keep focusing on it?” c. Thalamus Amplifies or quiets the signal → “Send this back to the cortex or drop it?” d. Cortex (Again) Gets the signal back and reacts → “Oh crap the thought is back, I guess something really is wrong, better think about it again.” • This is why the topic, theme, or subtype of OCD does not matter. Regardless, if it’s Somatic OCD, Harm OCD, Relationship OCD, etc.... you can plug in anything here and follow the pattern For Example: o Cortex (OFC/Prefrontal Cortex) Notices something and evaluates it (Why is my heart beating so fast? Why did my partner not respond to me? Why am I thinking about harming my family) o Striatum (Caudate Nucleus) Filters the thought: (Is this a heart attack? Are they cheating on me? Do I really want to hurt them? o Thalamus Amplifies or quiets the signal: (If this really is a heart attack/cheating/violence we better focus on it) o Cortex (Again) Gets the signal back and reacts – the compulsion (Let me check my heartrate, Let me text them again, Let’s avoid knives today) • I know it can feel like hell to have these thoughts over and over again, but there is a brightside to all of this. Our brains have been hardwired to protect us, what makes us different from Goldfish is “Meta-cognition” we can remember or learn about things to avoid shitty situations. It’s why someone can tell you, “Hey the stove is hot” and you can comeback in 20 minutes and not touch the stove. On the other hand, a poor goldfish like my boy Hendrix can see his buddy Jimmy jump into the filter and 20 seconds later he might be curious himself. So, then I gotta make sure to seal any holes or gaps so the same fate doesn’t happen to him. In many ways it’s remarkable that our brains can learn to recognize patterns and threats early on! • This why there is absolutely nothing wrong with having these “intrusive thoughts” our brains are doing their jobs to protect us the main issue is with the filtering. Its jumping from wow my heart is beating fast to “Geez is this a heart attack??” or going from thinking ‘why isn’t my partner isn’t texting me?’ to “they must be talking to other people.” When in reality, if we take a step back your heart might be beating fast because you just worked out, walked up a flight of stairs, had a cup of coffee. And Your partner might not be texting you because they are sleeping, running errands, working… or in my case getting overly invested in Greys Anatomy Fan Fiction. • Most people can have these intrusive thoughts/feelings and let them go. My brother can have his heart-beating fast, biceps twitching and legs shaking and simply say “I’m jacked bro, hop on the peptides” whereas someone with Somatic OCD might start thinking their nervous system is shutting down and they will have to rush to the doctors office “just to make sure” everything is okay. Or they will go down a WEB MD rabbit hole until they get the “certainty” they are looking for. It’s also why my old friend from college who still lives like he’s in a frat house can tolerate having stains on his furniture from God knows what and smoke out of a bong that looks like it’s got tuberculosis itself and carry on normally, whereas someone with Contamination OCD might believe they will get some rare undiscovered disease if they spend time at his place and feel the need to wash their hands repeatedly or wear long sleeves in his place even in the summer. • Often times we want to stop the thought and the anxious feeling we get from it but as a lot of you know, that’s not the goal, its best work to work backwards and stop the compulsion first. This is essentially what Exposure Response Prevention therapy is and why it is considered the “Gold Standard” in psychologically treating OCD which sets up my next section 2. Compulsions & ERP A. What are Compulsions? • Compulsions are simply the “thing” we do to “make the anxiety go away” • Compulsions reduce anxiety in the moment, but overtime they reinforce your fears and strengthen the CSTC loop as mentioned before • Every time we react to an intrusive thought with our compulsions, we reinforce that behavior and thinking pattern in our brain. As Follows: o Intrusive sensation or thought shows up o Anxiety spikes o You do a compulsion o Anxiety drops o Brain says: → “Good job, we avoided danger!” o Brain becomes more sensitive to that trigger, Checking or avoiding things to run from that feeling This leads to o → The intrusive thought hitting harder o → The anxiety hitting faster o → The compulsion becoming mandatory This is why OCD always grows if left untreated. B. The Main Types of Compulsions • Compulsions come in all shapes and sizes • However, I am sure yours, like mine, fall into one or multiple of these categories a. Physical compulsions: These are often the easiest ones to spot • Repetitive Hand-washing • Tapping/touching things in a certain way • Checking: I need to make sure the oven is off, doors are locked, etc… b. Mental Compulsions: The Silent Killers • Replaying events in our head • Over-analyzing • Self-monitoring: Does this “feel” right?” “is this normal?” • Constantly asking “what if?” – “What if I am ill” “What if I am gay” “What if I hit someone with my car” c. Reassurance Compulsions • Googling for certainty • Asking friends for confirmation • Reading forums – like this one “just to be sure” d. Avoidance Compulsions • Avoiding triggers • Avoiding eating for fear of contamination • Avoiding knives for fear of harm • Avoiding news/media about topics that trigger us C. Exposure Response Prevention (ERP) • Now that we know compulsions strengthen our OCD and what they might look like, let’s address how we can attack them and regain control over our lives • “If you know your enemy and know yourself, you need not fear the result of a hundred battles” – Sun Tzu • I believe this quote reigns true with the internal war that is OCD because once you identify what your triggers and compulsions are you can learn how to win the battle over them. Often with OCD once you conquer one theme another one pops up, but there is no need to freak out because the same tools can be used to disarm them a. Step 1 — Identify the trigger Thought, image, fear, sensation, memory, urge. b. Step 2 — Identify the compulsion Anything you do to feel safe in the moment. c. Step 3 — Create an exposure You deliberately bring on the trigger. d. Step 4 — Block the compulsion You let the fear sit there. e. Step 5 — Stay with it You do NOTHING to fix, analyze, check, or escape. o Anxiety rises → plateaus → falls And even if it doesn’t fall, IT DOESN’T MATTER. o Your tolerance goes up. o The CSTC loop rewires – The cortex notices the thought, but the Thalamus no longer sets off the blaring alarm To help I will fill one out for one of the OCD themes I struggle with which is Somatic OCD Step 1 — Identify the trigger(s) “What is this lump in my throat feeling? “Am I going to choke?” Step 2 — Identify the compulsion(s) Swallowing repeatedly to make sure I am not choking Googling if my symptoms are serious Asking friends if they also have dealt with a “lump in their throat” Step 3 — Create an exposure When I have this lump in my throat sensation, I will eat something super chewy. Step 4 — Block the compulsion No repetitive swallowing No googling No asking my friends for reassurance Step 5 — Stay with it No Instagram/Twitter for a cheap distraction D. ERP Misconceptions • ERP is not a “silver-bullet” that will permanently get rid of your anxiety • Instead, it’s about learning and becoming more confident: You begin to feel like you don’t have to “obey” your fears • You no longer need to spend so much time answering your thoughts • You no longer need to spend so much time wrapped up in debilitating compulsions • I am a huge UFC and Boxing fan so the way I view ERP is that it is sparing for your mind. It simulates the fight so when it shows up you aren’t as afraid of it. Sparing is uncomfortable, you are purposely inviting yourself to get hit, but once you get to the night of your fight your fear goes down. You know what to do when that jab comes, you know how to handle that trigger. • ERP does not get rid of “bad thoughts” instead it teaches you self-trust, confidence and compassion • When I was first struggling with OCD, I had an intense fear that I would spiral out of control and harm myself or others. I would avoid wearing belts to not strangle myself or someone else, avoid cutting food with knives for the fear that I would commit some sort of murder-suicide like a Manson cult member. I would avoid watching movies or playing video games that had violent themes. For months this really affected my life, however once I built up the courage to just pick up a belt and hold it for 3 minutes, everything began to change. In that moment I had tremendous anxiety but it was the start of true recovery, I eventually was able to do it again but this time for 10 minutes, after that I was able to wear belts again and no longer had my pants sagging, it led to me being able to go out to eat with family and friends and not freak out if I had to cut my food. It absolutely sucks in the moment, but it helps you get back to doing the things you love and feeling more in control of your life 3. Why ERP Does Not Always Work – Dealing with Chronic OCD • As I just said above ERP is not a silver bullet that will forever get rid of your anxiety, what frustrated me for the longest time is that I would do these exposures and see my anxiety decrease but not to the level I was satisfied with. I could cut my anxiety down from a 10 to a 5 and to many psychologists that would be enough. In my opinion, even a 5 is unhealthy and is something to work and improve on. If you have ever been in therapy or if you’re a therapist you are familiar with the Y-BOCS score, when I began therapy I started around a 32 which is on the severe side and then after doing my exposures and following my treatment plan for 6 months I cut that down to a 15 which is considered Mild OCD. Yes, my life was drastically better but I still felt stuck, so in this section I am going to explain why you might be in this phase of recovering but not recovered and how to get that 15 which is mild down to a 5 or 8 which would be considered subclinical and extremely manageable. 4. Medication • I am a very big advocate for taking medication to help with OCD symptoms • Psychologists don’t have the license or training to prescribe or talk about medication; you would be surprised at how many Psychologists are unfamiliar with the CSTC loop and other biological components I’ve been writing about on this post • Psychotherapy does not focus on the brain – they focus on behavior however when you understand the biology and pathology of OCD symptoms often greatly improve • Think about OCD as a table with wobbly legs, psychotherapy addresses one side with ERP, but the other side is still going to be off balance and the table is still not going to function well. Medication comes in and balances both sides. In combination therapy and medication are extremely powerful A. SSRI’s • The Data shows that SSRI’s often reduce OCD symptoms by 40-60% on average • For OCD medication typically kicks in about 8-12 weeks into treatment which is longer than Depression which often responds in 2-4 weeks • The best SSRI for OCD in my opinion is Fluvoxamine (Luvox) this is because Fluvoxamine directly influences the CSTC loop by working on Sigma 1 receptors, which is a tiny protein inside our brain that works on the Thalmus and Anterior Cingulate Cortex. Sigma 1 receptors help calm hyperactivity in these regions which leads to less intrusive thoughts and less compulsive urges • Lexapro (Escitalopram) is often what psychiatrist recommend first since its sort of a “catch-all” drug. Lexapro increases serotonin availability in the brain and when you have more serotonin in the brain you often have less anxiety, depression and obsessive thoughts. For general anxiety this is an amazing drug however OCD isn’t just anxiety, it’s also those sticky intrusive thoughts so what we need is a bigger push and that’s what Fluvoxamine does since it gives us a bigger push by more broadly working on OCD specific circuits like the CSTC. Lexapro helps calm anxiety but does not help with cognitive rigidity like Fluvox does. B. Tricyclic antidepressant (TCA) • Clomipramine (Anafranil) is the strongest Anti-OCD medication on the market and is more powerful than the SSRI’s I previously mentioned! • So you might be wondering why did I not bring this up first? Well like most things there is a catch –Clomipramine does not just work on serotonin like SSRI’s do it works on everything dopamine, glutamate, all the good stuff… so like Kanye West said “No one man should have all that power” • This drug, despite its power often leads to the most side effects. Dry mouth is common, as is weight gain and dizziness and in rare cases it affects your heart rhythm. So I would advise anyone interested to do their own research first and consult with your psychiatrist to see if this would be a good fit. But I wanted to throw it out there so everyone in this community can be aware of all their options C. Add on Meds/Antipsychotics • SSRI’s are often the first line of treatment when it comes to OCD but many people often find themselves needing additional assistance dealing with their symptoms. SSRI’s in combination with an Antipsychotic can yield many positive results for people. • I will start off with Low Dose Antipsychotics; these include Risperidone, Aripiprazole, Olanzapine – these work by modulating dopamine in the CSTC loop. I like to say that these can put out the fire in a room but not the whole building. • Abilify is a popular choice by psychiatrist since it serves as a dopamine modulator. When dopamine is low it helps increase neurotransmissions to increase it, when its high it dims transmission. Think of it like a light lever for your brain. You can slowly push it up when its too dark and lightly dim it when its too bright. A key note about Abilify is to go slow, it is a strong drug and you will feel 5 milligrams. With SSRI’s people can often tolerate larger doses but for Abilify its best to start low since too much can lead to Akathisia and your Central Nervous System feeling too overwhelmed causing a feeling of restlessness D. Supplements • This is big for a lot of people, everyone’s looking for a secret over the counter supplement that will help them but the truth is there is not many that have proven and solid track records when it comes to OCD. You may hear influencers talk about Glycine, Taurine, Ashwaganda, and Lions Mane Mushrooms but there isn’t enough clinical testing to say if these supplements actually work. If you find that they work for you then that’s great, keep taking them! But I am going to focus on ones with data behind it for safety purposes • NAC this is the one with the most testing behind it, researchers found out that people with OCD who take around 1,200 mg of NAC a day reported less symptoms • L – Theanine helps the body relax • Magnesium Glycinate – not OCD specific but is proven to help with sleep, so if you find yourself having intrusive thoughts at night or waking up and not being able to fall back asleep a 260mg dose of Magnesium Glycinate might be useful • Omega 3 Fatty Acids- The EPA in Omega-3s is shown to reduce brain inflammation and can help with serotonin receptor function