Practice English Speaking&Listening with: SECOND OPINION | OBSESSIVE COMPULSIVE DISORDER | BCBS | Full Episode

>> Behind every heartbeat is a

story we can learn from.

As we have for over 80 years,

Blue Cross and Blue Shield

companies are working to use the

knowledge we gain from our

members to better the health of

not just those we insure

but all Americans.

Some call it responsibility.

We call it a privilege.

"Second Opinion" is funded

by Blue Cross Blue Shield.

>> "Second Opinion" is produced

in conjunction with UR Medicine,

part of University

of Rochester Medical Center,

Rochester, New York.

[ Applause ]

>> Welcome to "Second Opinion,"

where each week we gather

medical experts

to discuss a real-life case.

I'm your host, Dr. Peter Salgo.

I want to thank our live studio

audience for being here.

I'm so glad.

And I'd like to thank you at

home for tuning in as well.

Now, our experts today are

Dr. Jonathan Stevens from the

Menninger Clinic in Houston,

an assistant professor of

psychiatry at Baylor College of

Medicine;

and Dr. Lou Papa, a primary care

physician from the University of

Rochester Medical Center.

And I'd like you to meet our

special guest, Kyra Mills.

She's going to share her

personal story.

>> I am an only child, and I

grew up with two very loving

parents.

My father has since passed.

I grew up in rural USA.

There was about 65 people in my

graduating class.

And in small-town America, you

really don't want to stand out,

and I did in a lot of ways,

and that was a challenge for me

growing up.

I felt very anxious.

I felt depression.

The more my stress increased,

the more my need to be organized

increased,

and I would feel this intense

anxiety in my gut.

And really the only way to

soothe it or get it to settle

down to a tolerable level

was to have certain rituals or

things that I did consistently.

And I remember being 9 or 10,

and bedtime ritual was always

very, very stressful for me.

And I would wash my face and get

into bed.

But let's say for some reason I

had to get out of bed.

If my foot touched the floor, I

would have to go through the

entire process of washing my

face, brushing my teeth,

washing my hands, and then get

back in bed and make sure all

the sheets were smooth.

All my stuffed animals would be

lined up.

Everything needed to be

in its place

and organized

for me to be able to be calm

enough to sleep.

And my mom realized... I think

she felt some red flag when she

stopped... when she refused to

participate in some of my

rituals.

So, there came a time when she

tried very hard to get me to a

psychiatrist.

She realized something was

wrong.

And it ended up being a huge

fight in a car.

She'd tried to trap me in a car

and take me there.

She felt it was that important

for me to go to therapy.

And I was just so resistant, and

I was so afraid of what they

might tell me or what was wrong

with me that I had no interest

in hearing, and I also had no

desire to change my behavior

because that was my sole source

of comfort.

>> All right, Jonathan.

You're a psychiatrist.

You're the guy she didn't want

to go see, but here she is.

She's in your office.

What do you ask her?

>> Well, first you want to

establish a rapport because I

could see anxiety... can be

anxiety about a lot of things.

You talk about sometimes

ordering, symmetry, but it could

be about contamination.

It could be about safety.

So, you really want to be gentle

in your initial approach, but

then you want to ask, "What kind

of things are bothering you?"

Try to understand from the

child's perspective, also with

informance from family, loved

ones, who are usually, by this

point, really concerned about

their child -- usually their

functioning, which starts to

drop, in addition to the

symptoms that they're

describing.

>> Kyra, what would

you have told him?

>> At that point in my life, I

don't know if I could have

articulated the real issues.

I would have given you my

"symptoms," if you will, or my

rituals.

I would have freely shared that

with you.

But I don't know if I could give

you an accurate view.

>> Okay.

But it was so strong.

I could have relayed that --

that that fear and that anxiety

was so intense.

I could have definitely at 9 or

10 given you that impression.

>> Lou, supposing she came to

you as a primary care physician.

What would you have done?

Why don't you ask her what you

would have asked her?

>> On a primary care level, it's

a lot more complicated because

she's expressing a lot of

different things.

There's expressions of

depression and anxiety, so I'd

probably try to evaluate those

first because they're more

common, and there's

good tools for evaluating

that and establishing that.

But the thing that really makes

it stand out, other than the

depression and anxiety, are this

outside driving force for that

ritualistic behavior, which is

different.

>> Were you aware while you were

doing these rituals that there

was something odd, that there

was something different?

>> I hear my mother's voice

echoing that there was something

wrong.

But for me, the only thing wrong

was that my bears weren't in a

row.

Most of my anxiety was at night,

and I think that's because I had

such a hard time turning off my

brain.

>> What people want to know is,

supposing you skipped a ritual,

you didn't brush your teeth and

wash your face --

>> Excellent question.

>> And what did that feel like?

>> Panic.

Panic, fear, and everything was

going to come undone --

that there would be this cascade

effect of "Okay,

my foot touched the floor.

I've not repeated these rituals.

And now everything bad is going

to happen.

I'm not going to sleep.

I'm going to get ill.

I'm going to miss school.

My grades are going to drop."

So, it was really...

It felt incredibly crucial to me

to follow these rituals

even though none of my friends

did it.

>> Now, you didn't want to go

get help when your mom wanted

you to.

>> No, no.

>> Oh, I heard that!

>> [ Laughing ] No!

>> That's not

altogether uncommon.

At least in adult samples, about

3/4 of adults with OCD

will, however, engage in

treatment, but 1/4 won't, and

that's still a large number.

For kids, I think the biggest

difference that I see, and in

looking at large samples, is

kids don't recognize these

rituals and these thoughts, the

obsessions, as something that's

outside of their self-concept.

Adults will come to me and say,

"Doc, I know this sounds crazy,

but..."

Kids won't do that.

They view that as something

that's just part of their

self-concept because their

self-concept is developing.

So this is really common.

>> What was your mom concerned

about?

Was it starting to affect your

ability to interact with your

friends?

What was it that --

>> No, she just saw it as

an abnormal behavior.

And "My kid is..."

As an only child, you know, you

have a lot of focus on you.

And she just saw at as "Eh...

This isn't normal."

>> But as you grew older, you

apparently recognized something

was wrong, and you sought help.

What brought you to that point?

>> Absolutely.

[ Sighs ]

It's exhausting.

The rituals become, in and of

themselves, a ritual, and it's

just so exhausting, and I said,

"Enough.

This... We got to get to the

root."

>> Were you looking for a

diagnosis?

>> I was looking for help.

>> Okay, and what did they tell

you?

When you finally got help, what

was the diagnosis they gave you?

>> Obsessive-compulsive

disorder.

>> OCD.

So, let's just for a moment set

some foundation here.

>> Sure.

>> What is OCD?

>> OCD starts off...

Obsessions are recurrent or

persistent thoughts, ideas, or

even images that are eventually,

over the course of the illness,

one will recognize as intrusive,

not part of oneself.

And people engage in a variety

of rituals or mental acts, which

are called compulsions, that are

trying to defuse or neutralize

the thoughts.

With younger patients, if you

feed the monster by doing the

compulsions, the acts, which

could be mental -- they don't

have to be behaviors --

that feeds the monster.

And the only way to really treat

it is to starve the monster.

That's how I would explain it to

a 10-year-old.

>> So the obsession is the

thought, and the compulsion is

the action to deal with the

thought.

>> The act to lessen the

anxiety, to neutralize it, and

it works initially.

But the more you do the

compulsions, the more you need

to do them to neutralize that

anxiety, which is excruciating,

to just say it as...

And the time it takes up can be

extraordinary.

>> So, let me hit a few

checkpoints here.

Do we know what's going on in a

person's body or brain

biochemically or neurologically

that makes this happen?

>> Well, there's studies,

functional magnetic resonance

imaging, that shows there's

areas of the brain that are

misfiring.

That could be

in the anterior cingulate.

That could be

in orbitofrontal cortex.

But there's also low serotonin.

So it is a brain disease.

However, it's also genetic.

So, there's genetic and

environmental, stress being the

big one.

Indeed, people with OCD, during

periods of stress, whether it's

bedtimes, whether it's exam

time or other stressful moments

in life, will often find that

their OCD really increases

during that time.

>> So, Jon, the primary care,

one of the things is it gets so

jumbled up with depression and

anxiety.

How often do you see those, you

know, especially in the adults,

do you see that as codiagnoses

or misdiagnoses

for people who have OCD?

>> All the time, Lou.

In fact, OCD is really the

silent disease because adults

that I see may come in for

another reason entirely, like

depression, even suicidal

thoughts, and then when you

start to ask about the...

then you will find maybe 10 or

15 years, people will go

suffering from horrible

obsessions or compulsive

and rituals

that take up and destroy much of

their day, impair their

occupation, impair their

schooling or even their family

relationships, but their initial

chief complaint was

"I'm feeling depressed"

or "I feel run down" or

"fatigued."

I know some people that do spend

six to eight hours a day

arranging, rearranging, and

alphabetizing books.

>> Six...

Wait. Just stop there.

Six to eight hours?

>> Right.

>> If you're awake for 12 or so,

50% of your life is spent with

your OCD.

>> But if you're a librarian,

that's fine.

So that's...

[ Laughter ]

So, but this oftentimes is not,

in a 10-year-old, what they're

doing.

It doesn't get you anywhere.

I've seen a lot of surgeons over

the years that have certain

compulsive tendencies --

now, that's not OCD --

in the OR.

So, some rituals can be really

helpful for structuring your day

or structuring a complex task.

But these rituals oftentimes

really make no sense, and

patients will eventually say,

"They're irrational.

They make no sense."

>> And, Lou, you've seen

patients in your practice who

have to wash their hands

all the time.

Eventually, the skin breaks

down, infections.

>> Absolutely, and, you know,

that's one of the big clues for

us, where they have an OCD that

results in something physical

that you can actually see --

they really have these chafed,

cracked hands

along with that history.

>> Well, you know, in every

episode of "Second Opinion,"

we look for game changers.

These are medical innovations

that are making a difference.

And here is something that's

going on in the area of OCD.

>> There's still a lot we don't

know about how deep brain

stimulation works.

If we can understand the

network, we have a better idea

of what targets might be

appropriate for the treatment

of OCD.

So, our research focuses on the

networks that mediate reward,

cognition, and the interface

between them.

The idea, of course, is that

the balance between reward,

emotion, and cognition are clues

to how we process information

both normally and balance our

behavioral outcomes normally

and how those go awry in various

mental health diseases.

So, this is the electrode on the

bottom there...

is the one that's going to

involve the more emotional

elements.

And the one on the top is going

to capture more cognitive

control.

Let's try, then, leaving it

at this place and turn on

green...green and the blue.

In the deep brain stimulation

therapeutic approach, we would

want to look at where the

electrode is and how those

electrodes interface with

specific network analysis that

we're doing.

By addressing the regions that

interface between the emotion

and cognitive-control areas, the

hope is that the patient will be

able to evoke more cognitive

control over these obsessions

and compulsives to overcome them

and relieve some of the anxiety

that they are producing.

>> And we're here with

Kyra Mills, who was diagnosed

with obsessive-compulsive

disorder, OCD.

Now, you told us about some of

the rituals you had when you

were a kid, and you did seek

help when you got older.

What was it like interacting

with people, long-term

relationships?

What was that about?

>> [ Sighs ] Panic.

>> Why?

>> Um, "I'm never going to get

married.

If this man doesn't choose to

marry me, I'm going to be alone

the rest of my life.

And then I won't have children.

And then what do I do then?

What is my purpose in life?"

So, my ducks had to be in order.

And it's so hard...

I don't know if you guys know

this, but it's very hard to have

someone comply [ Chuckles ]

when you want them to.

The only person you can control

is yourself.

>> You mean it was trouble

finding someone else to line up

your ducks...

>> Yes!

>> ...as you got older.

I think we get that.

>> Exactly.

Well put.

>> So the implication, when she

goes to...

When you go to get help,

the implication is there's help

to be had.

>> Yes.

>> So the question I have for

you is, is there help to be had?

>> It depends where you live

because some of these

interventions, especially

therapy, are really specialized.

Evidence-based psychotherapies

include cognitive behavioral

therapy with something called

exposure and response

prevention, and what that's

trying to do is eliminate the

compulsions, even the mental

acts, because by continuing to

do that, like we discussed

earlier, it "feeds the monster."

So, but doing that is very

difficult.

Doing other forms of therapy,

like relaxation or even

sometimes just psychoanalysis,

people think, do not help OCD as

much.

You really need that behavioral

component.

>> But you mentioned at least

one chemical, serotonin.

>> Yes.

>> And you mentioned there's MRI

evidence, if you will -- and I

know this is a gross

mischaracterization -- there's a

hardware problem.

The brain is misfiring.

So, that suggests to me from a

purely mechanistic perspective

that there might be medication

for this or some other

interventions like that.

>> Well, there are several

approved.

There's at least five approved

for OCD.

Those are common names like

Prozac, Zoloft, Celexa, Paxil,

and Anafranil, which is an older

one.

And at least four of those are

approved in youth as well,

under the age of 18,

so it's very important.

>> Are there specific behaviors

that you ask people to try,

to try and break this cycle, or

is that not something that they

can do?

>> Most people have tried, and

indeed, people with OCD usually

try first on their own,

but it doesn't work, or they use

a fear stimulus that's so much

that the anxiety gets worse.

And that's what convincing

people and adults that the

short-term worsening of anxiety,

when you do the correct kind of

therapies, is worth the

long-term gain --

that sometimes the anxiety might

actually get worse

when you start therapy,

at least transiently.

>> It's interesting because

that's how very often they'll

present to primary care, is with

anxiety, and it's interesting to

me that the compulsions

don't come out.

You would think that would come

out at the time of the

appointment, but it doesn't very

often until they see the

psychiatrist, or if you've been

seeing them for a while.

Fortunately, they get treated

with those medications that work

for those other indications.

Why is that?

>> Well, in terms of the

medications at least, there's a

delay.

And a lot of times, people take

the medicine, especially the

ones that I mentioned, and

expect to get better right away

because there are some other

medicines, ones that act

quickly, like Xanax, Klonopin,

and Ativan, which do not work

well for OCD.

But the ones that do work, the

serotonin medicines, can take

longer than the typical four

weeks that people might think,

"Oh, wait, for those medicines,

it takes four weeks for

depression."

Well, in OCD, it might take two

months, even 10 weeks,

which is a much longer time, and

sometimes at higher dosages.

>> Well, you heard her story.

If Kyra were seeing you,

how would you have given her a

recipe for change?

What would you have suggested?

>> First of all, when you start

asking the questions and you

start going through the

different types of obsessions

and compulsions, you can't just

rely on what a person tells you

because if you ask, sometimes

they will say, "Oh, yes, and I

have that hoarding.

Oh, yes, I have that hair

pulling.

Oh, yes."

And there's more there.

You have to go through it,

sometimes with a structured

instrument.

There's something called

the Y-BOCS, which is oftentimes

helpful in the office,

the Yale-Brown

obsessive-compulsive scale.

And there are others out there.

That's the one I use.

And it's a 40-point scale --

How much time are you spending?

How severe is it?

How much avoidance in your life?

But also getting the family

involved or the loved ones

because a lot of times, people

will ascribe certain of these

compulsions as... to other

things.

Some of the most poignant cases

in my career were with young

parents, new parents, that

refused to hold their newborn.

And they thought, "Well,

she's not ready to be a mother,"

or "ready to be a father."

But it was actually obsessions

that people had about dropping

the child, about drowning the

child, or some other thing that

led to the compulsion, which

for them was avoiding holding

the child.

>> I want to tick off a few

other compulsions because I know

just your bedtime routine was

not the only compulsion.

>> No, no.

>> Give me just the short form,

some bullet points.

What else were you doing as a

young woman or as a child?

>> I would shower probably two

or three times a day, never

reused the same towel.

Everything had to be in its

place.

And I come from a large Italian

family, and they love to cook,

and the garlic and the onions,

and most people would find that

smell homey or reminiscent, but

I was so petrified that it would

be in my hair or on my clothes.

And the smell.

>> You've grown up, and you're

in your 30s.

>> Yeah, late.

>> And I'm going to make an

assumption that you don't have

to kiss your teddy bears every

night before you go to sleep.

>> No, no.

>> But do you still have rituals

and things that you have to do

even now as an adult in

treatment?

>> I've done so much hard work.

I'm super proud of the amount of

work that I have done, and it

hasn't been that behavioral

therapy that we talked about.

For me, it was supportive

talk therapy.

>> Okay. Now, you're a mom.

>> I am a mom.

>> And we've already heard that

this does tend to have a

familial component.

>> Absolutely.

>> And you've got a daughter.

>> Yes.

>> What's this like, being a mom

and watching her, knowing your

past?

>> It's interesting.

It's very... [ Chuckles ]

She's a joy, but she's 12.

[ Laughter ]

It's a generational thing.

>> Oh, you're joining the club!

[ Laughter ]

>> Oh, yes.

>> Sorry.

>> She goes to the convent

next week.

[ Laughter ]

Let's hope --

>> It sounds funny, but tell me

about the things --

>> You're a healthy mom.

>> As she was growing up, were

there rituals that you paid

attention to her about caring

for her?

>> Interestingly enough, my

sleep phobia and my bedtime

ritual really...

I subjected her to it,

unfortunately.

I would black out the windows

with contact paper, and I had

sound machine, and her room

was her medically controlled,

temperature-wise...

I could tell you the moisture.

I could tell you the

temperature, and it was remote,

so I could be in the living room

and tell you.

But I say it because I got

through it.

Her room was literally a den

because my fear was that my

beautiful bouncing baby

wouldn't sleep, would get sick,

would die, and da-da-da-da-da,

and all would come undone.

So the same fear that I had as a

child really cropped up, and it

took a lot of work, and I

remember my therapist distinctly

saying this, and I'll never

forget it.

She said, "You know, Kyra, my

kids took naps

with sneakers on."

And I was... "Whoa!

What?!"

You know, my child's getting a

bath before her nap.

She's in jammies.

There's the den.

There's the noise machine.

And then I'm thinking, "Wow.

I really got to get a hold of

this."

>> Now, you're not on any

medication at the moment?

>> I am.

>> What medications are you on?

How many did you have to try?

Was it a balancing act, what?

>> Honestly, it is so exhausting

trying to find the combination.

I have probably tried two dozen

medications and combinations

thereof to try to control

the anxiety, the depression, and

the resulting compulsive

behaviors that I had.

And I think for someone that's

in such a dark place, it's

really hard to keep showing up

and keep coming back and keep

trying.

>> How difficult is it to get

the right cocktail,

the right combination?

>> For some people, it's easier,

but OCD is not something we

typically think as something you

would get on the right medicine,

and you're cured.

It's a chronic illness, and

you have to manage it.

And it could be fine for other

times in your life, and there's

times it flares up, and it's not

always predictable.

>> So, how do you get feedback

from patients?

How do you decide what drug to

start, what to stop, where the

cognitive therapy, the talking

therapy, begins and ends?

That's tricky.

>> That's where it's a team

approach, so hopefully, the

psychiatrist or the prescriber

is talking with the therapist,

is talking with the patient,

if their loved ones...

The team can help.

So you're not alone, and you

don't feel alone with the

illness because that's when

people sometimes get into a dark

place, when you talk about

depression.

>> Lou, is there a place for

primary care physicians here?

>> Yeah, I was just going to

ask -- I mean, some of it is,

I worry about misdiagnosis

if we diagnose these patients

wrong, and then, you know,

looping us in and how can we be

involved in that process for

these patients?

You know, as they get older, we

don't want them just to be

seeing their psychiatrists.

What are the things that it's

important for the primary care

doctor to do in management?

Is there a point that you hand

that off, or that never really

happens?

>> Well, it really depends.

There are a lot of primary care

physicians that would be

comfortable with the general

serotonin medicines that are

used for OCD.

But as they get more

complicated, maybe you want to

have a specialist.

This is something you need a

long-term treatment for.

And a lot of times, it falls to

primary care physicians because

they're there with patients for

the long term.

>> How common is OCD?

Is there enough people that have

it that you can have a

specialist in a community?

Or is it not that common,

where you really

have to seek out a specialty?

>> It's a great question, Lou.

People used to think that it

was rare.

But over a person's lifetime,

2 1/2 out of 100 people will

have OCD, and around

any given year about 1%.

So, that is really pretty

common.

>> One percent of 300 million

people -- do the math, right?

That's a lot of people.

>> Millions of people

worldwide...

>> Millions of people.

>> ...most of whom are not

getting treatment, most of whom

are not getting the right kind

of treatments, and most of whom

are going along in life

suffering.

That's why the World Health

Organization put this as one of

the top-ten diseases of any

disease in terms of earnings

lost and disability.

So a lot of people don't put OCD

up there with the most serious

conditions across anywhere of

medicine.

>> Okay.

Tell me one last thing.

How are you doing?

And do you think you're better?

>> I feel amazing, and I do feel

better.

I feel like I have a better hold

on my anxiety that triggers

my compulsions.

>> I'm not hearing you say

your anxiety is gone.

>> No. No, this --

>> And I'm not hearing you say

that it's okay if your ducks are

not in a row.

You still have some.

>> Oh, absolutely.

And I think what Jon said is so

accurate, that it flares.

So, you know, I'm in college

now -- this is

a second career for me.

[ Chuckles ] So the ducks come

marching back in from the pond.

And I got to get them all

situated.

But the awareness is key

for me, knowing that this is

something that I do have to

make room for in my life and

acknowledge it and treat it

accordingly.

>> I really want to thank you

for being here and sharing your

story.

>> Thank you for having me.

>> Oh, it's great.

Panel, I want to thank you,

too, for joining us.

Here's Kyra's advice to others

who may be suffering from OCD.

>> My advice to someone that's

been diagnosed with OCD or

thinks they have OCD is find the

right therapist.

If you don't have chemistry with

that therapist or social worker

or psychiatrist, psychologist,

keep looking.

Be patient with the medication

process.

Be patient with the dosage, the

type.

And do your best to try and to

trust the process because it

does get better.

>> I want to thank all of you so

much for being here in our live

studio audience.

And I want to thank you at home

for watching as well.

Now, remember, you can get more

second opinions and patient

stories on our website...

That's secondopinion-tv.org.

And you can continue this

conversation on Facebook and

Twitter, where we are live every

day with health news.

I'm Dr. Peter Salgo, and I'll

see you next time for another

"Second Opinion."

[ Applause ]

>> Behind every heartbeat

is a story we can learn from.

As we have for over 80 years,

Blue Cross and Blue Shield

companies are working to use the

knowledge we gain from our

members to better the health of

not just those we insure

but all Americans.

Some call it responsibility.

We call it a privilege.

"Second Opinion" is funded

by Blue Cross Blue Shield.

>> "Second Opinion" is produced

in conjunction with UR Medicine,

part of University of Rochester

Medical Center, Rochester,

New York.