Transcripts
Welcome to the Learn OCD podcast,
where we learn about all things OCD.
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:My name is Natasha Moharter, and I'm a
licensed counselor and OCD specialist.
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:The information presented here
is for educational purposes only.
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:It doesn't count as therapy.
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:It doesn't create a clinician-client
relationship, and it's not a
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:substitute for personalized
treatment from your own provider.
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:If you're in crisis, please reach
out to your local emergency services.
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:Let's get started.
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:Natasha Moharter, LPCC, CPC, MHC-9: In
episode one, Intro to OCD, we talked about
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:OCD obsessions and compulsions, and how
they're directly linked to one another.
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:Just a quick refresher.
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:Obsessions are intrusive and/or
distressing thoughts, urges,
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:images, or doubts that are
experienced as ego-dystonic.
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:Compulsions are actions.
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:They are done in direct response to
the uncomfortable obsessive thought.
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:And I used a word there that we're
gonna explore because I think it's
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:one of the most important concepts in
understanding OCD and also differentiating
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:it from other mental health disorders.
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:That word is ego-dystonic.
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:We're gonna contrast it with the
opposite, ego-syntonic, and then we're
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:gonna talk about how this concept
actually plays out inside the OCD brain.
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:My hope is that once you understand this,
a lot of what can be confusing or scary
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:about OCD starts to make a lot more sense.
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:All right, so let's define our terms.
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:ego-dystonic means something
that feels out of character.
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:It clashes with your values.
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:It can feel like it's coming from
outside of who you actually are.
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:It can clash with your sense of identity.
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:And because it feels so out of character,
it signals to the brain that it is a
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:threat, and it can produce distress.
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:It can come with shame,
anxiety, disgust, fear.
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:The word dystonic comes from the idea
of being out of tune, out of harmony,
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:the thought of dissonance with yourself.
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:Doesn't quite line up.
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:I think about when
magnets repel each other.
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:You can try your best to put them
together, you can potentially,
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:depending on how strong they
are, even superglue them, right?
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:But There's still gonna be
that internal force that is
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:pulling away from each other.
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:Ego-syntonic is the opposite.
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:It feels consistent with who you are.
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:It means a thought, urge,
image, behavior feels right.
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:It's in harmony with your
values and with your identity.
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:It doesn't produce the same internal
alarm as an ego-dystonic thought.
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:It might not even register as something
worth questioning 'cause it just fits.
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:It feels good, feels acceptable.
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:Here's an example that I
hope helps with this concept.
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:Let's say that you take pride in
being a caring, attentive friend.
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:That's who you are.
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:If a thought crosses your mind like, "I
should check in on her, they seemed off
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:yesterday," that feels completely natural.
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:It matches who you are, so you just do it.
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:There's not an internal tug
of war, no second guessing.
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:It's just ego-syntonic.
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:It's something that is
in line with your values.
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:I care about being an attentive
friend, so I'm gonna check on my
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:friend if something feels off.
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:But imagine this: let's say that you're
mid-conversation with that same friend,
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:and out of nowhere a thought pops in,
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:maybe I don't actually care about them.
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:Maybe I'm just faking it.
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:What if I'm actually lying about
really caring about this person
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:and just making them think that
I'm a good friend or that I care?
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:Their feelings might even be
hurt if they knew my thoughts.
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:Even though everything would tell us
that you actually really care about this
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:person, you didn't ask for that thought.
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:It just showed up, and because it
clashes so hard with how much you value
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:being a caring person, it really hurts.
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:That immediate, "Wait, what?
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:Why would I even think that?"
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:That unwanted distressing doesn't
match my value system, my identity,
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:or who I actually am or want to be.
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:That's what makes it ego-dystonic.
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:And this shows up differently
depending on the person.
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:OCD often, but not always, attaches to
the things that someone values the most.
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:It is also very personalized, So two
people with the same themes might
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:have completely different triggers
or thoughts or responses to them.
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:Someone with contamination OCD or even the
fear of vomiting might have the thought,
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:"What if I'm contaminated and I get sick?
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:What if I get someone else sick?
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:What if I get someone sick and end
up being responsible for their death?
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:What if I poison someone?"
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:And if washing and cleaning is the action
that follows those thoughts because the
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:thoughts themselves feel so distressing,
that could be an ego-dystonic compulsion.
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:Here's a phrase you might have
heard before: "I'm so OCD," or, "My
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:OCD helps me keep things clean."
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:My ADHD wishes my OCD
helped me keep things clean.
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:These statements often come from
people who don't fully understand
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:OCD and believe it to be the
stereotypical cleaning and organizing.
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:If it's OCD, there's an intrusive
thought that is ego-dystonic, and
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:it's saying, "Keep things clean,
or else insert the bad thing here."
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:It isn't ego-syntonic, or in other
words, I like a clean house because that
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:reflects what I want from my living space.
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:It is important to me.
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:It's in line with my values.
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:If it's OCD, I might not be
cleaning because I want a clean
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:house just to have a clean house.
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:I might be cleaning in response to
a really scary thought I had about
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:being responsible for something bad or
disgusting happening if it's not clean.
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:Someone with relationship OCD might
be with a partner they genuinely
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:love and still get thoughts like,
"What if I don't really love them?
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:Or they might ask themselves
over and over, "Am I actually
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:attracted to this person?"
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:And then they might follow it up
with compulsions of checking their
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:feelings, comparing their relationship
to others, confessing their thoughts to
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:their partner, which you can imagine,
all these things can cause a lot of
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:pain and challenge in relationships.
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:Someone who's dealing with scrupulosity
themes in OCD might have an intrusive
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:image come to mind during a prayer
and immediately feel like they've
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:done something unforgivable.
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:Someone with sexual orientation
OCD might have an unwanted thought
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:questioning their attraction, not
because they're actually questioning
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:it, but because the thought itself feels
like a threat to their sense of self.
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:Someone with just right or symmetry
themes in OCD might not even have a scary
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:thought at all, just an unbearable feeling
that something is wrong or incomplete
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:until something is arranged a certain
way or done a certain amount of times.
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:As you can see, the thoughts
have different content, but
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:they share the same mechanism.
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:Natasha Moharter, LPCC, CPC, MHC-9:
Now let's talk about how this actually
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:plays out inside the brain because this
is where OCD starts to make more sense.
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:Here's something that's important.
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:Everyone has intrusive, strange, unwanted,
even disturbing thoughts sometimes.
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:This is not unique to OCD.
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:A pet owner might have a sudden
unwanted image of hurting their dog or
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:cat, a new parent might have a flash
of an image of dropping their baby.
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:Someone standing at the edge of
a train platform might have a
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:fleeting thought about jumping.
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:Someone driving might have the
thought that comes out of nowhere
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:about swerving into oncoming traffic.
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:These thoughts are interestingly
enough trying to protect us.
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:It's just a normal byproduct of a brain
that's constantly scanning for danger.
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:That's how we stay alive.
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:The brain generates all kinds of
possibilities, including terrible
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:ones, as part of how it keeps us safe.
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:For most people, it's kinda just dismissed
The way you might dismiss a thought about
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:what you had for breakfast three days ago.
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:Studies comparing intrusive thoughts
of people with OCD to the intrusive
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:thoughts of people without OCD have
found that the thoughts themselves
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:are often nearly identical in content.
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:Violent images, unwanted sexual
thoughts, fears of contamination,
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:all of it shows up in both groups,
and this has been found across many
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:different countries and cultures.
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:So the raw material the actual content
of the thought isn't actually what makes
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:OCD What makes OCD OCD is that link
between obsessions and compulsions.
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:This ego-dystonic thought, urge,
image, or doubt comes in, and then
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:the person feels compelled to take an
action, in other words, the compulsion
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:because of that obsessive thought.
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:For most people, the brain
tags the intrusive thought as
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:meaningless and lets it go.
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:The OCD brain does something different.
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:Instead of dismissing the thought, it
appraises it as dangerous and meaningful.
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:It essentially asks, "Wait,
why did I have that thought?
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:What does that say about me?"
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:It could also come from a felt need to
prevent harm or make sure nothing bad
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:happens even from this stray thought.
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:And because the content of the thought,
again, is ego-dystonic and clashes so
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:sharply with the person's real values,
the brain treats the thought like a
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:fire alarm instead of background noise.
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:The goal with the compulsion is to
alleviate distress, anxiety, discomfort.
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:The compulsion provides a temporary
relief, which reinforces the cycle.
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:The compulsion feels rewarding.
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:The brain says, "Ah, that worked.
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:When I have this really scary
thought, I know what to do with that.
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:I'll just do this compulsion.
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:Because that helped to provide a brief
relief from the obsessive thought,
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:from the distress, the discomfort,
the fear, the anxiety, shame, guilt,
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:whatever it might have brought.
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:And what that also does is it
tells the brain that, "Hey, that
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:thought is actually a threat.
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:It's really scary.
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:We should do something about
that next time it shows up.
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:So let's be on guard.
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:Which naturally allows for that obsession
to come back even easier the next time.
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:Somebody without OCD might be able
to have that thought, assess it,
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:say, "Ooh, that's scary, but anyway,
it's not a threat," and move on.
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:OCD will see that thought, and people
often actually know logically that that
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:thought is not in line with their values.
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:They can reason with it all day long,
but this is also why traditional talk
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:therapy doesn't actually work for OCD.
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:Because no matter how much you
reason with OCD, it doesn't matter.
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:It wants to do the compulsion,
and it wants the relief.
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:It could want certainty.
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:It could want a decreased distress,
decreased experience of anxiety or pain.
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:But the goal is to break that cycle.
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:How do you not do the compulsion
and do something that is
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:actually more ego-syntonic?
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:The anxiety can be there.
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:It doesn't have to be there.
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:I don't like when it's there.
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:But I can still live a meaningful life.
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:I can still take steps towards
something that is important to me.
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:There's a concept that explains
why appraisal escalates so
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:quickly to distress, and it's
called thought-action fusion.
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:It's the belief that thinking
something is equivalent to doing
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:it, or thinking something makes
it more likely to actually happen.
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:So the brain isn't just registering,
"Hey, that thought was weird."
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:It's registering, "Having that
thought means something about me.
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:It's something I might do."
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:And you might start even
questioning, is that who I really am?
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:So to put the whole cycle together
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:Natasha Moharter, LPCC, CPC, MHC-9:
Intrusive thought, dystonic appraisal,
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:distress, compulsion, temporary relief,
reinforcement, and then it starts again.
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:So let's walk you through an actual
example of what this might look like.
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:Say someone with harm OCD is holding
their dog, and out of nowhere, an
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:image flashes through their mind of
them dropping the dog down the stairs.
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:That's an intrusive thought on its own,
remember, that kind of thought is common.
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:Most pet owners have some version of it.
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:Again, our brain seeks out both
potential good and bad options.
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:But here's where it diverges.
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:Instead of that image passing
through like background noise, the
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:brain appraises it as meaningful.
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:Why would I think that?
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:Is there some part of me
that wants to do that?
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:What kind of person even
thinks something like that?
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:Could I be responsible and do that
unintentionally and cause pain to my pet?
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:That thought is ego-dystonic.
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:It violates everything this person values
about being a safe, loving pet owner.
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:If the thought lined up with their values,
it wouldn't trigger this alarm response.
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:That appraisal produces such intense
distress, so panic, disgust, shame,
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:maybe even nausea, and to manage
that distress, compulsions kick in.
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:Maybe they avoid holding
their dog near the stairs.
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:Maybe they mentally replay the
moment, searching for proof that
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:they didn't actually want to do it.
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:Maybe they ask their partner,
"Hey, you don't think there's
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:something wrong with me, right?
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:Each of those actions brings relief . And
each one teaches the brain that this
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:thought is dangerous and that this
response is necessary, which means the
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:next intrusive thought about the dog
lands even harder, and the cycle repeats.
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:Often people will then start
to experience even new triggers
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:and new compulsions over time.
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:That's the mechanism, a normal intrusive
thought met with ego-dystonic appraisal
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:that spirals into distress and compulsion,
into this self-reinforcing loop.
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:I talked a little bit about this
earlier, but something I wanna
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:point out is that OCD is often
accompanied by guilt and shame.
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:When a thought clashes with your values
the way an ego-dystonic thought can,
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:it often doesn't just feel scary.
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:It can feel like you've done
something wrong even though
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:nothing actually happened.
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:You just had a thought, the
brain in that moment of dystonic
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:appraisal can respond as if the
thought itself was a moral failure.
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:I must be a terrible person
for even thinking that.
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:What does that say about me that
this crossed my mind at all?
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:That's guilt attaching itself to
something that was never a choice
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:or an action in the first place.
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:It was just mental noise the
brain happened to generate.
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:Recognizing that guilt and shame are
part of the appraisal, not proof that
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:something's actually wrong, is often
one of the relieving realizations
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:someone can have in treatment.
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:This is also why the distress itself is
actually useful clinical information,
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:not evidence against the person.
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:The horror someone feels about their own
thought is a sign of just how ego-dystonic
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:that thought is, how far it sits from
their actual value system and identity.
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:That mismatch, that clash, is the
whole engine of this disorder.
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:But here's where it can also get a little
bit tricky because two behaviors can look
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:identical from the outside and be driven
by completely different things underneath.
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:You might see someone spending
hours of time reading,
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:cross-referencing, digging for answers.
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:In OCD, that can
absolutely be a compulsion.
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:Someone with health OCD, for example,
might research a symptom over and
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:over, not because the research
is adding new information, but
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:because it temporarily quiets the
distress of not knowing for certain.
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:And because it only works temporarily, the
doubt comes back, and then they research
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:it again, sometimes even reading the
same thing over and over and over again.
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:Now, picture someone navigating a
genuine, complicated medical situation.
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:Maybe there's a rare diagnosis or
they're navigating a healthcare
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:system that's dismissed their
symptoms before, and they've had to
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:learn to advocate for themselves.
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:If they spend hours researching their
condition just so they can ask better
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:questions or push back when they're
being overlooked or to make sure that
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:they're actually getting the care that
they need, that's not a compulsion.
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:That research and preparation that they're
doing is in line with their values.
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:It's ego-syntonic.
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:They want to be informed, being their
own advocate, protecting their own care.
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:But with OCD, you're gonna see that
that research is excessive, maybe beyond
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:what somebody without OCD would do.
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:This is exactly why a compulsion
can't be identified by just
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:looking at a behavior alone.
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:Two people can do the exact same
thing, hours of research, repeated
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:checking, seeking information for
entirely different internal purposes.
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:What matters clinically isn't the
action itself, it's the function.
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:Is this behavior in service of one's
actual values and goals, or is it
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:primarily an attempt to neutralize
distress from a dystonic thought?
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:That differentiation is a careful
clinical judgment, which is exactly why
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:an accurate assessment from a trained
provider and OCD specialist matters.
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:so just to recap for today, ego-dystonic
thoughts feel foreign and they clash
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:with your values, which creates distress.
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:Ego-syntonic thoughts feel
consistent with who you are and
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:don't create that same alarm.
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:Intrusive thoughts are experienced by
nearly everyone, but what makes OCD
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:different is the brain's identification
that that thought, urge, image, or
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:doubt was dangerous and meaningful,
followed by the feeling of needing
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:to do something, AKA a compulsion, in
direct response back to that obsession.
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:That's it for this episode of Learn OCD.
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:Thanks for being here.
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:If this was helpful, share it
with someone who might need
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:it, and I'll see you next time
