Today we asked our community members and newsletter subscribers to send in questions for Dr. Jamie Feusner, one of the world's top OCD experts. Our focus for this Q&A was clinicians. He answered some of those questions here. Download our app for further discussion!
Dr. Feusner is Professor of Psychiatry at UCLA and Director of the UCLA OCD Intensive Treatment Program. His research focuses on body dysmorphic disorder (BDD), eating disorders, OCD, and gender dysphoria. He has conducted research on OCD investigating brain connectivity, predictors of acute and long-term treatment response, and neurometabolites.
Although his life’s work is to understand the brain’s many complexities, Dr. Feusner still makes time to snowboard and is an avid fan of Ariana Grande. He recently joined nOCD as Chief Medical Officer.
1. I was told by my psychiatrist, whom I respect very much, that I should not drink any alcohol because I have OCD and it's like pouring gasoline on a fire. Is this true?
Alcohol, in general, tends to worsen anxiety and depression, and these are common symptoms for people with OCD. In general, it’s better to avoid or minimize alcohol intake if you have OCD.
2. Do you think it could ever be possible to find a cure for OCD?
I think it is possible to improve the effectiveness of treatments for OCD to the point that symptoms are so minimal or unnoticeable that they cause almost no interference or distress in one’s life. Some would call this a cure, although because OCD is a chronic illness it would not be the same as, for example, a cure for an infectious illness.
3. As a parent really desperate to find help for my son, it’s hard to believe any other options will help. Where can we turn if we’ve tried ERP, CBT, and a bunch of medications?
It sounds like you’ve tried many options, and perhaps the ones that are considered “first-line” for OCD such as medications and ERP. When someone doesn’t respond to regular outpatient ERP, intensive outpatient (daily) treatment programs or residential programs may be effective. Medications may be optimized in terms of doses or combinations, and “second-line” medications can be added. Finally, there are neuromodulation (brain stimulation) treatments available that have FDA approval for those who haven’t responded to all of the above, which include transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS).
4. Has a cure/therapy been invented so far for OCD that doesn't involve medication?
There are very effective non-medication therapies for OCD called cognitive-behavioral therapy (CBT) and exposure and response prevention (ERP, a type of CBT). These are considered first-line treatments, along with medications and are as effective or more effective. In addition, there are neuromodulation (brain stimulation) treatments available that have FDA approval for those who haven’t responded to meds and ERP, like TMS and DBS (see question 3).
5. How should we all (patients, loved ones, clinicians) balance the need to try emerging treatments with the fact that there hasn’t been enough research on many of them?
The situations that arise when someone might consider trying an emerging treatment that might not have a lot of research conducted yet to evaluate the efficacy usually involve someone who has tried several different evidence-based treatments and either didn’t respond or couldn’t tolerate the side effects. In these situations, the patient (along with their clinician and loved ones) may really need a treatment to help them, but should carefully weigh the risks and potential benefits.
If a new treatment has low risks associated with it, trying it might result in improved symptoms. In addition, doing so could help the larger scientific community evaluate whether it could be a promising treatment for more people with OCD, particularly in the context of a research study. It is important to make a decision that you feel comfortable with, and to make sure you know all of the potential risks.
6. What do you do when a patient is seeing another clinician (like a psychologist) who has drastically different opinions about what’s best for them?
The best way to try to resolve this, if you are a clinician yourself, is to talk to the other clinician on the phone or in person to have a chance to ask questions and find out the other’s viewpoint as best as you can. This often helps resolve differences, but in some cases it doesn’t, at which point it is good to be transparent with your patient and explain your position and how it’s different from the other’s opinion, while maintaining respect for the other’s opinion so you don’t interfere with the patient’s relationship with them. If the patient is stuck not knowing what to do, suggest that he/she get a third opinion.
7. What is the best way to treat OCD in the form of breathing? Specifically, a sensation of being unable to take a deep breath.
In many patients, this symptom seems to be a form of “just right” OCD (sometimes called not just right experiences or NJRE). With exposure and response prevention, the patient usually practices intentionally breathing in a way it does not feel right– so they can learn to tolerate the feeling and/or so this feeling decreases in intensity. Medications for OCD can help at least partially too, as they tend to decrease the intensity of the uncomfortable sensation, how often it happens, and how strong the urges are to “get it right.”
8. I'm a practicing family doctor and have a 19-year-old son suffering from pure-O type OCD, which keeps morphing into obsessional ways of thinking, e.g. judging himself for past and current behavior, and makes him think he’s a bad person/doesn’t deserve better.
He is very smart but is struggling in college: procrastinating on the computer, online gambling, etc. His major OCD crisis happened just before final exams: his friends and other sudents accused him of “faking it” to get out of exams, which has just fed the OCD. His teenage brain is getting in the way of doing the work necessary to rewire his brain. I have encouraged exercise and he has just rejoined the gym and started playing guitar.
Medication hasn’t helped a great deal. My son has seen two psychiatrists, and tried max doses of Prozac (80mg) and Zoloft (200mg). He complained of side effects– with Anafranil too. He has been seeing a very good psychologist. How do I get his teenage brain to engage in the hard work needed to get better? We have suggested some time off, but he says that staying in school is the only thing that gives him a sense of identity at the moment. Any suggestions are welcome– being a health professional, I know how vulnerable young people are and it’s a crucial time in their psychosocial development.
In cases like this where someone has tried a few different treatment options that have not been effective enough, a possible next step could be an intensive exposure and response prevention (ERP) treatment program. As you mention, adolescence is a crucial time in psychosocial development, so it makes getting better imperative to minimize how much OCD interferes. However, for the same reason, he might not want to take time off school in order to do such a treatment.
The treatment might last 4, 6, or 8 weeks, which in the large scheme of things isn't so much time– it will often pay off in the long run because the rest of his university experience could be much easier and more enjoyable. If there is such a program where his university is, in some cases (e.g. in an intensive outpatient program) he might be able to arrange his schedule to do it without completely taking a semester off, or during a school break.
9. I'm wondering if severe skin picking on all ten fingers of a 17-year-old girl can be cured.
Skin-picking can be a psychiatric disorder (also called excoriation disorder) if it interferes with functioning and/or causes significant distress. It is related to OCD– and is called an obsessive-compulsive and related disorder– but is not exactly OCD. First-line treatment involves behavioral therapy, specifically habit reversal or acceptance-enhanced behavioral therapy. Medications such as serotonin reuptake inhibitors (SRIs) and N-acetylcysteine can also be effective in some. In some people, the symptoms can completely go away; in others they can be minimized to the point of not interfering.
10. I'm treating an elementary-aged child with OCD contamination fears related to human waste. It would be helpful if you would recommend school accommodations for a 504 Plan. The compulsive behaviors manifest during toileting times at school and peers have observed and questioned my client. Thank you!
An accommodation plan could be helpful to alleviate shame or embarrassment that could happen in the classroom, at least until the child has achieved improvement such that they're able to use bathrooms without avoidance or compulsions. I would recommend that this accommodation only be temporary, because ultimately the child/parent/therapist should work to get the child to the point of being able to use the bathroom without resorting to avoidant or compulsive behaviors.
11. How much do we know about why some treatments seem to work for certain people and not for others? And what kind of benefits might we see from knowing more?
Unfortunately, the clinical and research fields do not know a lot about why some treatments work well for certain people and not for others, and there's still a trial-and-error process for many treatments. However, researchers are working on figuring out how to predict who will respond better to some treatments.
This might require very large data sets from many different people, and it might require many different types of data (biological data such as brain activity and genetics, a person’s report of their symptoms, observable/measurable behaviors, demographics, and so on). The benefit of developing better prediction would be a more personalized medicine approach where one can find a much more direct path to the treatments or treatment combinations with the highest probability of success for them, individually. This will save time, suffering, and cost.
12. When you take a step back, what’s the most exciting thing in mental health research right now?
I think the three most exciting movements in mental health research now are the ability to use much larger sets of behavioral and subjective symptom data gathered using mobile technology to understand illnesses better and get better at prediction; our improved ability to understand the brain with improving brain imaging and analysis techniques; and new neuromodulation treatments. Many talented groups are thinking outside of the box to enhance or change the ways treatments are created and to figure out how they can reach more people. As our world has become very interconnected, these developments can happen faster than ever.
Thanks to Jamie for these thorough and very helpful answers. We'll be doing more Q&A posts soon, so be sure to keep an eye on the Group feed in our app.