Understanding OCD and Anxiety: Key Differences, Symptoms and Treatment Options with Dr. Marlene Taube-Schiff

Mark Antczak: Absolutely. That’s always a perspective that I’ve shared, that notion that you can have two folks that present in such similar ways, but have such distinct, unique features at the same time.

Dr. Marlene Taube-Schiff: Yes.

Mark Antczak: And, really going after that acknowledgement, too that so many clinician will on Psychology today will say that they treat OCD when they-

Dr. Marlene Taube-Schiff: Yes.

Mark Antczak: … have very minimal training-

Dr. Marlene Taube-Schiff: Absolutely.

Mark Antczak: … in OCD treatment-

Dr. Marlene Taube-Schiff: Yes.

Mark Antczak: … which is in large part why I think being able to educate and be able to talk about the unique components are so, so important here.

Dr. Marlene Taube-Schiff: Agreed. 100%.

Mark Antczak: I also had no idea you were from Hamilton. That’s where I was born. That’s so funny.

Dr. Marlene Taube-Schiff: Oh, it was just where I did my residency, actually. So, I have-

Mark Antczak: Gotcha. Okay.

Dr. Marlene Taube-Schiff: I was born in Toronto.

Mark Antczak: Gotcha. Fair, fair.

Dr. Marlene Taube-Schiff: I did spend a year in Hamilton. Yeah. It was great. Absolutely. St. Joe’s, I can’t say enough good things. That could be another podcast. It was so awesome, so.

Mark Antczak: Truly. Oh, I bet.

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: I bet, I bet.

Dr. Marlene Taube-Schiff: Yeah, yeah.

Mark Antczak: Well, why don’t we start with just some of the basics. This is our very first podcast in this series-

Dr. Marlene-Schiff: Right.

Mark Antczak: Just really kind of helping us understand the foundations of, “What is OCD?”

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: So for those that are listening, and they may not have a lot of background in it, how would you describe what OCD is, or what some of the main symptoms or criteria are for it?

Dr. Marlene Taube-Schiff: Yeah. For sure. It’s a great question. Individuals with OCD often will experience both obsessions and compulsions. When we think about obsessions, we talk about this idea of a person experiencing recurrent thoughts that are often very persistent. They can be urges, images, and, they really are experienced with a sense of being intrusive and a sense of being stressful to the person that’s experiencing them, which can cause a lot of anxiety, as well as other emotions. We can talk about that. There’s just generally a lot of distress in response to having those kinds of thoughts.

As a result of having those thoughts, as we can imagine, as we all do experience intrusive thoughts, which is something you and I can talk about too, people will try to ignore or maybe suppress those thoughts or urges or images, depending on how impactful and intrusive they feel.

So then in response to having those thoughts or urges or images, people will develop compulsions, which are repetitive behaviors. They can be overt. So, something you and I could see someone doing. They could also be internal. So, they could be mental acts that someone might be doing really without anyone else’s awareness. I think people become very skilled, if you will, at being able to carry out those compulsions without people noticing.

Mark Antczak: Very automated, too.

Dr. Marlene Taube-Schiff: Very automated. Yeah. If you see someone who’s been experiencing these types of things for decades, the way in which it happens is so habitual that sometimes it’s difficult to interrupt those processes. Right? So-

Mark Antczak: Absolutely.

Dr. Marlene Taube-Schiff: You know, think the internal acts, if you will, can sometimes even be, I wouldn’t say harder to treat. I don’t like to compare different presentations because  I think everyone is experiencing distress and discomfort within their own OCD story, if that makes sense.

So,  I think sometimes people feel, “My OCD is somehow worse or this might be harder to treat.” And I’m like, “No. I have the same tools in my toolbox that I can offer you. And, your experience of your experience is difficult, period.” Right?

Mark Antczak: Right, right.

Dr. Marlene Taube-Schiff: So, I do think about that a lot. And I think compulsions, when they happen, people will understandably engage in them because it feels like, in the moment, it can prevent or reduce that anxiety or distress.

All behaviour is motivated and serves a purpose. So, it’s not wrong that someone would engage in compulsions, by any means. It’s something that has served them, often short term, to allow them to feel better.

Would you want more around that, or I don’t know if you had any thoughts around it?

Mark Antczak: No, no. I think that makes a lot of sense.

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: Even just kind of really hammering that point home that compulsions, the way that I’ll often explain it to my own clients is, “It is serving a function. It is the most natural-

Dr. Marlene Taube-Schiff: Yes.

Mark Antczak: … reaction in the world. You have a lot of distress. And you do X, whatever compulsion may be, to alleviate a lot of that anxiety.” Right?

Dr. Marlene Taube-Schiff: Exactly. Yup.

Mark Antczak: Absolutely.

Dr. Marlene Taube-Schiff: Sure.

Mark Antczak: And as far as any specific, kind of unique presentations of OCD, anything you’d like to add about any of the other kind of symptoms that show up with that?

Dr. Marlene Taube-Schiff: Yeah. So I mean, I think when we think about the ways in which OCD can present, bottom line I find is that it can be about anything and everything under the sun, which makes it very difficult for people. There are areas, if you will, of OCD or the domains of OCD that can arise, often latch onto things that are very important to the person and that we think of are of value to them, or meaning, if you will. Right?

I guess some common, if you will, presentations of OCD, they can latch onto areas as sort of contamination. Contamination, though, can be contamination obsessions where we might think about germs or dirt or sort of feeling kind of contaminated, and sort of cleaning compulsions could arise at a result of that.

Contamination, though, we also talk about emotional contamination, where I’m sitting in a chair right now and I have what feels like a bad thought to me. So, now this chair has become contaminated. Or maybe, I’m in a restaurant and something like that happens, so now this restaurant becomes contaminated, or the food that I eat when I have the thought becomes contaminated.

So sometimes we talk to our clients about this idea of magical thinking, where our thoughts start to take on associations that don’t necessarily have any basis in the direct evidence that we have in the moment. Right?

Mark Antczak: That’s right.

Dr. Marlene Taube-Schiff: OCD can also kind of latch onto areas of symmetry, if you will, ordering, repeating, counting. Taboo types of thoughts can be a very distressing type of OCD presentation for individuals, where we think about someone that experiences intrusive aggressive thoughts, sexual related thoughts, religious obsessions and compulsions. And I think harm related thoughts are also very… They’re all distressing, but those can often be very distressing and sometimes even hard to tell someone about, even a therapist or a trusted loved one. Right? Because that idea what would someone think of me if they knew that I was experiencing thoughts-

Mark Antczak: Right.

Dr. Marlene Taube-Schiff: … such as these?”

Mark Antczak: I have a query about that because I’m curious how you navigate this piece or what kind of advice you’d give around this. We know that especially a lot of those kind of taboo oriented thoughts are-

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: … often so scary for some folks to admit or talk about because sometimes it feels like it falls within those limits of confidentiality. Right?

If you talk to any therapist and they kind of go through their initial spiel in that intake, they’ll say, “We will not tell anyone about any of this unless it could be hurting someone, hurting yourself, if a minor’s involved, or if there’s a vulnerable population being affected.”

And I’m curious, how or what kind of advice you might be able to offer folks if they’re trying to figure out, “Can I talk to someone about this?” Is it safe-

Dr. Marlene Taube-Schiff: Right.

Mark Antczak: … to make that distinction? “Oh, this is OCD.”

Dr. Marlene Taube-Schiff: Such a great question. I mean, we don’t want to confuse thoughts with actions, if you will, that maybe people have engaged in. When we think about some of the taboo situations, not thoughts themselves, but actions that people might carry out that sort of start to fall outside of OCD, if you will.

A researcher from Canada who sadly passed away, Dr. Jack Rachman, certainly did wonderful pioneering work in illuminating the idea that we all actually have these types of intrusive thoughts. And that’s part of psychoeducation, for sure, that I talk to people that I see about.

So, I’ve had taboo thoughts. Probably, Mark, you’ve had taboo thoughts.

Mark Antczak: Absolutely, absolutely.

Dr. Marlene Taube-Schiff: We all do, and that’s okay. And, we can talk a little bit more about what that means to people when they have them. But, that normalizing piece I think is important like, “Nobody goes to jail for thoughts alone,” if you will. Someone once said that. That’s certainly not my line, but I think it’s also really important.

I could have a thought that I really hate someone. I wish I could punch them in the face, but I’m not going to do it.

I think what happens is, people have these thoughts and they feel so real because they’re your thoughts. And lots of things that we think, we actually end up doing. So it’s how we can help people to understand that sometimes thoughts are just thoughts.

Mark Antczak: Right.

Dr. Marlene Taube-Schiff: They’re just neurons firing in our brain. And, the same thought of like, “The sun is out, and it’s a beautiful day.” That’s actually just a thought too. It’s a much more pleasant thought to have. But, I think helping people to see that it’s okay to talk about your thoughts. Thoughts are just thoughts. Thoughts are not fact. How do we start to make sense of that together? And it’s often, I think, its because what the thoughts mean to that person when they have them.

Mark Antczak: Right.

Dr. Marlene Taube-Schiff: Yea.

Mark Antczak: And, therein lies the appraisal model. Right? And-

Dr. Marlene Taube-Schiff: Exactly.

Mark Antczak: … the treatment of OCD, which is how we make meaning of our thoughts, and really just kind of hammering that point home. Every single person experiences intrusive thoughts. No one is-

Dr. Marlene Taube-Schiff: Absolutely.

Mark Antczak: … immune to intrusive thoughts, but how someone reacts to it or how someone makes meaning from it is what’s going to make or break OCD developing or it being kept at bay.

Dr. Marlene Taube-Schiff: Exactly. So, the great example that I’ve shared with clients before is, sometimes when I’ve come to an intersection and people are walking, I’ll have an intrusive thought like, “What would happen if I just kept going?” You know?

So in appraisal model, we sort of think about, “Okay. What does that thought mean to me?” Well, to me it means, “That’s a weird thought. That’s strange. It doesn’t really fit with who I am. I guess that’s just a thought.” And, it kind of floats away. Right?

But then, we could have an individual who has OCD who has that thought and then starts to think like, “I must be a really bad person for having a thought like that.” “Oh, wow. There was a mother pushing a baby carriage by. I must be a terrible person.” “I must be a terrible parent even if I’m thinking that I could harm someone else’s child.” And it goes down what we call, almost, the rabbit hole of appraisal and trying to find meaning in something that, my guess is, has no meaning at all. Right? Not to minimize it, but that person is probably just like you and me and wouldn’t actually drive through that intersection. But then when we start to go down that rabbit hole, that thought is given a lot of power and attention and weight. And, it starts to become more important.

Then the other person that had that thought that it just kind of, “Mmh. Weird thought,” and it kind of floats away. Right? So-

Mark Antczak: Right, right.

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: That notion or that thought, internal dialogue, “There must be a reason why I’m having that thought.”

Dr. Marlene Taube-Schiff: Exactly.

Mark Antczak: They’re like, “Why am I thinking this? Does that mean that I’m a danger to people? Does that mean I’m a dangerous person?” Which we could very much appreciate when we start to have that kind of internal dialogue, and we start to actually think we’re dangerous. We want to do something to try and prevent something bad from happening, ergo-

Dr. Marlene Taube-Schiff: Exactly.

Mark Antczak: … compulsions.

Dr. Marlene Taube-Schiff: 100%. Yeah.

Mark Antczak: Yeah.

Dr. Marlene Taube-Schiff: So, that’s what can happen.

Mark Antczak: Would you mind speaking a little bit about what thought action fusion is? That’s a unique proponent of OCD that relates to this piece here, as well.

Dr. Marlene Taube-Schiff: Yeah. So it’s often this idea that, “I’ve had this thought and that must mean something about me. It must mean that I am more likely to carry out that behavior than if I never had the thought, at all.”

So, if you’re, I don’t know, walking around and you’re in a park. And, you see kids and somehow you have a thought, “That child is cute or attractive,” or something. And then all of a sudden it’s like, “I’m an adult. Why am I having thoughts about children? What does this mean? mean that I’m more likely to carry that out, that action. I’m more likely to engage in this than if I’d never had the thought, at all.” Right?

So, having the thought in and of itself suggests that you’re more likely to engage in that. Right?

Mark Antczak: Right, right.

Dr. Marlene Taube-Schiff: Yeah, yeah.

Mark Antczak: And, I’ve had some folks also describe obsessions as urges. They almost feel like they are-

Dr. Marlene Taube-Schiff: Right.

Mark Antczak: … urges.

Dr. Marlene Taube-Schiff: Yes.

Mark Antczak: Can you speak to that a little bit?

Dr. Marlene Taube-Schiff: Yeah. So I guess when we talk about maybe some of the sexual intrusive thoughts, we could get into that a little bit, where people talk about what we call a groinal response, which is again, a very normal part of our physiology that sometimes happens in response to things that we find attractive. And sometimes just happens, frankly, because we’re human beings kind of navigating the world.

Even sometimes anxiety can kind of feel a little bit… I mean, anxiety’s arousing. Right? So-

Mark Antczak: Yeah, yeah.

Dr. Marlene Taube-Schiff: … when people talk about that, it’s like, “Well, I know I saw a picture of this. And then, I scanned my body and I had this groinal response. Wow. That must mean that I’m either attracted to the person in that picture or I’m attracted to a child.” Or, some kind of sexual intrusive thought that doesn’t feel like what the person typically wants to engage in, if you will.

But because they had the thought and they scanned and they noticed the groinal response, it’s like, “Wow. This must actually mean something. And now, I have to do a whole bunch of things, my rituals, in order to neutralize the thought, avoid looking at pictures like that, not go into areas where this kind of a person might be or children might be populating.”

So, yeah. It’s like hypervigilant scanning and a misinterpretation, if you will. And what we want to help the person to see is, “It’s okay that can happen. You can have a groinal response, and it doesn’t necessarily mean, though, that anything like that might happen.” And it’s sort of tolerating these physical sensations, if you will, as being part of our repertoire of being human and navigating the world. Right?

Mark Antczak: Yeah. Absolutely makes sense. And just even following that idea, whether it’s within the realm of sexual taboo thoughts or whether it’s just harm and safety, this idea that you having a thought doesn’t mean that you’re actively suppressing an urge. Because an urge, at the end of the day, is you trying to fight a desire to do something, whereas obsessions are often you worrying that you might do something. Right?

Dr. Marlene Taube-Schiff: Yes. Exactly. Right. Yeah. That’s great.

Mark Antczak: Really, really important distinctions, I think, to make here because truly this is where a lot of that nuance comes in. And I guess this is where, perhaps, the next question can come in where we talk a little bit about the differences between OCD and anxiety. Obviously, a lot of overlap between the two.

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: But, how would you describe what anxiety is and just some of the unique proponents of that one?

Dr. Marlene Taube-Schiff: Yeah. It’s a great question. And I mean, anxiety and OCD used to be a bit more lumped together, if you will [inaudible 00:20:35] used to think of the diagnostic categories. But now, OCD sort of has its own chapter, if you will, in a book that many psychologists, psychiatrists, other practitioners, will use.

Anxiety can be present in OCD. I mean, anxiety in and of itself is a natural emotion that we all need to experience. I always tell people, “I can’t get rid of your anxiety. I wouldn’t want to get rid of your happiness. So in the same way, I can’t get rid of that emotion of anxiety. Anxiety can be motivating. Anxiety can be protective when something is dangerous.

I would say anxiety is yet another important emotion that we all need to experience. And anxiety can exist within the context of OCD, but individuals with OCD can also experience emotions that are not just anxiety, if you will.

So, I think that can be really important. Disgust, I find, is one of those emotions that individuals with OCD can have that someone with generalized anxiety disorder, another kind of psychiatric presentation, that would not exist. Disgust would not be sort of a feature within that kind of an anxiety disorder or social anxiety.

So what’s, I think, important sometimes about OCD is that’s why we talk about this idea of distress. Because distress encompasses anxiety, but it also encompasses other emotions, as well.

Sometimes people talk about guilt and shame and disgust. We sort of think about these different kinds of emotions that can also emerge in response to these intrusive thoughts that you and I have been talking about.

Mark Antczak: Mm-hmm. Absolutely. And, anxiety gets thrown around so much. That word is so commonplace these days. Would you be able to give a really kind of basic definition of what anxiety is, or how it’s experienced?

Dr. Marlene Taube-Schiff: Mm. Yeah. So I mean, I think anxiety is… Not clinical anxiety, I just mean anxiety, in general, is aversive. We don’t like experiencing anxiety. I think if we sort of break it down, there’s probably physical and cognitive and feelings that go along with anxiety. Physically, anxiety, we all kind of, I think, have our symptoms that we tend to experience within the context of anxiety. We could be sweating. We could feel our heart rate increase. We might have difficulty breathing. I think those are some hallmarks, difficulty swallowing. There’s different things that people experience in the context of anxiety, thoughts-

Mark Antczak: Those fight or flight-based reactions so to speak.

Dr. Marlene Taube-Schiff: Exactly. Fight or flight-based. Thoughts can be somewhat catastrophic in nature, at times. Like, “I can’t do this,” or “Something really bad is about to happen,” or “I can’t handle this.”

There’s a true feeling of discomfort that I think people, then, really try to avoid. I don’t like to experience anxiety. I was a bit anxious before I came on to talk to you today. I don’t love it.

Mark Antczak: Absolutely.

Dr. Marlene Taube-Schiff: It’s not like, “Sign me up to experience anxiety.” But we often talk about, “Well, if something is of value to you and really meaningful, would you want to take that anxiety with you so you can then carry out something that’s of value?” And, it’s very important. It’s almost like keeping it in tow.

There are some situations where we can’t necessarily go into without anxiety. I could not have shown up today and not felt an ounce of it. It just wasn’t possible. Yeah. Public speaking, it’s a whole bunch of things. Right? So, I think it’s also helping people to see that anxiety, albeit uncomfortable, is not dangerous in and of itself. Nothing bad is going to happen, other than you’ll feel uncomfortable, if that makes sense.

Mark Antczak: Yup, yup. Absolutely. And just kind of noting that at the end of the day, anxiety is a protective mechanism gone rogue. Right? It’s-

Dr. Marlene Taube-Schiff: Exactly.

Mark Antczak: … a thing that we need. It’s a thing that’s hardwired into our evolution, into our genetics. But, it’s just doing such an incredibly good job that it’s making us have this overinflated fear of things that we typically wouldn’t be fearful of.

Dr. Marlene Taube-Schiff: Exactly.

Mark Antczak: The metaphor I often give is kind of like an overactive fire alarm and the toaster. You know?

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: We want the toaster there to protect us. Not the toaster, we want the fire alarm to protect us. We want to-

Dr. Marlene Taube-Schiff: Totally.

Mark Antczak: … make sure that it alerts us to fires, but not every single time we make toast, kind of-

Dr. Marlene Taube-Schiff: Exactly.

Mark Antczak: … thing.

Dr. Marlene Taube-Schiff: Because then it’s misfiring all the time. Right? So, sometimes we’re very sensitive to anxiety. This idea of anxiety sensitivity, which we know that individuals with anxiety disorders are a bit more tuned in. You can just feel that more often. You just feel those symptoms or you’re scanning for those symptoms. You’re more aware of them.

Again, it doesn’t mean you shouldn’t do the things that you’re going to experience anxiety during. But, it is kind of learning that it’s okay to experience that and still be able to do something that you really want to do.

Mark Antczak: Yeah. The line that I remember a mentor of mine once told me, “When someone’s really scared of doing something, tell them they can do it scared.”

Dr. Marlene Taube-Schiff: Exactly.

Mark Antczak: Right?

Dr. Marlene Taube-Schiff: That’s great.

Mark Antczak: It’s not ideal. We ideally don’t-

Dr. Marlene Taube-Schiff: Right.

Mark Antczak: … want to be facing a feared scenario when we’re sweating buckets or having major heart palpitations. But, it’s not a matter of whether or not you can do it, it can be-

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: … done. It’s just a matter of whether you allow yourself to go through it and endure that distress during.

Dr. Marlene Taube-Schiff: Exactly. Yeah. Totally.

Mark Antczak: Okay. So we talked about some of the physiology, so some of those fight or flight symptoms. We talked about some of those thoughts that can show up. As far as behaviors go, as far as the different manifestations of the reactions to anxiety, those, I imagine, link a lot to compulsions. So, what are some of the kind of typical more broad reactions we could have to something that we fear or to anxiety in general?

Dr. Marlene Taube-Schiff: Mm-hmm. Yeah. So anxiety, in general, I always think of avoidance as such a big hallmark feature when we think anxiety. That’s kind of a whole shutdown where we typically don’t want to do it, all the things that can make us anxious.

And in response to anxiety, there can be lots of other things too, which can be part of OCD and can just be part of, I think, behaviors that can go along with anxiety.

Checking to make sure that we did something right or the way we wanted to do it, I think can be a part of anxiety. Reassurance seeking can be a part of anxiety, which is basically checking with someone else to give you that extra boost that like, “Yes. You did that.” Or, “Yes. The lights are off.” Or, “Yes. This email looks good,” before you’re going to send it out. Or, checking on ourselves. “Did I read that correctly? Let me reread it again.”

Anxiety, I think can push those kinds of behaviors where we’re not necessarily believing in our actions. Right?

Trying to gain some kind of external, I guess, reinforcement that things are the way we need them to be, otherwise we might continue to feel that sense of anxiety.

Mark Antczak: Right. So pretty much anything that we do to give ourselves a sense of reassurance, to try and achieve-

Dr. Marlene Taube-Schiff: Right.

Mark Antczak: … a sense of certainty. Basically, something that we do that makes the bad feeling go away-

Dr. Marlene Taube-Schiff: Exactly.

Mark Antczak: … it sounds like.

Dr. Marlene Taube-Schiff: Yeah. Exactly. Yeah.

Mark Antczak: Okay, okay. So I mean, we’ve kind of talked about the two separate components. We know OCD has some unique elements. We know anxiety, more broadly has some overlapping tendencies.

Can you talk a little bit about where OCD and anxiety, more specifically, overlap? Or perhaps, give a couple of examples on some anxiety disorders and how it could look very similar to-

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: … OCD.

Dr. Marlene Taube-Schiff: One I always think about, because I find in its real presentation, can sometimes be like, “You’re not sure.” Generalized anxiety disorder and OCD share some features.

So, we just talked about the reassurance seeking behavior. That’s something we often can see in both of them. We talk about an intolerance of uncertainty, which can show up in both GAD and OCD.

One of the best explanations I ever got for that was sort of an allergy to [inaudible 00:29:23]. It’s hard to tolerate it, and you really want to know what you want to know.

And, I think those two presentations can have overlapping ways in that sense in terms of that intolerance of uncertainty.

I think obsessions sometimes can feel like worries, if you will. I mean, I think when we veer off into the idea of worries, we try to think a little bit more about sometimes beliefs that people have about worries. Sometimes people will have positive beliefs about worries. We may say they don’t feel as intrusive. I think sometimes when someone’s sitting with you, they might say it does feel really uncomfortable, maybe not intrusive, but uncomfortable to have these excessive worries.

So as clinicians, when we work with people, we want to try to tease these things apart. Not that the distinctions necessarily are going to change everything that we do with someone. There certainly are overlaps in terms of our treatment interactions, how we approach these things.

But from a conceptualization and being able to share that with the client, in terms of like, “This is more or less where we think these things are fitting into,” because there can be some unique [inaudible 00:30:45] of treatment that we would build in.

Mark Antczak: Yeah. It reminds me about the age-old question, because I know this can be a pretty polarizing opinion or question in the clinical community, the need for a diagnosis or the need to label something. Right? Because on the one-

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: … hand, being able to have someone come into your office and they say, “Hey, I keep getting these intrusive thoughts about harming my child.” And-

Dr. Marlene Taube-Schiff: Right.

Mark Antczak: … you say, “So, here’s actually happening. You have OCD. You have a form of-

Dr. Marlene Taube-Schiff: Exactly.

Mark Antczak: … harm and safety based OCD.” The palpable relief, the tears that often come in those moments.

Dr. Marlene Taube-Schiff: Absolutely.

Mark Antczak: It’s such a powerful moment. But, I also know that there’s a lot of folks that come in and they are very determined to have a label, especially if they maybe don’t just have OCD. Maybe, they have OCD, maybe some perfectionism which we know could fit into that OCD. Maybe, they have health anxiety, what have you. Is it important to be able to label and put things into boxes? Is that required-

Dr. Marlene Taube-Schiff: Yeah. Great question.

Mark Antczak: … to be able to get support?

Dr. Marlene Taube-Schiff: Yeah. So I mean, as a psychologist, of course, I’m able to diagnose and that’s one of the things that I do, and supervise others to be able to do and learn. It’s interesting because I worked in the hospital system for so much of my career. We would engage in more diagnosis. I was fortunate to have psychiatrists on my team, so sometimes we would look into medication options.

And when I began working in the community, I didn’t think there would be as much of a want for that. But as you said, really nicely, individuals do come in and they feel like, “I’ve really experienced this compilation of symptoms. What’s going on?”

And sometimes people will just come for that and I think, “Wow. That’s amazing that I’m able to help you kind of sift through all of this that you’ve been experiencing.” And maybe in those occasions, putting, I hate to say label. But putting a bit of a label on it or a bit of a name to it, if you will, I think can be very helpful.

I think I naturally get diagnostic impressions, if that makes sense, as a psychologist.

And, I do use them to be able to conceptualize what’s going on and share treatment recommendations. And, I tell that to everyone I see so I like to do a nice 90-minute session when I see someone for the first time, do what I call a thorough intake, which I always say, “Might feel like a lot of questions that I’m throwing your way,” but I said, “I want to understand who you are with respect to OCD, but who you are, with respect to all your other areas of functioning.” And then, put that all together and try to understand like, “What might be going on diagnostically? What might be contributing to that?”

So I don’t think it’s the end all or be all. I would never ever say that. I guess I’ve learned since I’ve been practising how much it actually can be helpful for the person. And also just when we think about evidence-based treatment like, “What would I think of pulling differently, if I sort of understand what’s going on a little bit differently, too?”

Mark Antczak: Absolutely. Yeah. It’s such an important piece, this idea that we, at the end of the day, are trained to be able to treat a variety of different symptoms. And we are based on the medical model, which is essentially rooted in, “Here’s your problem. Let’s figure out a way to address it.”

I’m very impressed that you’re able to cut down your intake to an hour and a half. Mine is an hour and 50 minutes. And I pretty much just say, “This is going to sound or feel like a giant interview. I just want to get a big sense of who you are-

Dr. Marlene Taube-Schiff: Right.

Mark Antczak: … and the different ways that you present.” It sounds like it’s walking that line of, “I need a little bit of an idea to have some structure, to have a little bit of guidance in how I approach this versus being open to the acknowledgement that this isn’t always black and white. It doesn’t always fit neatly into a box, and we need to have some flexibility with that.

Dr. Marlene Taube-Schiff: Absolutely. And it’s iterative, too. So when I do assessments, I also feel like this is one moment in time. But my assessment, if you will, keeps going. Right? Because you keep meeting with the person and you want to keep learning about them and understanding what’s going on with them over time, to really be able to share that with the person, too.

Mark Antczak: Yeah. Absolutely. So speaking of labeling and assessment-

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: … we know that OCD has kind of taken a more recent trend towards talking about subtypes. You go on any of the major OCD websites, you go on even major ERP platforms, you are going to find people categorizing the different subtypes of OCD that they have. Can you speak to that a little bit and maybe-

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: … whether or not you think it’s important, or… Yeah.

Dr. Marlene Taube-Schiff:       I’m a little mixed. I mean, sometimes, like you said, it can be helpful for people to think about it. Certainly when I first worked with OCD, it wasn’t something that we talked about in the way we do now.

I think that one of the risks, if you will, to subtyping is that someone might work on this one area of OCD. And then, hopefully feel better and maybe leave therapy. And then, OCD has a really nasty habit of morphing and changing, sometimes developmentally, sometimes just with life and stressors. And then it feels like, “Well, this is a whole new area of OCD.” Like, “How do I now transfer these skills that I’ve learned?”

So when I meet with people, and sometimes people come in and they would have, if we go by the subtype language, two or three or four subtypes. Their OCD has latched into different domains. I always say that whatever we’re going to work on in one domain, we can transfer it to another domain. Or, let’s mix things up if we’re working on things in what we call an exposure or response prevention hierarchy. We can mix stuff up. It doesn’t have to be that we can only work on your harm related OCD, and then we have to move on to your contamination related OCD.

So, I think it has probably helped people in terms of understanding things. But, there are also things that people will present with that aren’t going to fall in the subtypes because, once again, OCD can be about anything and everything.

So you might look for a subtype and then think, “Ooh. This thought doesn’t fall within a subtype. Does that mean something’s wrong with me? Does that mean it’s not OCD?”

So there’s sort of a risk, I guess, if you will, and sometimes self-diagnosing or reading too deep into all the things that people have captured, which might not capture what the person is actually experiencing, which might very well be OCD that just a subtype has not been named as of yet. Right?

Mark Antczak: Truly. And again, we have this natural tendency, I think as clinicians, but also as humans, to create structure, to label. I know even in my intake assessments when I’m going through all the major kind of obsessions and trying to identify a bunch of them using the Y-box.

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: It’s really tough when you have someone who says, “I get these intrusive thoughts about being in hell if I take a left or a right at this fork in the road. But I also am convinced that if I take a left, it’s going to result in this sexual taboo thing. And if I take the other direction, it’s going to…” Just so many different unique presentations. That’s-

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: … kind of where the limits come in, I guess. Right?

Dr. Marlene Taube-Schiff: I think so. I do. I think there’s so many unique presentations. For sure.

Mark Antczak: Absolutely.

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: So, OCD we’ve seen is popping up in the media a fair bit, and it has been in the media in some pretty specific ways. We have the individuals who just need to line things up perfectly, and we have the folks that clean things really perfectly, or the hand washing.

We know that OCD often gets misused as a little bit of a kind of tropey component, “Oh, I’m just a little bit OCD.”

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: “Oh, I’m just OCD about this thing.” You know?

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: Folks looking at their ingredients, the way that their fruit presents at the market. What are your thoughts on that? What would you say to those that use that flippantly or use it pretty often, that kind of languaging?

Dr. Marlene Taube-Schiff: I think it’s insulting, to be very honest, to the people that actually experience hours of their day being taken up by obsessions and compulsions. And I think, unfortunately, it becomes a bit stigmatizing, too. Right?

Mark Antczak: Yeah.

Dr. Marlene Taube-Schiff: I would never use that language. For sure. Because I think it doesn’t honour the people that I work with in terms of what they’re really experiencing. Can I use a public washroom and clean my hands a little bit more than if I’m in my home washroom? Yes. That’s just within the range of typical behaviours that people do when they’re in different situations. Right?

So, for an individual to truly, if you will, we’re talking about diagnosis, but kind of reach that diagnostic threshold, it really is significant impairment in a number of areas where they’re impacted, in terms of relationships, in terms of social or occupational functioning, in terms of daily tasks of living.

If someone just engages in something that feels, like you said, extra order, extra cleanliness, we’re not really touching on the depth I think that people do experience when they’re actually presenting with a diagnosis of OCD.

So it’s unfortunate, I would argue, and perhaps we really think about that lack of education and why something like this, that we’re doing.

And the focus on OCD through Anxiety Canada is so essential, so people really understand what it is and are validated in their own experiences.

Mark Antczak: Yeah. I came across a couple of weeks ago… My partner’s a very big coffee guy, and he found this tool. I guess it kind of flattens the grounds-

Dr. Marlene Taube-Schiff: Yep.

Mark Antczak: … before you pull a shot. And there’s an actual-

Dr. Marlene Taube-Schiff: … coffee guy, too.

Mark Antczak: Right? Yeah. So basically, I saw this tool that is meant to flatten these grounds-

Dr. Marlene Taube-Schiff: Yes.

Mark Antczak: … but it literally had an allusion to OCD in it, where the company brand name was… Ah. I don’t want to make a public call out here, but-

Dr. Marlene Taube-Schiff: Okay.

Mark Antczak: … they were literally equating, “Your grounds will be so perfectly flat that it-

Dr. Marlene Taube-Schiff: Oh.

Mark Antczak: … links to OCD. It’s just one of those examples where in theory, you see the folks in the boardroom kind of making that decision, and they’re saying, “This is a solid marketing strategy. This is really putting across-

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: … that our tool is going to be really good at what it does.” But then, we think about the folks that we treat and just the challenges and the pain that they deal with every single day to be compared to having your coffee grounds be perfectly dispersed. You know?

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: It really just goes to show the discrepancy and the dissonance that happens there.

Dr. Marlene Taube-Schiff: Agreed. Yeah. Absolutely.

Mark Antczak: Well, we’ve been talking a lot about OCD, anxiety. And one of the things that I think would be really helpful to also acknowledge in this conversation is the topic of personality disorders, because I think it’s a really common topic that’s happening, especially online.

We have a lot of folks that are talking about borderline and narcissism. Both terms blatantly get misused a lot, similar to the term OCD, as well.

But, can you tell us a little bit about what obsessive-compulsive personality disorder is, and what that may look like to folks?

Dr. Marlene Taube-Schiff: Yeah. Absolutely. So I’ll call it OCPD for shorthand, if that sounds okay.

Mark Antczak: Yeah.

Dr. Marlene Taube-Schiff: It is different than OCD. Sometimes there’s a co-occurrence. I think it’s around 25% maybe there can be a co-occurrence. But with OCPD, we really think more about this sort of preoccupation with orderliness, perfectionism, mental and interpersonal control, really at the expense of someone being able to be more flexible or open and not as rigid.

To be honest, I don’t love the term personality disorder, and I really don’t use it when I work with people. I talk about an interpersonal style or it’s almost like a character logical trait, if you will. So, it’s sort of built into a personality component.

And I guess one thing just to highlight about OCPD is, really, we talk about this term, which is called egosyntonic, which means that it aligns with how we feel as a person.

So when someone’s engaging in some of these behaviors, it doesn’t necessarily feel aversive. It often feels good, and it feels consistent with who I want to be. Because it’s an interpersonal style, it can often impact other people in their life.

Whereas OCD, as we’ve talked about a lot, those intrusive thoughts. We call those egodystonic, which means that they don’t feel like they align with who I really want to be as a person.

And those are some important distinctions between the two. When someone presents with both, we do sometimes want to think about the personality piece and how that might impact our ability to sort of get at the OCD. That’s probably a whole different podcasting conversation, but just wanted to note they are different. And hopefully I’ve highlighted the differences enough for our listeners.

It’s not the same. And having OCD does not mean you would have OCPD, and having OCPD does not mean you would have OCD, although they can co-occur at times.

Mark Antczak: Right. And, would you care to talk just briefly? What are some of the main ways that you notice OCPD show up very, very often or very frequently? Maybe some of the ways that other folks will have their relationships be impacted by it, because we know there’s some pretty unique characteristics involved.

Dr. Marlene Taube-Schiff: So, it can sometimes be a need for things to be done in a certain way, not necessarily because of an intrusive thought, just because you might like things to be organized in a certain way. I don’t know why this popped into my head, but I remember one sort of presentation. The dishwasher needs to be organized very precisely.  Plates need to be lined up in a certain way. It can be time-consuming. If someone else tries to do that task within the family, it can sort of ignite, again, these interpersonal challenges. Right? So-

I know that’s a small example. But, it’s those kinds of things that can sort of show up and people need to adhere to very specific rigid kind of ways and rules that to the person don’t necessarily feel problematic, but can feel problematic when other people are trying to live in that space.

Mark Antczak: That example is so comical to me because when we first got our dishwasher, I read how to most efficiently load it and what spots are going to lead to the best cleaning potential. This is where that spectrum lies. Right?

Dr. Marlene Taube-Schiff: Exactly. That’s what I was going to say. Exactly.

Mark Antczak: I have a strong preference to how those things need to be put into the dishwasher. I will have a little moment with my partner if he does it otherwise. But, it’s not to a point of dysfunction or it’s not-

Dr. Marlene Taube-Schiff: Right.

Mark Antczak: … impairing my quality of life, as we’ve talked about.

Dr. Marlene Taube-Schiff: [inaudible 00:47:25] in multiple tasks across different domains. Of course, didn’t want to minimize it or anything, just one-

Mark Antczak: No, no. Of course.

Dr. Marlene Taube-Schiff: Yeah, yeah. Absolutely.

Mark Antczak: So, we are going to be having some episodes in the future that dive into a lot of different topics. But, one of them is going to be talking about treatment in particular. And, this is kind of just a bit of a preview appetite question.

We know ERP is the gold standard. Everyone knows it as the gold standard, rather. That’s the one that everyone kind of talks about is absolutely necessary.

Dr. Marlene Taube-Schiff: Right.

Mark Antczak: Can you speak to just the range of different types of therapies that can treat OCD and just give a little brief description on the main ones that you might utilize?

Dr. Marlene Taube-Schiff: Yeah. For sure. So in terms of the main ones I utilize, absolutely exposure and response prevention. ERP, as you alluded to, falls under the umbrella of cognitive behavioral therapy, which also can incorporate cognitive strategies, which we know can definitely boost the effectiveness, looking at thought records. Looking at other tools we can get at to help people with an overinflated sense of responsibility and those kinds of issues that can emerge.

So, CBT, focus on ERP, is excellent for that. I also use, as it is evidence-based, acceptance and commitment therapy kind of infused into my ERP work, which often focuses on values-based approaches, and helping an individual engage in exposure, which is very much a part of ACT, in terms of experientially kind of living things, experiencing things. Not necessarily to acclimate to anxiety, but very much to engage in values-based moves and things that are aligned.

Inhibitory learning is sort of a whole other approach, if you will, where we also sort of can bring that into our ERP, really helping the person replace old learning with new learning in terms of things that emerge during ERP, things that they learned, things that they might be surprised by. So having different reflections within the realm of ERP. Another approach-

Mark Antczak: Can you clarify that term just a little bit more specifically, inhibitory learning?

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: What’s another way you can describe that?

Dr. Marlene Taube-Schiff: So, yes. So, another way would be sort of inhibiting that old learning, which the old learning might be, “When I engage with this particular task, I get anxious or I want to avoid or I want to shut down.”

And my new learning doing my exposure work might be recognizing that, “I can complete this process. And, I can laugh with my therapist or smile when I do this process. And, I make it to the other side.”

So, it’s this idea of how can we learn new things during our exposure work that can start to kind of replace, if you will, the old learning that has historically been there, that has prevented us from engaging in those things.

Mark Antczak: So, kind of like the disconfirmation model. So- Because I practice all these compulsions, when I do X, it actually prevents Y from happening. Oh, well, it turns out if I don’t do X, Y still doesn’t happen.”

Dr. Marlene Taube-Schiff: Right.

Mark Antczak: Same kind of idea.

Dr. Marlene Taube-Schiff: Yeah, yeah. Exactly. And then I guess just a quick nod to an approach. It’s called Inference based CVT. Then, evidence-based. It’s been around for quite a while. It comes out of Canada, from Montreal. And it’s really, I think, kind of finding its place very rightly so within our landscape of being able to work with individuals with OCD. It is a different conceptualization.

Obsessions are looked more at what we call obsessional doubts as opposed to intrusive thoughts. And, we start to unravel a process that’s called inferential confusion, which in a nutshell is about the narrative that our OCD can create in that we can so easily, if you will, step into because it feels so real. We often can sort of confuse, if you will, what’s happening in reality with what our OCD has really created for us that feels so powerful in that moment. It’s another kind of CBT, and it’s helping individuals to kind of relearn, if you will, or unwind and relearn that narrative and ground themselves very firmly in reality, using things such as five senses, common sense data, belief in what we call the real self.

And it really helps individuals to gain back the confidence in making decisions for themselves, not what their OCD, if you will, is sort of suggesting that they do.

So, I use that a lot in my practice. I think it’s excellent. I think it’s also a wonderful approach. People have sometimes tried ERP, and they’re not where they want to be. So, how amazing that we have more than one tool in our toolbox now. I think we’re pretty lucky as clinicians to have that.

Mark Antczak: Mm-hmm. No. Truly just even recognizing there is no one-size-fits-all approach.

Dr. Marlene Taube-Schiff: Absolutely.

Mark Antczak: Some folks could really resonate with one form of therapy. Sometimes we need a combination of different kinds of therapies.

Dr. Marlene Taube-Schiff: Yes.

Mark Antczak: Inferential based cognitive therapy is, from the sounds of it, becoming very popular because it doesn’t-

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: … require you to white-knuckle and go through the distress-

Dr. Marlene Taube-Schiff: Yes. Exactly.

Mark Antczak: … involved in exposure based intervention. So, it sounds like there’s a lot of potential there.

Dr. Marlene Taube-Schiff: Absolutely. Yeah. Absolutely.

Mark Antczak: Excellent. Well, Marlene, we’re just coming up to a close here. Any kind of final thoughts, any queries, any pieces that you’d like to share before we wrap up?

Dr. Marlene Taube-Schiff: Not much, Mark. I just wanted to thank you again for having me. And, it’s really such a privilege to be able to talk to you and to share this time with our listeners through Anxiety Canada.

And I just hope so much that what we talked about today resonates with some of our folks and really allows for them to, I don’t know, maybe reach out for help or learn a little bit more about what’s been going on for them.

Mark Antczak: Absolutely. Really, just reiterating that notion that you are not alone in this fight.

Dr. Marlene Taube-Schiff: Yeah.

Mark Antczak: It could be such a debilitating illness, but at the end of the day, there are a lot of programs, a lot of resources, and a lot of wonderful professionals like Marlene here, who have just been working with us so successfully. And, both of us have just seen the really tremendous outcomes that can come from this. So, hopefully, hope is a word that comes out of today’s first episode. So, thank you so much for joining us, and we hope to have you back.

Dr. Marlene Taube-Schiff: Yes. Thanks. Absolutely. Any time.

Outro:  Thank you for listening to #OurAnxietyStories, the Anxiety Canada podcast. To share your own story or to find resources and support this podcast, visit us at anxietycanada.com.