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Dr. Sharp: [00:00:00] Hello everyone. Welcome to the Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

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Hey, y’all. Welcome back to the Testing Psychologist podcast. Glad to be here. My guest today is Dr. Erika Vivyan. Erika is a bilingual English and Spanish licensed psychologist and an expert in assessing and treating anxiety, OCD, and behavioral problems in young people. She helps kids, teens, and young adults to figure out how their brains work [00:01:00] best so that they can meet their goals for home, school, and career in her “free time”. Totally get that.

Dr. Vivian is also a fitness instructor and she enjoys calming her own worries through running, dancing, kickboxing, and weight training. I knew that there was a reason that I connected with Erika, we both share this love of exercise as a means of emotional regulation. I would be a completely frazzled and dysregulated person without my running, so I connect with that.

We’re talking about OCD and related concerns during this episode. Erika indulges a lot of my questions, which seem to veer toward myself and some of my family members. Apparently, compulsive behavior runs pretty consistently within my family. So I ask some of those questions, which she good naturally answers. We also talk about the definitions and [00:02:00] manifestations of OCD’ we talk about ways to assess OCD symptoms in children, and we of course get into the typical rule-out when considering a diagnosis of OCD and how to differentiate those, including ADHD and autism spectrum disorder. So, lots to take away from this episode as usual.

As we transition to the conversation, I, of course, invite any practice owners interested in some group coaching and accountability to check out thetestingpsychologist.com/consulting. You can schedule a pre-group call and we will figure out if group coaching could be a good fit for you.

All right, let’s get to my conversation with Dr. Erika Vivyan.

Hey Erika. Welcome to the podcast.

Dr. Erika: Thank you so much for the opportunity to be here. I’ve been a fan of your podcast for a while now, so it’s really awesome to be able to contribute to this knowledge base and just be a part of your show.

Dr. Sharp: Yeah. Well, I’m happy to have you. Thanks for listening. It’s super cool to be able to connect with folks and get to hear all of these areas of expertise and like you said, contribute to the knowledge base, right?

Dr. Erika: Yeah.

Dr. Sharp: Well, welcome. We are talking about OCD and differential diagnosis of OCD and any number of other things, which is exciting. It’s funny, I feel like I’m having this experience a lot lately where I think, how have I not done an episode on this topic before? That gives me hope that there are many more episodes still out there, but I’m glad that you’re here to [00:04:00] tackle it. It’s definitely necessary.

I usually start with this question of why this is important to you. Out of all the things you could do in our field, and ways to spend your time, why this?

Dr. Erika: I got started in the OCD realm by way of my first job after licensure. I got into a group practice and I was very interested in anxiety and anxiety disorders. I felt like exposure and response prevention and the CBT framework that’s used to treat those types of disorders was just so cool and so effective and so evidence-based. And then I started treating OCD within this group practice. And I also wanted to keep up with my testing skills because I’m trained in educational psychology.

So, as I launched into that piece of my therapy work, I realized that working with a lot of OCD and anxiety disorders really informed the way that I did my [00:05:00] assessments and it kept popping up as one of my differentials, mostly because I got a lot of internal referrals for anxiety disorders, possible OCD. And there are so many areas of overlap with OCD and you talked about at the beginning, OCD and a lot of other things that we assess for, but especially our testing bread and butter in a pediatric assessment like ADHD and autism spectrum disorder, there are so many different areas of overlap. And if you include anxiety and OCD in that Venn diagram of sorts with multiple overlapping circles, you get a lot of questions. I’ve had to really learn that differential diagnosis to make sure that I’m answering my client’s questions.

Dr. Sharp: Yeah, for sure. I love how that works in so many ways: we have the experience and then it informs other experience and then we [00:06:00] turn a specialty from that, and before long, you’re just down the rabbit hole of this one particular area.

Dr. Erika: Yeah. I really found that because I think in a lot of educational psychology or school psychology coursework, you learn so much about assessment. And then in my practicum and internship and postdoctorate, I did so much therapy that I realized that those are not really two entirely separate skill sets and that a lot of your work informs your other work. And then of course the more clients you meet, the more families you meet, and the more you realize those patterns that are really helpful in figuring out those differential diagnoses. And then, of course, the most important piece that I tell all of my assessment clients is that I just want to point folks to the right resources and the right recommendations in the community.

Dr. Sharp: Yeah, absolutely. Well, like you said, there’s I think a lot of confusion and maybe even misinformation out there around OCD and autism [00:07:00] in particular, but of course, there’s an overlap with just regular anxiety, ADHD, and other things too. I’m excited about this conversation almost more just for my own curiosities from the audience.

Let’s start with maybe just some definitions and basic information. Folks I’m guessing have some sense of OCD and what it is, but tell me in your mind, how are you conceptualizing OCD these days? What are the major facets? What do we need to be aware of?

Dr. Erika: Yeah, when I talk with either my therapy clients or my assessment clients about OCD, I like to describe the specific symptoms, but then also how they interact with each other because there’s a cycle of OCD.

With OCD obsessive-compulsive disorder, you’ve got the obsession with which not every parent [00:08:00] or kid or teen comes in saying, well, I have obsessions. They usually come in and say, I have some really big worries about- we have those very typical OCD themes that we’ll think about. Like, I’m really worried about germs, or I’m really worried about how perfect my handwriting looks, or I’m really worried about something awful happening to my pet cat. And usually, they describe them as these really big overwhelming worries, and that piques my interest.

And then my next question is about, well, are you experiencing compulsions? And again, most people don’t come in and say, I have compulsions. They say, well, I have this funny ritual where I tap the door three times and then I’m sure that nothing will happen to my cat. And that’s a pretty clear, obsessive-compulsive cycle than when we get into the obsession, and every time someone does that compulsion, they feel relief. And that’s really the primary mode of how obsessive-compulsive disorder works.

The other piece that I [00:09:00] always ask about, and we ask about this in all of our clinical interviews as well, is this really causing a problem? And in the DSM-V text revision diagnostic criteria, it’s pretty clear for OCD- if it’s causing functional impairment, it also helps to measure it in time. So sometimes I’ll ask folks over the first few sessions, or this time between the intake session and the testing session, I’ll say, well, then time it. Time how long these rituals are taking, or how many times a day do you ask your mom for reassurance about your pet cat or your handwriting? How many pieces of paper do you crumple up? Noticing really that functional impairment that’s caused by that obsessive-compulsive cycle.

Dr. Sharp: It is interesting. I found out just the other day, I have a 9-year-old and an almost 11-year-old and we were talking about rituals, I think [00:10:00] and routines and… No, I know what we were talking about. I promise this is going somewhere. We were talking about funny personal quirks. We were asking one another about funny personal quirks people might not know about. And my 11-year-old said, I always take nine bites of food because that’s my lucky number. And I was like, what? That’s so interesting. How have I not known that about you?

I don’t know that that’s OCD necessarily, but you could probably tell me. This is one of those mental rituals that turn into a behavioral thing, but I don’t know that it’s causing impairment necessarily, but it was very interesting that it’s a numbers-driven behavior.

Dr. Erika: Yeah. And I think obviously having a dad as a psychologist, you’re being, oh, you’re counting the number of bites?

Dr. Sharp: My wife is also a therapist and we cut our eyes across the counter across the bar, and we’re like, What?

Dr. Erika: But [00:11:00] I think that’s an interesting question because I do get that a lot in assessment intakes as well. Like, oh, well my kid’s lucky number is this, and they do this a certain number of times or they count to this number of ceiling tiles or floor panels. And that’s again, when we ask the functional impairment question, but I also ask the question of, what would happen if you only took eight?

Dr. Sharp: Sure.

Dr. Erika: Because usually, it’s not a big deal. Or like, I don’t know. It’s fine. But kiddos with OCD, especially when it’s heading that moderate to severe range, which we’ll talk about the CY-BOCS-II and other ways to measure OCD in an assessment, they’ll usually say, I’ll throw a fit or I won’t eat my sandwich. Either I’m avoiding that obsessive trigger entirely or I have a complete emotional meltdown which I define differently than a tantrum, but they’re really melting down because of the emotional distress of taking eight bites instead of nine or counting eight-floor tiles instead of nine [00:12:00] really feels awful. And that obviously contributes to that functional impairment piece as well.

Dr. Sharp: Right. Since you mentioned it, you just said that you differentiate between emotional meltdowns and tantrums. What do you mean by that?

Dr. Erika: Especially in the anxiety at OCD world, I ask most folks on their intake questionnaire if they’re kiddos or they’re teenagers sometimes have meltdowns or tantrums, and most people are like, yeah, meltdowns tantrums fits. They lose it.

What I define as a meltdown, sometimes looks like a really emotionally triggering event. We often associate meltdowns with an OCD trigger like I have this obsession, but I can’t complete the compulsion, then I’m having a meltdown. That often happens in the autism literature as well, where we think about, okay, the kiddo has a new [00:13:00] T-shirt on and they didn’t cut the tag out. That’s a really big sensory problem for them. They might have an emotional meltdown.

Whereas a tantrum, because I also often treat oppositional defiant disorder and conduct disorder, is more like, I want this thing or I want control of this situation, and I will throw a tantrum until I get it.

And there’s, again, if we’re thinking about Venn diagrams and overlap in our conversation today as a general theme, I think there’s a lot of overlap because often when a kid is having a meltdown caused by OCD, autism spectrum disorder, or any number of diagnoses, they’re emotionally dysregulated because something is not going their way and their brain is wired to have that big emotional response to it. And parents tend to figure out that they can turn off that meltdown by giving in to OCD. Okay, you can take your 9th bite of a sandwich or you can do whatever that compulsive cycle is for any kiddo.

With a tantrum, I once had a [00:14:00] family, I think this is where it really solidified for me. I had a family describe, the kiddo was throwing tantrums about going into the store because they were socially anxious. They didn’t want to go into the store. They wanted to stay in the car. And then the other kiddo was throwing a tantrum because they couldn’t go into the store because the other kid was having a tantrum in the car. And that meant they couldn’t get the toy or the candy that they really wanted from the store. One was avoidance. I would like to not go in the store because people will look at me, and the other one was approaching, like, I would like to throw a tantrum until somebody buys me that candy bar I really want.

Dr. Sharp: Yeah. I think a lot about that collaborative and proactive solutions literature around like, kids are just doing the best that they can at any moment in time, right? When they’re melting down or tantruming or whatever, it’s just a reflection of them not having the skills to deal with whatever is happening emotionally.

Dr. Erika: Absolutely. And I often talk with parents about that too in parent coaching and even in feedback sessions. [00:15:00] They’ll ask, well, is it because of the OCD or the autism or the ADHD that this tantrum is happening? Yes, there is something different about their brain and how they emotionally process things. And there are things that we as adults can do to support those emotions and help make it a little bit easier for them. Again, that’s a really tough gray area in terms of what the kiddo can do in using their resources as well as what the parent can do given their time and financial and patience resources in the moment.

Dr. Sharp: Right. I don’t know if this is beyond the scope of our interview or not, but it’s a whole can of worms, this idea of parental reinforcement or enabling a lot of these behaviors especially with OCD. I hear about that a lot.

Dr. Erika: I feel like that could be an entire process and an entire separate [00:16:00] conversation in the way that we talk through, especially giving a diagnosis. I was listening to one of your other episodes about feedback and how you involve parents and kids in that process, but giving that feedback for a diagnosis of OCD versus autism spectrum, most parents will say, some sort of rendition of the question, is this nature or nurture? Is it my fault that my kid is this way?

And again, I always say, it’s not your fault. It is your responsibility to support them which is a huge responsibility for parents receiving that diagnosis. But I think that brings us back to this differential diagnosis question of, if something is an autism spectrum disorder but not OCD, then there’s a different way of approaching that versus if something is, sometimes it’s an autism spectrum disorder and an additional diagnosis of OCD. And then it’s about differentiating which symptoms belong [00:17:00] in which camp, and really helping folks to understand that there are some overlaps, but there are also some very clear distinctions. And that helps to guide our recommendations as clinicians.

And then for folks, I don’t know how many of your listener listeners are testing psychologists, but also providing therapy or group interventions or whatever, or obviously have at other points in their career. But I think that really lends itself to how you talk about the next steps in intervention and saying, this is why we treat OCD with exposure, but with autism spectrum disorder, we might do some more accommodation to reduce those tantrums, and here’s why.

Dr. Sharp: Right. I want to bookmark that and definitely circle back to that differential and in cases where kids have both autism and OCD and how you sort through that. Don’t let me forget to bring that back up here in just a little while.

I do want to circle back [00:18:00] as well to the obsessions and the compulsion. I’ve read and seen and heard a bit about this idea of mental compulsions and maybe on a related but different track, like just pure obsessional OCD, and do you have to have compulsion? I’m curious if you have thoughts on that whole realm.

Dr. Erika: Yeah. Pure O or pure obsessional OCD is a great mystery. I’ve had several conversations with my colleagues in the anxiety OCD sphere here in Austin about does it really exist, or as you said, are folks describing pure obsessions as it just feels awful. I’m not doing anything about it.

Usually, in my experience, they’re doing some mental compulsion. Sometimes it’s using their previous [00:19:00] cognitive reconstruction from their therapist and saying, it’s okay for me to do this, saying I can do this because I don’t have to listen to my OCD. That’s very different. Or sometimes their compulsion is actually avoidance and they just avoid anything that triggers their obsession to avoid that discomfort because, as I said, the way that the DSM and most psychologists conceptualize OCD, there has to be an obsessive-compulsive cycle. And usually, in therapy, we try to get rid of the compulsion. And that’s how I describe it in my feedback session is, as we try to get rid of the compulsion, the obsession might still be there.

It is definitely more complex, especially as you get into the differential diagnosis of thinking, is this person really obsessing over this thing and there are not any compulsions that we can behaviorally see, or is it an anxiety disorder where they’re just really distressed by their anxiety? Or is it an autism [00:20:00] spectrum disorder where they have this specific ritual and it just feels awful not to do it that way? And that’s where you have to get into those really good data sources and clinical interview skills.

Dr. Sharp: Yeah. I guess it’s just a philosophical question maybe, is it OCD without compulsions?

Dr. Erika: Yeah. And some of it I think relates back to theme too, because we have like a very clear understanding of what some of those OCD themes are, like severe worries about contamination and then avoidance. Well, is that generalized anxiety or is it obsessive-compulsive? And it depends on the individual and their specific presentation.  So, it helps to really know them well. And I think that goes back to your initial question of when I’m doing an assessment now as someone who also treats OCD as a therapist, I want to know everything about that OCD, so I can really answer that question of, is this OCD and or is it OCD [00:21:00] or?

Dr. Sharp: Right. Can you give any examples of maybe less… actually, let’s do both- most common and maybe less common obsessions and compulsions that we might see. You’ve named some of the most common if there are any other big ones that we should be aware of or on the lookout for, but I’m more curious honestly on the less common presentations- the ones that might fly under the radar and get missed.

Dr. Erika: I think those ones are really fun because they often confuse parents and kids and teens and anyone, just because they don’t present like typical OCD. We know from the movies that contamination OCD worries about germs and hand washing often until your hands are bloody and raw. That’s a very common obsessive-compulsive cycle. We see that in a lot of folks, or sometimes we see that when people are younger and then they’re sitting morphed into something more wild and unique.

Some things that people don’t always [00:22:00] recognize are OCD are just images that flash into your head. Some people will experience a really gruesome image of someone being injured or stabbed or something really terrible happening. And people will describe that to me… I’ll ask, do you ever have really scary violent images pop into your head? And they’re like, no, only after I watch a horror movie. Okay, that seems typical. Versus, yeah, sometimes I’m just sitting at my desk and I have this image of somebody with their arm cut off pop into my mind. That feels much more intrusive. And most folks don’t call it an intrusive thought. They’re just like, there’s this weird image that pops into my head.

And then again, you ask about the compulsive cycle. Well, what do you do to get rid of that? And some people have to do a specific tapping ritual or some people just have to like get up and do something else or do a mental ritual or just say that’s super uncomfortable.

Another one that I see really commonly in younger kiddos [00:23:00] is a compulsion asking for reassurance. I’ve had several kiddos where they ask their parents, well, am I going to have a bad dream tonight? Or are all the doors locked? And parents often feed right into that cause they’re like, of course, it’s my job as their parent to make them feel safe. And then it becomes that obsessive cycle. And if the kiddo is not aware if the doors are locked or they make the parent go back and check, then it reaches the point of possibly being an obsessive-compulsive cycle.

Dr. Sharp: Just as a personal example of that, we’re right in the middle of working through some of this with my 9-year-old daughter, the other kiddo. I’m starting to see a theme with my kids here where it’s like separation anxiety, but there’s so much checking like, when are you going to be home? Checking mom’s location on the iPad. What are you doing? Where is everybody? And that kind of thing. It’s challenging.

[00:24:00] Dr. Erika: I think that’s definitely something that I see in my work all the time. We all are aware that there’s a very neurotypical way to have worries about your parents and your family and your kids. That’s very common because we care about the people that we love, obviously.

And, that’s again, when we go back to that functional impairment question, like, well, is it causing bedtime to be 2 or 3 hours later than normal? Then, okay, let’s figure something out. It is helpful I think for parents to differentiate between them.

I think folks in the OCD world might be really aware of this, but something that pops up for all of us who are very social justice oriented and aware of the world, if a kid comes in and asks, well, am I gay? Sometimes we’re like, oh, well you can be gay if you want to be, that’s fine. And if it really triggers them and makes them feel really anxious and uncomfortable, [00:25:00] it might be that they have societal expectations that scare them about possibly coming out as gay or they might have homosexual OCD, which I’ve treated times. And it’s also really difficult to evaluate because, again, you’ll notice that compulsive cycle of…

One of my clients used to say, I can’t watch Brokeback Mountain because it really triggers something in me, even though I have a girlfriend and I really think that I’m not gay. But that was a cycle of, oh, you might have an obsession about possibly being gay despite the fact that you’re not actually questioning your sexuality. And it’s a difficult ground to tread for parents, caregivers, and teachers, but also for therapists to make sure we’re challenging the OCD or appropriately diagnosing the OCD if it’s there.

I’m trying to think. The other common one that you brought up was like lucky numbers or [00:26:00] things like that. But something that folks might not be aware of as an obsessive-compulsive or related disorder could be something like a hoarding disorder where kiddos tend to save bits of string rocks and leaves.

It’s hard in kids and teens because they don’t own their own space. They’re living in their parents’ house. And parents will throw away their stuff for them. It’s really clear to see hoarding disorder as a subset of OCD in adults because usually there are bunches of boxes of stuff in their homes. But with kids, it’s more of that parent-child conflict if we can’t get rid of this box of old toys or rocks because it’s so uncomfortable. And I think that’s another one that folks are not as aware of.

Dr. Sharp: Yeah. In your experience, just going off that last example, what’s the obsession that drives that behavior? Or are [00:27:00] there any common ones or is it across the board?

Dr. Erika: Yeah. Sometimes there’s an obsession just in thinking about like, I need to hold onto these things or I will lose the memories attached to them. There’s that and over intensified, which I mean, that’s how psychopathology works. It’s more than we would see typically, like holding onto rocks to remember the memories instead, many of us will hold onto pictures to remember the memories because that seems to be more of a relevant trigger for the memory.

But often the obsession is about it either I don’t want to get rid of that memory or I just feel awful if I have to leave it behind. And again, that’s where you are asking about whether are there pure O obsession compulsion cases. Are there pure obsession compulsion cases? Because some people just feel awful if they don’t do the compulsion. And those can be tough to suss [00:28:00] out as well, especially if you’re also trying to differentiate between other diagnoses.

Dr. Sharp: Right. That’s a great question. I didn’t really think of it in the reverse, but I wonder, in your experience, have you found that folks who seem to have pure C behavior or presentation, that if you dig deep enough, there is some O behind it? Whether it’s, I don’t want to feel bad or this is going to be scary.

Dr. Erika: Yeah. I have several clients who come in with very clear contamination obsessions, but the compulsions are just so much clear than what they’re actually worried about. They can’t describe, like, I’m worried that I’m going to be sick if I do this. It’s really like, nope, just feels gross. It doesn’t feel like OCD because the obsession is just, I am so concerned with not feeling that discomfort.

And that’s often the [00:29:00] case in OCD or other anxiety disorders where the discomfort itself is what the fear is. And that can be considered an obsession. And then you can see it, you can see it play out in the cycle. I’m doing this with my head, I’m going in a circle. But you can see it play out in that cycle where you’re like, oh, you do the thing just to avoid discomfort, and then you come back.

So it’s really an obsession with, I don’t want to feel that way. I don’t want to feel contaminated even though when looking at that behavior with the naked eye, there’s nothing about it that’s truly contaminated. And that’s often the difference. If we’re thinking about differentials between OCD and anxiety, that’s sometimes the difference is that anxiety is an overblown worry that everyone has and OCD might be like, that doesn’t quite make sense. Like, I might be really worried about, for example, stabbing a family member and so I have to check all the locks. Okay. If that’s how the OCD cycle works for you, then that’s how it works for you. But it’s very different than for [00:30:00] example, in an anxious brain where it’s more of an overgrowth of other anxieties that folks feel all the time about school work, things like that.

Dr. Sharp: Sure. I’ve run into a few kids who have a lot of what would I call it, almost like conditional behavior or conditional statements. I don’t know if you’ve run into much of that, but like if this, then that. If I don’t take this number of steps on the way to school, then my family’s going to die later today, or something like that. Do you see much of that, and how does that fit into this whole?

Dr. Erika: Absolutely. Like the old saying, step on a crack breaks your mother’s back. That’s just like a tiny middle obsessional loop. But what’s interesting, and the more I dive into research with kids especially is that most kids have some sort of ritual that way, like a magic number, a lucky number, an unlucky number, or a favorite color. Like there are things [00:31:00] that kids do that look a little obsessional. And oftentimes they don’t hit the point of being functionally impairing or they also don’t stick around for long.

And they’re just like a little developmental blip. Like, oh, your brain got stuck on this thing for a year and now it’s moving on. But those if-then statements are very common among kids and among people with OCD as well. Again, you’re asking how long has this been happening. Was it functional impairment? But a lot of folks will say things like, well, if I have this image of stabbing my mom with a knife, then I will definitely do it. And OCD has convinced them that they will definitely do that. Then OCD gives them another if-then statement where if I tap the doorways three times before I walk through them, then I won’t hurt anyone. And that’s where you get to that like, oh, so your brain has somehow convinced you that this [00:32:00] is going to prevent you from hurting someone but if from an outside perspective we don’t see that connection.

And folks differ on how much insight they have into their own if-then statements. But often again, when we see that it’s not quite logical in some places I’ll remind folks, oh, like OCD is not logical, but OCD says what it wants to tell you. And then it becomes thoroughly distressing. And I think that’s the part that’s really helpful for parents to understand. For example, in feedback, it’s like, yeah, we know that this is not logical but it feels as though if kiddo doesn’t tap three times on the door, then they’re going to hurt you. And that feels so awful to your kid. Saying it that way sometimes helps parents to understand like, oh, that’s why they have a total meltdown going back to our previous aside.

Dr. Sharp: Right. Are there times when OCD behavior is actually developmentally appropriate?

[00:33:00] Dr. Erika: That’s a really good question. Because like I said, a lot of times those obsessions and compulsions are little blips on a typical developmental trajectory, and they don’t become full-blown OCD. I think in that way, yes. And there are also times that we see the obsessive-compulsive or even the anxiety cycle being totally developmentally appropriate like does it make sense for…

I have a lot of kiddos with either anxiety or OCD who have to say, I love you to their parents before they go to bed. That makes total sense. You want the last thing to say that you say to your mom or dad to be, I love you. Again, when it becomes problematic when mom or dad is away for a night and you have to call them 20 times till they pick up and answer it, then it becomes like, oh, this could be a problem, not just for the kiddo, but for the family system.

[00:34:00] I definitely think that those OCD things can be entirely developmentally appropriate until they cause a disruption in the kiddo’s life or sometimes in the family system and how the logistics of the family will continue to function if everyone is either accommodating the kiddo or not.

Dr. Sharp: Right. I’m going to ask you one more question about this area of diagnostics and so forth, and then I would love to get into the assessment and differential diagnosis part. But do you know much about postpartum OCD? So this is crossing over into adult stuff, but I’ve seen some examples of that as well. I’m curious if you have experience with that.

Dr. Erika: Yeah, as somebody who specializes in kids, teens, and young adults, I haven’t seen any examples of postpartum OCD in my own [00:35:00] work but in working previously for group practice on anxiety and OCD, obviously we see an increase in OCD symptoms for some people postpartum. And I think it’s really helpful for those who do psychological assessments for adults as well, is to think about, we often include postpartum depression, as a rule, out but we know that that increases with hormonal changes after giving birth, but we don’t always recognize that there could be obsessive impulsive cycles there.

Again, in drawing back to some of the previous episodes that I’ve listened to for you, it’s almost like I want OCD to always be a differential diagnosis especially when we think about like kids and teens, that’s often where OCD pops up but also in folks who are postpartum to make sure that we’re not leaving something out if we’re doing a full psychological on someone who just gave birth rule out depression, rule out OCD [00:36:00] because we know that that is a common presentation.

Dr. Sharp: Yeah. It’s fascinating. I’m just outing my entire family here. This is personal. I can’t remember if I’ve talked about this on the podcast or not, but there was a time, following the birth of our first kid, when I like absolutely was having intrusive thoughts. And that’s not normal. I’ve never really struggled with that, but absolutely having intrusive thoughts about hurting him, dropping him, like throwing him over the stair railing in our house, like accidentally, but on purpose somehow, like classic intrusive obsessional thinking. And I was the dad obviously. This is not the postpartum anxiety that you typically on, but it’s fascinating.

Dr. Erika: Yeah, it is fascinating because I always tell folks when I give an OCD diagnosis, it’s usually related to something that means so much to them. So when you think about it that way, when you have a kid, that [00:37:00] little being means so much to you that if there’s any genetic or situational propensity for those intrusive thoughts, they’re going to show up about that kid.

They’re not going to show up about your tomatoes in the garden because when you have a newborn you do not care. You do not have obsessional thoughts about throwing the tomatoes at the fence. You have obsessional thoughts about what if somehow I hurt this precious child. And I like to remind folks of that because sometimes people are like, why do I obsess over this? And I always remind people, it’s probably because we really care about it. You really care about your health, you really care about your family. Those are the things that usually pop up as obsessions.

And I think in working with a group practice of a lot of young parents, I remember every time we had a baby shower and someone had a newborn, they would poke at it, but everyone would come up with the same experience that you had. Like, now I check on my kid every five minutes. It’s not obsessive because we just care so much about that life. But again, I [00:38:00] think that helps us to understand for ourselves and the clients that are coming to us for help, why is this coming into my head? And it feels so much better to know like, oh, it’s OCD. It’s because I love my kids so much. That’s great.

Dr. Sharp: Sure. I like that reframe. That’s nice. Well, let’s talk about the assessment process. I am tempted to just start in the interview. If you’d like to start somewhere different, we can, but I’m curious, what does this assessment process look like? Again, just assessing for OCD and then we can get into the differential diagnostic realm.

Dr. Erika: Like I was saying before, I think my assessment process has definitely grown and shifted in response to my specialization in OCD and anxiety because now I include not just a screen for like, do you have intrusive [00:39:00] thoughts? But now I ask, are there weird images that pop into your head? Do you really worry about germs or hurting somebody but it seems like it’s coming out of nowhere?

I phrase it in the way that my clients phrase it to me when I’m doing therapy on that side. And then I phrase it that way in my assessment intake. I also always screen for those compulsions, like, are there specific repetitive behaviors, which we’ll get into this with the differential with autism. But repetitive behaviors, like specific rituals, bedtime rituals, and morning rituals, we all have those rituals.

But then I ask what would happen if you changed it. Would it totally freak you out? And that gets at the cycle of would it cause you distress if you changed it? Because really a part of that obsessive-compulsive cycle is that the compulsion is aimed at reducing your distress. You’re doing the thing to try to get rid of the worry because the worry is so awful. And then I always ask questions about functional impairment, but I give that benchmark of like, do you think that’s taken up an hour of your day? And some people will tell me a [00:40:00] few little obsessions, and they’re like, well, if I put them all together it probably takes up 2 or 3 hours. It delays my bedtime. Or I’m always late to work because I’m doing all these things. So, I think that’s helpful to think about.

And then I always ask about insight because per the DSM, you figure out if someone has really good insight, fair insight, or really poor insight. And as you can guess with young kiddos, they’re like, yeah, but I thoroughly believe that if I don’t do this, then something bad’s going to happen to my mom or my pet or something. Teens tend to be hit or miss. They’re either like, okay, I completely understand that this makes no sense. Or they’re like, nope, fully convinced. And adults are on the same bandwagon as young adults. College students that I see are either very convinced that what their OCD is telling them is entirely true, or they can see straight through it, but they still do the compulsion just in case. And sometimes those are the tougher ones to figure out.

But in the interview, I like to use the language that my therapy clients use. And [00:41:00] I always ask about big worries, intrusive thoughts, rituals, and then that functional impairment, is it getting in your way more than an hour of your day?

Dr. Sharp: Yeah. Do you find that people are ever protective of their obsessions and compulsions? Or do folks tend to want to get it out in the open and maybe change it?

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[00:42:00] All right, let’s get back to the podcast.

Dr. Erika: I think folks with OCD tend to want to get it out in the open. I’m thinking of another differential because OCD and eating disorders are so related or just overlapping.

Dr. Sharp: Oh my gosh, yes.

Dr. Erika: But an eating disorder is a fear of becoming fat and then obsession with food restriction or over-exercising, whatever. It’s a very similar cycle. But folks with traditional eating disorders such as anorexia or bulimia, they’re not going to tell you about that cycle. Their parents might, their partner might. They’re not going to tell you.

Kids with OCD are like, yeah, I totally do this thing. And it might be related to it, but no one’s really phrased that question to them before because most parents are like, why do you keep asking me the same question? Kids are like, I don’t know. But if they come in for an assessment, even if it’s for an ADHD or an autism assessment, because they think that’s, in general, our most common referral questions, I’ll ask them, do you do those [00:43:00] things because it just feels right or do you do them because you’re really worried about getting sick or hurting somebody? And they’re like, oh.

Sometimes they want to get it out into the open because it’s explanatory, just like we talk about in the testing process, I think every part of the assessment process is therapeutic. I think that that question in an intake interview can be really therapeutic for a young person with OCD.

Dr. Sharp: Yeah, definitely. I’m curious, as far as the way you structure your interviews and do just clinical decision-making about what to ask for, are you going into the interviews just generally asking about repetitive behaviors and repetitive thoughts and things like that and then deciding do I go autism, do I go OCD, do I do both? I’m curious just about. That’s a very poor question, but maybe you’re intuiting what I’m getting at? How do you do that?

Dr. Erika: From the beginning of the interview? How do I know what I’m really looking [00:44:00] for?

Dr. Sharp: Yeah. And then, how do you create or follow that decision tree in the moment of saying, I need to go down the OCD path here versus I want to go down the autism path, or maybe I’m going to do both?

Dr. Erika: That’s a good question. On my intake questionnaire, I ask about the core components of those, especially those two areas like core components of obsessive-compulsive disorder, obsessions, or worries, Intrusive thoughts are how I label it on the intake questionnaire. And then do you also have compulsions rituals or specific things that you always do in the same way? Knowing that compulsion ritual, things that you always do in the same way could be a component of restrictive repetitive behavior for autism spectrum disorder.

And then also on that list of symptoms for autism spectrum disorder, I include difficulty making friends, maintaining friendships, understanding social relationships, but then things like specific interests, things like that. And most [00:45:00] parents respond to these intake questionnaires so they know which things they’re concerned about for their own child. But then when I get actually to the intake and I’ve already reviewed which things they checked off, whether or not they checked off those boxes, I’m going to ask that major question. What do you want to know from this assessment?

And usually, parents are pretty well-versed. I am in the Austin area, so parents come in, I would like to know if my child is on an autism spectrum disorder. I’m like, okay, that’s great. I’m glad you read a lot about this, you’re prepared for that diagnosis if it’s there, awesome. And if I have someone asking about autism anxiety disorder, I ask them, what makes you think that that might be what’s going on? Most folks have a few specific examples. They’ll say like, my kid’s been hand flapping since they were three, or they just don’t have any friends. And depending on what their main reasons for asking that question are, that flags me into entirely different areas of my general [00:46:00] intake interview.

If they’ve been hand-flopping since they were three, I ask about obsessive-compulsive symptoms and ticks because that could be a tick if it’s not related to autism spectrum disorder. I want to rule that out. If they say, well, my kid doesn’t have any friends, I’ll ask, did they have friends before or is this like a new social anxiety withdrawal? Or have they always had trouble making friends? And what do you notice when they interact with peers?

Usually, I end up going through at least two or three, or four sub-areas of my diagnostic interview to make sure that I gather enough information to really differentiate. But I like to go back to folks’ initial question of like, well, does my kiddo have autism? Maybe. But what makes you think that? And why? Or if they say, I think I have OCD. Sometimes they’re coming in from another OCD therapist but sometimes they’re like, my other therapist who doesn’t specialize in OCD thinks I have OCD. And that’s when I have to [00:47:00] ask all of the questions, like, let me understand those obsessions compulsions, but also I’m going to ask you if those restricted repetitive rituals occur in the context of any social difficulty.

Dr. Sharp: I got you. This goes without saying, but this is why we theoretically get paid a lot to do what we do. This is not an easy job.

Dr. Erika: I like to tell folks, this is why I spend hours and hours on each psychological assessment. I don’t want to answer your question without a ton of data and information because otherwise, my answer is useless.

Dr. Sharp: It’s so true. Well, let’s talk about the formal assessment process. Is there is anything else you might want to add to the interviewing process or questions things we need to be looking for, asking about, that we haven’t mentioned?

Dr. Erika: I think the interview process is more, especially at the beginning, before I have any [00:48:00] data, I want to know what you think and what you think is most important. And then if I’m noticing like you’re telling me a lot that it sounds like OCD, then that’ll obviously guide my process. But what’s interesting, I think if we think about particularly the differential between OCD and autism spectrum is if I have a suspicion of OCD or autism spectrum, I’ve got another giant clinical interview that I’m going to pull out either the ADI-R or the CY-BOCS-II. And I’m going to spend another hour or two really diving into just one section.

So, it’s a clinical screening interview and then a really intense interview about one or both sets of those symptoms. And then I’ve got a bunch of other data and I think that we right into my testing day to make sure I get anything else that I might need to answer that question.

Dr. Sharp: Yeah, sure. You bring up an interesting point that is crossing the bridge into formal assessment, which is when do you pull out some of these [00:49:00] narrow band questionnaires or interviews or whatever you want to call them in this process?

Dr. Erika: Yeah. I think our work is so strangely dictated by billing and insurance and consent forms and things. Like I said, as a professional, I thoroughly believe that even in a therapeutic process, assessment is part of that therapeutic process. You’re providing psychoeducation about what’s going on in someone’s brain. But at some point, for specific diagnoses, and I think this is just the way the industry has worked is that when someone asks me, well do I have ADHD or do I have autism spectrum disorder? I say, well, that takes a more thorough assessment. I’m not going to tell you that in my hour-long intake session. There’s just no way. And that’s when I usually refer them either to another professional I know or to my own waiting list I think we should do this process and I think this is going to be really helpful.

[00:50:00] And there’s also that gray area where if I have a client who I’m pretty sure has OCD, I will sit with them for the second session after the broad-based interview session and then do a full CY-BOCS and make sure that I really understand the intricacies of their OCD. Sometimes because I’m their therapist and I’m going to treat it, or sometimes because I’m going to send them back for another evaluator to complete that assessment or do it in my own practice. So there’s a very gray area there I think for a lot of clinicians who are well versed in assessment and in therapy to make sure that we pull out those assessments at an appropriate time and make sure that we’re giving the right recommendations or resources.

Dr. Sharp: Yeah. You’ve mentioned the CY-BOCS two times. What is that for anyone who may not know?

Dr. Erika: The Yale-Brown Obsessive-Compulsive Scale, for kids, starts with C, [00:51:00] the Children’s, and it goes through all of the lists of obsessions. And I like to use it for folks that are not quite sure if they have obsessions because it goes through that list of things that sometimes come up as obsessions that like we talked about are not that common. And then it goes through a whole list of compulsions that, again, are really common ones like hand washing, and the ones that are not so common.

And then the new one, the CY-BOCS-II has a whole section on avoidance which is another of my favorite categories to think about because I think it captures some of that wondering if there’s really a compulsion there. The compulsion is sometimes just avoidance. And then it goes through and quantifies those symptoms. I find it very helpful in adding to the data set in a psychological assessment in that it gives you some numbers. Numbers are great to put on your data summary and describe it to [00:52:00] someone that when they’ve gone through hours of testing and describe to someone what that clinical interview comes out to be.

I think in a traditional clinical interview we’re like, we think that you have this diagnosis but with a CY-BOCS, like I was talking about the ADI-R, it also gives you some quantitative results of this is what I think is going on here because of the responses that you had compared to these clinical diagnostic criteria. It also really helps to determine severity because it lets you know how much, and how often those obsessions and those compulsions are getting in the way of someone’s life.

Dr. Sharp: Yeah. Are you doing any other standardized interview rating scales to get at OCD symptoms?

Dr. Erika: Specific to OCD, not really. Usually, if someone is coming in for concerns with OCD, I also do standard emotional behavior rating scales like a BASC [00:53:00] because often the anxiety scale will pop up really high because the obsessions are really high. Or with kids, I’ll do a SCAS or RCADS `to rule out other parts of anxiety, especially because OCD is so often comorbid.

Sometimes with those data, obviously, we’re taking them within the context of our interview and making sure we know. I have a person who was avoiding leaving the house but not because they were socially anxious. It was because of the OCD and contamination. So helping us to inform those things with just a little bit more data to rule out if OCD is causing problems in other areas or if it’s comorbid with other anxiety disorders, possibly.

Dr. Sharp: Yeah, that makes sense. I don’t know if there’s any research to support this, but just anecdotally, I’ll see sometimes that atypicality scale on the BASC will pop a little [00:54:00] bit with like strange behaviors and sometimes […].

Dr. Erika: Yeah, it depends on what the compulsions are. I was taught in my training also to look at that for autism spectrum disorder. But sometimes it’s elevated and sometimes it’s not depending on the severity of autism spectrum disorder because some folks can blend right in and other folks are doing some really interesting ritualized or repetitive behavior and I think both OCD and autism could easily pop up there.

Dr. Sharp: Yeah, absolutely. Well, is there any value in the testing, like in the cognitive testing that may help us differentiate or diagnose OCD?

Dr. Erika: With OCD, if I am really concerned about, like, I actually have a few in my assessment pipeline right now where someone comes in for an OCD assessment, I’m like, okay, I’ll do an assessment, and maybe we’ll start therapy. But then I have a [00:55:00] million other questions about, is this also ADHD or is it autism spectrum? I’m going to need to do more questionnaires, and more clinical interviews to really answer that question.

I think the only reason is if I were trying to rule in or out OCD or differentiate between OCD and, for example, autism spectrum or ADHD, I know that the cognitive profiles that I’ll typically see, for example, somebody on the spectrum might be really random and have a lot of highs and lows. But with OCD, most folks tend to have a really typical cognitive profile that there are highs and lows, but they’re not as dramatic as we might see from somebody on the spectrum.

And obviously, there are exceptions to that general pattern but again, and I have two of these in my pipeline where I’m thinking, well, this could be OCD, but is there also comorbid ADHD because that’s going to really complicate the treatment of OCD a little bit? Then I’m looking [00:56:00] at, are there difficulties with processing speed, working memory, or other executive functioning things that could get in the way of OCD treatment?

I think when you think about assessment as it’s not just for what is the appropriate diagnosis, I feel like my question is really what are the appropriate recommendations and what is going to have to be done in a therapeutic setting in order to treat whatever the primary diagnosis is because even if young kiddo has OCD, if they also have ADHD, that became my therapy specialty at my previous group clinic, then you’re going to have to do a lot of other behavioral things to support them in doing ERPs. That helps me to understand more. So looking at that data, not what is the appropriate diagnosis, but also what’s going to happen in the therapy room to make that diagnosis easier to manage.

Dr. Sharp: Yeah. Speaking of ADHD and OCD, [00:57:00] this is one of those things I don’t know if you have this thing where I heard it in graduate school maybe, and then just hung onto it over the years without checking to see if it’s right or not, but this idea that ADHD and OCD and Tourettes are all like very closely tied together genetically. Is that real? Is that true?

Dr. Erika: I haven’t heard the same research on OCD and ADHD together. I do see them very commonly together. And I guess in general, I know I was saying, because of my experience with parent training and PCIT, I tended to get all of the ADHD cases at my previous clinic. But I feel we have a lot more research now on OCD and Tourettes, like Tourette, OCD in ticks, and all of that stuff. So I often look at that as a genetic cluster. But we also recognize that for folks with ADHD, there are just so many common comorbid diagnoses.

[00:58:00] Those are the kiddos. And I also work with kiddos who have PANS. When you look at it that way, PANS or pandas also often look like OCD, ADHD, anxiety, and parents just come in saying, my kid has alphabet soup. Like, I just have all of the things.

I think in looking at that from a diagnostic perspective, ADHD is one of the common things that we probably diagnose in our work, but also just one of the most common diagnoses that we might give from the DSM, it is very often comorbid with OCD. But I don’t particularly know the research on the genetic component there.

Dr. Sharp: It’s good motivation for me to go and actually look it up again

Dr. Erika: To keep looking up the things that we remember from graduate school and we’re like, is there new research on that?

Dr. Sharp: Yeah. Seriously. Especially at this point in time. That was not a short period ago.

[00:59:00] Let’s get into the real differential diagnostic picture. I would love to start with autism just because that for me is the more challenging differential diagnosis between OCD and other things. I’m curious how you approach a differential diagnosis with OCD and autism. What are the distinguishing characteristics?

Dr. Erika: I think one of the clearest distinguishing characteristics there, is if someone comes in with like, well, I have this specific bedtime ritual, which is like very common in kids and teens, if they have that ritual and if you change it, they get upset, like that’s not helpful differential because kiddos on the spectrum might have difficulty changing that ritual routine. But again, that’s where I ask those questions and look for the data on, is this kiddo really having obsessive [01:00:00] worries that are related to that ritual? But then you’re also diving into all of the other data that you can collect from questionnaires, structured interviews, and ADOS. Are they also really having that social difficulty because rigid and ritualized behavior is one thing?

For example, I had a kiddo more recently that was very rigid but super social. And it’s actually really hard to find that post covid lockdown in 2020 because I feel like a lot of kids have become less social because there have been fewer opportunities for that social development. But then when you put them in a standardized social situation where an adult is observing their interactions like the ADOS, it’s pretty clear that they can tell you a story. They can be creative, they can make eye contact. Like it’s easy to rule that out in some cases. I’m not saying it’s always easy.

The other things that I look for, [01:01:00] in OCD versus autism, a lot of kiddos on the spectrum, and this is not part of the diagnostic criteria but it can be, with the difficulty making changes in routine that transitions or changes can be really hard. I hear that a lot from kiddos who might be on the spectrum or from kiddos who might have ADHD that transitions are hard. But for OCD alone, those transitions aren’t really a big deal unless it’s something to do with their compulsion. If they haven’t changed their compulsion, then they’re not going to transition.

But I usually ask, and this helps with ADHD, OCD, and autism is like, can they transition from their preferred activity, usually screen time, to a less preferred activity, or does it usually cause a tantrum where they just want to go back to the preferred activity or a meltdown where they’re just freaking out and they’re not even able to enjoy that preferred activity anymore? Because that differentiation is really helpful in figuring out, well, if it was OCD, [01:02:00] they might have a meltdown. If it was autism, they might have a meltdown. If it was ADHD or maybe oppositional behavior, they might have a tantrum and just not let go of that iPad.

But figuring out and observing that behavior, I think the difference between a clinical interview and an observation of all the things that we do in a psychological assessment is super helpful because I use iPads and Q-Interactive for all of my cognitive testing. So if Kiddo is not able to transition from that just because they have an obsession or a specific, I’ve had kiddos with OCD with a very specific ritual about their iPad and how they turn it off and how they dock it, that might look really different in kiddo who’s got something else going on.

Dr. Sharp: Great. Is there any other way that you think of differentiating, especially those repetitive behaviors and like sussing out, is there a different quality for autistic kids [01:03:00] in terms of like “compulsive behavior or just repetitive behavior” compared to OCD?

Dr. Erika: Yeah. There was a really good example. We were talking at an OCD-like case conference that I attended recently where someone brought up an example of a kid who had a very strong obsession with a specific type of toy. And then we see that a lot in kiddos on the spectrum. And this particular person was really upset that they couldn’t keep buying that toy. That was their obsession, that they wanted to keep buying it and collecting more. But the question that was asked that I thought was so helpful is, do they enjoy it? Do they enjoy playing with that toy? Is that something that they want to do or is it something like, I don’t want to play with the toy in this way? It’s emotionally distressing.

Most people on the spectrum or with OCD do not want to continue doing their compulsions. They are annoying and not fun. I don’t want to keep doing this. I don’t want to keep arranging my toys this way, [01:04:00] but it feels like I have to, versus someone who’s just collecting toys because they have a very specific interest and who might be on the spectrum, then that feels like, oh, they’re really enjoying this. They’re much more into this than other kids their age. That differentiation between like, are they lining up all the toys that they have collected because they like their toys and they have a very restricted interest in those toys or are they lighting them up because if they don’t line them up correctly, their OCD makes them feel awful?

And again, that comes down to, have we done a full interview of all of the different things because often with OCD we’ll also have multiple areas of the session. So, it’s not just that one thing versus folks on the spectrum, they might have a few specific interests but most people that I talk to will say, well, they like this, this, and this. And those are the things, those are the topics. That’s what they go back to. Versus somebody who is experiencing obsessions, they might have obsessions in five or six different areas. And that really helps me to say [01:05:00] like, that might be one of their obsessions if it’s not a very clear specific interest to them.

Dr. Sharp: Yeah, that makes sense. I like that. That’s a good point. Let’s talk about, I’m particularly interested in OCD versus phobia, especially when you talk about avoidance as a compulsion. That’s really interesting to me. What are your thoughts on that?

Dr. Erika: I think what’s interesting about OCD and anxiety disorders in general, including phobias, is that avoidance is one of the biggest contributors to that cycle that continues the psychological disorder. For example, a phobia, if you keep avoiding it, I love using this personal example for me because my mom taught me to fear spiders and I avoided spiders and I still don’t like spiders. But since buying my house and having a bunch of spiders crawls under my door, I can’t avoid them. I got to get rid of them somehow. So [01:06:00] changing that avoidance has helped me to reduce that phobia.

But when you think about that in this cycle of OCD, again, sometimes it comes back to the theme. And it comes back to we know that arachnophobia is a very clearly defined phobia. And avoidance of that is pretty typical. It’s an overgrowth of very common anxiety. A lot of people don’t like bugs and creepy crawlies, but a specific phobia, which I see a ton of insect phobia, which sounds awful being here in Texas because the bugs are huge. But we do exposures to them and it gets better.

So when you think about it that way, that avoidance is just excessive avoidance instead of a compulsive ritual where you have to check the door a million times and put specific things all over the house and ask your partner a million times, did you kill that spider? That might feel more [01:07:00] compulsive. But avoidance is sometimes on its own indicative of that could be a fear of phobia and anxiety. But when that avoidance is coupled with a full compulsive ritual, and again, like I was saying before, OCD is rarely one obsessive-compulsive circle.

There are often multiple obsessions and compulsions, which is why I love doing a Y-BOCS or a CY-BOCS and figuring out all of the different cycles that we might have versus the reason that I love treating specific phobias and diagnosing specific phobias that we’re pretty confident we can make that a lot easier to handle in a few exposure sessions. Whereas OCD tends to be whackable that even if I address that one specific avoidance, it might pop up somewhere else and come up with a different fun compulsion for someone to do.

Dr. Sharp: That’s fair. What are the other major differential diagnoses that we might want to talk about?

Dr. Erika: [01:08:00] I think if we’re talking about OCD versus everything else I think if someone comes in with a question of OCD or autism, I almost always, and I’m sure a lot of assessment psychologists do this as well, I almost always have a screening in place and do some cognitive and executive functioning measures to rule out ADHD because if a kid with OCD symptoms like they’re throwing tantrums or meltdowns, it’s hard to tell when you’re first working with a family, is that difficulty with managing that emotional dysregulation or are they responding with a compulsive avoidance that often becomes a meltdown in order to avoid that feeling of discomfort?

And because we know that kids with ADHD do struggle with, or individuals of all ages with ADHD, [01:09:00] struggle with that executive functioning and being able to respond calmly and coolly in the face of emotional distress versus impulsively throwing a bit and trying to get what’s happening away from them, I like to rule in or out ADHD to make sure that: A, it’s not also in the way of treating the OCD, but B, that some of those meltdown behaviors that especially young folks with OCD tend to exhibit are not also, or instead explained by ADHD.

Dr. Sharp: Sure. That makes sense. Let’s see. We have covered a lot of ground over the past hour or so. What else feels important? Now, I know we could dive super deep into any of the topics that we’ve brought up, but as far as walking away [01:10:00] today, anything that you want to throw out there that we may have missed or want to keep on people’s radars as far as assessing or differentiating OCD?

Dr. Erika: Yeah, I think it’s just really helpful to recognize, like, we’ve been talking a lot about OCD versus everything else, but I think in our training for psychological assessment, I know I didn’t get a lot of like in-depth training on OCD before I started treating it. So I think using OCD as another differential on your radar and just another quick set of questions like, do things pop up in your mind? Do you do specific rituals because of those things? Even if you add those two little questions to an intake interview for your assessment, it opens up the possibility of catching more folks who do have OCD or have OCD possibly that explains some of the symptoms that came in for the assessment or in addition to some of the things that brought them in for the assessment.

And I think [01:11:00] as assessment providers, we are just always, I feel like my intake interview question list has become so long. But also I always want to have at least one or two screener questions for each of these different areas to make sure that I am really properly diagnosing and supporting the clients that come in because I think as we all go through our training and meet more clients, we learn more about what other presentations might show up. And like I said before, if we’re not screening for those things or if we’re not asking those specific questions, we might not be providing the best possible recommendations.

And I know that’s everybody’s goal. Whether you’re on the client side or on the provider side, we want to make sure that we’re providing good recommendations. I think in that vein, we haven’t really talked yet about the difference between how you would treat an OCD ritual rigid behavior versus an autism spectrum ritual rigid behavior.[01:12:00] That might be another rabbit hole.

Dr. Sharp: Yeah, that’s so true. And we said we were going to talk about kids who have both autism and OCD.

Dr. Erika: Yes. Which one should we tackle first?

Dr. Sharp: Let’s do the identification and then we can do the treatment. How about that?

Dr. Erika: Okay. Yeah, that makes sense logically. In thinking about folks who might have both OCD and autism spectrum disorder, we do this all the time with differential diagnoses because we know, I’m sure you have previously diagnosed someone with both autism spectrum disorder and ADHD, which just means that their executive dysfunction and their inattention hyperactivity-impulsivity must be above and beyond, but we would expect from somebody on the autism spectrum.

And I do the same thing with OCD. If I’m certain and positive that someone either has OCD or autism spectrum disorder, [01:13:00] then with those rituals and rigid behavior, I have to be very sure that if someone’s on the spectrum and I’m also diagnosing OCD, then their rituals and rigid behavior are above and beyond what you would expect from someone on the autism spectrum.

It might not just be that they need a very clear specific schedule for the day and transitions are really hard for them. It might also be, and this is where we look at like obsessive-compulsive symptoms that are very clearly separate. For example, if someone on the spectrum has contamination OCD, it’s going to be pretty clear that they have a hand-washing ritual that might totally play into their autism spectrum rituals and rigid behavior, but their hand washing becomes a functional impairment. It is either taking up too much time or causing them to have cracks in their hands. Or they have a separate obsessive-compulsive cycle, not around a specific routine or ritual but it looks more like a mental [01:14:00] compulsion like they always count the number of steps that they take. That feels much more like an obsessive ritual if it’s causing functional impairment versus an autism spectrum ritual that might be related to their specific interests or that might be more repetitive in nature.

Dr. Sharp: Sure. I like it. That’s a nice explanation. You really have to think about above and beyond. And the ADHD example is a good one. We do that fairly frequently.

Dr. Erika: Yeah, I think those are the most common things that pop up for us. So then when we add in more differentials, we just have to make sure there are totally things that overlap. I’m staring at my handout with all of the overlapping symptoms. There are always going to be things that overlap. Even in like basic anxiety versus depression debate, there’s tons of overlap between those two things. So, when you’re looking at that differential diagnosis, we look at whether is above and beyond, and [01:15:00] are there things that are very clearly separate from one of those diagnoses, but indicate that something else is going on there and is causing functional impairment?

Dr. Sharp: Sure. Let’s talk about the treatment component. We can just maybe tackle this small slice of treatment for each of these groups. But how do you approach the treatment differently with these?

Dr. Erika: I think I can approach this question because I know that folks who listen to the podcast are testing psychologists, so they’re looking at what do I write in my recommendation section if I am diagnosing OCD or autism spectrum disorder or both. As somebody who very frequently treats OCD and less frequently, but often also treats folks on the autism spectrum for therapy, my recommendations have definitely changed in the time that I’ve spent with my therapy clients, in addition to my assessment clients.

If I’m giving recommendations related [01:16:00] to obsessive-compulsive disorder, I am a huge stickler for making sure that they receive cognitive behavioral therapy, but it must include exposure and response prevention. And I don’t want to send them to someone who only treats anxiety and depression, which uses a lot of cognitive restructuring, which could totally get in the way of OCD as we know that we really want them to be focused on those exposures. I think more recently, I’ve been diving into the research on acceptance and commitment therapy and making sure that as they’re doing those exposures, folks are ready and willing to do those exposures. Because obviously, that’s the toughest part about doing anything that’s going to challenge an obsession or a worry even in anxiety treatment. And I think that can be complicated if there are obviously comorbid diagnoses like ADHD or autism where it’s more [01:17:00] complex to deliver an exposure and response prevention type treatment.

And then on the autism spectrum side, obviously our gold standard treatment, and the reason that a lot of folks come in for assessment is to get that autism spectrum diagnosis so they can access ABA therapy. I know there’s a lot of research out there on ABA therapy and also making that very constructive and caring and supportive of the folks that we’re treating on the spectrum to make sure that we’re helping them to build up those behaviors that function for their own lives and for the families.

Working with kids and teens, and I think in general, my client population is students- it’s pre-K to college. So that has a lot of different meanings for someone on the autism spectrum, getting services in school or being able to access [01:18:00] special education automatically because of an autism spectrum diagnosis, no matter really how severe their symptoms are, versus, I know for a lot of my folks that I’ll diagnose OCD. I live in Texas and a lot of schools will be like, that’s just like a 504. Is that all they need? That’s fine. And sometimes that’s totally true. And sometimes it’s a true emotional disturbance and it’s not allowing them to finish their homework because their handwriting has to be perfect.

I tend to be very clear in my recommendations that because of this diagnosis, either OCD or autism spectrum, they would probably qualify under this area of the special education law to make sure that my student clients are able to get either the 504 services or the special education services that they need, as well as I, was talking about, those outside therapy services that are evidence-based for the diagnoses that we settle on.

Dr. Sharp: That sounds good. [01:19:00] Well, like I said, I know there are so many different branches of this trail that we could follow. And I think this is a great overview. We got into detail on certain aspects of the topic, which I think will be super helpful for folks. But I’m really grateful for your time and expertise that you were willing to come on and share and your tolerance of my personal stories and for making this about my family members. Thanks for that.

Dr. Erika: Yeah, of course. This was really fun. I think personal stories always make things more accessible to ourselves as clinicians because we’re people first, but also to our clients when we’re explaining like, here’s a story that makes sense when we’re describing this differential or this cycle of what’s happening.

Dr. Sharp: I appreciate that.

Dr. Erika: That’s definitely relevant to our OCD versus everybody’s rabbit hole.

Dr. Sharp: There you go. That’s very validating. Well, it was great to connect with Erika, and [01:20:00] hope that we talk again soon.

Dr. Erika: Of course. Thank you so much for having me.

Dr. Sharp: All right y’all, thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.

If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes or Spotify or wherever you listen to your podcasts.

If you’re a practice owner or aspiring practice owner, I’d invite you to check out the Testing Psychologists Mastermind groups. I have mastermind groups at every stage of practice development: beginner, intermediate, and advanced. We have homework, we have accountability, we have support, and we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the [01:21:00] details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call and we will chat and figure out if a group could be a good fit for you. Thanks so much.

The information contained in this podcast and on the Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests [01:22:00] of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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