Managing OCD and Anxiety: Expert Insights from Dr. Robert Zambrano

In this episode of The UpTick, I chat with Dr. Robert Zambrano, a clinical psychologist and cognitive behavioral therapist specializing in Tourette Syndrome (TS), Obsessive-Compulsive Disorder (OCD), and anxiety disorders. Dr. Zambrano shares his journey from an OCD-focused practice to becoming a key figure in the treatment of Tourette's, discussing the overlap between TS and OCD and the unique therapeutic approaches he uses. 

Dr. Zambrano is a certified expert in Cognitive Behavioral Therapy, particularly in Exposure and Response Prevention (ERP) for OCD, and has been working with patients since 2000. He is also involved with the NJCTS Tim Howard Leadership Academy and specializes in treating persistent tic disorders and body-focused repetitive behaviors (BFRBs). His practice, Stress and Anxiety Services of New Jersey, offers specialized telehealth services for anxiety disorders.

Episode Highlights:
[1:25] - Dr. Zambrano shares how he unexpectedly entered the field of Tourette Syndrome through his work with OCD.
[6:14] - Discussing the overlap between Tourette Syndrome and OCD and the percentage of people with TS who also have OCD.
[10:23] - Delving into "tourettic OCD" and how it differs from standard OCD, with real-world examples from Dr. Zambrano's practice.
[14:50] - The importance of practicing therapy techniques like Habit Reversal Training (HRT) at home and integrating them into daily life.
[18:07] - Addressing anxiety in people with Tourette’s and how it can exacerbate tics.
[27:30] - Understanding cognitive therapy and the power of recognizing that we don't have to act on every thought our brain produces.
[39:22] - How to respond when others don't react kindly to tics and the importance of finding your tribe.

Links & Resources:

Dr. Robert Zambrano’s Website: http://www.stressandanxiety.com

Remember, each story shared on this podcast brings light and understanding to the diverse experiences within the Tourette's community. Your journey is your own, and it's filled with potential and promise. If this episode resonated with you, I encourage you to like, share, and leave a review to help us connect with more listeners.

Transcript

Dr. Zambrano: 0:00

They have that in common, that when when people with Tourette's engage in tick behaviors, what they're really doing is they're sort of Metaphorically speaking, scratching an itch. There's an urge that precedes the tick behavior they engage in the behavior that urge subsides with OCD. It might be more of a sensation or a thought, right? So the common example might be, I touched something that my mind tells me might be contaminated, that thought causes me a great deal of anxiety, and so I engage in some kind of safety behavior of excessive washing or perhaps avoiding touching things, and then the anxiety may subside, right? So it's a similar mechanism, right, that we engage in behaviors aimed at alleviating uncomfortable sensations or thoughts.

Michael Leopold: 0:43

Welcome to the uptick, brought to you by The New Jersey Center for Tourette syndrome and associated disorders, empowering children and adults through education, advocacy and research, by sharing the stories and experiences relevant to the TS community. Welcome back to the uptick. I am here with Dr Robert Zambrano. He's a clinical psychologist and cognitive behavioral therapist in East Brunswick, New Jersey, and he specializes in Tourette anxiety and OCD. Dr Zambrano, it's great to have you here.

Dr. Zambrano: 1:18

Great to meet you, Michael. It's

Michael Leopold: 1:19

a pleasure to be on the program. We'd love to hear a little bit about how you first got into the Tourette space. Yeah, it

Dr. Zambrano: 1:25

was really unexpected in my life. Actually, I remember in grad school, of course, like most psychologists, learning about Tourette syndrome as just an interesting part of the DSM, and not really getting a whole lot of training in it at that point. I didn't, don't think our program really had much to say other than this is what Tourette's Syndrome is. I catered my career. I sort of was really interested in the niche of OCD. That's been something I always had a passion for treating. And as a cognitive behavioral therapist, I really love that there are evidence based therapies that we know are really effective for helping people with OCD. So that's always been something I've been attracted to, just the idea of sort of following treatments that the research says this is the way to go. And at the time, cognitive behavioral therapy wasn't as popular as it is now. So it was really a nice time in my career to carve out an area where I was sort of well known for being the guy in my year of school who was really interested in that, like, super passionate about it. So fast forward, a few years later, I had just left working at a psychiatric hospital in Secaucus that I really enjoyed working at, but pursued my dream of working in a private practice. So I joined. It's been 18 years now the practice that I'm working at now called stress and anxiety Services of New Jersey, and at the time, it was taking a little bit longer to build up a caseload, right? And so most of us in the world of private practice know that you get paid per the amount of clients you see. And I was in a relationship with somebody who I was very interested in continuing that relationship with, and we were living together talking about marriage. And so I said, All right, let's, let's get moving with this. But I need to make a little bit more money, because engagement rings and weddings are no cheap thing. So I kind of put the word out there that I was looking for some extra part time work, not hearing a lot. And then one of my mentors from my grad school, Dr Lou Gatwick, sent me a random email one day said, Hey, I heard you were looking for something. You're at Rutgers and you're in the graduate program that I attended, were actually looking to add somebody to work with our Tourette Syndrome program. They had already had somebody well established who really knows her stuff, Dr Lori Rockmore, shout out, Lori. Here's this who was heading up that program, but they wanted to add another licensed individual to the staff to help out with with having that program move forward. So I said, Great, wonderful opportunity. Problem is I knew nothing about Tourette's. Lou said, You'll be a natural. You're an OCD guy. We remember that this was your niche. This is something that you're really passionate about, and there's a lot of overlap. And it did so happen at that point in my career, because our practice is really well known for treating OCD that I was, I was seeing a lot of OCD cases and starting to see a few Tourette's cases here and there, even though what we know is most people with OCD don't have Tourette's, a lot of folks with Tourette's do have OCD. So there is some overlap there, neurologically speaking. And so if you treat enough OCD, you're going to see a lot of Tourette's over the years. If you do it long enough. I said, Sure. Why not? You know, it'll be good just for my private practice work as well to learn more about this disorder. So I joined, and the funny thing was, the first day of my training with Dr Rockmore and hearing from, you know, some of the big experts in the field, totally blanking on the name right now, but we had a big time speaker. I was really excited to learn more about Tourette's and work with Tourette's the day before, the person who I was hoping to buy an engagement ring decided that she made me want to end the relationship instead. So that was a sad but weird origin to my introduction to Tourette syndrome. I was really just looking for another gig to make a lot of money. The side, but, well, two wonderful things came out of it. Number one, I eventually met and married a different woman who I'm still married to today, and very happily so we have a lovely, amazing family. But the second wonderful thing that came out of it was really sort of getting in contact with an amazing community and learning about, I think, really at the time, and hopefully less so now an underserved population of folks with Tourette Syndrome. So it was really just fascinating to learn more and more about effective therapies for people with Tourette's and away we went. So I worked at the Tourette Syndrome program at Rutgers University for a few years, and then as my caseload built up, I had to make the difficult decision of leaving the program so I could focus a little bit more on my private practice work, but I to this day, continue seeing a number of folks with Tourette's Syndrome. Typically, most of the time they come through the door during their elementary school years and into their teenage years, but every now and then, we'll get an adult as well who comes in who'd like to learn a little bit more about managing either verbal or motor tics.

Michael Leopold: 6:00

You mentioned the CO occurrence of Tourette and OCD. And as many of our listeners know, around 50% or so. Yeah, which rat have OCD? Seven actually should ask you. You probably know the updated stats on that, how prevalent is OCD in the truck community?

Dr. Zambrano: 6:14

And what I've seen, it's pretty steady around those numbers, right? So, so depending on what study you'll see it's usually hovers in the 5055, 60% range, but over the years, it's stayed pretty consistent in terms of that's the overlap that you tend to see. Do

Michael Leopold: 6:29

we notice any differences in OCD when it is coming along with Tourette versus OCD as a standalone condition?

Dr. Zambrano: 6:37

I mean, I think, as with lots of things, with Tourette's, it's so idiosyncratic, right? So it depends on which person you're working with. So I would say, in general, when I work with people who have both Tourette syndrome and OCD, the OCD isn't radically different than a person who has OCD that doesn't have Tourette Syndrome. There can be a lot of overlap, right? In terms of Tourette Syndrome, sometimes we prefer people refer to something called heretic OCD, right? In other words, that's an OCD that's based on doing things in a way that just sort of feels right, right? So it's not that sort of rhyme or reason that we get with a lot of OCD, as in, like, I tap something three times and almost as a superstitious kind of act, then my intrusive thought goes away, or at least subsides, because I've done some sort of compulsive behavior aimed alleviating anxiety with tritic OCD. It's almost like I do something until it just sort of clicks. And so it's a different mechanism for alleviating that anxiety, but it's, it is repetitive in nature, and it still has the same goal of sort of, again, alleviating anxiety. And I think that's that's kind of common as an overlap between OCD itself and Tourette's, you know, as two completely distinct disorders. We can say they have that in common, that when, when people with Tourette's engage in tick behaviors, what they're really doing is they're sort of, metaphorically speaking, scratching an itch, right? There's an urge that precedes the tick behavior they engage in the behavior that urge subsides with OCD. It might be more of a sensation or a thought, right? So the common example might be, I touched something that my mind tells me might be contaminated, that thought causes me a great deal of anxiety, and so I engage in some kind of safety behavior of excessive washing or perhaps avoiding touching things, and then the anxiety may subside, right? So it's a similar mechanism, right? That we engage in behaviors aimed at alleviating uncomfortable sensations or thoughts. But in terms of, again, your original question, is there a big difference in between the OCD that people with Tourette's have versus the OCD people who don't have Tourette's has not necessarily. What we might find is a lot of folks with Tourette's may have a little bit more difficulty with frustration tolerance. They may have a little bit more difficulty with impulse control. So it's really hard, just from a clean OCD perspective, right where we say we're asking somebody to tolerate discomfort. So the therapy, as I'm sure a lot of your audience has heard the main therapy, what the research backs for years and years and years, is what we call exposure and response prevention treatment. If you've been in the field longer, like someone like me, the old literature would call it ERP. You see more and more these days people calling it ex RP, but in both cases, it stands for exposure and response prevention. So ERP is essentially whatever it is that might trigger that uncomfortable OCD feeling. We're going to trigger it on purpose, and then we're going to train people to suppress the response, the compulsive response that's aimed alleviating that anxiety, and instead, teaching them to tolerate, to sit with these temporary, but perhaps very intense and unpleasant feelings. Right now, you take a person with Tourette's who might have a much harder time with that again, maybe lower frustration tolerance threshold, might tend to be more impulsive in some of their behaviors. That might be a more difficult protocol to execute. The response prevention portion of it, the triggering any we could trigger anybody who has OCD if. Getting them to sort of withhold that, that response, I'd say that would be a difference that you sometimes see, not always, but sometimes seeing folks with threats that it's a little harder for them to resist the compulsive behavior. But on the flip side, somebody who doesn't have OCD, who just has really intense OCD, might report the same thing.

Michael Leopold: 10:18

I mean, Chris, you can elaborate on that other the treatment of more of that touretic OCD,

Dr. Zambrano: 10:23

sure with a toretta OCD, so I'll give you an example, somebody who I worked with many years ago their Tourette OCD, was not thought based. It wasn't I need to do this, or else something bad will happen, right? Which is very common with OCD, right? So again, I need to wash my hands, or else I'll get a disease, or else this experience discussed toretic OCD might be more along the lines of, I just have some sort of sensory experience, some sort of urge that I can't quite explain, different than OCD, where there's an idea or a thought behind it, right? And then I might try and eliminate that urge by engaging in a just right kind of behavior, so that the person I worked with years ago, I remember, would suddenly look up in the corner where I'm doing it right now, and then I would see them tracing in a certain way. And they would explain, I don't know why I have to do this, but my eyes have to go and trace the room, right, yeah. And if I don't do it right, I just have to keep doing it. And you might even ask that person, well, what does doing it right mean? And it wasn't like I had to do it three times, or I had to do it precisely. It just feels right, like your brain just tells you when it's good. I don't know when it's right, but I feel it. I can't explain it exactly. It just sort of clicks at some point. So toretta OCD really behaves like that. It tends to lack ideation, but it has a certain kind of just, I don't know what it is, but I'll know it when I feel it. And so the therapy for exposure Response Prevention would be very similar to what we would refer to as Habit Reversal training when we treat people with Tourette Syndrome. So it might be when you catch yourself starting to trace what would be a competing response. So if your eyes want to go right slowly, maybe it would be, let's close our eyes right, because now we're not able to fulfill the compulsion, because our eyes are closed and our brain says, I have to see a thing a certain way. Or if the person closes their eyes and they say, but I can still feel my eyeballs moving. As simple as it sounds, it might be, if your eyes want to slowly move to the right, what can we do differently? Ideally, it would be, let's instead hold it towards the left. If my eyes want to move that way, I'm going to make my eyes go that way. So it's almost like this tug of war that happens in our brain, and we're trying to just wait out the urge. Urge has passed. Okay, now I can just go back to not fighting anything. And so that's a competing response. Some people might have a harder time doing that. So we try and maybe loosen up the rules, so to speak. So let's say, if their eyes want to do trace that way, but slowly and precisely, I might say, well, let's do it fast. Let's just whip around the room. We're going to sort of put our brain on notice. We're going to prove to ourselves that I don't have to do what my brain tells me to do. I don't have to do exactly how it's trying to get me to do it, and then slowly but surely, we can get them to to resist more effectively, and with any luck, then we're not reinforcing the habit, and the habit sort of dies out. It's interesting

Michael Leopold: 13:20

to hear, because I imagine if I had this putting myself in the shoes of that person, that patient, and if you told me to quickly zip my eyes from from place to place, point to point, I would probably say, Oh, I'm doing it. And the Eric isn't going away if it doesn't feel just right. But I guess what you're saying is, over time, habitually, you know, your brain might change and evolve on that point. So really, it's a lot of the same things we would use for sure.

Dr. Zambrano: 13:45

And the important thing is we want to tell our clients like the goal isn't for the urge to go away. Good news is it will anyway, because everything is temporary, right? There's never been a thought, a feeling or a sensation that was permanent. Now it's easy for me to say, because I'm not dealing with the intense discomfort of not engaging in the feeling. So somebody might, after a minute, say, I'm doing it and I don't feel any better, and I get it. I get why they want so badly to experience that relief. But at the end of the day, we're still trying to teach them that at least a fundamental building block of this process is to say we're going to prove to ourselves that we don't have to do what our brain tells us to do, and that maybe it will feel really uncomfortable, and that that's okay, because then we proved ourselves that we can do uncomfortable things without having to give it. One of

Michael Leopold: 14:29

the hallmarks of a reversal training is that eventually you get to the point where you're you learn how to do this, how to make competing responsibility. You can practice on your own. You can do this at home, integrated into your life. It sounds like that's also kind of a goal of this as well. It's, you know, not just something we're going to do in the therapy session. We go home and then can practice it and continue, because that's how you make it a habit. It's

Dr. Zambrano: 14:50

absolutely, absolutely, you know, one of the in our practice, I think a lot of us, our training method, is to teach people through metaphors and stories, right? So one metaphor we use is, it's. Really good. If you want to get in shape, if you want to hire a trainer, that's great. Trainers introduce structure. They teach you how to do things. They teach you how to do them, right? But if you then spend the rest of the week not working out, you're probably not going to get a lot of results. In fact, probably the trainer might have been a waste of money and time. I mean, I'm never going to knock going to the gym once a week, but if we're if we're pursuing certain goals, we understand it's got to be done consistently and more than just once. So I think that that fits with this model. Again, the difference between, I think, OCD and Tourette's is the expected outcomes are kind of different as well. In other words, with my Tourette's clients, we really do kind of talk about this is part of how your brain functions, and that's okay, and that what I'm trying to teach you to do is how to manage this. When you choose to manage it, part of my job is also educating families about, you know, it's maybe it's okay for your kid to take it home or in private spaces, because holding it back is really uncomfortable, and that's all right, because we're not, we're probably not going to extinguish Tourette's via Habit Reversal training or exposure therapy. This is just part of their neurological mix, and we're teaching them these things, maybe, if we're lucky, so they don't happen as often as they have been. Or, more practically speaking, in terms of we can maybe learn greater control so that we can pick our spots, so we can say, in a situation where I want to manage the tic, I can use these techniques I'm learning in therapy, whereas with OCD, you know, we might have slightly more ambitious goals, right? To be able to say, if we do this consistently enough, this exposure and response therapy treatment, that we might get to the point where the urge or need to engage in the compulsive behavior, might extinguish, right? That doesn't mean we've cured the OCD, but it may mean that we get to the point where the symptom that you're in treatment for isn't that meaningful, isn't causing much disruption, right? I do sometimes with my clients, say, almost in the tongue in cheek, way that I can, I can cure the D in your OCD,

Michael Leopold: 16:59

yeah, yeah. It's not interfering with major life functions anymore. You can go about and do your thing, live your life exactly. So

Dr. Zambrano: 17:07

we emphasize, well, what is the what is the date, right? So it's a disorder. It's it causes dysfunction, it causes distress, it causes delay. All those Ds are important. And so if I can teach a client to get to the point where, yes, I still have these thoughts. Maybe even these thoughts produce uncomfortable feelings that I wish were not there. But if I'm at the point where I'm not delayed by them, I'm not distressed by them, it's not really interfering with daily functioning, then that's the point where we say, you really done something important and meaningful, right? This is no longer having the same kind of control over your life as it used

Michael Leopold: 17:44

to, yeah, really got the, you know, took away the disorder part of it. Now it's just your brain. This is just something it does, and it's not a link behavior problems in your life anymore, right now, the other challenge that a lot well, one other challenge a lot of people in our community faces anxiety and at another area where you have a lot of experience with the clinical side of it, anxiety, as many of us know, can make our ticks worse. Oh, yeah. Curious how we would approach that with a patient,

Dr. Zambrano: 18:07

absolutely, especially with the Tourette's patient. When I start working with a client, I want to make sure that we are optimistic but also realistic. And so what that means is that not everybody is going to experience very significant reductions in ticks for whatever reason, some people don't benefit as much from Habit Reversal trainings and what we call CBIT for Tourette's. But what we do know is sometimes there's actually more bang for your buck in terms of managing the anxiety that may be exacerbating the ticks. As a cognitive behavioral therapist, folks who do CBT when it comes to anxiety, one of the main tools is what we call cognitive therapy. So it's really helping a client identify what is it that we're telling ourselves that produces the emotional response that we're having so very commonly? To introduce that concept, when I first start working with people, I kind of tell a silly little story that I've been telling for since I was in grad school, so over 20 years, I'll, heck, I'll include you in the story, right? So let's imagine that you and I have never met each other, that I'm a complete stranger to you, and I'm sitting at a Barnes and Nobles, reading a magazine and drinking a cup of coffee, and then you walk in and I look in your direction, and I go, I make some kind of face. Now we're gonna assume I don't have a motor tick in this situation, but a lot of people might have an emotional response to that stimuli occurring. I'll put you on the spot. Michael, what do you think? What emotion? By emotion, I usually mean like a one word, so not a thought, but like a feeling. What feeling do you think you'd be experiencing in that self conscious

Michael Leopold: 19:32

or embarrassed? And that could be me, I would, you know, what was it? Do I have is my nose bleeding? Do I face like immediately I would go into kind of a defensive you're doing a great job, right? You know, my reaction would be, what's wrong with me, right?

Dr. Zambrano: 19:45

So exactly. So you might you your personal style, how your brain functions. It might say, Oh, this guy is looking at me, making faces at me because he doesn't like how he look, or something embarrassing about me. Maybe. There's a stain on my shirt, right? That would be your thought. And that thought, the natural conclusion of that thought is, I feel embarrassed or I feel self conscious, the person who feels anxious, it's the same exact stimuli I tell the story the same way every time. The person who feels angry, I like to think of it as a default New Jersey emotion. The person who feels angry might have a different set of thoughts, right? So who is this guy? What right does he have to look at me that way? He's being a real jerk, right? I should put him in his place, so that would produce that thought. Now, somebody who feels scared would have a different set of thoughts, right? That person seems dangerous, that person might want to harm me, right? The person who feels sad would have a completely different set of thoughts. That person is judging me, that person doesn't like me. He's just like everybody else who doesn't like me. I feel so ashamed of myself. I'm so sad about this, right? So we could go on and on, but the point is that any emotional reaction that we have is a byproduct of what we tell ourselves with anxiety disorders, one of the building blocks that we like to teach our clients, teach our clients is, let's, let's learn to sort of identify what it is that we're telling ourselves, but let's also understand that our feelings are not facts, and our thoughts merit exploration. So let's say, if you came into the therapy room and you were telling me, Oh, this guy looked at me, at the Barnes and Nobles, and I'm so upset because, you know, I'm sure I must have done something to embarrass myself, and he must have thought I was so weird. Well, I would encourage you to look at what else could it be? In fact, you already did a good job, right? You identify. Well, maybe he was thinking something else. Maybe he looked at the clock on the wall and realized that he's running out of time and hasn't finished his coffee. So that face was disappointment. It had nothing to do with now, I also told my clients, yeah, maybe you were completely right. Maybe what you were thinking was true. He was judging you. He did think your shirt looked ugly or you had a weird stain on your shirt. He was laughing at you internally or disgusted with your parents, right? Those things can be true, but how do we know? Right? So we want to, we want to help people be really open minded to there could be other possibilities. And that's one branch of cognitive therapies. We say, Okay, let's, let's talk about what evidence, what information do we have that would lend us to believe that your hypothesis is accurate, and is it possible that there's other ways to look at this? My clients generally like doing that better than the other part, but I think the other part's really important, which is, what if what you're thinking is true, right? So what if i What if that person was judging you, Michael, what if he did think you looked silly and gross with that big old stain on your shirt? And usually, so that's, you know, we start to ask what are called Socratic questions, and this is where the psychologist gets to play dumb and try and dig deep. Help the client dig deeper. We sometimes refer this technique also as the downward arrow. Let's get underneath the thought and okay, why is that thought important? And so that helps people identify their beliefs. And then the more, the more consistent they are at identifying what they're telling themselves, how it makes them feel, what distortions in thinking they might be having. So I might teach somebody, Oh, it sounds like you're doing a little mind reading. You're acting as if you know what the person is thinking when we really don't. Or maybe we're doing some magnification. Maybe that guy did think your shirt looked ugly. Is that really that important? What do you think? And they might tell me, they might, they might defend their position a little bit. Well, here's why it's so important, and then I just keep asking them more follow up questions. It's not my job to tell them, and it's not important, and you need to get over it. It's my job to help them sort of reach healthier thoughts that maybe are in line with their values and what they think is really important. But then my job is to have them not sort of accept their beliefs without maybe investigating them a little bit. Now, the B and CBT, that's behavioral sometimes, that, again, involves exposure therapy. So if people are really anxious, let's talk about common anxiety that people with Tourette's have. What if these new classmates I'm going into middle school, and what if none of them know what Tourette's is, and I start making all these noises or having all these motions? What if people start to judge me? What if people are mean to me again? We could do some cognitive therapy where we talk about, Okay, what if? How likely is it? What's happened in the past? What would you want to do? What is your game plan if someone is rude or disrespectful to you? But we can also talk about, okay, that's a legit fear. People in middle school can be mean. Somebody might make fun of you. What's a good way to sort of manage this? Now, sometimes I try and suggest to clients, maybe we're going to have to educate others about what Tourette's is. Hey, I have Tourette's. It's not my fault. I make these sounds or have these motions I can't control. It's a neurological thing. It would be really cool if you guys would just ignore it and leave me alone. So many of my clients over the years have said I'm not doing that. That's embarrassing, and sometimes even the parents don't want to do that, because, well, now my child is being labeled. I get it. I get it. You know, I don't know if I was that age if I would have wanted to be labeled and have to publicly announce or explain to people what this is. But what we also find is that is a behavior that is a choice that for a lot of folks makes. Actually a dramatic difference right now. Now we don't have to spend all day worrying about, what if somebody notices? What will other people think? Now we actually have some agency in that process, right? I can teach people what this is very empowering. Yeah, if we're really concerned about like, people are going to think I'm doing this because I'm attention seeking or trying to be weird. Not that the person with threats owes anyone an explanation. But I think part of deep using that particular anxiety is again, getting ahead of it and being able to say, Hey, this is the thing I do. Please take it or leave it and be kind. And now I can take the pressure off myself to have to control all these things, when maybe what's more effective is letting folks know it is what it is. And I hope that you can accept it and ignore it. I like the

Michael Leopold: 25:42

way you worded some of that, of like, getting in front of it, getting in control of it, or getting, you know, getting to the forefront of it. Because, you know, I think at least for me personally, a lot of my anxiety is sort of, it comes around, fear of the unknown, or, like, I don't even understand what, what's going to happen next and how I'm going to react to it, and it's all just kind of this vague, overwhelming mass of like, you know, so when I break down, or a therapist and I would break down, okay, what? What are my worries? What could happen? And then let's play out each of those if they were to happen, or if they don't, you know, you've just given me kind of a map of of what is all going on. It gives me that visibility, and I think that clarity, because it's really just not knowing that. That's what scares me.

Dr. Zambrano: 26:23

It can be so scary because there's so much in fact, if we're honest with each other, with ourselves, right, most of life, we have no control over but we also don't want to forget that we do have control over ourselves. We we still have free will. We could still make choices. And so that's why it's really important to talk about. You know, yes, I can't control what the kid in your middle school class is going to say to you, but you can control how you respond, right? That's different than react. Our reactions are sort of instantaneous, right? So I might My instant reaction might be, I feel sad, I feel scared, I feel angry, right? That's an emotional reaction, but we have free will where we can choose how we respond, and so part of the process of therapy is helping people decide how would you like to respond, even if it sounds unrealistic, even if it sounds like I don't know if I could do that, well then great, let's, let's role play it. Let's practice it. Let's, let's do it on smaller scales, so that you're really sort of training yourself. Okay, I do have some agency when it comes to dealing with my anxiety. There are things I can do that are healthy. I can't guarantee the results, but it's good to at least know that I'm not helpless.

Michael Leopold: 27:31

You have agency in this. There are things you can do and you will do something, you know when that time comes. I

Dr. Zambrano: 27:37

think one of the other really cool things about cognitive therapy that I really enjoy is that the more people get in touch with, you know, understanding that I have a brain, my brain thinks thoughts that I can't control. That this is true of every human being, the two of us, right? Whatever thought pops into our head, we didn't ask it to show up, that it just it's there. And I try and teach my clients that, hey, we because we all have brains, and our brains have been absorbing experiences for our entire life that the thoughts we have are not within our control. So the way I think about the world, the way I react to things, is a byproduct of my gender is a byproduct of the part of the world. I'm from New Jersey, so maybe I have the tendency to sort of view things aggressively and get angry the era that we're from. I was born in 1976 so growing up in the 80s and 90s maybe gives me a different view of the world. I am a first generation American. I'm My parents are both in Colombia, so maybe those life experiences, the religion I grew up in, the people that I encountered in my life, all of those things come together and determine why I think the way I do, but it's not up to me how I think that just happens randomly. So the more we do cognitive therapy, the more people become aware of like, oh, wow, I'm really learning like, what my thoughts and beliefs are. The more we can just notice them and not be controlled by them. So when I feel irritated or upset about something, I've gotten so much better as I've gotten older, so I've just noticing, and almost it doesn't sound weird, but I do think I try and teach my clients to think this way. I try and teach myself to do this. I'll just notice. I'll say, Ah, I noticed my brain is getting irritated about something. And I remember that most of the time that my brain gets irritated about something, it's usually something it's usually something that's kind of silly when I think about it afterwards. And it's super liberating, right? Like I don't have to react the way that I always reacted. I can just go, okay, that's just my brain thinks. I can notice what my brain thinks, and I can just let it go. I can move on. Unless it, you know, it does some things, of course, require action and responses, but most of the time, it's just like, You know what? This is just my brain saying stuff. I don't have to pay attention to it or take it too seriously. You

Michael Leopold: 29:49

know, this point here was such a powerful coping mechanism for me in new lake with impulsivity, growing up like a lot of people with ADHD and dread have challenged with impulsivity and. I think for me, I not an issue anymore. But I think I was really able to manage it better when I got to a place where on my good days,

Dr. Zambrano: 30:08

I get a thought that comes to my head suddenly and I There's something so powerful about being able to acknowledge it as a thought and then say, like, what do I want to do with this? So I want to, why do I feel this way? Do I want to just blot it out and say it? Do I want to maybe wait a minute and say it if I still feel like saying it? And I found it was so empowering when I realized I don't have to say the thing first thing that comes to my head, I can actually sit on it and then make a decision later. Easier said than done. But I think there was some kind of growth that took place in me, when I when I got to that place, that's awesome. I think getting better at that has definitely made my marriage a lot better, right? The benefits in life. But we're like, I'll have a thought, or I'll have an emotion, because the emotion almost like happens like so so quick that I'm not aware of the thought, right? And then I get better at sort of not saying something or regret or acting like a big baby, like I sometimes do, and then afterwards realizing my reaction was a byproduct of some distorted thinking that I don't actually agree with. When I stop and look at it, my wife will tell you, I have not mastered the not making a face part of it. But, you know, because she's pretty awesome, she is pretty good at sort of accepting, and we've had, you know, I think one of the fun, or maybe not so fun, parts of being married to a therapist, is that I talk about how, yeah, my brain was having a moment there. I'm really sorry my brain was telling me one thing, but I realized that, like, maybe, maybe I don't exactly agree with my brain. And social like, you know, in her good bones, she like, Oh, that's cool. And other times, like, you're therapizing again. Yeah, we're always in progress. But exactly any

Michael Leopold: 31:44

other challenges that you see in working with this population, any common concerns or questions that come up a lot in our demographic, our listeners may want to hear

Dr. Zambrano: 31:52

about. One of the things I see a lot is, How do I respond to people who don't respond kindly? Right? I think that's a difficult one. And you know, there is no right or wrong option right that I do try and let people know, it is not your obligation or responsibility to educate others. But you know, when people do stare, it's uncomfortable, and I know all of us would wish it didn't happen. I wish everybody would automatically assume when somebody is blurting something out, or perhaps having some sort of motor tic that might look odd to somebody. You know, I wish everybody would make almost the automatic assumption this person might have a tic disorder. No big deal. I can just ignore it. But not everybody knows what this is. It's actually why I'm really passionate about going out and educating other people about what Tourette's is, right? Because I think slowly but surely, we make the lives of people with Tourette's a little easier. What's nice is, when I first started giving presentations and teaching about Tourette's, people were kind of starting to hear about it, and now I've reached the other end of the spectrum, where most people know what it is and they just want to know more about how to be helpful. Yeah, to that evolution in it unique challenge is that most, a lot of psychiatric disorders are sort of invisible, right? We don't always know that someone is struggling with depression or anxiety, right? Their OCD isn't always terribly visible, but I think Tourette's is often on public display. And so what's the best response? I don't know that there's a solid answer for that, other than let's figure out what the best response is for you, right? And so sometimes it really is. Some folks are super good at just radical acceptance. I get that they think it looks weird. I don't think I'm doing anything wrong. Yes, I might feel uncomfortable or embarrassed, but that's not my problem. That's theirs, and they'll be okay. Some of these folks that I work with, I mean, a lot of members of the tourist community are like the most sensitive in a good way, right? Compassionate, empathic people who it's it's kind of almost amazing, like their thought is, I don't want to make other people uncomfortable, yeah, and it's so sweet. It's so lovely to sort of think that way. But we can say, maybe we'll just sort of accept that it's not your fault if they do experience a moment of discomfort, and that whatever it is that they're experiencing, like, all emotions are temporary, so we don't have to concern ourselves too much. But again, if we want to preempt, be preemptive, we can explain, right? I've worked with parents who do things like, when their kids get on an airplane, they might take a moment to talk to the folks sitting near around them, or even, like, give them a little, you know, a little card or something that explains, hey, my my child has Tourette's he or she may be making some sounds or having some motions that might be distracting. Please understand that it's not their fault, and do your best to ignore them, or, if need be, even let me know, and we can figure out how we can work this out together, right? I've had lots of parents do those things, ideally, with the child being on board with that, and it gives them a permission structure to simply just be present in a place and understand that if I do tick, hopefully most people around us will be understanding and kind and just ignore it. Or if you know, maybe they're trying the best, their best to ignore it, but they're getting annoyed or frustrated. So that's okay too. This flight isn't forever. Eventually we'll get we'll all get off the plane, and they'll move on with their lives, and it's most likely not going to be the thing that ruined their vacation or even ruined their day, even if it was for some short period of time I had to endure some mild frustration or irritation. So I think that's one of the big unique challenges of working with folks with Tourette's. The other one, I think that is really common, is that fear of like, will I or my child be able to have normal relationships? Will they be able to be treated fairly when they're looking for a job, right or interviewing for a position? That's a really legitimate concern, which is why, again, I think as early on as possible, teaching folks with tourists to be comfortable, sort of explaining what it is even and I know people often think it's corny, but to talk about how you know what, living with stuff like this can be very character building, right? Can build greater empathy. Can prove great resilience, some of like, the most cool and amazing people I've met, and before we kind of went on microphone, we're talking about the Tim Howard academy that the New Jersey Center for Tourette Syndrome does, and like some of the best humans I've met have been at that conference, right? These are like kids who were so much more courageous than I was at their age, right? Who were just natural leaders. And I know it sounds like I'm trying to look for a false silver lining, but I genuinely believe that sometimes having Tourette's like almost forces you to be more public than you originally would have been. It kind of might bring out some of those leadership qualities, or it might force you to sort of be more out and open. And I think the kids who manage it really well, they're the ones who are just battle tested, and they can handle anything. And so to being able to show to share that story proudly with potential employers as part of your college essay. I don't think it's using your disability or disorder. I think it's it's speaking your truth,

Michael Leopold: 36:48

your Exactly. It's your experience, and nothing wrong with with writing about it. That's a very genuine, authentic topic to pick

Dr. Zambrano: 36:55

for the most part. I think folks with Tourette's, I'm not going to lie to you, there are some people who would not choose to not be friends with somebody just because of their own ignorance or their own discomfort, but I also don't think it's completely disqualifying. And so those who kind of despair at the idea that I'll never make friends, nobody's ever going to give me a shot, I have never known that to be completely true if the person is willing to overcome some of the anxieties and push through and take take some risks. There's always somebody out there who's kind there's always some somebody out there who's just not going to care, who's going to ignore it. So I think helping them face those challenges as well are really important.

Michael Leopold: 37:34

You'll find your people, your circle, your you know, your allies, and all of that around you. Yes, there's people that are just jerks. There's also a lot of it comes from a place of not knowing, right? You know, if you see a motor tick or you hear the vocal tick, it may look odd. It looks unusual. It sounds like we see all the time. It's only weird when you don't know what it is, or they don't have a name for it. It's only you know that that's what it in their their head, they're thinking, oh, you know what's going on with that guy. We're

Dr. Zambrano: 37:59

just not used to it. Yet. You're not used to

Michael Leopold: 38:01

it exactly. I've been acclimated to it, like there needs to be some kind of explanation for it. And then it suddenly becomes like, oh, okay, like, now I have something about it and put that, that anxiety at ease. It's whatever, if they're a decent person. And oftentimes, you know, I like to assume most people, are they? My advice for those, those kids, or those, you know, people looking to get their first job out of college and stuff, and they're concerned about how others might view them, an employer, potential colleague. I think the more we can be proactive and kind of own that conversation ourselves. One, yes, it's empowering, but it also can can help you, because you can kind of control that narrative and give them some kind of assurance or something, not that you have to do this, like we said, you know, is your choice, but it can definitely work in your favor. I think a lot of a lot of the bad reactions we get come from people just not getting it. I sometimes

Dr. Zambrano: 38:51

are almost referred to it as a sort of jerk filter, right? And maybe that's being a little unfair, because, you know, we're all trying to find our tribe, as you mentioned earlier, right? We're all trying to find the people we fit in with. And I don't know about you, I want to find the people who are accepting, who are open minded, who are kind, right? So to me, you know, we can even say having something like Tourette's that's the most efficient way of ruling out the folks who aren't kind hearted, who aren't as understanding, or who might just need more time than we're willing to invest to teach.

Michael Leopold: 39:22

That's a really good point. You know, it is that filter. And if you try, you do your disclosure speech, and they're still not having it. They're not they're so that. Well, then there you go. That's a person that shouldn't be in your life.

Dr. Zambrano: 39:33

One of my best friends growing up had a pretty significant stutter, and when I first met him, it's, it's not that I chose not to be his friend because of the stutter. I just I was aware of a stutter, and we didn't quite have a friendship yet. And I remember, this is funny. I he had laser tag. He's the only kid I knew who had, like, a home laser tag game. I don't think he was the cool kid, but he was the, like normal kid like me, who stuttered pretty badly. But. Like, all right, I want to see what this laser tag thing is about, right? So I'd hang out with him, and then, like, that was almost his foot in the door, or, luckily, my foot in his door, because, you know, I kind of quickly saw this guy's really witty. This guy's so smart. He's got a super cool family, amazing dude. And, like, we became super close friends for many, many years. And it's not that his stutter went away, but it's just how much I cared about it disappeared, versus when I first met him. You know, if you asked me, like, about him, I'd be like, Oh yeah, the kid who stutters, right? And then he just became my best friend who just so happens to stutter. But it's like the 10th thing I would

Michael Leopold: 40:42

use to identify not a not on your the forefront of the list there. It's funny. I had Jeremy Lichtman and his father, Jeremy, we're both on the podcast a number of episodes ago, and I remember I was asking them about, what advice do you have for parents of newly diagnosed children? And I think it was his father, Jeremy's Father, that said something to the effect of, have cool toys, you know. So that way your kid's birthday party, yeah? You know, there's something else there. Then they see, oh, great guy, you know, great friend rest of my life, yeah? Well, Dr, zbrot, it's been great having you on the podcast. Uh, thank you again. So much for joining. I like to end these episodes by asking my guests if there's any advice you have for the truck community and the floor is yours to give anything. I know there's so many answers to that question. Sure, I'm curious what kind of comes to your mind here.

Dr. Zambrano: 41:33

I mean, I think probably a little bit of some of what we already talked about, but I genuinely feel it really is so important for folks to sort of be open about the diagnosis right, to be able to say that this is something you live with and that you get to decide on what terms you live with it when you know that this is something you're afraid of. You know, in other words, what are people going to say? What are people going to think? Then maybe we pivot in the other direction and say, You know what, I'm just going to be open about it that I don't that I don't have to act like this is a thing to be ashamed of or a thing to be hidden. This might be a thing that's frustrating. This might be a thing that people have to learn to ignore. But, you know, I think people of goodwill, and they are everywhere will, you know, make make peace with your symptoms, and that it's you know, if not, then that is their problem, right? That isn't a sign that there's something wrong with you. There is something that is different about you, and that's okay. And to sort of go beyond that, to be able to say that this really does have the potential to be shaping in such a positive way for you, again, building that resilience, building that courage, building that empathy, those are all wonderful things if we don't succumb to being overwhelmed by anxiety or frustration, right? And I understand as a therapist, that's always easy for me to say, but I also have the benefit of having worked with this population for almost 20 years. I see it happen too often to think that I'm just lucky enough to meet all these outlier Tourette's cases, like most of them genuinely are fantastic kids that any parent would be proud to have and that anybody would think like, wow, this I would totally hire this person, or make or be friends with this person. He seems great. She seems awesome, right? So, you know, I think so that making sure that we bolster any self esteem issues that might be underlying that it's okay to really sort of feel awesome about yourself, to love yourself, to be courageous and accept yourself, even if not everybody will accept you. That's okay. I think that's a powerful message that I always like to make sure that my clients walk away with

Michael Leopold: 43:36

be unapologetically you.

Dr. Zambrano: 43:38

Yes. Well said, sir.

Michael Leopold: 43:40

Ah, you too well. Thank you having you on. Thank you again to all of our listeners. Stay tuned in two Tuesdays from now, we will be watching our next episode. Thank you so much. Thank you. Thank you for listening to the uptick, brought to you by The New Jersey Center for Tourette syndrome and associated disorders, empowering you to stretch the boundaries to live your best life. The NJ center for Tourette syndrome and associated disorders, njcts, its directors and employees assume no responsibility for the accuracy, completeness, objectivity or usefulness of the information presented on this podcast, we do not endorse any recommendation or opinion made by any guest, nor do we advocate any treatment you.