Selected Podcast
Obsessive-Compulsive Disorder
Dr. Nick Dewan discusses getting your life back if you have obsessive-compulsive disorder. He shares treatment options available if you suffer from OCD and how, without treatment, these types of obsessions and compulsions can greatly affect a persons quality of life. Learn more about BayCare's behavioral health services.
Featured Speaker:
Nick Dewan, MD
Dr. Nick Dewan is a pioneer and an accomplished physician leader and sports psychiatrist with a nationally respected track record in health care value improvement and information technology. Currently, he serves as Chief Medical Officer for the Behavioral Health Division of the BayCare Health System. In 2015, he published his third book on information technology “Mental Health Practice in a Digital World: A Clinicians Guide”. His clinical experience includes work in emergency, hospital, outpatient, addiction medicine, and sports medicine settings. He is a sought after speaker and is interviewed by local and national media on behavioral health issues and sports performance topics. His work on clinical guidelines, performance bonuses for quality, efficient use of healthcare, best practice adoption, and patient empowerment and technology positions him as a leading expert in an era of accountable healthcare. He is a member of the physician leadership team within the BayCare Health System providing input to the hospitals, medical group, accountable care organization, and insurance-based initiatives. He has the respect of national hospital, managed behavioral health, community mental health, and consumer advocacy groups, and sits on the Council of Healthcare Systems and Finance of the American Psychiatric Association. Dr. Dewan is also a member of the Board of the Positive Coaching Alliance of Tampa Bay. He is a graduate of the Medical College of Ohio, and completed his residency in psychiatry at Los Angeles County-USC Medical Center and UCSD School of Medicine. He is a Diplomate of the American Board of Psychiatry and Neurology and the American Board of Addiction Medicine. He is also a board certified physician executive and a former collegiate tennis player and coach. Transcription:
Obsessive-Compulsive Disorder
Melanie Cole (Host): Are you a really intense worrier or sometimes or frequently have obsessive thoughts? It could be an obsessive compulsive disorder. My guest today is Dr. Nick Dewan. He’s the chief medical officer in the Behavioral Health Division of Baycare Health System. Dr. Dewan, what are OCDs and is there a difference between obsessions and compulsions?
Dr. Nick Dewan (Guest): OCD, otherwise known in my field as obsessive compulsive disorder, is a disorder of both obsessions, which is thoughts and compulsions, which is behaviors and people that suffer from this condition, suffer from this condition and they experience distressful symptoms for more than an hour a day, which is very different from “somebody being obsessed” or having rituals. So these are things that are very strange and feel very irrational and interrupt or disrupt the normal course of life, and I can tell you more details as this conversation proceeds, but it really is something that is significantly impairing one’s life, and that’s the only time when people really need treatment. Normal trying to be tidy, trying to make sure things are right, making sure you say the right things, that’s normal human behavior. So obsessive compulsive disorder is when it goes beyond and interrupts and disrupts your life.
Host: How common are they Dr. Dewan and tell us about some of the forms because as you said, normal worrying, everybody has that at some point, but these take specific forms sometimes, maybe in the form of hording or checking or hair pulling, hand washing, things that we’ve heard about. So speak about how common they are and these different forms.
Dr. Dewan: Okay, so obsessive compulsive disorders are between 1% and 2%, so that’s how much of the population is suffering from them. Now in traditional or classic obsessive compulsive disorder. You mentioned you can have the cleaning, you can have something called symmetry, you can have something called ordering or counting compulsions, you can also have what’s called forbidden or taboo thoughts, which can be aggressive or sexual or religious in nature, or you can be in fear of harm. Now that’s classical obsessive compulsive disorders. Hording disorder is a variant. It’s different. It’s when you want to keep things because something bad will happen if you let them go. It’s different than collecting things. A lot of people collect things. They have a collection of medals, or a collection of trophies, or a collection of stamps, that’s different than holding onto things and filling your entire house. The skin picking or your hair pulling is a completely different type of what’s called compulsive act, and it’s a different disorder or different condition than say obsessive compulsive disorder, but 1% to 2% of the population really does suffer from this. It does run in families. Twins, about 0.57 correlation rate, so that’s 57%, that’s monozygotic; then dizygotic it’s about 24% so there is a genetic basis for this. There’s a tremendous amount of family inheritance with this. So really it’s primarily a biological condition. There are other factors that we know that are contribute to this. There can be what’s called severe stressors or trauma early in life that could set off the condition. There is something that’s in the scientific literature called PANDAS and that’s panda like the bear with an “S” at the end of it, and that stands for – it has to do with what I would call an autoimmune neuropsychiatric disorder associated with streptococcus. So pediatric autoimmune neuropsychiatric disorder associated with streptococcus, basically strep throat. Now there are some researchers in the country that don’t believe that severe streptococcal infections can lead to OCD in childhood. There are others that have spent their entire careers researching this, and the confusing part is that a lot of people have strep throat growing up, so the fact that a small percentage develop obsessive compulsive disorder could be a coincidence or it could be for real. There’s research both ways. I hope that explains or at least answers your question that you posed to me.
Host: It absolutely does and I thank you for that answer. So what age do these begin to manifest themselves and when is it time to see a healthcare provider. You mentioned at the beginning that they start to effect your life with these compulsions, keep you from going out or from social activities or have problems in school or work. When do they show up and when do you advise somebody to seek help?
Dr. Dewan: Well these conditions rarely develop in adulthood, rarely. So beyond age 35 it’s extremely rare to see this come out of the blue. This is really a condition that can start earlier in your preteens and then in your teens and then into young adulthood, and males usually have it earlier than females, and we can often see this condition in adolescents, and it’s really better to address it earlier rather than later, and the reason why people don’t seek help is sometimes it’s quite embarrassing to have these strange thoughts that are not explainable and sometimes people just say oh that’s just growth phase or it’s just them becoming different and figuring things out when it actually could be an underlying significant obsessive compulsive condition that can actually be treated. So it’s real important if there’s – once again, let me – the four things, if there’s an obsession about, oh things are dirty, I got to spend two hours cleaning everything, or I’ve got to make sure everything is at a 90 degree angle and it takes you two hours a day to make sure everything is the right way, or that you’re having really strange thoughts about hurting things or being harmed and it takes hours and hours out of your life, that’s when you know it’s time to talk to a professional to get help, and the sooner, the better because the more it goes on and the more it festers and the more it preoccupies your life, the more difficult it is to treat. So early adolescence, late adolescence, not really in late – after age 35, so catch it early. Now there are a lot of people that don’t show up for care until after age 35 because they’ve been embarrassed about it, but they often say, you know I’ve had this since childhood, or I’ve had this since I was a teenager, or I got it in high school and it just kept on festering and got worse.
Host: What does treatment look like, Dr. Dewan, and even if somebody waits that long to go, are treatment options still available? Do they look like cognitive behavioral therapy or psychotherapy or do they look more medicational? Tell us just a little bit about treatment.
Dr. Dewan: There are many, many different treatments for, and I’m going to just talk about obsessive compulsive disorder, the classic thing that everybody kind of has a good idea about, and there is a standard therapy called exposure and response prevention therapy. It is a very systematic approach that deals with anxiety symptoms, and exposure stands for the patient, or the client, is exposed to what I would call the anxiety provoking situation. They are taught not to respond in their normal habit, and when they’re taught not to respond in their normal habit, the anxiety about the situation goes away. Now that can take hours of therapy. You can have an hour to two hour therapy session a day. You might need 30 to 50 to 60 to 70 sessions to help this anxiety get reduced, but that is the goal standard way of doing. We call it more behavior therapy rather than cognitive behavior therapy. There is sort of a cognitive approach, saying that this is normal, but the actual technique is what we call behavior therapy technique. Now that’s – that technique should be done no matter what, whether medications are used or other types of interventions are used and OCD is one of these conditions where there’s actually significant amount of what’s called not only medical treatment but neural interventional treatment. So let me describe that for you. You do have what’s called a medication approach, traditional medicines that we use in depression, they’re called SSRIs or serotonin reuptake inhibitors. Most people may have heard of medicines like this, things like Prozac, Lexapro, Zoloft, these are the kinds of things – the medicines that are used for this condition and they tend to work really well. There are other medicines called Luvox or Nafronyl that are more potent, what we call serotonin medicines and they’re also used and we know that for the last 20 to 30 years, success has been achieved by using medicine. The neural interventional side is something very, very unique for OCD in particular. We know in OCD there are what’s called the circuits in the brain, and when I talk about neural circuits in the brain, I often think of if you’re in a town and you’re traveling and you go to one of these roundabout kind of things where you have to drive around and there might be five roads emanating from the roundabout. Then you go down one of those roads and there’s another roundabout, and then you go down another road and there’s another roundabout. Well the way the brain works is those roundabouts are really what I would call structures or locations in the brain, and that they communicate with multiple other sections of the brain. In OCD, there’s a disruption in either that roundabout or in the roads that go to the next roundabout or what I would call constellation of cell. Well neural interventional treatment in OCD can actually involve surgery. Actually going into a part of the brain and sort of, what I would call, ablating one of the little roundabout sections. It’s sort of like what we do in cardiology when somebody has an abnormal rhythm, the cardiologist – the interventional cardiologist will go in there, sort of reduce what’s call the rhythmic location and so you don’t have the sort of sputter rhythms that are being sent out. So we have surgery in OCD. We also have something called an implantable device, sort of like a pacemaker that’s inserted – that’s connected to a particular part of the brain. Once again, to – let’s go to that roundabout, the signals aren’t working, so it modulates the stop and go of those messages from different circuits in the brain, and finally we have something called transcranial magnetic stimulation, which focuses on – sends a magnetic – creates a magnetic field in a particular part of the brain that we think is related to the sequence of the disruptive thoughts and it modulates that. So this is one of the few disorders in the world that we have what’s called neural interventional strategy. So this is one of the few disorders where you can have – you can get better just with psychotherapy – behavior psychotherapy. You can get better with medications and psychotherapy, but for extreme cases, people that spend 12 to 15 to 18 hours a day suffering from this, there’s a very small portion that can benefit from what’s called neural interventional psychiatry. So this is a very, very fascinating area of science. It’s a very fascinating area of treatment, and we still are not at a place where we can say we can cure everybody, but 60% to 70% of people, we can get great outcomes on.
Host: Wow, that’s such a great explanation, Dr. Dewan, and so many tools in the toolbox to help people with OCDs. Wrap it up for us if you would with your best advice about what you would like friends and family to do if they notice that somebody has these, is there a way to help to say, don’t do that, does that work? And what you would like people to know about the time, that it’s really important that they seek help.
Dr. Dewan: One thing I would say to families is it’s not your fault. This is primarily a usually a genetic, biological condition. It can be treated very well. If you see a loved one spending two, three, four hours, saying things, repeating things, checking things, washing things, and they appear distressed and you think they’re distressed, and they’re not living their life to the fullest, that’s when you can say I’ve noticed this happening, are you okay? You could have this and I would direct them to look it up on the web, go to the International OCD Foundation website, read all about it, and there are lots of treatments available and there’s hope available, and that’s what I think family and friends should say, this is treatable, this is normal, this is recognizable and there’s lots of help available.
Host: Perfect, thank you so much Dr. Dewan. You are such a good educator and thank you for coming on and sharing your expertise about this condition for which so many people suffer and some don’t seek help, as you said they might be embarrassed so thank you again for joining us. You’re listening to Baycare Health Chat. For more information, please visit baycare.org, that’s baycare.org. This is Melanie Cole, thanks so much for joining us.
Obsessive-Compulsive Disorder
Melanie Cole (Host): Are you a really intense worrier or sometimes or frequently have obsessive thoughts? It could be an obsessive compulsive disorder. My guest today is Dr. Nick Dewan. He’s the chief medical officer in the Behavioral Health Division of Baycare Health System. Dr. Dewan, what are OCDs and is there a difference between obsessions and compulsions?
Dr. Nick Dewan (Guest): OCD, otherwise known in my field as obsessive compulsive disorder, is a disorder of both obsessions, which is thoughts and compulsions, which is behaviors and people that suffer from this condition, suffer from this condition and they experience distressful symptoms for more than an hour a day, which is very different from “somebody being obsessed” or having rituals. So these are things that are very strange and feel very irrational and interrupt or disrupt the normal course of life, and I can tell you more details as this conversation proceeds, but it really is something that is significantly impairing one’s life, and that’s the only time when people really need treatment. Normal trying to be tidy, trying to make sure things are right, making sure you say the right things, that’s normal human behavior. So obsessive compulsive disorder is when it goes beyond and interrupts and disrupts your life.
Host: How common are they Dr. Dewan and tell us about some of the forms because as you said, normal worrying, everybody has that at some point, but these take specific forms sometimes, maybe in the form of hording or checking or hair pulling, hand washing, things that we’ve heard about. So speak about how common they are and these different forms.
Dr. Dewan: Okay, so obsessive compulsive disorders are between 1% and 2%, so that’s how much of the population is suffering from them. Now in traditional or classic obsessive compulsive disorder. You mentioned you can have the cleaning, you can have something called symmetry, you can have something called ordering or counting compulsions, you can also have what’s called forbidden or taboo thoughts, which can be aggressive or sexual or religious in nature, or you can be in fear of harm. Now that’s classical obsessive compulsive disorders. Hording disorder is a variant. It’s different. It’s when you want to keep things because something bad will happen if you let them go. It’s different than collecting things. A lot of people collect things. They have a collection of medals, or a collection of trophies, or a collection of stamps, that’s different than holding onto things and filling your entire house. The skin picking or your hair pulling is a completely different type of what’s called compulsive act, and it’s a different disorder or different condition than say obsessive compulsive disorder, but 1% to 2% of the population really does suffer from this. It does run in families. Twins, about 0.57 correlation rate, so that’s 57%, that’s monozygotic; then dizygotic it’s about 24% so there is a genetic basis for this. There’s a tremendous amount of family inheritance with this. So really it’s primarily a biological condition. There are other factors that we know that are contribute to this. There can be what’s called severe stressors or trauma early in life that could set off the condition. There is something that’s in the scientific literature called PANDAS and that’s panda like the bear with an “S” at the end of it, and that stands for – it has to do with what I would call an autoimmune neuropsychiatric disorder associated with streptococcus. So pediatric autoimmune neuropsychiatric disorder associated with streptococcus, basically strep throat. Now there are some researchers in the country that don’t believe that severe streptococcal infections can lead to OCD in childhood. There are others that have spent their entire careers researching this, and the confusing part is that a lot of people have strep throat growing up, so the fact that a small percentage develop obsessive compulsive disorder could be a coincidence or it could be for real. There’s research both ways. I hope that explains or at least answers your question that you posed to me.
Host: It absolutely does and I thank you for that answer. So what age do these begin to manifest themselves and when is it time to see a healthcare provider. You mentioned at the beginning that they start to effect your life with these compulsions, keep you from going out or from social activities or have problems in school or work. When do they show up and when do you advise somebody to seek help?
Dr. Dewan: Well these conditions rarely develop in adulthood, rarely. So beyond age 35 it’s extremely rare to see this come out of the blue. This is really a condition that can start earlier in your preteens and then in your teens and then into young adulthood, and males usually have it earlier than females, and we can often see this condition in adolescents, and it’s really better to address it earlier rather than later, and the reason why people don’t seek help is sometimes it’s quite embarrassing to have these strange thoughts that are not explainable and sometimes people just say oh that’s just growth phase or it’s just them becoming different and figuring things out when it actually could be an underlying significant obsessive compulsive condition that can actually be treated. So it’s real important if there’s – once again, let me – the four things, if there’s an obsession about, oh things are dirty, I got to spend two hours cleaning everything, or I’ve got to make sure everything is at a 90 degree angle and it takes you two hours a day to make sure everything is the right way, or that you’re having really strange thoughts about hurting things or being harmed and it takes hours and hours out of your life, that’s when you know it’s time to talk to a professional to get help, and the sooner, the better because the more it goes on and the more it festers and the more it preoccupies your life, the more difficult it is to treat. So early adolescence, late adolescence, not really in late – after age 35, so catch it early. Now there are a lot of people that don’t show up for care until after age 35 because they’ve been embarrassed about it, but they often say, you know I’ve had this since childhood, or I’ve had this since I was a teenager, or I got it in high school and it just kept on festering and got worse.
Host: What does treatment look like, Dr. Dewan, and even if somebody waits that long to go, are treatment options still available? Do they look like cognitive behavioral therapy or psychotherapy or do they look more medicational? Tell us just a little bit about treatment.
Dr. Dewan: There are many, many different treatments for, and I’m going to just talk about obsessive compulsive disorder, the classic thing that everybody kind of has a good idea about, and there is a standard therapy called exposure and response prevention therapy. It is a very systematic approach that deals with anxiety symptoms, and exposure stands for the patient, or the client, is exposed to what I would call the anxiety provoking situation. They are taught not to respond in their normal habit, and when they’re taught not to respond in their normal habit, the anxiety about the situation goes away. Now that can take hours of therapy. You can have an hour to two hour therapy session a day. You might need 30 to 50 to 60 to 70 sessions to help this anxiety get reduced, but that is the goal standard way of doing. We call it more behavior therapy rather than cognitive behavior therapy. There is sort of a cognitive approach, saying that this is normal, but the actual technique is what we call behavior therapy technique. Now that’s – that technique should be done no matter what, whether medications are used or other types of interventions are used and OCD is one of these conditions where there’s actually significant amount of what’s called not only medical treatment but neural interventional treatment. So let me describe that for you. You do have what’s called a medication approach, traditional medicines that we use in depression, they’re called SSRIs or serotonin reuptake inhibitors. Most people may have heard of medicines like this, things like Prozac, Lexapro, Zoloft, these are the kinds of things – the medicines that are used for this condition and they tend to work really well. There are other medicines called Luvox or Nafronyl that are more potent, what we call serotonin medicines and they’re also used and we know that for the last 20 to 30 years, success has been achieved by using medicine. The neural interventional side is something very, very unique for OCD in particular. We know in OCD there are what’s called the circuits in the brain, and when I talk about neural circuits in the brain, I often think of if you’re in a town and you’re traveling and you go to one of these roundabout kind of things where you have to drive around and there might be five roads emanating from the roundabout. Then you go down one of those roads and there’s another roundabout, and then you go down another road and there’s another roundabout. Well the way the brain works is those roundabouts are really what I would call structures or locations in the brain, and that they communicate with multiple other sections of the brain. In OCD, there’s a disruption in either that roundabout or in the roads that go to the next roundabout or what I would call constellation of cell. Well neural interventional treatment in OCD can actually involve surgery. Actually going into a part of the brain and sort of, what I would call, ablating one of the little roundabout sections. It’s sort of like what we do in cardiology when somebody has an abnormal rhythm, the cardiologist – the interventional cardiologist will go in there, sort of reduce what’s call the rhythmic location and so you don’t have the sort of sputter rhythms that are being sent out. So we have surgery in OCD. We also have something called an implantable device, sort of like a pacemaker that’s inserted – that’s connected to a particular part of the brain. Once again, to – let’s go to that roundabout, the signals aren’t working, so it modulates the stop and go of those messages from different circuits in the brain, and finally we have something called transcranial magnetic stimulation, which focuses on – sends a magnetic – creates a magnetic field in a particular part of the brain that we think is related to the sequence of the disruptive thoughts and it modulates that. So this is one of the few disorders in the world that we have what’s called neural interventional strategy. So this is one of the few disorders where you can have – you can get better just with psychotherapy – behavior psychotherapy. You can get better with medications and psychotherapy, but for extreme cases, people that spend 12 to 15 to 18 hours a day suffering from this, there’s a very small portion that can benefit from what’s called neural interventional psychiatry. So this is a very, very fascinating area of science. It’s a very fascinating area of treatment, and we still are not at a place where we can say we can cure everybody, but 60% to 70% of people, we can get great outcomes on.
Host: Wow, that’s such a great explanation, Dr. Dewan, and so many tools in the toolbox to help people with OCDs. Wrap it up for us if you would with your best advice about what you would like friends and family to do if they notice that somebody has these, is there a way to help to say, don’t do that, does that work? And what you would like people to know about the time, that it’s really important that they seek help.
Dr. Dewan: One thing I would say to families is it’s not your fault. This is primarily a usually a genetic, biological condition. It can be treated very well. If you see a loved one spending two, three, four hours, saying things, repeating things, checking things, washing things, and they appear distressed and you think they’re distressed, and they’re not living their life to the fullest, that’s when you can say I’ve noticed this happening, are you okay? You could have this and I would direct them to look it up on the web, go to the International OCD Foundation website, read all about it, and there are lots of treatments available and there’s hope available, and that’s what I think family and friends should say, this is treatable, this is normal, this is recognizable and there’s lots of help available.
Host: Perfect, thank you so much Dr. Dewan. You are such a good educator and thank you for coming on and sharing your expertise about this condition for which so many people suffer and some don’t seek help, as you said they might be embarrassed so thank you again for joining us. You’re listening to Baycare Health Chat. For more information, please visit baycare.org, that’s baycare.org. This is Melanie Cole, thanks so much for joining us.