Understanding Obsessive-Compulsive Disorder: Debunking Common Misconceptions

His extensive experience in mental health positions. Help them advise us on clinical curriculum practice guidelines, and specialty clinical programs such as obsessive compulsive disorders, Autism Spectrum Disorder, substance use disorder and eating disorders. Dr. Ramin really has an impressive resume. He has been specializing in OCD and OCD related disorders for over 35 years and is considered one of the foremost OCD experts

and clinicians across the world. In fact, Dr. Freeman is widely regarded in the healthcare community for helping more people recover from OCD than any other clinician in America. One of the many areas we Embark have found alignment with Dr. Freeman is his significant contributions to measurement based care, and

standardizations of care. He's a prolific researcher and serves as a member of the scientific advisory board of the International obsessive compulsive disorder Foundation, acting as expert consultant to the organization on research matters. And in fact, his research has been published in nearly 100 articles and professional journals, which is particularly impressive given. He is someone who is in the practice setting, not the

research or academic setting. Suffice to say Embark is fortunate to have Dr. RAMAN as a clinical leader and partner. Welcome Dr. Raman.

them. It's really a unique disorder, and very debilitating condition. There's also so many misunderstandings, as I'm sure you're gonna share with us, and it's very commonly misdiagnosed.

compulsions, on the other hand, are some sort of repetitive act and, and typically, it is some sort of behavioral act that we can observe something that someone feels compelled to do to try to neutralize that unwanted obsessional fodder to get rid of the anxiety that it causes. So this might be something like in response to say, the fear of dirty becoming dirty and contaminated washing and cleaning over and over again.

But compulsions can also be another thought. I mean, it can be something that we can't observe something that someone does silently in their own mind, again, in an attempt to prevent something bad from happening, or to get rid of that anxiety that is caused by that social thought. So it's important to think about it as really a two part problem obsessions and compulsions.

themselves. The question is, you know, what are some of those common misconceptions with OCD and misdiagnosis where some people think they may have it or may think they don't have it is just because I have certain thoughts about something that may be stressing me out, doesn't necessarily mean that I have diagnoseable OCD. What have you seen in your work that are some of the most common misconceptions and what leads to misdiagnosis and how should people be thinking about it in

terms of when are the those behaviors? Maybe something that more represents OCD than just typical thoughts and behaviors that people may have?

the word tremendous exaggeration of the norm. Point simply being as we go back to our 2.2 part definition obsessions and compulsions. The obsessional part Alec seems to be universal. I mean, everyone gets unwanted thoughts from time to time. And it just seems that again, this exaggeration of the norm where someone with OCD has so many of those thoughts, and does so many repetitive compulsions, whether it's checking, washing, counting, cleaning, whatever it might be, that it creates

interference or disorder in their life. And then that's when someone like me says, Well, you have obsessive compulsive disorder. But again, to your point, everyone's you know, this, a lot of these symptoms kind of ring bells and say, you

have done that from time to time. But you know, when your child or young adult starts to do, you know, starts to have these issues so much that it creates this interference in their life, you know, that's when it really is time to be thinking about getting an assessment and perhaps, treatment, but it is commonly misdiagnosed as you as you said, and the real error, I guess here is that just because someone does or thinks something over and over and over again, does

not make it obsessive compulsive disorder. And, you know, like the media in lay people, you know, really kind of misunderstand that. And a perfect example, Alex is, you know, kind of excessive video game playing. You know, I've gotten phone calls from parents saying, oh, you know, Dr. Freeman, you're an expert in OCD. My son has OCD. I'm so sorry to hear that. What sort of symptoms he has, he cannot stop playing video games. And I'll say, Well, you know, I never say

never, but chances are, that's actually not OCD. And they'll say, Well, I don't understand. He's thinking about them all the time. He can't stop playing them. It's the he can't go to school, it's interfering with the social life of the differences. Again, if we go back to the definition of an obsession, it's an unwanted thought, right? Whereas if you ask Johnny, do you like thinking about playing video games? He says, yep. And do you like playing video games? Yep. It's a

problem. And it can be a serious problem. But in a way, it's almost kind of the opposite. And so the, again, the take home message is just because you think or do something over and over again, does that make it OCD? Great

parents or their teachers or their spouse. You know, we've gone into the classroom and spoken to teachers, of course, after obtaining proper consent, and teach us a passion, we had no idea, you know, that Johnny had these problems, because, again, Johnny, he might be washing his hands like mad at home, but you know, he is not going to display the symptoms in front of his friends. And so he's kind of sweating bullets all day long at school. Because again, just this fear of

embarrassment. So you have this tendency for people with OCD to not discuss this stuff, they tend to hide it, they tend to keep it to themselves. Most people who come into an OCD treatment program, for example, will say I've never met anyone else who had this problem. I've never been able to talk with someone else who has this problem. So there's this tremendous relief and kind of normalization, if you will, when patients do come in but so this is a problem that is common.

It's also commonly misdiagnosed. And then there are many, many people who are suffering in silence because of again, this fear of embarrassment and not wanting to discuss This with friends, family, whatever, even to the point of not wanting to discuss it with their mental health care providers, so they might have engaged in mental health care. I've gotten calls, you know, Hey, doctor even Yeah, this is Dr. Smith, I have this patient who has OCD. I've been seeing them for three years.

They just told me last night they have OCD. Well, what were you treating them for depression? So they were even afraid to admit this type of issue, even to their mental health care provider?

get over that stigma? To figure out if we should be trying to find more help for that family member for that child? Yeah,

suffering that people with OCD go through. You know, at the top of this podcast, you had mentioned the, how disabling it can be, and the World Health Organization, or WHO has rated as it the 10th leading cause of disability in the world, Alex, and they're not just talking about behavioral health problems, they're actually talking about medical problems, such as anemia, and falls, all these things. OCD is in 10th, leading cause of disability so it's, it's very disabling, very

impairing causes a lot of pain and suffering. And, you know, when, when a loved one starts to feel that maybe something's off, maybe they start to pick up on some of these symptoms, again, keeping in mind it's a two part problem obsessions and compulsions. If you start picking that up, you know, I think the best thing to do is to approach your loved one, have a conversation with them, you know, ask them if they're having issues. Hopefully, they would feel comfortable in confiding in

their parent, or sibling or whatever it might be. The other thing that I would suggest, and you had mentioned the international OCD Foundation, their website is a tremendous wealth of psychoeducation material, I mean, that they they go into great length of what it is what it's not what to do, you know how to talk with a loved one? And, you know, certainly that's another thing that someone could do just even inform themselves a little bit, you know, hey, I don't know, is

this OCD? Isn't it? Is it normal, you know, going there and reading up a little bit on some of the resources they have, can be very, very helpful. And then when talking with a family or friend, you know, perhaps even suggesting that they go on the internet, and there are other organizations as well. But, you know, the iocdf is really kind of that clearinghouse for information for patients and their families. Great.

have a more serious conversation. Would you mind doing that as we think about parents, and, or a loved one or an older sibling? is they want to bring it up? They're not sure exactly what words? How do I bring it up? And how do I start that conversation? How would you do that? Maybe do that with me right now? Sure.

are gonna happen. No, maybe not immediately, but at some point, you know, that conversation is going to register with someone and they're going to realize that, you know, hey, you're, you're a trusted person who cares about me, but yeah, you know, I think that my suggestions more specifically, you know, you know, I would approach you Alex and just say, hey, look, you know, I was noticing that you were kind of

getting stuck over there. And having trouble you know, with that door lock or, or I notice you you know, you were avoiding touch Everything's at the dinner table and then had to go and wash a couple of times during the meals. And, you know, and I don't know what's going on Alex, you know, I'm just doing this because I care about you. And it just seems like you were really struggling. So it's something up, you know, I mean, is there

something going on? You know, I'm a person you can trust, I'm a person you can confide in, you know, I, assuming I'm a layperson, you know, I don't really know, you know, but I am aware of this condition known as obsessive compulsive disorder, and just a little bit I know of it, it seems like, maybe some of

these things are relevant for you. But again, you know, please feel free to talk with me, whatever you say, I'll keep to myself, I won't share with your parents or, you know, unless you give me permission to do so. But, you know, I'm here for you. I can listen, I can try to help you in any way, shape, or form. I'm not trying to exaggerate what was going on. But it did

seem like you were really struggling. And it just gave me a sense that this is kind of a something, you know, your parents had told me that you were kind of struggling with a few things. And, and you know, if nothing else, you maybe you could talk to some friends, your school counselor, but I'm always here for you, and we'll help you in any way that I can.

they don't want to talk to you about it. But that experience of acceptance will allow them to talk to the person they did want to wasn't able to tell them those words, but they feel like I really want to tell this person. And because you helped me feel accepted in the situation. Now I feel comfortable telling them. And so I think it's a great way to engage with a friend or even even a child in that way as is. It's maybe maybe it's one of many conversations, maybe it's

one and nothing comes up for a couple of weeks. And then they say, Hey, Dad, you were you brought that up? And you saw me during this break that I was doing this thing? Can we talk a little bit more about that? And exactly,

appears to be at least in part genetically influenced. So when you're talking about parents, and you're talking about genetics, you know, obviously what that means is that at least in part, you know, this was passed on OCD tends to run in families, right? It does not appear, though, to be really

kind of parenting in and of itself. And so for example, when you look at adoption studies, and so say you have someone who is adopted, who there's positive biological family history of OCD, and they're adopted into a family that is OCD, free, they are more likely to have OCD because of that biological influence. Vice versa is also true if your biological parents were OCD free and you're adopted into a family that is positive

for OCD. You're not going to develop OCD, you can't really make someone OCD, so it does seem to be neuro biologically abnormality that's influenced at least in part genetically. But again, we are all products of our our past and influenced in the environments that we are brought up in but you know, the the biggest thing that seems to be involved with the parents. And you had mentioned this in some of your opening remarks is

this concept of what we call family accommodation. And it you are absolutely right, it is always very, very well intended to begin with. None of us like to see our children or our loved ones in distress. OCD causes lots of distress. And so parents try to kind of run to the rescue of their children. So they start opening doors for their kids so that they don't have to touch a door handle that appears to be contaminated. They start trying

to help them in other ways. And initially, it does allow Johnny to kind of sidestep their OCD and get on with whatever it is that they're trying to do get to their little league game on time type of thing. But what it ultimately does, those kind of fanned the flame of OCD, and it actually literally makes the severity of the OCD worse, and reduces the response to treatment, unless addressed. And so that is one way that unfortunately, families can kind of make the situation more

difficult. But again, it's it's natural. I'm not saying I wouldn't do it myself, right, or you. We care about our kids. We love our kids. We don't want to see him in distress. But it has this kind of paradoxical effect, it has this kind of opposite negative impact on the OCD in the long run. So it has to be addressed in treatment.

you don't like to see them feel uncomfortable. Yeah. And so what would you say, if, as a family member, as a parent, if, in that case where we got to get to the baseball game, or we got to get to school on time, we're going to be late again, instead of accommodating, which they do instead?

solution. So the exposure is geared toward the obsessions, the response prevention, as some people refer to it as ritual prevention, is targeting the compulsion. So again, two part prompt two part solution, if a if a family is engaged in that type of treatment, then their clinician, their provider, will be instructing them in kind of a series of steps to address and

reduce accommodation. It's tricky, Alex, if you try to do this without being in that context of treatment, and let me tell you why, you know if that child is because is going to become quite dependent on that accommodation. And if parents were to just say, okay, look, you know, I listen to this podcast, it's Reman guy said accommodations bad starting to come out, we're just not doing it anymore, right? That's not

gonna go so well. I mean, it could cause World War Three in the house, it could cause a tremendous rush of distress for that young one, because, again, they've become dependent on it. So it's something that, you know, I think families need to note has to be addressed, I would encourage them to reach out to a provider to try to get some assistance on kind of the step wise approach to reducing and ultimately eliminating that, but just pulling the rug out from under on probably is not

gonna go so well.

Expert? Sometimes they're the same. A lot of times, they're not or maybe there's other anxiety issues, or there could be substance use issues or eating disorder. Eating issues is how often do you find co occurring disorders and how should parents think about seeking help for their child? Yeah,

comorbidity is the rule meaning. Most studies find that children with OCD have about 60% of kids with OCD will have at least one additional diagnosis, the really common comorbidities in kids, ADHD, tic disorders, depression, as you mentioned, other anxiety disorders. So it is pretty common. And, you know, some of these things like the depression, Alec seems to be

kind of secondary to OCD. In other words, as you learn more about OCD, it's not really a question as to why is somebody sad and feeling hopeless and helpless, it's a bad thing to have, right. And so I think quite naturally, it starts to pull people's mood down. So depression, for example, is commonly secondary to the OCD. And what I mean by that is, if you get into good treatment, if you are in treatment for OCD is really kind of you want high quality exposure and response

prevention, but you also need the right dose of it. And I'll get back to that in a moment. But if you're getting high quality treatment for their OCD, and their OCD symptoms go down, the depression tends to go along with it more often than not, I mean, they're depressed because they're anxious, right. And so the good news is there as you you know, you can kind of get a little too for one, but some of these other things that you

brought up are freestanding problems. And at times, there may be some treatment overlap, a clinician treating your OCD could maybe just pivot the treatment plan slightly to be able to address some of these other conditions. And then some of them may need some expertise that your OCD provider might not have. And so then there there may need to be, you know, a

referral elsewhere. And the the order of that treatment also depends, I mean, again, if it's a primary OCD, that really means that it is the number one problem causing interference in your child's life, then that should be the priority. And

these other things can, can can wait. Now, it also depends get back to the dose from for a moment, and we talk about dose of treatment all the time when we think about medication, you know, 20 milligrams of this versus 40 milligrams of this dose rarely comes up Alex when we're talking about psychosocial treatments, but there is truly a dosage effect for many

behavioral health and addiction problems with OCD for sure. And what I mean by that is, you know, the, the more complex, the more complicated the OCD, and that is within OCD, also with comorbidity, right, I mean, you know, do they have other things going on, which we said is already the rule. It's how much good ERP how much high quality treatment do you need to get

better, and there is this dosage effect. And many people because of that level of disability, remember, it's a 10th leading cause of disability, the world may need more than high quality one or two hours a week. So they may need intensive outpatient, which might be two, three hours a day, three to five times a week, they may need a day treatment program, they may need residential care, and that 24 hour support. Now, thankfully,

you know, that is a small minority of these patients. But it is enough that obviously there are specialty OCD residential programs that in that case, they have they have enough time with this youngster to not only address the severe OCD, but these other comorbid problems as well. Yeah.

there. They just weren't able to leave the house. And so there's part of it in terms of there was this initial step and it didn't mean that that first step we couldn't even accomplish. So fortunately, we were able to enroll in the virtual program as a first step with the main goal of helping this young boy teen boy be able to leave the home first of all, to be able to transition to be to his near his Tom and accessible to be there

in person and continue that treatment. You know, we we know that you recently co authored an article on the benefits of telehealth for pediatric OCD, I would love if you could share a little bit what you found in that study?

very, very quickly, right. And within seven days, we transitioned, you know, literally over 1000, patients that were receiving intensive treatment in IOP, AND PHP, to telehealth because of the, you know, the pandemic, obviously. And we began to collect data immediately, because we wanted to make sure that this treatment was still effective. This study that you mentioned, that we published, really supports that. So to make a long story short. Now, again, this is primary OCD.

In kids, and they're receiving three hours a day of treatment, a day or six hours a day of treatment in the day treatment, or partial hospital programs, the outcomes were basically identical. This treatment, when done in a high quality structured kind of protocolized or manualized, fashion, produced equal outcomes in these in these patients. The only difference is we needed two days longer for the telehealth IOP to get the same benefit, which was kind of an interesting little thing.

It's not insignificant. I mean, especially if you're a payer, I mean, two extra days that there's a cost to that. But the bottom line is, is these kids got better equally telehealth or in person. Now, what I think will be fascinating, Alex, any kind of follow ups to those things? Is we also however, were aware that there were probably, you know, some young individuals who did not do as well, telehealth I mean, at the individual level, not at the group level with hundreds and

hundreds and hundreds of patients. And there were probably people who didn't respond to telehealth, who would have responded to in person. And I think the the interesting thing would be to kind of find out what predictors, you know, would we be able to what kind of data could we collect from an individual who is considering treatment, and say, you know, what, Alex, based on your responses to this, you have a choice, you could do telehealth or in person, or based on your

responses here, you know, you really need to do in person. And that ability to predict would be incredibly powerful. You brought up a perfect example of someone who could get geographic access to this clinic, but was too anxious. And the goal in treatment was to lower that to get him to come up with some, as you know, no matter how many clinics you have, say, California that you brought up, it's an enormous state. And you could still be four or five, six hours away from your nearest

specialty clinic. And as a result, being able to plug in telehealth would be a huge advantage.

ERP just one or two hours a week. But then there's a subset of patients who just have to have more than that, I mean, it's just the dose isn't high enough. And so then this is where the IOP has come into play. In some cases, even those partial hospital programs or PHPs, provide six hours and then of course, residential for thankfully, the minority of patients. But again, it is a fairly large number because of how common the problem is, but it's very, very treatable. Just

some examples. You know, the the overall kind of success rates that one will read about in the field 80 to 85% of people who will engage in this treatment, respond to care and get significantly clinically meaningfully better. In my world, you know, 90% of our IOP patients responded, 81% of our residential patients responded. And that's interesting, because these residential patients were considered treatment refractory, you know, they were considered patients who were were not able

to get better from treatment. And it's all about the dose piece, right, they just didn't have enough dose of it. And once given that proper dosage, they got better. The reality of though is this, you get out of it, what you put in it, and this is not a treatment, Alex that one can benefit from, passively. This is not something that one can absorb, but it is one that

you have to be an active participant in. And as a result, you know, when you hear things like 85%, or 90%, or whatever it might be, you know, there are patients who do put in effort who don't respond, nothing's perfect. But the vast majority of patients who don't respond are unfortunately, either unwilling or unable to really do the work that they need to do it is against something where, you know, it is an active engagement in this treatment. But if people do that, they get better.

five, six hours a day, and RTC being able to step up. And that's good, just good health care, good health care system where we intervene at the lowest level of care, possible, least invasive, try to get that to work. But if it doesn't, we can quickly step up so we can nip nip it in the bud and then step them back down, it's less expensive, less invasive, that continuum of care is really important for delivering good outcomes.

anymore. And then if they go right back into outpatient, if they go from that to one hours a week, that's kind of a big thud, if you will, and, and and to your point in, in medicine, in a, you know, general medical surgical world, you know, there's these step downs. And that's exactly what we have to build in our world. And, and so it's, it's being able to ratchet it up if they need more dose, but then it's that stepping down

as well. And in the key here, to your point, Alex, is that even if someone has tried what they believe is truly high quality ERP, you don't want to throw the ERP baby out with the bathwater, so to speak. You don't want to sit back and say, Well, we tried that and it didn't work. It could be again, that the dose of the treatment you're receiving did not match the severity and the complexity of what you needed.

straight home. It's as if you had knee surgery, and you go straight home with no physical therapy. That doesn't mean the knee surgery. What wasn't effective, as long as you didn't do the proper continuing, continuing care needed, developing more of that. If I'm a parent, and I'm looking for a therapist, because it may be the one to two hours, or maybe you have been doing the one or two hours, but it's not working. And

so I want a higher dose. So I'm looking for an IOP, or the PHP, partial hospitalization program, therapeutic day treatment program, or even RTS C. Now I'm a parent, what should I be looking for? What should I be Googling, what type of treatments exist? What type of programs are there out there?

And how can you guide me a little bit into making sure that it is high quality and that I know that we likely are going to get the right dosage, the right interventions and treatments that are the most effective?

treatment, Alex's. That is this idea that research has found this treatment to work for this condition. But when we think about evidence based treatment, we also have to make sure Yeah, but that clinician can apply that evidence based treatment to patients just as well as that study did, right. So you know, I can, I can say I do these things. But that doesn't mean I

really know what to do. And so you got to do your homework, most people spend more time picking out the person who's going to tile their bathroom than they do their mental health care provider, unfortunately, you know, right, Alex, and so you got to do your homework, you have to do your due diligence, and you want to make sure that they do this. You want to ask them, how many patients with OCD have you treated? How many have

you treated successfully? You know, if they're starting to use some of the jargon, ERP, obviously, or exposure work or exposure hierarchies, and that's just the big master list of all of the exposures that that this young person with OCD is going to have to do that starting to ring some bells. But you know, ask questions, I mean, be informed. This is important.

And, sadly, there are not that many people who specialize in this, we did mention the international OCD foundation before they do have a tab, find a therapist, I'm assuming parents could reach out to Embark in Embark would also steer people in the right direction. I mean, obviously, you might have a program that could help them in the vicinity that they live, or you could direct them elsewhere. But it takes a very specific kind of intervention to be effective.

And in the end the dose to your point.

nudge that depression along as well as the OCD. These medicines provide somewhere between 25 and 30% symptom reduction in the average patient. Some people get much more production than that some people unfortunately, get none. But on average, you can expect about a 25 to 30% symptom reduction, which could be the difference between being able to go to school or not, or being able to go to work or not, or being able to engage in social relationships or not. The medicines are rarely enough in

and of themselves. In ERP is really again, considered the gold standard. So there was an expert consensus study done many years ago that I participated in and the consensus of the expert OCD community was that everyone with OCD should get exposure and response prevention, some should get exposure and Response Prevention Plus medication. Great.

you give? What steps can individuals take to raise awareness about OCD and reduce that stigma? and advocate for better understanding and support? Yeah,

have a medical condition. Right? And, and we unfortunately, separate out mind from body. This is a medical condition, as I said, every year we get more and more evidence that it is truly a neurobiological issue, a medical issue. And, you know, I think that that's the key, I mean, it just realize that there are many people out there with this condition, some famous,

most not but many people with this condition. And then I think just that the hope of treatment, I mean, you know, I think, you know, knowing that there is effective care out there, and that there is hope. And there is help, also, you know, dramatically reduces all that fear and stigma as well.

adulthood, late 20s, maybe around 30. For most, it tends to plateau off, but it's plateauing off at a pretty debilitating level, right. And so, you know, it is common, it's debilitating, it's not going to go away on its own. And there are resources to help. And you're just going to have to, again, kind of roll up your sleeves and find the right provider. The good news is, as you know, there are more and more trained providers every year. There are more and more intensive programs every year,

still not nearly enough. And then to your point, if you don't have geographic access, you might be able to plug into a good telehealth program. And the good news is insurance tends to support these programs. You know, they insurance understands OCD, and understands how debilitating it is and and understands it's not just a whim or a phase that Johnny's going through. And if anything, it's going to get worse. And so they do support treatments and including intensive treatments. Great.

have Dr. Freeman on to talk about OCD. We appreciate you following liking and sharing this episode. You can go to where you can find our podcasts or our YouTube channel to follow and we look forward to seeing you on the next one.