The four kinds of OCD – Intrusive thought predominant

From Part 1:

Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.

Part 2

Part 3

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Intrusive thought predominant

“Hi Doctor, we have a consult for you,”

“Go ahead.”

“He is a 18 year old male with daily, intense suicidal ideation. We’ve placed him on a form 1 and he’s in the emergency waiting for you.”

***

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Early on in my career as a psychiatry resident, I met a young man, just graduated from high school at one of the hospitals I was working in. I was working in the Psychiatric Emergency Service (PES) at the time, and had been asked to see the man by an Emergency Medicine colleague.

As these things go, you don’t always get the most information. Really all I knew about this person was that he was eighteen, was going to university for engineering, and had daily, intense suicidal thoughts.

As I walked down the hallway to meet him, I considered a differential in my head. Could it be depression? Psychosis? Had a manic depressive fallen into my lap? Or a personality disorder, perhaps?

***

“Hi, my name is Dr. Barron, I’m one of the psychiatry residents.”

“Hi I’m Sam, nice to meet you.”

“Nice to meet you as well. My emergency medicine colleague asked me to speak with you, is that OK?”

“Yes of course.”

“Let’s start with your understanding of why you are here in hospital.”

***

We began speaking, and very quickly it became apparent that Sam was not depressed. He wasn’t psychotic. He definitely wan’t manic. I couldn’t even get a whiff of a personality disorder off of him. What the hell was going on?

I didn’t know it yet, but what I was seeing was a common manifestation of OCD, called intrusive thoughts. These thoughts are intense, and are very bothersome to the person. Some classic examples include:

Suicidal thoughts (killing yourself)
Violent thoughts (killing a random person or a family member)
Sexual thoughts (homosexual behaviours if you are heterosexual, heterosexual behaviours if you are homosexual, or pedophilia)
Blasphemous thoughts (against your own religion*)

An important point here is that blasphemous thoughts typically only occur when someone cares about being blasphemous i.e. it would not be considered a blasphemous thought to pee on a church if you didn’t care about peeing on churches.

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So wait. Suicidal thoughts can be intrusive? How is that different that a regular suicidal thought? Well, in intrusive thought predominant OCD, the thoughts are egodystonic, meaning they are in direct conflict with that persons values. In other words, a person with intrusive thought predominant OCD does not want to kill themselves, hurt someone, abuse a child, or disrespect a religion. In fact, they are often extremely disturbed by these thoughts.

Another important point to remember is that all forms of OCD have some level of intrusive thought based symptoms, however, the intrusive thoughts are not the predominant feature.

In contamination based OCD, intrusive thoughts of contamination cause extremely debilitating compulsions, focused around cleanliness, which tend to be the primary feature.
In doubt based OCD, compulsory checking tends to be the predominant feature.
In numeracy/symmetry based OCD, extreme cognitive rigidity and intolerance, as well as compulsions, tend to be the predominant feature.

***

“So doctor, what do you think is wrong with me?”

“Well, this sounds like OCD, a treatable illness. This doesn’t mean you have to kill yourself, or hurt anyone. These thoughts you are having don’t represent anything about who you are, or anything bad about you. In fact, the fact you’re so bothered by them shows how much you value human life. We’re going to help you.”

***

These are real examples of OCD at it’s strongest. Fortunately, most of the people in the above example recovered reasonably well. Why share this? OCD remains one of the most under-recognized mental illnesses, and hopefully this helps dispel some of the myths.

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Of depression

Sitting in the doctor’s office, I hear the words. They leave her mouth like an anvil and slam upon the floor, the noise made by each previous contact making the next syllable more impossible to hear.

“You have depression.”

I leave my body and float out of the chair. I’m outside the hospital, gazing down on all that was. I’m flying further, and further, overcoming the very curvature of the world, and then I see it. My future, everything that will become of me, and all that was, laid before my very eyes.

My first sense is loss. Loss of mystery, of individuality, and most importantly, of choice.

My head is spinning. I’m falling, crashing through the sky. I miss the chair and my body and drown below into the depths of hell. I’m confronted by all that has ever scared me, a violent torture to my all-seeing soul.

I’m fired, divorced, my family has shunned me. Strangers spit on me, I’m left to rot. Slowly I decay into nothingness until the coolest realization, as I’m forced to linger while all I once loved is forgotten to me.

My heart skips a beat and I’m back in the chair. The doctor is still talking, I realize to myself. I haven’t heard a damn thing she’s said to me in the last five minutes. I hope it wasn’t important.

“The important thing is that there is hope, treatment, and I am going to help you.”

I stumble home from the office, dreading the moment I finally stop. When my footsteps no longer crowd my ears, I’m left with my thoughts. Depression. What does this mean?

It takes a while, but my life takes a surprising fork as I journey on the path to recovery. I actually get better. I’m working again, and somehow, my relationships are more fulfilling. It’s a Saturday, and I want to go to the park. Why? Just because. It’s a refreshing release, to finally do something because.

On Monday, I’m back in her office. She’s asking me questions and I can’t stop thinking about this chair.

“How are you feeling?”

I speak for a while and we exchange pleasantries. She’s happy to hear I’m doing well. In a way, it feels surreal. The doctor catches my smile and asks me what’s up, and I give a small chuckle.

“Last time I was here, I thought I was drowning.”

Editor’s note: The above is a fictional piece I wrote, as inspired by a recent conversation I had with a patient regarding the meaning of a diagnosis. They had felt a diagnosis made a lot of assumptions about them, and what their future looked like. They were glad to be proven wrong.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Shootings, imitation, and media responsibility

Editor’s note: It is with great sadness I address, in today’s blog, the recent mass shootings in the United States. I think most of us are speechless and unable to really come up with words to describe how we feel about these events. I know I find myself at a complete loss for words. Eventually, I’ll write something on why a lot of these horrible events happen in the first place, but for now, here’s something relatively small and I think achievable, that we can do abut it.

The most shocking thing to me, regarding the news of two mass shootings out of the United States, is how little it seemed to affect me. Dozens. Dozens of corpses, strewn across a parking lot, live on CNN.

I finished my coffee and sneaked an extra piece of bacon.

This would be the story of the day. Live! Delivered straight to my door. The regular C-list Sunday content was quickly scrapped out of the way, and before you knew it, faces more typically seen on a Tuesday night at prime time were popping up on my screen.

Man, the bacon was good today.

Before lunch, I knew everything about Texas. The weapon, the number of casualties, the broken social policies responsible for the slaughter before my eyes, how much Trump was responsible. I was eating it up, my brain piecing it together, piece by piece.

I wonder if the orange juice has pulp?

By dinner, it was slowing down. Every detail that could seemingly be milked from the day was in the public arena, for Republican and Democrat to fight over like two wild dogs. And then it happened. The second shooting. This time, I did have some shock. This was, even to me, the most faithful detached news-connoisseur.

I found myself wondering, was this a coincidence? And of course I already knew the answer. Of course this was no coincidence. Coincidences don’t exist in this universe of mind and want and lust and need.

What I was seeing, in collective horror with much of the continent I am sure, was unquestionably in part a result of imitation. We see it all the time. Terrorist attacks in clusters, mass shootings in clusters, suicides in clusters. We know this phenomenon exists yet we do nothing to stop it.

Columbine is where this began – the reasons on why these young men have turned so violent aside, had you ever heard of a school shooting in such detail before that tragedy? Every excruciating detail, parading word for word out of the mouth of children for our viewing pleasure, on live television. It was simultaneously awful, incomprehensible, and world-changing. For Columbine would usher in the age of school shootings, each one more gruesome than the next, and each time we would ask why, while the news coverage has only grown greater.

The pictures from the Ohio shooting were scrolling before me. The body count continued to climb. I found myself wondering if this day would finally move the powers-that-be in the United States Congress to do something material on gun control. I was also dreaming of living in isolation in the pacific on my imaginary private yacht.

There was pulp. Love it.

The news media were on their feet today, and presumably using the vigour gained through covering the Texas massacre, the details on the Ohio case were public before everyone knew it. They began spitting demographic details out about him, though I did notice one thing missing.

His name.

I took some solace in this. Maybe they’re finally beginning to get it. Maybe they realize that prime time production level, all-day coverage of terrorism and mass murder, inspires some other troubled young men that this is their chance. Maybe there was some appreciation that these young, troubled men need a voice, and that the media has given them one?

There are blueberry muffins in the freezer, I remember.

I will not give CNN too much credit. It was Prime Minsiter Jacinda Ardern who stood in front of the world and announced she would not utter the name of the person responsible from her own mass tragedy in New Zealand.

Though we have come a long way. I you ever want to be disturbed, Google “CNN Iraq war coverage,” and try not to throw up. No, you’re not watching a sequel to “Top Gun.”

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Dr. Travis Barron is a resident physician in Toronto, Canada.

The pills aren’t working

“I’m never trying this again, it was awful. I thought you said this thing was supposed to make me feel better?”

“I’m sorry that happened to you. As we discussed, some side effects like nausea and headache are quite common when you start–“

“Start?! I took this thing for four whole days, doctor. I need a different pill. Will my depression and anxiety every go away?”

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Medication selection can be a painful time for patients. As with our diagnoses, often times there is trial and error in selecting the right medication that works for you. When it gets to the fourth, fifth, and sixth medications in some cases, it can be demoralizing, not only to the struggling person, but to their doctor. The fact is the science isn’t the most clear to the researchers in the laboratory, let alone a doctor in the office, and for that reason arriving at a suitable psychiatric treatment regimen can take some time.

Don’t despair – the medications work! Not only often, but usually. I see and help people recover every single day in my office, and it can be refreshing. However, that’s not always the case. Sometimes, struggling lasts a little longer than we would like it to. Sometimes, people lose faith in the system and look elsewhere for help. These cases can be tough; but there’s an upside! In my opinion, the majority of these treatment failures are actually preventable. So what am I talking about?

There are many reasons a particular medication regimen does not work. First and foremost, the most common reason I see, as described in the example above, is a misunderstanding of the expectations of an antidepressant or anti-anxiety medication.

Anti-depressants take time to work.

The textbooks would tell you that you need six weeks at a suitable dose to have a full effect. What does this mean? Here’s an example;

Week 1 – Sertraline (Zoloft) 25mg, oral, daily
Week 2 – Sertraline 50mg, oral, daily
Week 3 – Sertraline 75mg oral, daily
Week 4 – Sertraline 100mg, oral, daily
…
…
Week 9 – Sertraline 100mg, oral, daily
FULL EFFECT
Week 10 and onwards – Sertraline 100mg, oral, daily

The dose this person required was 100mg, and not until 100mg was achieved for six weeks do we see full effect.

What if 100mg isn’t enough? Well, a further increase may be required. The maximum recommended dose of sertraline is 200mg. You and your doctor may ultimately try a 100mg dose for a few weeks, decide it is sub therapeutic, and titrate further. Yes, this means we can be talking week 15, 16 in some case. But remember – this is for full effect. In reality, a skilled clinician and a patient can often tell after the first four weeks of a treatment whether there may be a significant benefit from a particular medication. That’s what the doctor’s are for!

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Side effects are expected and will happen.

And they aren’t permanent. Like anything, your body takes time to adjust to anti-depressants and anti-anxiety medications. In fact, the presence of side effects shows that the medications are getting to the brain and having some kind of effect! It’s important to appreciate that this is a normal part of the journey, not only with starting, but with significant dose increases.

Side effects suck and the last thing your doctor wants to do is make you feel worse – like all things in mental health, trust me, it’s an investment! Side effects like nausea and headache and anxiety tend to go away after the first half week-full week of therapy (yes, anti-depressants and anti-anxiety medications can cause transient anxiety – it’s your brain adjusting to the changes). Doctor’s are also all about safety, and don’t worry, the side effects are reversible with dose decrease.

What is considered a true treatment failure?

Part of my job when you come see me for a mental health problem is to take a detailed medication history; people have often tried multiple medications over time, and if something hasn’t worked in the past, it’s unlikely to help in the future. But what constitutes “doesn’t work?”

Not the above example. For a course of an SSRI to be considered a treatment failure, you need to have completed at least six weeks on an appropriate dose of that medication. A rough estimate of an “appropriate dose” is half the maximum dose.

***

The moral of the story? The medications work, they take time, and they can be a nuisance. Careful time, understanding, and collaboration with your physician is the best way to work through a mental health disturbance. With patience, I promise we’ll help you.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The four kinds of OCD – Numeracy and Symmetry

From Part 1:

Part 2

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Numeracy and Symmetry

Have you ever seen a kid walking in the mall (sorry Gen Z), jumping from small blue tile to small blue tile?

“Avoid the lava!”

“Watch out for the monsters!”

This is a completely normal behaviour, and many children, including myself, dabble a little in the lava-tile game.

But imagine if to you, it meant a little more. Imagine that your found yourself unable to walk on white tiles, because of a crippling sense of anxiety that if you did, something bad would happen. You would probably know this doesn’t make much sense, which only adds to the madness.

It wouldn’t be easy going to the mall.

This type of behaviour, in it’s extreme form, falls under the umbrella of a symmetry/numeracy based obsession. In this type of OCD, the obsessional thought is usually something along the lines of, “if this isn’t this way, than something bad will happen.” There may or may not be a specific type of “bad”-consequence perceived. Some examples;

***

An eight year old boy goes through the home and makes sure every single TV and computer has the volume set on an even number. His father has the TV on 15 one day, and the child gets very upset and throws a temper tantrum when his father doesn’t let him change it. The next day, his mother asks him what happened. The boy responds, “if the numbers are odd numbers, I’ll die.”

A twenty four year old woman is late for work every day. She’s eventually fired from her job, and ends up in a doctor’s office while she is off of work. “I think I need help doctor.” “OK. You’re in the right place. What do you think is going on?” “Every time I look in a mirror, I can’t leave until I catch my nose at the perfect angle, perfectly symmetric. I don’t know why, I just can’t. Some days it takes up eight or more hours.”

A fifteen year old is teased at school for his quirky behaviour. He doesn’t tell his parents why, and they only know that he is being bullied. One day, when dad is picking the boy up from school, dad notices the boy jumping from dark tile to dark tile on the sidewalk. “What was that about?” dad asks when the boy gets in the car. The boy blushes and says, “can we just go?”

***

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it, and the remainder of the, “four kinds,” series.

Dr. Travis Barron is a resident physician in Toronto, Canada.