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.
Intrusive thought predominant
“Hi Doctor, we have a consult for you,”
“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.”
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.
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.