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.

The four kinds of OCD – Numeracy and Symmetry

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

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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?”

***

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, and the remainder of the, “four kinds,” series.

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

The four kinds of OCD – Doubt

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.

Doubt

Sometimes, OCD can be obvious. Other times, it is more nuanced. This is the case with obsessional doubt, one of the most common, but under-recognized, subtypes of OCD.

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So what makes doubt obsessional? To understand that, we need to remember what makes an obsession an obsession. An obsessional thought is unwanted, and comes about seemingly out of our control. This is called an intrusive thought. Obsessional thoughts occur over and over again, and won’t go away. Importantly, obsessional thoughts consume a significant amount of time, and result in a functional impact. Remember, if it’s not causing you problems, it’s not a disease!

Taken all together, obsessional doubt occurs when someone repeatedly doubts they have remembered something. Obsessional doubt is also often coupled with compulsions, to relieve the anxiety associated with the doubt. Compulsions in doubt-based OCD tend to complement the doubt, and therefore the compulsions tend to be reassurance-based. Now I know this sounds underwhelming, but trust me, it can be debilitating. The following are some examples of people I have met (with their stories altered, of course) with obsessional doubt.

***

Richard was a 27 year old man living in Toronto. He was getting ready to go out on a date one evening and found himself very anxious. He was getting ready to head out, and had the sense he had forgotten to turn off the stove. He checked the stove and realized it was off. He did this two hundred and twenty two times, for good luck. Before he knew it, he had missed his date.

Dema was a 29 year old female admitted to an inpatient psychiatric ward for severe OCD. During rounds one morning, the word “complete,” was mentioned. Dema fixated on the word and became unable to answer any other questions. She repeatedly asked I repeat the word, “complete,” so that she could ensure she had heard me pronounce it correctly.

Mohammad was a 17 year old young man. He presented to my office one day complaining of difficulties studying. He found himself unable to move beyond the first few pages of his notes, as he felt he had to perfectly memorize everything if he were to succeed. He reflected on a similar incident a year prior, where he developed a fear he would forget his memories with a family member. He would repeatedly look at pictures of the memories he had, to ensure they were real memories. This would take hours a day.

***

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, and the remainder of the, “four kinds,” series.

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

The four kinds of OCD – Contamination

Yesterday, in the language matters segment, we discussed what Obsessive-Compulsive Disorder is not. Why is this important? I find that a large driver of stigma against mental illness, is the emergence of medical and psychiatric language in common speech. When this language is used carelessly, a false image of a world where everyone has a mental illness can develop, and people become jaded to the topic. By discussing what mental illness is not, I’m hoping to dispel at least some of the myths and stigma surrounding the field.

OCD is real, and it’s debilitating – but it’s not all doom and gloom! OCD happens to be treatable, and the first step towards treatment is diagnosis. OCD happens to be one of the most underdiagnosed and missed psychiatric illnesses, so getting the diagnosis can be harder than you’d think.

Before we begin, I’ll reiterate a point from yesterday’s discussion – for it to be OCD, or any mental illness, there has to be a functional impact. In other words, if it doesn’t cause you a significant problem, it isn’t an illness! I’m not in the business of policing thoughts and behavior.

The four kinds of OCD

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.

Contamination

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Perhaps the most widely known manifestation of OCD is contamination fears. People with contamination-based OCD will have obsessional thoughts of contamination, meaning they are extremely preoccupied with the idea that germs, disease, or some contaminant substance, will spread through some form of contact. These fears can go both ways, meaning the individual may have fears they will become contaminated, as well as fears they will contaminate others. These thoughts can consume hours a day and make thinking about anything else near impossible. Importantly, these fears typically do not make sense to the person experiencing them. I person with an obsessional thought that they will develop cancer from touching doorknobs knows this doesn’t make a whole lot of sense. But alas, their brain obsesses over it. This kind of thought is called an egodystonic thought, meaning that the thought or belief is different from how you actually feel.

Contamination obsessions may manifest with compulsions. An important point here is that for a diagnosis of OCD, you do not need both obsessions or compulsions, just one or the other (both tend to be present but one or the other may go under-recognized). Examples of contamination compulsions may be wearing many layers of clothing and gloves, despite it being a warm day. People may have to wash their hands thirty times or more after touching food, just until it feels right.

Contamination-based OCD is not being a neat freak, though being too much of a neat freak can be a mental illness. What am I talking about? To be honest, it’s a difficult topic to relay in words, but essentially, it gets down to what is driving the neatness. If someone has true obsessions (best elicited by a physician in their office), they will probably be having a thought more akin to, “I’m going to get AIDS from these scattered papers,” than someone who is just very neat, who would be having a thought like, “I need the room to be clean otherwise I won’t be calm.” The very neat person is displaying cognitive rigidity, which can looks like OCD, but is distinctly different. Rigidity is more alike what we would call a personality trait.

Editor’s Note: Stay tuned for the remainder of, “The four kinds of OCD.”

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

Language matters – What OCD isn’t

“The chicken smells delicious.”

“I know, I marinated it 24 hours.”

“That’s amazing. I think they’re ready to be flipped.”

“OK, let me do it. The lines need to be perfectly crisscrossed,” she laughed, “it’s my OCD.”

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Obsessive-Compulsive Disorder is a mental illness characterized by obsessions, a specific type of thought that occurs over and over, and compulsions, repeated rituals or activities that typically relieve anxiety associated with obsessions. Now, before you realize that you definitely have thoughts that won’t go away, and self-diagnose yourself with OCD, you probably don’t. In fact, only about two and a half percent of the population (2.5%, or 5/200) in North America will experience true OCD at any point in their lifetime.

So what’s going on? Before we talk about what OCD is, lets talk about what OCD isn’t.

OCD is not rumination

“Ugh, I can’t believe he said that to me!”

“I know, what a dick.”

“I’ve been thinking about it all day… all I can see is his face…”

We’ve all been in an argument. A heated one. Probably with a relative. If you’re unlucky, maybe even a mother-in-law. These things are upsetting, and they’re part of life. But they also suck. It can be difficult, and is certainly common, to find yourself ruminating about a fight, a conflict, or other sources of stress like a work problem or a death in the family.

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OCD is not rigidity

“Make sure you have the papers on her desk laid neatly.”

“What do you mean?”

“She’ll freak out, she likes everything neat, she’s so OCD.”

A feature of true OCD is how unmovable many of these behaviours seem to be at the surface. Someone with severe, untreated OCD may find themselves incapable of leaving the house without checking the stove one hundred and twenty nine times. They may find the alternative, leaving without doing this, intolerable. This is an example of a rigid behaviour.

There are other examples of rigidity, as described in the example above with the desk and the papers. If people have high standards, or are very anxious, they can often have similar intolerance towards certain aspects of their life being altered. For example, if you are a perfectionist, you may have intolerance towards a messy desk, and therefore be very rigid when it comes to desk tidiness. If you are very anxious, you may have to leave for work twenty minutes earlier than you have to, despite getting there thirty minutes early, every morning. You may find leaving later intolerable. This might even cause conflict with more laid-back loved ones.

OCD is kind of getting a song stuck in your head – forever.

If you’re lucky, it’s a song you like. All the same, it can be annoying to get a song stuck in your head. It’s also quite common.

Current psychiatric opinion supports that this phenomenon is similar, or maybe even the same, to many true obsessive thoughts. The main difference between getting a song stuck in your head and OCD? Impact and duration.

The single most important feature of OCD is that it causes a functional impairment. As a physician, I’m not in the business of judging you, your thoughts or your behaviours. When a behaviour begins to cause functional impact, and impair your quality of life, it becomes a disorder. True OCD also taks up a significant amount of time, which is in part how it causes a functional impact. Yes, “Hey Ya!” by Outkast is annoying, but getting it stuck in your head on July 1 is not the end of the world. True OCD, can be debilitating.

 

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So what is OCD?

A twenty three year old female law student. She’s spends six hours, every evening, after a long day at the university, studying. She does this for weeks and finally writes her exams. She fails miserably, and it’s devastating. She comes into your office complaining of depression and you start to talk about the exams. “I couldn’t study everything, I never had time.” “How is that possible, you studied so much!” “I couldn’t get past the first chapter. Every time I read a paragraph, I freaked out and was worried I forgot it, so I had to repeat it over and over and over until I had it perfectly memorized.”

A eight year old boy is seen standing in the corner of the house before he leaves for school. His mom notices he’s muttering under his breath for a few minutes and finally he leaves for school. That night, before bed, she asks him about the muttering. He finally opens up. “Every time before I leave for school I have to say, ‘Mommy loves me,’ one hundred times before I go or you’ll die.”

A thirty year old man lives at home with his parents. He’s brought in to the psychiatric emergency by his father one evening. His father discloses that his son has been unwell and has been unable to wash or clean himself. He has an intense fear that his left index finger will cause AIDS, and has been unable to touch anything, or anyone with it. Including himself. He’s required his family to bathe him.

These are all examples of real people I have met – with their stories heavily altered, though the principles remain – with true OCD, functional impact is real. To be fair, these cases were pretty straight forward, and not everyone is so lucky OCD can go undiagnosed and missed for decades, resulting in real people having real suffering for unnecessary reasons.

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What about the example above?

Well, it depends. This person probably does not have OCD. When I hear a comment like this, I immediately suspect “OCD” is being substituted for “rigid behaviours,” due to the behaviour being fairly unusual for typical OCD. There are forms of OCD which focus on symmetry (stay tuned!), though I suspect this is not the case here, because the person is laughing about it. Remember, it’s only OCD if it’s significantly inhibiting your function!

Editor’s Note: Stay tuned for What to do about OCD, and The four kinds of OCD.

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