Self doubt and ocd
The Role of Doubt in OCD
By Judy F. Minkove on 11/14/2017
It’s not uncommon, says psychiatrist Gerald Nestadt, to hear someone joke over cocktails, “I’m so OCD,” implying that the person is exceedingly fastidious about everything. But obsessive-compulsive disorder, which affects some 3 percent of the world’s population, is no laughing matter.
Now he’s digging deeper to understand another component of the disorder: doubt. “I’ve been fascinated by its clinical relevance,” Nestadt says. “Doubt is not based on insufficient knowledge to make decisions. It’s a behavioral trait.” In the context of OCD, he theorizes, doubt demonstrates a “lack of confidence in one’s own memory, attention and perception necessary to reach a decision.”
Nestadt gives the example of patients who feel compelled to keep checking their front door to ensure that it’s closed. “They check it with their own eyes, but yet still need to go back and jiggle the lock to be sure,” says Nestadt. He suspects a genetic basis for this behavior, though environment also plays a role.
In a recent study published in Comprehensive Psychiatry, Nestadt and his colleagues report an investigation of 1,182 adults with OCD who were assessed to evaluate the relationship between doubt and OCD’s clinical features. “It’s the first investigation of the clinical significance of the doubt construct in OCD,” says Nestadt.
Doubt was assessed with the following questions: After you complete an activity, do you doubt whether you performed it correctly? Do you doubt whether you did it at all? When carrying out routine activities, do you feel you don’t trust your senses—i.e., what you see, hear or touch? Cases were categorized as mild, moderate, severe or extreme on a “doubting” scale.
The study found that doubt in patients with OCD was strongly related to the number of checking symptoms and, to a lesser extent, to the number of contamination/cleaning and hoarding symptoms patients experienced.
The findings, says Nestadt, suggest that doubt has important implications for understanding the nature of OCD. For one thing, the severity of doubt was distributed in the sample such that many cases were rated as severely burdened with doubt, whereas a sizeable proportion were rated as having no or little doubt. “This suggests that doubt may not be a core feature of all OCD cases, but rather a frequently occurring symptom of, or related to, the disorder,” says Nestadt.
The biggest surprise, he adds, was the finding that “the more doubtful you are, the more dysfunctional you are; 80 percent of the doubters were extremely dysfunctional.” Most likely, explains Nestadt, these symptoms emerge “from a neurocognitive vulnerability in the mental life of the individual, which has a basis in neurophysiology.”
So, what can provide relief for these patients? “Typically, 60 to 70 percent of people respond to cognitive-behavioral therapy,” says Nestadt. “But in patients with severe doubt, only about 35 percent respond. That’s where antidepressants come in.”
Next up, Nestadt and his colleagues are developing a multi-item instrument to assess doubt dimensionally in clinical and nonclinical samples. “With greater understanding about the neuroscience behind decision-making in patients with OCD,” he says, “we can
Why it Happens and What to Do
OCD — also known as the “doubting disorder” — can make you question things that you were sure of just 5 minutes ago.
Obsessive-compulsive disorder (OCD) is a mental health condition where you experience obsessive often uncontrollable anxious thoughts with frequent compulsions in response to those thoughts.
If you have OCD, you may find yourself fixated on a single thing, like making sure the dishes are clean. Even after confirming the dishes have been washed, you might start to doubt your memory of having checked the dishes or doubt that you washed them properly. You might go back out and rewash the dishes — just to be sure.
“OCD is also known as the ‘doubting disorder,’” says Dr. Holly Schiff, a licensed clinical psychologist based in Connecticut.
“One of the driving forces of compulsions in OCD is chronic doubt. Your brain tricks you into thinking that something has been overlooked, and this fear drives the individual into repeating the action again,” Schiff explains. “Doubt is a hallmark of the disorder, and it overrides any sense of logic or intelligence an individual might have.”
At the core of OCD is doubt of your own memory. Trying to remember if something happened or if you did something correctly can quickly become an obsession. This level of obsession can interfere with your life and quickly consume your focus.
“Memory is a tricky thing,” explains Dr. Amy Marschall, a licensed psychologist.
“With OCD, the person has more doubt and uncertainty about their memory than is typical or helpful, and they have a fear of what will happen if they are misremembering,” she says.
This leads to the compulsive element of OCD, where you feel compelled to verify and double-check something as a way to relieve stress and anxiety temporarily.
The doubt that comes with OCD can really start to influence your home and work lives over time, too.
For example, if you’re trying to get a work task done but are obsessively thinking about your safety and doubting if you locked the front door, you might stop working while you think through all the possible negative consequences of leaving the door unlocked.
You might lose more work time as you act on the compulsion, leave your computer, and check on the door.
If you think you may be experiencing symptoms of OCD, you may benefit from talking with a mental health professional who specializes in OCD and other related disorders. They can help set up an effective treatment plan.
Talk with a therapist
After talking with a mental health professional about your experiences, they can provide a professional diagnosis and set up treatment options for you.
“OCD can be diagnosed by a mental health professional through a thorough diagnostic interview where you answer questions about your history and symptoms,” explains Marschall.
It is also important to talk with a professional because OCD symptoms can be shared with other disorders, meaning that while your symptoms may present as OCD, they may be stemming from a different or comorbid disorder.
“OCD can be present if someone also has another disorder, such as anxiety or depression, and it can be present in individuals with neurodevelopmental differences such as ADHD and autism,” says Marschall.
There are several ways that a therapist can help you manage your OCD symptoms. One of the most commonly used methods of OCD therapy is cognitive behavior therapy (CBT). This therapy aims to address and help you rethink negative behaviors so that they have less control of your life.
One of the most successful methods of CBT is exposure and response prevention (ERP). A 2019 review concluded that ERP is one of the most effective treatment options for OCD.
“[With ERP], you create a stimulus that triggers the desire to engage in the compulsive behavior but prevents the client from doing the compulsion,” explains Marschall. “This reduces the stress and anxiety by showing the brain that the compulsion is not needed.”
While CBT can’t fully cure OCD, it can make the symptoms of OCD more manageable.
“People with OCD can also benefit from traditional talk therapy from orientations other than cognitive behavioral therapy,” says Marschall. “There are medication options for OCD as well.”
Therapy costs can often be out of reach for some people, which means you may need to consider lower-cost alternatives. One of the best alternatives to therapy, when you are on a tight budget, is to attend a support group.
While it isn’t a substitute for one-on-one therapy, you can find a lot of comfort in hearing other people’s stories and sharing your own.
In addition, the more you can connect with people also dealing with OCD, the less likely you will feel alone in facing its challenges.
The International OCD Foundation provides a list of support groups that you can filter to find meetings closest to you. Also, there are options to attend meetings online.
According to the National Institute of Mental Health, the causes of OCD are unknown, but common risk factors are genetics, brain structure, brain function, and the presence of childhood trauma.
In other words, the factors that put you at risk for OCD are all things outside your control today.
OCD is a very real disorder and can’t be easily “fixed” by talking yourself out of it or deciding to stop doubting yourself.
It is important to remember that OCD is a complex mental health disorder and shouldn’t be ignored if it begins to take hours away from your day. Know that you don’t have to struggle with OCD alone, and there is help available if you choose it.
Self-doubt: 6 ways to overcome it
Clinical psychologist and co-founder of YouTalk service Anna Krymskaya tells where self-doubt comes from, how it differs from low self-esteem, how to overcome it and what signs can be used to recognize a person who is insecure
We all have moments when we feel like we're not up to par: maybe we didn't reach our goals at work, got a low score on an exam, or weren't quite savvy in a conversation. It is perfectly normal to doubt your competences and realize your shortcomings from time to time. Moreover, it is even necessary for self-improvement and development. The problem arises when we get “stuck” in this feeling of inferiority, self-doubt becomes an obstacle to self-expression and prevents the achievement of goals.
What is self-doubt
The American Psychological Association defines self-doubt as a feeling of inferiority, inability to cope with life's difficulties, accompanied by a sense of general uncertainty and anxiety about one's goals, abilities and relationships with other people. An insecure person is sure only that everything turns out worse for him than for others, and that everyone else is smarter, stronger, more beautiful, and so on.
Uncertainty makes it difficult to adequately assess one's capabilities. Instead of working on self-development, an insecure person gives up because he does not believe that his efforts can fix something, which means that he believes that it is not even worth starting to do something.
Uncertainty is often confused with low self-esteem. But these states are not the same, although they often coexist with each other. The word "confidence" (English confidence) comes from the Latin fidere - "believe, trust." To be self-confident means to believe in yourself and, in particular, in your ability to successfully or at least adequately interact with the world. A confident person is ready to take on new challenges, seize opportunities, handle difficult situations, and take responsibility if things go wrong. Confidence is also something that is noticeable to others.
Self-esteem is how a person perceives his own value and significance of his personality, life, activities. Self-esteem does not depend on skills, it is unconditional love for yourself as you are. A person with adequate self-esteem has a belief about himself that goes something like this: "I am a good person, entitled to attention and respect from others - simply in fact, and not because I deserve it in some way."
Constant and strong self-doubt, low self-esteem and a sense of superiority of others over oneself together form what is called in psychology an "inferiority complex".
Signs of self-doubt
It is noteworthy that many find it difficult to determine their level of self-confidence. You can feel confident in one area of your life, but in another - feel insecure, doubt your abilities and not understand what is holding back their development.
Insecure people, as a rule:
- Socially withdrawn - they avoid social events or force themselves to be socially active, but at the same time they feel tense, as if watching themselves from the side;
- Experiencing constant anxiety, which shifts the priorities of attention and leads to a distorted perception of reality;
- Cannot accept compliments because they do not believe they are being told the truth;
- Worry about what other people think of them;
- They neglect to take care of themselves, because they see no point in it, because nothing will change anyway;
- Not ready to take on challenges and step out of comfort zone;
- Constantly doubt the decisions made;
- Retreat from conversations that may lead to conflict, even if they think they are right;
- Constructive criticism is poorly received, it touches and hurts them;
- Rarely speak out in group conversation;
- Constantly explain and justify their actions;
- Complain and blame other people a lot, removing responsibility from themselves and their actions;
- Often resort to defensive body language, cross their arms over their chest, walk with a stern face, unconsciously hiding from people;
- Seek the approval of others;
- Pessimists and afraid of the future;
- They are ashamed when they do not achieve perfection in any business;
- Apologize often;
- Buy things they don't really like;
- They lie simply to embellish their stories, which they do not find interesting enough;
- Often avoid eye contact;
- Use self-deprecating humor as a defense mechanism: it's better to joke about yourself before someone else does.
Where does self-doubt come from
There are a lot of factors that affect self-confidence. These are the characteristics of family upbringing, and the culture in which the child grew up, and relationships with a romantic partner, the environment and mental health status.
The development of self-confidence depends on contact with significant adults in childhood. First of all, let's talk about parents. Ideally, in order not to grow up insecure, the child should receive from them a sense of self-worth - when adults notice and support the activity and initiatives of the child, give him the freedom to experiment, believe in his abilities, praise and reward for success. At the same time, they do not depreciate in case of failures, allow mistakes (and also admit their mistakes and apologize for them), are interested in the opinion of the child and take it into account when making decisions, respect the child’s boundaries as well as their own. One part of these points is aimed at loving and accepting the child as a whole. The other is to support his actions, the ability to notice successes and not grieve over failures. Accordingly, the former will cultivate a sense of adequate self-esteem, the latter - self-confidence.
However, it is difficult to find a family in which these recommendations will be fully implemented. No wonder so many people feel insecure. But if the childhood experience was unsuccessful, this does not mean that it will determine the rest of your future life and you will not be able to overcome self-doubt. In adulthood, we have the opportunity to fill in the gaps, give ourselves the care, love and support that was not enough in childhood. You can start with a trip to a psychologist. Perhaps the main advantages of psychotherapy are the ability to “get acquainted” with a small one, work through injuries and make up for deficiencies.
In addition to childhood trauma, there are enough triggers in today's world that make us feel inadequate and insecure. This is, for example, a flood of information from companies that sell us products and services designed to fix "problems" with our body or lifestyle that we would otherwise not notice. Or social networks that broadcast the idea that others allegedly always have perfect relationships, a great career and a model appearance.
Self-doubt and low self-esteem can also be a consequence of more serious trauma associated with the experience of violence - physical, sexual or emotional. In such cases, work with a specialist psychologist is necessary. Do-it-yourself strategies for coping with uncertainty in such a situation can often be useless and sometimes harmful.
How to become more confident
Confidence is not an innate, fixed characteristic. It is an ability that anyone can acquire and improve over time. If you are reading this article, this is already a good start. Even learning and understanding what confidence is is a big step in the right direction.
Working with a psychologist will help speed up this process. It will be based on a strategy developed taking into account your inputs: the characteristics of childhood upbringing, the presence of traumatic experiences; the environment you are in right now.
But there are also some tips and exercises that will be useful, regardless of your experience. To overcome self-doubt, you can try to do the following:
Write down everything that you can praise yourself for
Try at the end of the day to note what exactly today you did well, in what areas you managed to advance, what strengths to show. By devaluing ourselves and our actions, we often hinder the development of our confidence. Try to fix your thoughts and appreciate even the smallest successes. They are no less important than great achievements.
Acknowledge your emotions
To overcome insecurity, it is worth starting to acknowledge every emotion, including the most difficult ones. Try saying words of encouragement to yourself, change your internal dialogue to supportive instead of critical. For example, instead of “you still won’t succeed, as usual”, you should say “you will definitely succeed, and if you don’t succeed this time, then try again, then you will succeed for sure!”. It is not scary if at first these words do not sound sincere. Think about how you would talk to a child, how you would support him - and try to support yourself in the same way.
Talk frankly with loved ones
Insecure people strongly depend on the opinions of others. The paradox is that few of us know what others really think of us. You can try to talk to friends and loved ones - ask what qualities they value in you and whether any of these qualities are unique. You can also try to find out what others think you are really good at and what they can rely on you for. Sometimes we get too carried away with self-criticism and forget to notice the good in ourselves.
Make a list of your valuable resources
Try to write down on paper your valuable resources: knowledge, education, skills, professional and personal experience, character traits, circle of acquaintances, values and beliefs, goals and plans. Perhaps in the process you will find items that you forgot about and they will pleasantly surprise you. Then you can reread the list and note the resources that you can rely on in different situations - including difficult periods of life. You can also think about what resources you would like to develop and sketch out a plan of action. Starting to do it, with new experience, you can gain stability and confidence.
Transform fear into interest
Another domain of uncertainty is shyness and fear in dealing with people. Often, it is with those whose opinion he cares that an insecure person will feel heaviness in communication and awkwardness. It is worth trying to transform fear into interest and involvement. Every time you notice yourself concentrating on the other person's thoughts about you, try asking yourself why this person is interesting to you, what you like about him, and what you don't understand. This approach will help to neutralize fear, keep the conversation going, create a comfortable environment for communication and overcome uncertainty.
Take care of your physical and emotional health
if you do not get enough sleep and feel lethargic. It can be helpful to think about whether you are resting enough - and resting enough to really replenish resources.
If some people need to be alone and do nothing to restore energy, then others are charged with new emotions, travels and impressions. It is important to be in touch with yourself, listen to yourself, try to understand your true needs. Just taking care of yourself already helps you feel more confident.
A prominent role among mental illnesses is played by syndromes (complexes of symptoms), united in the group of obsessive-compulsive disorder (OCD), which received its name from the Latin terms obsessio and compulsio.
Obsession (lat. obsessio - taxation, siege, blockade).
Compulsions (lat. compello - I force). 1. Obsessive drives, a kind of obsessive phenomena (obsessions). Characterized by irresistible attraction that arises contrary to the mind, will, feelings. Often they are unacceptable to the patient, contrary to his moral and ethical properties. Unlike impulsive drives, compulsions are not realized. These drives are recognized by the patient as wrong and painfully experienced by them, especially since their very appearance, due to its incomprehensibility, often gives rise to a feeling of fear in the patient 2. The term compulsions is also used in a broader sense to refer to any obsessions in the motor sphere, including obsessive rituals.
In domestic psychiatry, obsessive states were understood as psychopathological phenomena, characterized by the fact that phenomena of a certain content repeatedly appear in the mind of the patient, accompanied by a painful feeling of coercion [Zinoviev PM, 193I]. For N.s. characteristic involuntary, even against the will, the emergence of obsessions with clear consciousness. Although the obsessions are alien, extraneous in relation to the patient's psyche, the patient is not able to get rid of them. They are closely related to the emotional sphere, accompanied by depressive reactions, anxiety. Being symptomatic, according to S.L. Sukhanov , "parasitic", they do not affect the course of intellectual activity in general, remain alien to thinking, do not lead to a decrease in its level, although they worsen the efficiency and productivity of the patient's mental activity. Throughout the course of the disease, a critical attitude is maintained towards obsessions. N.s. conditionally divided into obsessions in the intellectual-affective (phobia) and motor (compulsions) spheres, but most often several of their types are combined in the structure of the disease of obsessions. The isolation of obsessions that are abstract, affectively indifferent, indifferent in their content, for example, arrhythmomania, is rarely justified; An analysis of the psychogenesis of a neurosis often makes it possible to see a pronounced affective (depressive) background at the basis of the obsessive account. Along with elementary obsessions, the connection of which with psychogeny is obvious, there are “cryptogenic” ones, when the cause of painful experiences is hidden [Svyadoshch L.M., 1959]. N.s. are observed mainly in individuals with a psychasthenic character. This is where apprehensions are especially characteristic. In addition, N.S. occur within the framework of neurosis-like states with sluggish schizophrenia, endogenous depressions, epilepsy, the consequences of a traumatic brain injury, somatic diseases, mainly hypochondria-phobic or nosophobic syndrome. Some researchers distinguish the so-called. "Neurosis of obsessive states", which is characterized by the predominance of obsessive states in the clinical picture - memories that reproduce a psychogenic traumatic situation, thoughts, fears, actions. In genesis play a role: mental trauma; conditioned reflex stimuli that have become pathogenic due to their coincidence with others that previously caused a feeling of fear; situations that have become psychogenic due to the confrontation of opposing tendencies [Svyadoshch A.M., 1982]. It should be noted that these same authors emphasize that N.s.c. occurs with various character traits, but most often in psychasthenic personalities.
Currently, almost all obsessive-compulsive disorders are united in the International Classification of Diseases under the concept of "obsessive-compulsive disorder".
OKR concepts have undergone a fundamental reassessment over the past 15 years. During this time, the clinical and epidemiological significance of OCD has been completely revised. If it was previously thought that this is a rare condition observed in a small number of people, now it is known that OCD is common and causes a high percentage of morbidity, which requires the urgent attention of psychiatrists around the world. Parallel to this, our understanding of the etiology of OCD has broadened: the vaguely formulated psychoanalytic definition of the past two decades has been replaced by a neurochemical paradigm that explores the neurotransmitter disorders that underlie OCD. And most importantly, pharmacological interventions specifically targeting serotonergic neurotransmission have revolutionized the prospects for recovery for millions of OCD patients worldwide.
The discovery that intense serotonin reuptake inhibition (SSRI) was the key to effective treatment of OCD was the first step in a revolution and spurred clinical research that showed the efficacy of such selective inhibitors.
As described in ICD-10, the main features of OCD are repetitive intrusive (obsessive) thoughts and compulsive actions (rituals).
In a broad sense, the core of OCD is the syndrome of obsession, which is a condition with a predominance in the clinical picture of feelings, thoughts, fears, memories that arise in addition to the desire of patients, but with awareness of their pain and a critical attitude towards them. Despite the understanding of the unnaturalness, illogicality of obsessions and states, patients are powerless in their attempts to overcome them. Obsessional impulses or ideas are recognized as alien to the personality, but as if coming from within. Obsessions can be the performance of rituals designed to alleviate anxiety, such as washing hands to combat "pollution" and to prevent "infection". Attempts to drive away unwelcome thoughts or urges can lead to severe internal struggle, accompanied by intense anxiety.
Obsessions in the ICD-10 are included in the group of neurotic disorders.
The prevalence of OCD in the population is quite high. According to some data, it is determined by an indicator of 1. 5% (meaning "fresh" cases of diseases) or 2-3%, if episodes of exacerbations observed throughout life are taken into account. Those suffering from obsessive-compulsive disorder make up 1% of all patients receiving treatment in psychiatric institutions. It is believed that men and women are affected approximately equally.
The problem of obsessive-compulsive disorder attracted the attention of clinicians as early as the beginning of the 17th century. They were first described by Platter in 1617. In 1621 E. Barton described an obsessive fear of death. Mentions of obsessions are found in the writings of F. Pinel (1829). I. Balinsky proposed the term "obsessive ideas", which took root in Russian psychiatric literature. In 1871, Westphal coined the term "agoraphobia" to refer to the fear of being in public places. M. Legrand de Sol , analyzing the features of the dynamics of OCD in the form of "insanity of doubt with delusions of touch, points to a gradually becoming more complicated clinical picture - obsessive doubts are replaced by ridiculous fears of" touch "to surrounding objects, motor rituals join, the fulfillment of which is subject to the whole life sick. However, only at the turn of the XIX-XX centuries. researchers were able to more or less clearly describe the clinical picture and give syndromic characteristics of obsessive-compulsive disorders. The onset of the disease usually occurs in adolescence and adolescence. The maximum of clinically defined manifestations of obsessive-compulsive disorder is observed in the age range of 10-25 years.
Main clinical manifestations of OCD:
Obsessive thoughts - painful, arising against the will, but recognized by the patient as their own, ideas, beliefs, images, which in a stereotyped form forcibly invade the patient's consciousness and which he tries to resist in some way. It is this combination of an inner sense of compulsive urge and efforts to resist it that characterizes obsessional symptoms, but of the two, the degree of effort exerted is the more variable. Obsessional thoughts may take the form of single words, phrases, or lines of poetry; they are usually unpleasant to the patient and may be obscene, blasphemous, or even shocking.
Obsessional imagery is vivid scenes, often violent or disgusting, including, for example, sexual perversion.
Obsessional impulses are urges to do things that are usually destructive, dangerous, or shameful; for example, jumping into the road in front of a moving car, injuring a child, or shouting obscene words while in society.
Obsessional rituals include both mental activities (eg, counting in a particular way, or repeating certain words) and repetitive but meaningless acts (eg, washing hands twenty or more times a day). Some of them have an understandable connection with the obsessive thoughts that preceded them, for example, repeated washing of hands - with thoughts of infection. Other rituals (for example, regularly laying out clothes in some complex system before putting them on) do not have such a connection. Some patients feel an irresistible urge to repeat such actions a certain number of times; if that fails, they are forced to start all over again. Patients are invariably aware that their rituals are illogical and usually try to hide them. Some fear that such symptoms are a sign of the onset of insanity. Both obsessive thoughts and rituals inevitably lead to problems in daily activities.
Obsessive rumination ("mental chewing gum") is an internal debate in which the arguments for and against even the simplest everyday actions are endlessly revised. Some obsessive doubts relate to actions that may have been incorrectly performed or not completed, such as turning off the gas stove faucet or locking the door; others concern actions that could harm other people (for example, the possibility of driving past a cyclist in a car, knocking him down). Sometimes doubts are associated with a possible violation of religious prescriptions and rituals - “remorse of conscience”.
Compulsive actions - repetitive stereotypical actions, sometimes acquiring the character of protective rituals. The latter are aimed at preventing any objectively unlikely events that are dangerous for the patient or his relatives.
In addition to the above, in a number of obsessive-compulsive disorders, a number of well-defined symptom complexes stand out, and among them are obsessive doubts, contrasting obsessions, obsessive fears - phobias (from the Greek phobos).
Obsessive thoughts and compulsive rituals may intensify in certain situations; for example, obsessive thoughts about harming other people often become more persistent in the kitchen or some other place where knives are kept. Since patients often avoid such situations, there may be a superficial resemblance to the characteristic avoidance pattern found in phobic anxiety disorder. Anxiety is an important component of obsessive-compulsive disorders. Some rituals reduce anxiety, while after others it increases. Obsessions often develop as part of depression. In some patients, this appears to be a psychologically understandable reaction to obsessive-compulsive symptoms, but in other patients, recurrent episodes of depressive mood occur independently.
Obsessions (obsessions) are divided into figurative, or sensual, accompanied by the development of affect (often painful) and obsession of affectively neutral content.
Sensual obsessions include obsessive doubts, memories, ideas, drives, actions, fears, an obsessive feeling of antipathy, an obsessive fear of habitual actions.
Obsessive doubts - persistently arising contrary to logic and reason, uncertainty about the correctness of the actions being performed and committed. The content of doubts is different: obsessive everyday fears (whether the door is locked, whether windows or water taps are closed tightly enough, whether gas and electricity are turned off), doubts related to official activities (whether this or that document is written correctly, whether the addresses on business papers are mixed up , whether inaccurate figures are indicated, whether orders are correctly formulated or executed), etc. Despite repeated verification of the committed action, doubts, as a rule, do not disappear, causing psychological discomfort in the person suffering from this kind of obsession.
Obsessive memories include persistent, irresistible painful memories of any sad, unpleasant or shameful events for the patient, accompanied by a sense of shame, repentance. They dominate the mind of the patient, despite the efforts and efforts not to think about them.
Compulsive impulses - urges to commit one or another tough or extremely dangerous action, accompanied by a feeling of horror, fear, confusion with the inability to get rid of it. The patient is seized, for example, by the desire to throw himself under a passing train or push a loved one under it, to kill his wife or child in an extremely cruel way. At the same time, patients are painfully afraid that this or that action will be implemented.
Manifestations of obsessive ideas can be different. In some cases, this is a vivid "vision" of the results of obsessive drives, when patients imagine the result of a cruel act committed. In other cases, obsessive ideas, often referred to as mastering, appear in the form of implausible, sometimes absurd situations that patients take for real. An example of obsessive ideas is the patient's conviction that the buried relative was alive, and the patient painfully imagines and experiences the suffering of the deceased in the grave. At the height of obsessive ideas, the consciousness of their absurdity, implausibility disappears and, on the contrary, confidence in their reality appears. As a result, obsessions acquire the character of overvalued formations (dominant ideas that do not correspond to their true meaning), and sometimes delusions.
An obsessive feeling of antipathy (as well as obsessive blasphemous and blasphemous thoughts) - unjustified antipathy to a certain, often close person, driven away by the patient from himself, cynical, unworthy thoughts and ideas regarding respected people, in religious persons - in relation to saints or ministers churches.
Intrusive acts are acts done against the will of the sick, despite efforts made to restrain them. Some of the obsessive actions burden the patients until they are realized, others are not noticed by the patients themselves. Obsessive actions are painful for patients, especially in those cases when they become the object of attention of others.
Obsessive fears, or phobias, include an obsessive and senseless fear of heights, large streets, open or confined spaces, large crowds of people, the fear of sudden death, the fear of falling ill with one or another incurable disease. Some patients may develop a wide variety of phobias, sometimes acquiring the character of fear of everything (panphobia). And finally, an obsessive fear of the emergence of fears (phobophobia) is possible.
Hypochondriacal phobias (nosophobia) - an obsessive fear of some serious illness. Most often, cardio-, stroke-, syphilo- and AIDS phobias are observed, as well as the fear of the development of malignant tumors. At the peak of anxiety, patients sometimes lose their critical attitude to their condition - they turn to doctors of the appropriate profile, require examination and treatment. The implementation of hypochondriacal phobias occurs both in connection with psycho- and somatogenic (general non-mental illnesses) provocations, and spontaneously. As a rule, hypochondriacal neurosis develops as a result, accompanied by frequent visits to doctors and unreasonable medication.
Specific (isolated) phobias - obsessive fears limited to a strictly defined situation - fear of heights, nausea, thunderstorms, pets, treatment at the dentist, etc. Since contact with situations that cause fear is accompanied by intense anxiety, the patients tend to avoid them.
Obsessive fears are often accompanied by the development of rituals - actions that have the meaning of "magic" spells that are performed, despite the critical attitude of the patient to obsession, in order to protect against one or another imaginary misfortune: before starting any important business, the patient must perform some that specific action to eliminate the possibility of failure. Rituals can, for example, be expressed in snapping fingers, playing a melody to the patient or repeating certain phrases, etc. In these cases, even relatives are not aware of the existence of such disorders. Rituals, combined with obsessions, are a fairly stable system that usually exists for many years and even decades.
Obsessions of affective-neutral content - obsessive sophistication, obsessive counting, recalling neutral events, terms, formulations, etc. Despite their neutral content, they burden the patient, interfere with his intellectual activity.
Contrasting obsessions ("aggressive obsessions") - blasphemous, blasphemous thoughts, fear of harming oneself and others. Psychopathological formations of this group refer mainly to figurative obsessions with pronounced affective saturation and ideas that take possession of the consciousness of patients. They are distinguished by a sense of alienation, the absolute lack of motivation of the content, as well as a close combination with obsessive drives and actions. Patients with contrasting obsessions and complain of an irresistible desire to add endings to the replicas they have just heard, giving an unpleasant or threatening meaning to what has been said, to repeat after those around them, but with a touch of irony or malice, phrases of religious content, to shout out cynical words that contradict their own attitudes and generally accepted morality. , they may experience fear of losing control of themselves and possibly committing dangerous or ridiculous actions, injuring themselves or their loved ones. In the latter cases, obsessions are often combined with object phobias (fear of sharp objects - knives, forks, axes, etc.). The contrasting group also partially includes obsessions of sexual content (obsessions of the type of forbidden ideas about perverted sexual acts, the objects of which are children, representatives of the same sex, animals).
Obsessions of pollution (mysophobia). This group of obsessions includes both the fear of pollution (earth, dust, urine, feces and other impurities), as well as the fear of penetration into the body of harmful and toxic substances (cement, fertilizers, toxic waste), small objects (glass fragments, needles, specific types of dust), microorganisms. In some cases, the fear of contamination can be limited, remain at the preclinical level for many years, manifesting itself only in some features of personal hygiene (frequent change of linen, repeated washing of hands) or in housekeeping (thorough handling of food, daily washing of floors). , "taboo" on pets). This kind of monophobia does not significantly affect the quality of life and is evaluated by others as habits (exaggerated cleanliness, excessive disgust). Clinically manifested variants of mysophobia belong to the group of severe obsessions. In these cases, gradually becoming more complex protective rituals come to the fore: avoiding sources of pollution and touching "unclean" objects, processing things that could get dirty, a certain sequence in the use of detergents and towels, which allows you to maintain "sterility" in the bathroom. Stay outside the apartment is also furnished with a series of protective measures: going out into the street in special clothing that covers the body as much as possible, special processing of wearable items upon returning home. In the later stages of the disease, patients, avoiding pollution, not only do not go out, but do not even leave their own room. In order to avoid contacts and contacts that are dangerous in terms of contamination, patients do not allow even their closest relatives to come near them. Mysophobia is also related to the fear of contracting a disease, which does not belong to the categories of hypochondriacal phobias, since it is not determined by fears that a person suffering from OCD has a particular disease. In the foreground is the fear of a threat from the outside: the fear of pathogenic bacteria entering the body. Hence the development of appropriate protective actions.
A special place in the series of obsessions is occupied by obsessive actions in the form of isolated, monosymptomatic movement disorders. Among them, especially in childhood, tics predominate, which, unlike organically conditioned involuntary movements, are much more complex motor acts that have lost their original meaning. Tics sometimes give the impression of exaggerated physiological movements. This is a kind of caricature of certain motor acts, natural gestures. Patients suffering from tics can shake their heads (as if checking whether the hat fits well), make hand movements (as if discarding interfering hair), blink their eyes (as if getting rid of a mote). Along with obsessive tics, pathological habitual actions (lip biting, gnashing of teeth, spitting, etc.) are often observed, which differ from obsessive actions proper in the absence of a subjectively painful sense of persistence and experience them as alien, painful. Neurotic states characterized only by obsessive tics usually have a favorable prognosis. Appearing most often in preschool and primary school age, tics usually subside by the end of puberty. However, such disorders can also be more persistent, persist for many years and only partially change in manifestations.
The course of obsessive-compulsive disorder.
Unfortunately, chronization must be indicated as the most characteristic trend in the OCD dynamics. Cases of episodic manifestations of the disease and complete recovery are relatively rare. However, in many patients, especially with the development and preservation of one type of manifestation (agoraphobia, obsessive counting, ritual handwashing, etc. ), a long-term stabilization of the condition is possible. In these cases, there is a gradual (usually in the second half of life) mitigation of psychopathological symptoms and social readaptation. For example, patients who experienced fear of traveling on certain types of transport, or public speaking, cease to feel flawed and work along with healthy people. In mild forms of OCD, the disease usually proceeds favorably (on an outpatient basis). The reverse development of symptoms occurs after 1 year - 5 years from the moment of manifestation.
More severe and complex OCDs, such as phobias of infection, pollution, sharp objects, contrasting performances, multiple rituals, on the other hand, may become persistent, resistant to treatment, or show a tendency to recur with disorders that persist despite active therapy. Further negative dynamics of these conditions indicates a gradual complication of the clinical picture of the disease as a whole.
It is important to distinguish OCD from other disorders that involve compulsions and rituals. In some cases, obsessive-compulsive disorder must be differentiated from schizophrenia, especially when the obsessive thoughts are unusual in content (eg, mixed sexual and blasphemous themes) or the rituals are exceptionally eccentric. The development of a sluggish schizophrenic process cannot be ruled out with the growth of ritual formations, their persistence, the emergence of antagonistic tendencies in mental activity (inconsistency of thinking and actions), and the uniformity of emotional manifestations. Prolonged obsessional states of a complex structure must be distinguished from the manifestations of paroxysmal schizophrenia. Unlike neurotic obsessive states, they are usually accompanied by a sharply increasing anxiety, a significant expansion and systematization of the circle of obsessive associations, which acquire the character of obsessions of "special significance": previously indifferent objects, events, random remarks of others remind patients of the content of phobias, offensive thoughts and thereby acquire in their view a special, menacing significance. In such cases, it is necessary to consult a psychiatrist in order to exclude schizophrenia. It can also be difficult to differentiate between OCD and conditions with a predominance of generalized disorders, known as Gilles de la Tourette's syndrome. Tics in such cases are localized in the face, neck, upper and lower extremities and are accompanied by grimaces, opening the mouth, sticking out the tongue, and intense gesticulation. In these cases, this syndrome can be excluded by the coarseness of movement disorders characteristic of it and more complex in structure and more severe mental disorders.
Speaking about hereditary predisposition to OCD, it should be noted that obsessive-compulsive disorders are found in approximately 5-7% of parents of patients with such disorders. Although this figure is low, it is higher than in the general population. While the evidence for a hereditary predisposition to OCD is still uncertain, psychasthenic personality traits can be largely explained by genetic factors.
Approximately two-thirds of OCD patients improve within a year, more often towards the end of this period. If the disease lasts more than a year, fluctuations are observed during its course - periods of exacerbations are interspersed with periods of improvement in health, lasting from several months to several years. The prognosis is worse if we are talking about a psychasthenic personality with severe symptoms of the disease, or if there are continuous stressful events in the patient's life. Severe cases can be extremely persistent; for example, a study of hospitalized patients with OCD found that three-quarters of them remained symptom-free 13 to 20 years later.
TREATMENT: BASIC METHODS AND APPROACHES
Despite the fact that OCD is a complex group of symptom complexes, the principles of treatment for them are the same. The most reliable and effective method of treating OCD is considered to be drug therapy, during which a strictly individual approach to each patient should be manifested, taking into account the characteristics of the manifestation of OCD, age, gender, and the presence of other diseases. In this regard, we must warn patients and their relatives against self-treatment. If any disorders similar to mental ones appear, it is necessary, first of all, to contact the specialists of the psycho-neurological dispensary at the place of residence or other psychiatric medical institutions to establish the correct diagnosis and prescribe competent adequate treatment. At the same time, it should be remembered that at present a visit to a psychiatrist does not threaten with any negative consequences - the infamous "accounting" was canceled more than 10 years ago and replaced by the concepts of consultative and medical care and dispensary observation.
When treating, it must be borne in mind that obsessive-compulsive disorders often have a fluctuating course with long periods of remission (improvement). The apparent suffering of the patient often seems to call for vigorous effective treatment, but the natural course of the condition must be kept in mind in order to avoid the typical error of over-intensive therapy. It is also important to consider that OCD is often accompanied by depression, the effective treatment of which often leads to an alleviation of obsessional symptoms.
Treatment of OCD begins with an explanation to the patient of the symptoms and, if necessary, with reassurance that they are the initial manifestation of insanity (a common concern for patients with obsessions). Those suffering from certain obsessions often involve other family members in their rituals, so relatives need to treat the patient firmly, but sympathetically, mitigating the symptoms as much as possible, and not aggravating it by excessive indulgence in the sick fantasies of patients.
The following therapeutic approaches exist for the currently identified types of OCD. Of the pharmacological drugs for OCD, serotonergic antidepressants, anxiolytics (mainly benzodiazepine), beta-blockers (to stop autonomic manifestations), MAO inhibitors (reversible) and triazole benzodiazepines (alprazolam) are most often used. Anxiolytic drugs provide some short-term relief of symptoms, but should not be given for more than a few weeks at a time. If anxiolytic treatment is required for more than one to two months, small doses of tricyclic antidepressants or small antipsychotics sometimes help. The main link in the treatment regimen for OCD, overlapping with negative symptoms or ritualized obsessions, are atypical antipsychotics - risperidone, olanzapine, quetiapine, in combination with either SSRI antidepressants or other antidepressants - moclobemide, tianeptine, or with high-potency benzodiazepine derivatives ( alprazolam, clonazepam, bromazepam).
Any comorbid depressive disorder is treated with antidepressants at an adequate dose. There is evidence that one of the tricyclic antidepressants, clomipramine, has a specific effect on obsessive symptoms, but the results of a controlled clinical trial showed that the effect of this drug is insignificant and occurs only in patients with distinct depressive symptoms.
In cases where obsessive-phobic symptoms are observed within the framework of schizophrenia, intensive psychopharmacotherapy with proportional use of high doses of serotonergic antidepressants (fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram) has the greatest effect. In some cases, it is advisable to connect traditional antipsychotics (small doses of haloperidol, trifluoperazine, fluanxol) and parenteral administration of benzodiazepine derivatives.
One of the main tasks of the specialist in the treatment of OCD is to establish fruitful cooperation with the patient. It is necessary to instill in the patient faith in the possibility of recovery, to overcome his prejudice against the "harm" caused by psychotropic drugs, to convey his conviction in the effectiveness of treatment, subject to the systematic observance of the prescribed prescriptions. The patient's faith in the possibility of healing must be supported in every possible way by the relatives of the OCD sufferer. If the patient has rituals, it must be remembered that improvement usually occurs when using a combination of the method of preventing a reaction with placing the patient in conditions that aggravate these rituals. Significant but not complete improvement can be expected in about two-thirds of patients with moderately heavy rituals. If, as a result of such treatment, the severity of rituals decreases, then, as a rule, the accompanying obsessive thoughts also recede. In panphobia, predominantly behavioral techniques are used to reduce sensitivity to phobic stimuli, supplemented by elements of emotionally supportive psychotherapy. In cases where ritualized phobias predominate, along with desensitization, behavioral training is actively used to help overcome avoidant behavior. Behavioral therapy is significantly less effective for obsessive thoughts that are not accompanied by rituals. Thought-stopping has been used by some experts for many years, but its specific effect has not been convincingly proven.
We have already noted that obsessive-compulsive disorder has a fluctuating (fluctuating) course and over time the patient's condition may improve regardless of which particular methods of treatment were used. Until recovery, patients can benefit from supportive conversations that provide continued hope for recovery. Psychotherapy in the complex of treatment and rehabilitation measures for patients with OCD is aimed at both correcting avoidant behavior and reducing sensitivity to phobic situations (behavioral therapy), as well as family psychotherapy to correct behavioral disorders and improve family relationships. If marital problems exacerbate symptoms, joint interviews with the spouse are indicated. Patients with panphobia (at the stage of the active course of the disease), due to the intensity and pathological persistence of symptoms, need both medical and social and labor rehabilitation. In this regard, it is important to determine adequate terms of treatment - long-term (at least 2 months) therapy in a hospital with subsequent continuation of the course on an outpatient basis, as well as taking measures to restore social ties, professional skills, family relationships. Social rehabilitation is a set of programs for teaching OCD patients how to behave rationally both at home and in a hospital setting. Rehabilitation is aimed at teaching social skills to properly interact with other people, vocational training, as well as skills necessary in everyday life. Psychotherapy helps patients, especially those who experience a sense of their own inferiority, treat themselves better and correctly, master ways to solve everyday problems, and gain confidence in their strength.
All of these methods, when used judiciously, can increase the effectiveness of drug therapy, but cannot completely replace drugs. It should be noted that explanatory psychotherapy does not always help, and some patients with OCD even worsen because such procedures encourage them to think painfully and unproductively about the subjects discussed in the course of treatment. Unfortunately, science still does not know how to cure mental illness once and for all. OCD often has a tendency to recur, which requires long-term prophylactic medication.