Repost from the old site.
This is an update to a previous post about schiz OCD, which is a particular subtype of OCD, or obsessive-compulsive disorder, an anxiety disorder which I suffer from. Fred Penzel, one of the world’s top experts on OCD, wrote to me and chided me for writing about all these different types of OCD, saying that they were all just the same thing.
Well, I will beg to differ on that. Sure, they are all just the same thing in a way, but it is important to elucidate the different types for differential diagnosis – in order to help clinicians to determine what is the proper diagnosis for individuals. I say this because people with many OCD subtypes are often misdiagnosed. The misdiagnosis is usually psychosis, schizoaffective disorder, schizophrenia or bipolar disorder.
Harm OCD is the fear that one is going to hurt or kill someone, or people in general. I spoke to one sufferer, a millionaire, who had not left the house in three years other than for short trips. After reading my articles, he was finally able to go out longer than he had in years. He’s terrified that he’s a serial killer and that he’s going to attack people or try to kill them when he goes out.
An excellent therapy for people like this is to tell them to put a knife in their pocket and walk around town with it, going in stores, sitting down to talk to people. I recommend especially going into stores where the clerk is alone so the patient could potentially “kill the person and possibly get away with it”. Remain aware of the knife in your pocket as you talk to the clerk alone in the store.
There is another therapy that one therapist is using for harm OCD. The client comes in and after he sits down the therapist pulls out a knife, holds it and says, since you’re a possible serial killer maniac, I am going to need to arm myself with a knife when I talk to you. The session is then conducted as the therapist nervously toys with the knife, watching the client’s every move.
Periodically the therapist jumps up and holds the knife defensively, yelling, “Hey, don’t move like that! I could have sworn you were making some dangerous moves in my direction. This could also be done with a close friend or a mature family member if you trust them enough.
The “therapist” makes it known that since the client is a total maniac, the therapist will need to be armed at all times when the client is around, because “you never know what a psycho will do”.
Other therapies include reading books and watching movies on serial killers, writing essays on why the thoughts are actually real killer thoughts and not just OCD, and making tapes of murderous fantasies and listening to them over and over. These have worked pretty well.
A common symptom of harm OCD is knife avoidance. I had a teenage girl come talk to me a while back who just started getting the harm symptoms. She had them all the time now and was cutting school because she could not study. She came from a traditional Hispanic family and she was afraid to tell them about the symptoms. She was terrified and secretive about the problem and had taken to avoiding knives.
She periodically opened her parents door to check and make sure they were still alive and she had not killed them (OCD makes you doubt your own memory in a very weird way). I told her she wasn’t going to get better on her own and got her to make a doctor’s appointment with a clinician.
The important thing about harm OCD is no one has ever acted on these thoughts that we know of.
It is important for clinicians to understand harm OCD because many clinicians falsely think that the person is dangerous and try to consider other dx’s such as psychopathy, sociopathy, antisocial personality disorder, etc.
I am starting to get a lot of mail from people with POCD, or the fear that one is a pedophile. I also wrote an article about that. I haven’t yet figured out any good therapies for these folks. I know that all the ones I have talked to so far just have POCD. Unfortunately, I do not think the pedophiles show up for therapy unless it is court ordered.
I just tell them if they are around, say, little girls and they get these unpleasant thoughts, to just go ahead and think them and don’t worry about it. I am convinced that the problem here is not so much the thoughts but the way that the person reacts to them. There is no harm in thinking sexual thoughts about minors as long as one will not act on them, although for most people it will be more of a passing thing.
I have talked to people who have been angrily challenged by their therapists about whether or not they are really pedophiles. One said, “Ok, look, you can’t hide behind this OCD thing. If you have these feelings you need to tell me. It’s a serious condition.” Most POCD sufferers will get totally freaked out by this. POCD is little known and I believe most clinicians are ignorant of it.
One therapy that I have heard of is to go to parks where kids hang out and just stay there until you can’t take the anxiety anymore.
The obsession that one is gay is very common. Some therapists that do not understand HOCD, or Homosexual OCD, think that the person is really gay or might be really gay. This leads to sessions about whether or not the person is really gay. As HOCD sufferers are already freaking out about whether they have HOCD or are just “coming out of the closet”, this approach is not helpful.
Which brings us to schiz OCD. Here is a 40 page thread full of people with OCD who are terrified that they have schizophrenia or are psychotic. What usually happens is that they have a fear of going insane like a lot of people do. They do research on schizophrenia and psychosis and worry they might get the symptoms. Wa-la, they get the symptoms!
They read about delusions and they get “delusions” – the same ones they are reading about. They read about hallucinations and then obsess whether or not they are hallucinating, hearing or seeing things. They are not hallucinating at all – they just think they are!
I went through that whole 40 page thread and did not see one person who was either psychotic or had schizophrenia. You can tell by the nature of the symptoms and also the way that they communicate in their posts. People with OCD are pretty sensible and rational when they speak and write. This is the paradox of the illness.
As my first therapist said to me 24 years ago at USC when I was having horrible symptoms, “You know, sitting here talking to you, you seem like a really rational, reasonable person. So how come you’re acting so crazy?” Indeed. My symptoms were largely hidden; I was getting a teaching credential at the time and doing student teaching.
I was quite busy. I also somehow had a very active social life and a beautiful girlfriend with whom I was having a very passionate relationship. At the same time, I was going out of my mind. I was pretty much terrified all the time, though I tried to cover it up. The horrible thought started about an hour after waking and went all day with no stopping it. Sleep was a blessing as it was the only thing making the thought go away.
The thought had a simple theme which I will not go into here. I remember my heart slamming away in my chest as I walked across the USC campus. This was how I spent my middle 20′s. I got high on coke, booze and pot, went to countless parties and clubs, somehow managed to date all sorts of women (How the heck did I pull that off?) and should have been having a blast. Instead, I was in my own little Hell of sorts.
Untreated schizophrenics have a way of talking that does not make sense. This is called “loosening of associations” or “thought disorder”. If you have ever had a conversation with an untreated schizophrenic, you know what I am talking about.
I recently got a mail from a woman who has been diagnosed with schizophrenia twice (once by a psychology professor) and schizoaffective disorder once. She had a prior OCD dx and a long history of depression. Social functioning is good with a circle of close friends. She is now trying to get back into school again. She was working, even at the height of “psychotic” symptoms, as a secretary.
We can see certain things here. Untreated schizophrenics typically lack good social functioning. The illness just ruins all of that. It is not possible for an untreated schizophrenic to be employed and function well at a decent occupation – schizophrenics cannot work unless they are on meds. Schizophrenics also cannot do well in college courses if they are not being treated.
Here are some of her symptoms:
Watching TV and a thought pops into her head that the people on the TV are talking directly to her.
On the computer and a word pops out on the screen and she gets the thought that it has special meaning for her.
Thought pops into her head that she is Jesus or God.
Man walking behind her – thought pops into her head that maybe he is following her or going to harm her, so she hurries away.
The next reaction after she gets the thought is confusion, and she wonders what is real anymore. There is a part of her mind telling her that the thoughts are true and another part fighting them, trying to stop them and panicking because the thoughts are crazy and insane and this means she is going insane.
Psychotic people do not operate in this dual mode of thinking while suffering delusions. The term delusional fixation was not coined casually; it has real basis in reality. To put it bluntly, if you think you are going psychotic, then you cannot possibly be going psychotic.
I have spent some time with psychotic people. I was best friends with a young Black guy who was going through the early stages of paranoid schizophrenia. I hung around with him just about every day for a year or so.
He was hearing voices a good part of the time. We would be driving in the car and he would say, “You hear that?!” and point to the radio. Voices were coming out of the radio. I said I did not hear it and he accused me of lying. After a while, I told him that my hearing was very poor and that was why I could not hear them.
I was never really afraid of the guy, but I had to quit hanging around with him because he just had too many problems. He was untreated, worsening, and still trying to manage his life, move out of his Mom’s house, go to school, pay bills, get an apartment, and get a job. He could not manage to do any of these things, and I was driving him around everywhere trying to help him get his life together.
It was definitely an interesting experience to be around this person. This guy had no idea whatsoever that he was ill and he thought the problem was all other people. He fully believed all his delusions and and to him the hallucinations were real.
People were putting transmitters in the radio, the vents and under houses to send nasty messages to him. He wasn’t hearing voices at all. Everything was fully real to him. Of course, it’s impossible to get these people into treatment as they don’t see that they are ill.
Looking back at the woman above, I do not believe she is schizophrenic at all. Further, extended courses of a variety of atypical antipsychotics have produced absolutely no benefit whatsoever. The only drug that gave her any benefits at all was a high dose – 80mg – of Prozac.
A schizophrenic with extremely mild symptoms like this would surely benefit from an atypical, not to mention numerous different ones. The fact that the “delusions” were only ameliorated by high dose Prozac gives a clue to the OCD nature of the illness.
I think the problem here is the woman’s reaction to the thoughts and not the thoughts themselves. As therapy, I would tell her to stop reacting to the thoughts and relabel them as “stupid”, “crazy”, etc. Tell yourself that OCD is trying to make you fear things that are actually harmless. Ignore the thoughts or blow them off.
If there is a guy walking behind you and you get a thought that he might harm you, just stay there with the thought and don’t run. If he seems harmless enough, stop for a bit until he catches up and ask him the time.
The truth here is that you cannot run from your fears. OCD is a process of running from one’s fears. As long as you are running, you stay ill. Your fears are like a deep, dark swimming pool. No matter how scary, you just have to go to the board, swallow hard and dive right in. Then you climb out and do it again. You do it over and over and eventually you just get used to it, because your body does not want to feel anxiety all the time.
Eventually, tolerance results via the body’s natural process of adapting to fears. If there is some thing or situation that persistently frightens you or causes you anxiety, the thing to do is to just repeatedly put yourself in that situation and then fight the urge to run away from the fear. By staying with your fears, eventually they dissipate.