Category Archives: Symptoms

Can OCD Be the Root Cause of Other Mental Disorders? If So, Can It Possibly Be the Cause of Schizophrenia in Some People?

Answered on Quora. 

There are definitely some other disorders you can get as a consequence of having OCD, such as Depression, Panic Disorder, Social Anxiety, and suicidality. However, schizophrenia and psychosis is not one of them.

But many OCD’ers worry that they may get schizophrenia or that they are in the process of getting it. Sufferers call this S-OCD, Schiz OCD or better yet OCD with the Schizophrenia or Psychosis Theme. This is simply someone with OCD who has adopted the theme of a fear of going psychotic. As with most other forms of OCD, the fear can cause symptoms that seem to mimic the fear itself. In this case, it can cause symptoms that mimic schizophrenia or other psychoses on the surface, however, careful prodding and questioning generally makes a differential diagnosis between OCD and Schizophrenia fairly straightforward.

Nevertheless, many S-OCD’ers sadly get diagnosed with schizophrenia or other psychoses by ignorant clinicians and as a result are medicated inappropriately. This subtype of OCD is very poorly known and often misdiagnosed.

I run into S-OCD’ers with incorrect diagnoses of Psychotic Depression, Schizoaffective Disorder, Schizophrenia, etc. on a fairly regular basis. The fact that when OCD is very bad, OCD’ers appear psychotic on the surface (but are not psychotic) confuses matters even more. It takes an experienced clinician to figure out what is OCD appearing psychotic and what is an actual psychosis.

At times the two illnesses are found in the same person, and sometimes in these cases it can be hard to figure out where the OCD ends and the schizophrenia begins or figuring out if a given symptom is best seen as one illness or the other. When the illnesses occur in the same person, it is sometimes called schizo-obsessive disorder. These people, who have much better insight than other schizophrenics, sometimes have a tendency to hide symptoms, which makes diagnosis even more confusing.

But having OCD is not going to give you schizophrenia. That’s not possible.

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Filed under Anxiety Disorders, Depression, Mental Illness, Mood Disorders, OCD, Psychology, Psychopathology, Psychotherapy, Psychotic Disorders, Schizophrenia, Symptoms

Yet Another Gay Lobby Lie: Gays (or Gay Teens) Have Very High Suicide Rates Compared to Straights

RL: I work in mental health, and I have to diagnose people a lot, or at least offer my opinion of a diagnosis as I cannot give out legal DSM diagnoses . I even have to do differential diagnosis constantly where I have to figure out which of two diagnoses a person has. Believe me, these cases can be very confusing.

Magneto: In your opinion, is being transgender a mental illness? I mean, I am aware of the statistics that gays/trans people have a far higher suicide rate than heterosexuals, which would seem to suggest that it is a mental disorder.

Gay men and lesbians in fact do not have a higher suicide rate than heterosexuals. This even applies to gay teens, the ones they scream about suicide risk all the time about. The Gay Lobby has been lying about this one forever now. It’s another one of their lies. It’s not even true.

What is true that at least gay men have a higher rate of attempted suicide than straight men. Lesbians may be similar. This is particularly true in the case of gay teens. If gay men act like women, we would expect to see this, as women have extremely high rates of attempted suicide but the completed rate is much lower. So while women try to kill themselves a lot more, more men actually do it. You know, we men like to get stuff done. We don’t like to mess around or beat around the bush about things.

Partly this is down to method. Women tend to use pills, and men tend to use  guns and ropes. Guns in particularly are quite lethal. Only rarely does a gun suicide fail. However, pills are an inefficient way to commit suicide, as they often do not work.

My own father tried to kill himself with pills and failed. Four of my ex-girlfriends tried to do it, and all failed, although one almost succeeded. Not long ago, I was dating three women at once, and all of them had attempted suicide recently. Two of them did it right under my nose so to speak.

In women, this is often a histrionic gesture, a cry for help, or a desire to get any sort of attention, even negative attention. Suicidal women are a lot more ambivalent than suicidal men. So, assuming gay men are like women, then an elevated attempted suicide rate without an elevated completed rate would make sense.

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Filed under Gender Studies, Homosexuality, Mental Illness, Mental Patients, Politics, Psychology, Psychopathology, Self-injury, Sex, Women

Numbing Out As Either a Symptom-Derived or Core-Derived

Messi writes:

Schizoids are really attached to their aloofness for some reason. I don’t really get it, it just makes me feel vulnerable and trapped.

As for the neurology vs. psychology argument, I’m not sure. Some parts are unquestionably neurological – you can’t “think” your way out of flat affect. Yet at the same time, the most effective tips are usually psychological.

It seems like their 2-levels of schizoid-ness. There’s the emotional depersonalization and blunted affect, which can only be fixed through physical changes like sleep deprivation, anemia or medication, and the psychological layer beneath it with the withdrawal and vulnerability. You can’t work on the bottom layer without breaking through the top first.

It is looking like the top layer of schizoidness is the symptom cluster and it seems to be biological. In this case the numbing is core-derived in the brain. This can only be altered as Messi points out by actually changing your brain.

The commenter points out that he doubts if you can think your way out of a flat affect. I would add that I doubt if you can think your way to a true flat affect either.

What is the difference between flat, blunted and constricted affect? A therapist told me I have constricted affect but not a blunted or flat affect.

I used to be very emotional but I just deliberately and gradually numbed myself out in order to cope with a lot of ugly life stresses. At the time, I could not think of any other way to cope. Every time something awful would happen to me or around me, I would feel myself numbing out just a bit more. It seemed to be a perfectly logical thing to do. I wasn’t even thinking about it or whether or not it was a good idea, I was just doing it without questioning it as there didn’t seem to be any alternative.

I do not really mind that much but it is true that a lot of people really do not like it one bit. They think I am Spock or a robot. It’s not true as I do have emotions, but it more than they are muted in terms of showing them to the outside world. I have been trying to get my emotions back for many years now since I pretty much deliberately killed them off, but I do not seem to be able to do so. Why that is I have no idea.

I know a lot of wildly emotional people, mostly females.

Quite a few girlfriends have been like this. I remember once I was lying in bed with a girlfriend one morning and she was looking at me and suddenly she looked stunned and she said, “You don’t have any feelings. How come you don’t have any feelings?” She was a notorious emotional rollercoaster, probably a Borderline, though she was wildly, head over heels, out of her mind in love with me. I said, “I don’t want to end up like you. Look at you. That’s what happens to emotional people. Your emotions are all over the place, here, there and everywhere. I don’t want to be like that.” She seemed to think that was a pretty good answer.

Also I look around at Man World and it seems like in US Man World, a lot of men have pretty much cut off or shut down their feelings. That seems to be simply a normal way of being a mature, adult, masculine man. We use words like “businesslike, controlled and stable” to refer to these people. So I feel that by numbing out, I am just being a normal, masculine man in my society. What’s wrong with that? Men are not supposed to be all emo.

I remember when I was pretty emotional, it seemed like every time I got emo people, mostly men, would start giving me a hard time about it. They acted like I was screwing up or blowing it by showing those emotions. I guess the message really is, “You’re acting like a girl.”

The whole message I got is that in Man World they want you pretty much shut down. One thing was for sure, that’s that you can’t get sad. In and in the world of offices, you can’t get mad either. The life of many middle class men in our society seems to be, “You can’t get mad and you can’t get sad.” Of course a lot of them do anyway, so what you find is a lot of men masking rage and especially depression with drugs, alcohol, gambling, sex, workaholism, and probably numbing out.

I hear that all sorts of folks numb themselves out and you should not confuse this symptom-derived numbing with core-derived personality structure numbing, which may be biological, as in the case of schizophrenia, schizoid PD and schizotypal PD.

In the former type a formerly emotionally full person simply numbs out as a defense mechanism to cope with life. Probably emotionality is recoverable somehow and anyway, in most cases, they are probably not as numbed out as you might think. A lot of them probably have emotions that they are just hiding pretty well.

In the latter case the numbing out is a core essential part of the personality structure, possibly biologically mediated. If it is biologically derived, there was never a full emotional life to numb out in the first place. They were numbed out biologically from Day One.

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Filed under American, Biology, Culture, Gender Studies, Man World, Mental Illness, Neuroscience, Personality Disorders, Psychology, Psychopathology, Psychotic Disorders, Schizophrenia, Schizotypal, Symptoms

Not All Psychological Disorders Are in the DSM

David Mowers writes:

What would you consider to be a condition of someone who was introverted to the point of Anhedonia but on occasion has schizoid breaks with reality assaulting other people but in such a way as to be fully in control and capable of avoiding legal punishment for their actions?

In fact, was so fully confident in their ability to do anything that they did such without consideration of social conditions, rules or laws to the point that they appeared extroverted to others?

First of all, those would not be schizoid breaks. The only schizoid symptom here in the withdrawal to the point of anhedonia.

Second, I would say that this aggressive behavior is highly choreographed, stylized, shrewd, devious and manipulative. This is not typical aggressive behavior. Instead, this person is acting out a carefully plotted and planned out aggressive act as if they were acting a role in a play. In other words, for some reason, with this aggressive behavior, they are “putting on a show” for some reason.

There is also a lot of cocky overconfidence in the way this person describes how they can expertly choreograph this aggression in such a way as to avoid punishment. I’d say there is some narcissism going on there. This person is way too overconfident and it’s probably going to get them in trouble some day if it hasn’t already.

But this is not any known psychological disorder in terms of an actual documented syndrome. Is the person happy or unhappy with this behavior? How do they feel about the anhedonia?

It is important to note that many things that cause psychological distress are not really diagnosable DSM disorders. All sorts of things cause distress in life, and individuals experience distress in all sorts of ways that do not necessarily line up with diagnosable conditions.

I have had clients who clearly had something obviously wrong with them, but they did not meet criteria for any known DSM disorder. Sure, they had symptoms of one or more disorders, but not enough to meet criteria for any one of them in particular.

Human beings are variable, and it is all too common for someone to present with a symptom or two of a more than one disorder. If you add them all up and throw the ingredients all together, you can bake up something called a disorder, but it typically is not in the DSM nor does it look like anything described but not in the DSM. In other words, it is not a known “syndrome.”

Often it is hard to even say if the disorder is an anxiety disorder, a mood disorder, a substance use disorder, etc. You can have mood, anxiety, disassociate, personality, substance use and even psychotic symptoms all presenting at once in a single individual. In these cases, you don’t even have the option of diagnosing Anxiety Disorder NOS, Mood Disorder NOS, Psychotic Disorder NOS, etc. The person has simply piled a group of symptoms together in a one from column A, three from column B, two from column 3, etc. fashion.

Unfortunately, this sort of thing is quite common. A lot of times you end up treating individual symptoms and defenses instead of whole packages called disorders, which probably makes more sense in  a lot of cases anyway.

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Filed under Mental Illness, Psychology, Psychopathology, Psychotherapy, Symptoms

Behavior in Manic Episodes: An Overview

Jason Y writes:

Seems like some of them can go into a rage when not on meds. Breaking phones, computers.

I do not know much about schizophrenic violence, but I can definitely attest on a first hand basis that during the manic phase of manic depression, people can be quite violent.

There are different types of manic episodes: Hypomanic, euphoric,  and irritable/angry/violent/paranoid. They can also be psychotic at times, but manics usually are not psychotic.

This post will describe the irritable/angry/violent/paranoid manic.

These types tend to be psychotic for briefer periods and wild, violent, dangerous,  and criminal yet not psychotic for longer periods

They can be very verbally hostile and violent, pretty much trying to pick fights and start fights with various people nearly every day. They scream, yell, threaten and menace people a lot. They also do minor violence like throwing food around, throwing objects, breaking windows, throwing cordless phones. In addition, they smash toilet seats and they are very found of smashing holes in walls and doors.

It is not uncommon for them to acquire weapons during this phase, either guns or knives. Sometimes the guns don’t even work, but they use them to threaten their enemies anyway. Showdowns with enemies with one or more parties armed with guns, knives or swords are fairly common. Manics grab baseball bats, poles and sticks and chase enemies, usually ordinary strangers, down streets howling abuse at them and throwing the weapon at the stranger as the stranger runs away in terror. The manic will explain that the stranger out for a stroll at night was really one of the enemies in an elaborate disguise.

Mania is a time of extreme aggression, guaranteed violence, regular menace and often enough brandishing of weaponry.

Housemates of manics often end up arming themselves to defend against the manic, often with knives. Some carry weapons around with themselves fulltime to defend against possible attacks by the manic. Housemates frequently pull weapons, often household knives, on manics in self-defense during fights and showdowns.

They also steal a lot like drug addicts, and if you live with them, pretty soon you are going to have to start hiding your money, car keys, dope, etc. They will even sneak into your bedroom at night while you are sleeping to steal car keys, money, etc.

They are basically a total menace and a lot of them act like sociopathic criminals and seem to become almost completely evil. A guy I know has a relative who goes manic from time to time and when he goes manic, my friend says, “He turns into Charles Manson.”

They have no attention span whatsoever and are always leaving doors open, leaving the stove on with things cooking on it, forgetting things, etc. They start something, get halfway through it, get distracted and go off to something else so everything ends up half done including meals and just about any task. Their personal hygiene declines a lot for some reason. Often they take to wearing the same clothes for days on end. They sleep in their clothes, often with the lights on and music blaring. It’s not uncommon for them to start smelling bad after a while, possibly because they sleep in their clothes, don’t change their clothes often, etc.

If they are smokers, they will dramatically increase their smoking often by 2-3X the previous level. If they are drinkers, they will often drink very heavily to the point where they are drunk most of the time. If they are driving around when they do this, they will soon get one or more DUI’s.

Property destruction is very common, either their own or other people’s property. They may even destroy most of their own property for no apparent reason. They can also destroy other people’s property, smash up objects or steal others clothing, pile it and set it on fire. They may also set some of their own property on fire, especially clothing.

Manics commonly make public loud, often violent and menacing public scenes which can attract the attention of the police. The manic runs out to the divider of a major highway, takes off their shirt, screams and yells violent threats and sets the shirt on fire in the highway median. Or the manic runs onto a highway median with a baseball bat and runs up and down the median swinging the bat wildly and threatening their enemies.

Arrest and imprisonment during a manic episode is very common. The friend I quoted above says the family member who goes manic always gets arrested at least once during most every manic episode. They are often arrested for minor crimes like DUI or disturbing the peace. Often people who are victimized by the manic are reluctant to press charges because the manic is so obviously insane that it seems wrong to hold them criminally responsible for whatever they have done. If they are arrested, they are usually released very quickly. The manic will raise Hell in the jail, destroying his cell, rattling the bars of his cell endlessly and engaging in a lot of loud screaming and yelling, often with threats or violent overtones. They raise such Hell in jail that they often attract the attention of jailers. The ensuing confrontation will typically end up with the manic being beat up, sometimes badly, the by the jailers and police in the jail.

Sometimes manics are out in public looking and acting so crazy that police officers take them in simply because they seem so out of it. The officers do it our of sheer concern for the manic’s safety. The manic simply appears too out of it to be wandering about in public. In these cases, the manic will be held for a day or two at most and then released.

They usually do not go psychotic but sometimes they can become psychotic. Often they are seriously crazy, but if you closely examine them and think about what they are saying, doing and believing, they really are not psychotic. They aren’t crazy, they are “wild and crazy.”

For instance, a manic, dressed in rags with wild eyes, may thrown up their arms and yell, “I am Jesus Christ!” If you ask them if they are really Jesus, they will forget about and move on to some other topic, or say it was a joke or an allegory.

But sometimes there are psychotic episodes, often paranoid psychoses. If a manic does not have a single enemy on Earth, they will quickly accumulate a number of enemies within a few months of a manic episode. Many of the people encountered during the episode will be transformed by the manic into “enemies.” These can include friends, family members, employers, drug dealers, bank employees, police, etc. If you are in close proximity to a manic for a few months and don’t manage to get transformed into an enemy, consider yourself lucky.

They may stop eating because housemates are poisoning their food. Housemates, friends or banks are typically accused of stealing their money and many conflicts result as the manic confronts the “thieves” about the “stolen money.” For instance, a manic may blow through a large bank savings of say $10-15,000 very quickly in a matter of a few months in the middle of an episode. Then when they realize they have no money, they will accuse the bank of stealing their money. This will result in numerous trips to the bank and angry, sometimes menacing or even violent arguments, confrontations and showdowns with the “thieves” at the bank.

The enemies may make regular rounds to their home, leaving calling cards and destroying things here and there. The enemies come by the house and damage the manic’s vehicle. They set up surveillance stations outside the manic’s home where they keep the manic under surveillance at all times. They may become convinced that the world is going to end.

Confidence increases greatly. A single male manic who rarely dates suddenly has a girlfriend.

Most manics are not hospitalized during their episodes unless they are wildly psychotic. But wildly psychotic manics are atypical. More common is the wild, violent behavior, fleeing delusions and paranoia. Often others make frequent attempts to hospitalize the manic by calling the police. However, many manics, curiously enough, no matter how crazy they are acting, are able to remarkably pull themselves together and present themselves as quite sane when the police show up. If hospitalized, they quickly become “sane” in the hospital and are ordered to be discharged. They can become angry, threatening, menacing and even violent towards psychiatrists who are evaluating them for admittance. Some manics appeal their hospitalization, go to court, appear completely sane and are ordered released. When the police show up to take in a manic on a 5150 (danger to oneself or others) commitment call, 80-90% of the time, the manic will pull themselves together and appear completely sane to the officers. Manics can be wildly manipulative and conniving like the finest psychopaths and they can even earn the sympathy of the police officer. The manic expertly spins a brilliantly elaborated made-up stories, often with the full range of emotions from outrage to tears in a performance rivaling that of a professional actor. The manic will go on about how these evil people who called the cops on them were victimizing them and committing crimes against him in all sorts of ways. The police who have come to commit the manic often end up being won over by the manic, side with the manic and blame the victims for the “crimes” they have committed against the “poor, innocent” manic.

The fact that the craziest manics around can completely pull themselves together and appear cool as a cucumber and sane as can be leads many to believe that manics are engaging in a lot of this behavior on purpose and there may be something to that.

Manics stay up all night long making all sorts of racket, playing loud music and occasionally screaming, yelling and threatening others. You never sleep well with a manic in the house. They sleep, if at all, only a few hours a day, and often at odd hours, typically in the daytime with no particular regular schedule.

They are absolutely unaware that they are ill no matter how crazy they are. They hardly sleep at all. They quickly blow through any money they have and then they are broke and begging or menacing everyone around them for money. Then the manic begins to sell or pawn off all of their possessions in order to get money.

The vast majority of ordinary people have no understanding whatsoever of manic-depressive illness and are unable to identify mania even when it is displayed right in front of their face. Charming hypomanics are often regarded as completely sane and even exemplary people. People who meet them think they just met the coolest person around and are mystified at others who insist that the manic is ill. Angry, irritable, paranoid manics are typically not recognized as ill as almost everyone has zero understanding of mania. Hence there are various attempts to explain the behavior away via other explanations. Laypeople often think that these types of manics are on drugs such as glue, meth or cocaine. Others simply think the manic is a frightening, menacing, dangerous, violent criminal type of person who belong in a jail or prison. They look at a manic and can’t see the illness so they simply see a criminal who needs to be put away. Others think the manic is simply an unstable, hotheaded, violent type, a crank, a kook or a loose cannon ho should be avoided at all costs.

If they have a job, they are guaranteed to lose it in the manic phase because no one will continue to hire any human being who acts like that. Sometimes they can get another job, but then they will lose that one too. If they have an apartment, they will get evicted. And a number of times, they even lose their vehicles in a variety of ways. Bottom line is unless you have some rescue system, a manic episode is a short trip to homelessness.

The manic episode ends after 5-8 months. They often start in the spring and end in the fall, often beginning right around the spring equinox and ending right around the fall equinox. At other times, an episode begins around the fall equinox and ends around the spring equinox. The episodes seem to be tied into the seasons in some unknown way, possibly having to do with the number of daylight hours in the day.

When the episode ends, the manic’s life lies in ruins. If he had a car, it’s now gone. Any job they had was lost and any new jobs they got during the episodes were lost. If they had an apartment, they were evicted. They will have sold or pawned most of their possessions. Their body bears the brunt of 6 months of heavy drug, alcohol and tobacco use. They have destroyed most if not all of their friendships and burned through most of their relationships. These people generate a lot of hatred in others and it is common that former friends and relatives say they hate the manic, never want to see them again and with they were dead. The manic comes to, the episode ends, and unbelievably, the manic is often back to their old self, which is typically as normal as anyone else you might meet walking down the street. It is very hard to believe that this completely normal person was a crazed, terrifying maniac only a few months prior.

The manic is none the wiser for all of his wild and dangerous and destructive adventures. In fact, he has learned nothing at all except maybe that people are mean and the world is out to get them.

The manic typically refuses to acknowledge that they were ill during the episode and instead tries to explain it away in different ways. The doctor gave them some pills that made them “a little wild.” it was all the fault of those pills. They manic was “sick” or “not feeling well” or “upset.” The manic will continue to nurse all of the conflicts that they developed during the episode. The manic will blame others for all of the bad things that happened during the episode, the loss of vehicle, job or jobs, housing, arrest and imprisonment, hospitalization, fights, violence or showdowns, and loss of income, which will be blamed on “the thieves.” Even many years later, the manic will remember the episode as a time of great injustice when thieves stole money from them and everyone around them turned into evil criminals who endlessly victimized them for no reason. Housemates or others who pulled weapons on the manic in self-defense will be referred to as maniac criminals who tried to kill the poor, innocent manic. The loss of the vehicle will be blamed on others, usually “the thieves.” The employers will be referred to as terrible people who unjustly fired the manic for no reason whatsoever. All behavior done in the episode, no mater how crazed or insane, will either be denied or explained away as completely logical. A manic takes all of his expensive electronic equipment to the balcony of his apartment and throws it down to the ground, smashing $1,000’s worth of TV’s, record players, CD and DVD players, guitars, speakers, amps, musical equipment into pieces on the ground. Years later, the manic will righteously defend this behavior as completely rational and angrily blame the people who called the police on him as evil, horrible people who got him arrested for no reason at all.

If you tell the manic they were mentally ill during that period, they will either laugh it off or more commonly will angrily deny it. Some manics even threaten to beat up or punch out anyone who says they are mentally ill. When well, former manics often assault those who say they were mentally ill during the period or who say that the former manic has mental illness that needs treatment.

Manic depressive illness is hard to treat. They are usually not ill enough to be committed even during wild episodes. While manic, they have no insight whatsoever and aggressively deny that they are ill. It’s hard to treat somebody who angrily denies that they are ill in the first place. When they come out of the episode, they are often quite sane, so it appears that there is nothing to treat in the first place, and the manic has typically framed the episode in such a way as to explain it is something more than mental illness.

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Filed under Corrections, Crime, Law enforcement, Mental Illness, Mood Disorders, Psychology, Psychopathology, Psychotherapy, Psychotic Disorders, Symptoms

Female Prisoner Too Violent to Ever Be Let Out

Here.

She obviously gets some sort of a DSM diagnosis.

So what do we give her? Antisocial Personality Disorder (sociopath)? I am not so sure about that due to all the self-harm, although she is vicious. Since when do sociopaths display all this self harm? Sociopaths hurt others, not themselves, and they only kill themselves when the jig is up. They commit suicide to avoid arrest or in prison to avoid the pain of imprisonment, but only rarely in other cases, though some get alcoholic, depressed and suicidal in middle age as the sociopathy starts to burn itself out. I think she has some psychopathic traits though and would score fairly high on Hare PC-L test.

She mostly looks like a Borderline. Borderlines can be quite violent, even female borderlines. And borderlines are notorious for horrific self-harm, suicide threats and suicide attempts. They are not usually this violent though. This crazy bitch has murdered a fellow inmate and attacked guards several times, carving up one’s cheek.

Is there a syndrome called Borderline-Sociopath or Sociopathic Borderline? If there is, she might be something like that.

Whatever she is, she sure is awful evil for a female. Females are not usually this bad. Females can be evil, but their evil is more annoying and infuriating than dangerous. Male evil is much worse because it is menacing, violent, dangerous and homicidal. I have dealt with some evil females in my life and while I wanted to kill most of them at the time, obviously I never did it or even tried or plotted. On the other hand, none of them were really dangerous to me. They were just trying to be as infuriating as possible to provoke the maximum possible violent and crazed reaction from me. I call it “trying to get murdered.”

I will take female evil over male evil any day though. Evil men are terrifying. Evil men have tried to kill me, and I say that with all seriousness. I have had scenes with evil males where it was literally kill or be killed. “I either try to kill these guys, or do nothing and let them kill me.” Others have not tried to kill me but instead beat me very badly, even with heavy objects.

As long as humans are not physically dangerous, they can sort of be tolerated no matter how wicked they are. But violence and the threat of injury or death via attack is a whole other matter.

 

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Filed under Australia, Borderline, Corrections, Crime, Gender Studies, Law enforcement, Mental Illness, Mental Patients, Personality Disorders, Psychology, Psychopathology, Regional, Self-injury, Sociopathy, Symptoms, Women

Bizarre Obsessions

Repost from the old site.

OCD (Obsessive-Compulsive Disorder) is a very strange illness. Although it is lumped in with the anxiety disorders, some have observed that it has qualities about it that imply that maybe it should be moved elsewhere. On tests, OCD’ers have showed similarities with schizophrenics on certain variables. The suggestion was made by the researchers that OCD may be related to schizophrenia.

Nevertheless, OCD generally does not lead to schizophrenia, nor do anxiety disorders lead to psychosis. That is old psychoanalytic stuff. According to psychoanalysis, as the person “regressed”, they moved first into neurotic “defenses” (the anxiety disorders) and later into psychotic “defenses” as the decompensation progressed. This early thinking has been largely rejected in recent days. But some still rings true.

An old Abnormal Psych book from the 1950’s, big on the decompensation stuff above, said that when a person recovered from a mental illness, they generally went back to a the personality they had previously. That sounds about right?

Anyway, most people afflicted with an anxiety disorder would have a hard time believing that they are utilizing some sort of a defense, because they are so horribly miserable all the time. I feel the same way about a psychosis. Whatever is going on, it cannot be any kind of defense mechanism. Defenses are designed to help us cope, not to make us go nuts!

Since OCD is so terribly misunderstood and the general public has such an ignorant attitude about mental illness, I want to delve into the topic of bizarre obsessions. I will list some bizarre obsessions that I have read about and heard about from sufferers:

1. A man is afflicted with thoughts that he is a fish. He checks himself in the mirror for tiny gills and reads dictionary definitions of fish and wonders if he has gills. He feels terrified whenever he sees pictures of fish. He tries to stop the thought every time it comes into his head and describes it as crazy.

2. A man is terrified that the Night Stalker is going to kill him. No reassurance can stop these fears. The problem? The Night Stalker is safely locked away in a maximum security prison and cannot possibly get at the man.

3. A man is worried that he may possibly be the Devil. This would account for continuous thoughts of committing serial murder, torturing victims, pedophilia and cannibalizing victims.

4. A man has thoughts “Aliens are sending me messages”. The thoughts come in “red neon Technicolor like the signs in Las Vegas” in his mind. He spends all his time resisting the thought and describes it as crazy.

5. A boy has thoughts that he “has to kill his grandmother”.

6. A young woman has thoughts that “wolves follow her everywhere she goes” and that every time she walks anyway, she feels compelled to “walk north”.

7. A man has the thought that there are tiny razorblades on his fingernails, although he admits that he can’t actually see or feel them. Hence he is afraid to touch people.

8. A woman is afraid to walk past garbage of any kind, especially trash cans, because she is afraid she might “lose a little bit of her essence” every time she is goes past. So she avoids garbage cans.

9. A man fears that his overwhelming sexual guilt comes out of his fingertips and goes onto any printed paper, or any surface that can be written on. The sexual guilt will flow out of his fingertips onto newspapers, magazines, etc, and his sexual guilt will be available for everyone to see. Hence he licks his fingers all the time to prevent sexual guilt from flowing out of them.

10. A man fears that the ghost of the dead Jeffrey Dahmer is coming into his body and possessing him, and is causing him to have terrible thoughts about murder.

11. A man gets the thought, “They are poisoning me” sometimes when he sits down to eat. He goes ahead and eats the food anyway.

12. A lawyer throws away his coffee several times a day because he fears someone may have poisoned it.

13. A 29 yr old woman obsessively reads the paper to see if she has committed any murders. She constantly worries that she may have murdered someone.

14. A man worries that he may actually be a woman. Not a woman in a man’s body as in a transsexual, but that he actually is a woman. He spends hours studying his body in front of the mirror trying to figure out if he is a woman or not.

15. A man worries if his dog is really his dog. Perhaps it really belongs to someone else? As he continues these worries, he begins to worry that his dog may actually not even be a dog. Perhaps it is some other species?

16. A man constantly worries that he is hearing voices and hallucinating. Upon questioning, it seems that he is just hearing everyday noises and worrying that maybe they are voices or hallucinations.

At first glance, the overwhelming majority of people looking at these symptoms would say that these people are psychotic and that these thoughts are delusions. Unfortunately, many clinicians will also diagnose these people as psychotic and say they suffer from delusions. The problem is that not one of the people above is psychotic and there are no delusions in the series above.

It’s simply OCD and the thoughts are obsessions, not delusions. The difference between obsessions and delusions is a difference that continues to elude some clinical psychologists and psychiatrists.

The way most people immediately said Seung-Hui Cho, the VT shooter, was psychotic shows that most people associate any kind of strange thinking and behavior with “psychosis”. Most clinicians also said Cho was psychotic. I continue to argue that we lack clear evidence of psychosis in Cho’s thinking and behavior.

Psychotic people have enough problems as it is; although I’ve never experienced it, it’s clearly not adaptive, and in many cases its very painful. They don’t need to be lumped in every deranged homicidal maniac who comes along.

Likewise, folks with OCD have plenty of problems as it is without being called “psychotic”, “schizophrenic”, etc.

Sigmund Freud was wrong about OCD in some ways, but he was limited by his era. Nowadays, Freud would surely be a biological psychiatrist. He has some interesting things to say about OCD. First of all, he said: “This is certainly a crazy illness!” On the other hand, he also said, “They are not psychotic.” He also hinted that the illness may be biological in nature.

For schizophrenia, Freud felt that there was something wrong with their brains. He suggested that in the future, we might be able to find something wrong with their brains. He also said that talk therapy was of no use to schizophrenics.

As you can see, for all the derision heaped on him, Freud was right-on in some very crucial observations about common mental illnesses, observations that continue to hold up in our biological era today.

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More on Schiz OCD

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.

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 was good with a circle of close friends. She was 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 really never afraid of the guy, but I had to quit hanging around with him because he 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 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 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 probably 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.

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What Is Schiz OCD?

Repost from the old site.

Well, to be honest, it’s nothing, nothing officially anyway. It’s simply a colloquial name given to a certain variety of OCD, or obsessive-compulsive disorder, this type being the Pure-O type, or obsessions without compulsions*. I have recently discovered, after perusing some OCD boards, that Schiz OCD is actually quite common, though it is a very disturbing type of OCD and is often misdiagnosed.

The person with Schiz OCD starts out worrying that they either have schizophrenia or are going to get schizophrenia. They start to read all about schizophrenia, including all of the symptoms. Then they start to misinterpret stimuli in their environment as being due to hallucinations.

They hear noises in the environment and think that they are hearing voices or hallucinating. They see things out of the corner of their eye and start worrying that they are having visual hallucinations.

Keep in mind that it is considered normal to hallucinate for brief periods on rare occasions. It is not uncommon for normals to report hearing indistinct voices for 5-10 seconds a couple of times over a 5-10 year period (or even more often than that) – a person who experiences such an experience will likely say, “My mind is playing tricks on me.” Transient hallucinations are not necessarily pathognomic of any disorder.

The real problem with schizophrenia is that the person is afflicted with frequent or continuous tormenting voices that the person insists are real.

In addition, the Schiz OCD sufferer starts worrying that they are going to develop schizophrenic or get psychotic delusions. Pretty soon, “delusions” or “psychotic thoughts” start popping into their minds. In more serious cases, the “delusions” or “psychotic thoughts” repeat endlessly in typical OCD style.

Some Schiz OCD’ers report seemingly every schizophrenic and psychotic thought and delusion known to mankind (they are either getting them out of the books or making them up on their own).

I once had a Schiz OCD client who had experienced hundreds of “psychotic delusions”. It was abundantly clear that he had OCD.

Some Schiz OCD’ers commit themselves to mental hospitals, often repeatedly, insisting that they must have schizophrenia. At the hospitals, the doctors are not very nice to them, and the nurses make fun of them, saying that they have “medical student syndrome”.

Some Schiz OCD’ers insist that they are delusional – their delusion being that they have schizophrenia. The “delusion that one has schizophrenia” is not an appropriate symptom for a diagnosis of a psychotic disorder.

People with Schiz OCD are often in a great deal of pain, but they are not psychotic at all, and, in general, they are not dangerous in any way whatsoever. The “delusions” are simply obsessions that are often vigorously resisted in the stereotypical obsessive manner.

There may also be a lot of checking involved Checking in Schiz OCD may involve spending a lot of time checking to make sure the “psychotic thoughts” are not true.

Some of the more common thoughts that Schiz OCD’ers report are, “They are poisoning me,” when being served food, “They are against me”, about anyone, especially a loved one, “This is a message for me”, if they see a piece of paper, etc.

The thought about being poisoned is quite common, with many Schiz OCD’ers reporting it. Nevertheless, they generally go ahead and eat the food anyway. I do not think someone who really thought they were being poisoned would go ahead and eat the food.

Proper diagnosis is essential in these cases, as I have seen a number of cases where clinicians falsely diagnosed Schiz OCD’ers as psychotic. They are not psychotic; they have OCD. It is also very important to distinguish between obsession and delusion, and a lot of clinicians seem to have problems with this distinction. The bizarre, psychotic-like nature of the obsession is diagnostically confusing, but it does not mean it is a delusion.

An obsession is defined as the following:

Obsessions as defined by (1), (2), (3), and (4):

1. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress

2. the thoughts, impulses, or images are not simply excessive worries about real-life problems

3. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action

4. the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.

If the “psychotic thought” or “delusion” has the qualities above, it is an obsession. A person with a true delusion simply accepts the thoughts as absolute fact with a conviction so deep that you cannot change their minds even if you argue with them all day and night. They believe it the same way that you believe your name is whatever your name is. Furthermore, delusions are never resisted.

I have known psychotic persons who had delusions and hallucinations; it is simply impossible to try to argue them out of their false ideas and sensory illusions. Typically, persons in the midst of a psychosis do not have the slightest clue that they are ill.

It is true that in the early stages of psychosis or even schizophrenia, the person may have some level of awareness and insight that something is not ok. This is especially true of more educated persons who know a lot about mental illness.

There is a media report of a poignant case where a young man experienced the early stages of schizophrenia, went to the library and researched his symptoms and diagnosed himself with schizophrenia. However, soon afterwards, he became full-blown psychotic, and all insight was lost.

The lack of awareness of being psychotic makes it difficult to get these persons to take medication. Often they have to be convinced to take medication via subterfuge.

It is also true that schizophrenics who are on anti-psychotics and are getting a good response can have better or even good to excellent insight.

I have personally lived with psychotic persons for months on end, have spent months befriending and socializing with a schizophrenic on a near-daily basis, and have spoken with schizophrenics who were actively psychotic. I have never encountered a single psychotic individual who had the slightest bit of insight into their condition.

All of my efforts to talk psychotic individuals out of their delusions or convince them of the false nature of their hallucinations have been fruitless. It is a mystery to me how any clinician can claim to do psychotherapy with an actively psychotic person.

It is not uncommon for Persons with Schiz OCD to be be diagnosed psychotic or even schizophrenic – I have seen a number of cases. Let this paper serve as a warning that differentiation between obsession and delusion is of profound importance, as proper diagnostics is an essential pillar of treatment. Incorrect diagnosis poses numerous risks to clients, including exposure to dangerous drugs, damage to self-esteem, confusion, etc.

Persons with Schiz OCD often have a history of other forms of OCD, such as HOCD (Homosexual OCD or obsession with the idea that one is gay), POCD (obsession of the idea that one is a pedophile), Harm OCD (obsession that one is rapist or murderer), Germ OCD (obsession about contamination), etc.

I recently encountered a man who had obvious Schiz OCD. He had just gotten back from a visit to a psychiatrist who diagnosed him as “a little bit psychotic” and tried to put him on anti-psychotics.

She gave the following reasons why he was psychotic:

  1. Harm OCD and schiz OCD were not “typical” forms of OCD
  2. If he was worried about going psychotic, it must be because he is going psychotic.

She also said that most psychotic people have insight into their illness – in fact, the very definition of psychosis precludes insight.

Nevertheless, although anxiety disorder does not lead to psychosis, and OCD in general does not progress to psychosis, sometimes OCD presents as the leading edge of schizophrenia, usually in a young person. In such cases, full-blown schizophrenia occurs within no more than two years after development of OCD. OCD and schizophrenia can also co-occur, strange as it may seem. There are articles in the literature about such “schizo-obsessives.”

Some persons who seem to be suffering schiz OCD may be experiencing the onset of schizophrenia, although I have yet to encounter one. In cases where a person with schiz OCD is regularly actually hearing things, further investigation is warranted. In some cases, schizo-obsessives who are more stabilized on meds will present with a concern that they may have Schiz OCD. Differential diagnosis can be quite difficult in these cases.

However, it is likely that a person in the early stages of schizophrenia will experience their strange thoughts as ego-syntonic instead of ego-dystonic – that is, the thought will not be immediately marked as crazy and vigorously resisted, but will instead be embraced as verifiable reality.

Perspective is important. The main problem here is OCD’ers being diagnosed as psychotic, not the other way around. I have encountered quite a few OCD’ers misdiagnosed as psychotic or schizophrenic, but have yet to encounter a psychotic person misdiagnoses as having OCD.

Little has been written about the treatment of Schiz OCD. I recently encountered a man who experienced an almost 100% loss of Schiz OCD on Anafranil, one of the best anti-OCD drugs on the market. He also stated that other SSRI’s have been successful in preventing relapse. When Schiz OCD is very bad, medication is often necessary. A successful response to SSRI’s will typically vindicate the OCD diagnosis and end the differential diagnosis confusion.

Little has been written on the cognitive-behavioral therapy (CBT) of Schiz OCD. One sufferer informed me that the strategy of accepting the thought and just letting it pass on through without debating it seemed to be helpful. Resistance in OCD is often counterproductive, as it often just strengthens the obsession.

There is a serious dearth of literature and knowledge of Schiz OCD. This paper will hopefully spur more research into this poorly-understood type of OCD.

Here and here are a couple of more articles on schiz OCD.

*Dr. Fred Penzel suggested to me that actual pure-O OCD is quite rare. He is correct. What he means is that most pure-O types engage in reassurance seeking, checking and mental compulsions. Sure they do.

On the other hand, OCD’ers seem to want to distinguish between the more ruminative types who do not have overt rituals (no one who knows me would think I have OCD because I do not wash my hands all day or turn lights off and on 20 times). Furthermore, clinicians also seem to want to make this distinction. When I was diagnosed with OCD myself, I was told that I was a “classic obsessive” – implying rumination and lack of overt rituals.

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OCD Versus Psychosis OCD with Psychotic Features

This is another in a series of articles on psychiatric diagnosis. This one will focus on the interface between OCD and psychosis. Keep in mind that there is a now a dx called “OCD with psychotic features.” Here are five cases of OCD with psychotic features. As you can see, these people believe in some really strange stuff! They are also very, very ill.

Case 1

Z suddenly developed rituals at age 17. While watching television he looked up and saw a man’s face at the glass kitchen door and heard a voice say: “Do the habits and things will go right”. He came to believe in a ‘power’ that could bring him luck if he could retain it within his possession through ritualising.

He bought an electric guitar which he felt contained the ‘power’ and would turn the controls ritualistically. He often saw a ‘black dot’ the size of a fist leave his body and enter some object around him. When experiencing the loss of the ‘black dot’ he felt compelled to ritualise to regain the ‘power’ that he believed was contained in it.

At age 19 he began to believe that a workman possessed a second ‘power’ for evil and began a second set of rituals to ward off this evil power while striving to retain the good one. He believed absolutely in the ‘power’ and feared disastrous consequences for himself and his family should he fail to retain the good and repel the evil power.

Before his admission to hospital, obsessions and compulsions affected every area of his life. Before performing any action he felt compelled to imagine the letter ‘L’ and the phrase ‘X away, power back’ for up to 20 minutes. He felt unable to sit on chairs or walk on grass or leaves, and slept with his feet uncovered for fear of the ‘power’ being transferred to some object from which he might be unable to retrieve it.

On leaving home he constantly retraced his steps to place his foot on a crack in the pavement or a leaf that he felt he had trodden on and so lost some of the ‘power’. If he saw the black dot leave his body (about 20 times a day) he had to touch the object it had entered and superimpose the letter ‘L’ and the phrase ‘X away, power back’ in his mind until he saw the black dot return.

From age 18, Z also had recurrent depression, hopelessness and suicidal urges, with deliberate self-harm (overdoses and wrist-slashing) when he was in a depressed mood. He said he harmed himself to appease the power or as a wish to die “when everything was perfect” after a day of ritualizing.

Case 2

Y developed beliefs about a ‘power’ at age 13. He felt that everyone had a certain ‘quality’ or ‘goodness’ which was stored in the brain as a ‘power’. He believed that other people drained the power from him and replaced it with their own rubbish (feces and urine). The exchange of power was triggered by an image in his mind of a face or object. When it happened he felt distressed, ‘dirty’ and ‘horrible’.

He could only regain the power by doing complex rituals. He imagined the person’s face and that he had detached their head from their body and sucked the power from the major vessels of their neck or from their eyes. He then transferred the power back into himself by banging his palm on a particular spot on his forehead, and breathing out repeatedly. This made him feel relieved and ‘good’, but as the events recurred up to several times a minute the relief was short-lived.

He felt ‘compelled’ at times to get revenge on people who stole his power by drawing with his finger on a wall a deformed and ugly representation. If he touched anything he left a ‘power’ trace behind and so had to touch it repeatedly to get the ‘power’ back. Y’s belief in the experience was absolute. He knew it might seem strange to others but believed that if they experienced it, they would understand.

From age 17 he also had recurrent depression, hopelessness and suicidal urges requiring hospital admission.

Case 3

At the age of 8, X had transient counting rituals associated with fear of harm coming to others. When she was 15, after a relative died, she feared that harm would befall her family and friends unless she completed specific tasks. She thought a supernatural ‘power’ inserted unpleasant thoughts into her mind, e.g. “if you read that book a relative will die”.

She believed unshakably that the power was supernatural, but could not explain it. To appease the ‘power’ and the thoughts, she developed complex counting rituals pervading her daily activities. She also did ritualistic hand-washing and checking. She avoided specific numbers, colours and clothes and counted from 0 to 8 on her fingers and toes throughout the day.

She repeated rhymes, avoided multiple numbers she associated with death or harm, and brushed her hair hundreds of times a day. She felt unable to resist the rituals, as her belief in negative consequences was absolute. Before she was admitted to hospital, rituals took all of her time until she fell asleep.

X had two episodes of moderate depression at age 25 and 34, both associated with worsening of her OCD. She had never harmed herself.

Case 4

At the age of 7, W developed fear of harm coming to relatives. He engaged in hand-washing and touching rituals to prevent this. Gradually he began to believe that ‘spirits’ or an outside force ‘reminded’ him to carry out his rituals lest harm should result. He associated the numbers 13 and 66 with harm and, if he saw them, believed they were placed by an external force to remind him to carry out his rituals.

He defended his belief absolutely but said he could not be 100% sure “because one can never be sure about anything”. He was unable to resist his rituals, as his belief in the negative consequences of not doing so was absolute. His rituals centered around numbers, complex counting, and avoidance of specific numbers. At age 31 he developed fear of contamination associated with many rituals of avoidance and hand-washing.

Prior to admission he was homeless and had thrown away all his ‘contaminated’ possessions, carrying all he owned in two carrier bags.

Case 5

For 20 years V had had a fear of being transported into another world. At age 17 he worried that reflections in mirrors represented another world, and had complex checking rituals involving mirrors. This gradually spread to all reflective surfaces. He believed that turning on electrical switches, using the television remote control or hearing car engines turned on could cause him to be ‘transported’ and constantly checked to make sure this had not happened.

He believed that if he ate while in another world, he would be forced to stay there, and so either avoided eating, or ate with complex rituals, or induced vomiting. Other rituals involved switching electrical switches on and off and wearing particular clothes. The ‘other’ world was tangibly the same as the real one, but ‘felt’ different – he felt that friends and family, although appearing the same, were ‘different’ and might have been replaced by ‘doubles’. The symptoms gradually worsened, occupying all of his time prior to admission to hospital.

When he was 27 he suffered severe depression requiring in-patient care, and again at age 30. He had no history of self-harm.

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