Types of obsessions: intrusive, emotional, aggressive

All of us to a greater or lesser degree happened to focus on any thoughts or actions that at the moment seemed important to us, caused concern or annoyance. They are usually associated with the upcoming fateful event or situation, which can fundamentally change our life, therefore the obsession of such thoughts is quite understandable. Obsession - besieging a person against his will is not his usual thoughts or ideas that arise periodically and involuntarily, with a clear mind, from which he himself is unable to free himself by his strong-willed effort. Sometimes these thoughts induce a person to compulsive actions (compulsions) or generate irrational, unjustifiable fears (phobias). These manifestations can complement the obsessions, but modern psychiatry considers them separately.

Human consciousness remains clear, logical thinking does not suffer, therefore fixing on obsessive, alien to his consciousness unhealthy thoughts and the inability to get rid of them causes the patient negative emotions until the development of depression and neurosis.

Epidemiology

Statistics show that in the world, approximately 1-2% of the population suffer from obsessive-compulsive disorder. However, there are still neurotics, schizophrenics, people with other mental disorders, suffering from obsessions, and those who do not go to the doctor without considering themselves sick, just because they are obsessed with obsessive thoughts. Many researchers argue that the pathology is very common and second only to phobias, dependence on psychoactive substances and clinical depression.

In general, gender balance is observed among patients with obsessions. As a rule, most of the first time those who complained about the symptoms of the compulsive state are children, more often in the period of adulthood (over 10 years), and young people in active working age, but cases of disease among mature and elderly people are not ruled out. Among the children, male patients predominate, women predominantly fall ill at the age of over 20 years.

[1], [2], [3], [4], [5], [6], [7]

Causes of the assumption

At present, the etiology of the onset of the obsessive syndrome has not been established for certain. It arises as an independent disorder and is often observed in the symptomatic complex of other mental and neurological diseases (schizophrenia, epilepsy, neurosis, personality disorders, encephalitis), the etiological factors of which are also being studied. There are still many "white" spots in the mechanisms of the process of higher nervous activity; nevertheless, there are several theories reinforced by the studies that explain the development of obsessions.

[8], [9]

Risk factors

Risk factors for the emergence of obsessive thoughts of a different nature have a biological, psychological and sociological origin.

The first include organic pathologies of the central nervous system, its morphological and functional features, disorders of neurotransmitter equilibrium, features of the autonomic nervous system, certain hereditary traits, and transmitted infections.

The latter are related to constitutional-personal characteristics, accentuations, contradictions between aspirations and opportunities, influence on the psychic life and behavior of children's experiences and impressions, psycho-traumatic situations, inertia of excitation and instability of inhibition. In the group at risk of developing obsessive syndrome, people with high intelligence, who have a strong stubbornness, are prone to anxiety, doubt and excessive detail, with "excellent man's syndrome."

Sociological reasons are associated with a variety of conflict situations, overly severe upbringing, situational contradictions between the presentation "as it should" and "as you like."

[10], [11], [12], [13]

Pathogenesis

Pathogenesis, respectively, is also considered so far hypothetically and has many theories. The most famous of them, recognized by modern medicine and, at least partially, explaining the essence of the processes are the following:

1. Deep psychology sees the causes of obsessions in unconscious child sexual experiences (according to Freud); in the psychological contradiction between the desire for power, power and a sense of own insolvency (according to Adler) and subconscious complexes (according to Jung). These theories explain the emergence of an obsessive syndrome in psychogenic disorders, but biological causes are not disclosed.
2. Followers of the school of academician I.P. Pavlov developed his theory that the pathogenesis of compulsive states is analogous to the mechanism of delirium development, that is, both processes have an unusual inertness of excitation followed by the development of negative induction. Later, Pavlov himself and many of his students regarded it as one of the main links and the influence of the supranational inhibition developing in the zone of inert excitation, and besides - the simultaneous unwinding of both processes. The critical attitude of the individual to the obsessions was explained by the low, in comparison with the delirium, the saturation of the morbid excitation and, accordingly, the negative induction. Later in the works of representatives of the school of this direction it was noted that obsessive thoughts diametrically opposite to the nature of the subject are associated with ultraparadoxical inhibition when excitation of the brain centers responsible for absolutely polar views occurs. It is noticed that in the process of constant struggle of the individual with obsessive states, the processes in the cerebral cortex are weakened, and asthenia, reversible due to treatment, develops in patients with obsessive disorders. The exception is the subjects of the psychasthenic constitution. The theory of the representatives of this school echoes the modern neurotransmitter theory, describing the lesions of the structures of the brain at an organismic level accessible in the first half of the last century. Nevertheless, in this theory, with a sufficiently clear description of the activity of the higher parts of the brain in obsessions, the origin of these pathological processes is not indicated.
3. Modern views reflect neurotransmitter theories.

Serotonin (the most comprehensive) - connects the appearance of obsessive states with a violation of the interaction between the orbital-frontal part of the gray matter of the brain and the basal nuclei. Hypothetically, in subjects with obsessive syptoms, the reverse capture of serotonin occurs more intensively, which leads to a serotonin deficiency in the synaptic cleft, and because of this, part of the interneuronal transmission is not carried out. Serotonin theory is confirmed by the effectiveness of drugs belonging to the class of SSRIs (selective serotonin reuptake inhibitors) in the treatment of obsessions. It also agrees well with the theory of mutation of the hSERT gene, explains the appearance of obsessive neurotic states, as well as - in personality disorders and in part - in schizophrenia. However, the origin of this pathology does not bring complete clarity.

Dopamine (describes a possible particular case) - it is established that in schizophrenics and people suffering from obsessive-compulsive disorder, the level of dopamine-the neurotransmitter of pleasure-is increased in the basal nuclei. Neuroscientists also found that the concentration of dopamine increases in any person with pleasant memories. The theory is based on these two whales, suggesting that some patients intentionally stimulate the production of dopamine, tuning in to pleasant thoughts. Dopamine dependence arises, and with time and addiction. The patient needs more dopamine, he constantly evokes pleasant associations in his brain. Cells of the brain, working in the regime of hyperstimulation, are depleted - prolonged dopamine dependence can cause serious damage to brain health. This theory does not explain many cases of obsessive syndrome.

1. Hereditary predisposition - mutation of the gene hSERT (a carrier of serotonin) increases the probability of a genetically determined factor of anxiety disorders. Now this theory is actively being studied, in addition to the presence of this gene, it is noted that the importance of the socium in which the carrier of the mutated gene resides is of great importance.
2. Infectious diseases, in particular, streptococcal infection can cause autoimmune aggression of their own antibodies, randomly directed at destruction of the brain basal brain tissue. Another opinion based on research indicates that the obsessional syndrome is caused not by streptococcus, but by antibiotics, which treated the infection.

Many researchers have long noted that depletion of the body after the infection, in women after childbirth and during lactation, led to an aggravation of obsessional neuroses.

[14], [15], [16], [17], [18], [19]

Symptoms of the assumption

Obsessions arise in a number of psychogenic, neurotic states or mental disorders. It is manifested by the involuntary emergence of obsessive thoughts, memories, ideas and ideas perceived by the patient himself as unpleasant, completely alien to him and alien, from which the patient can not free himself.

Psychological symptoms of obsessions - the patient constantly "digests" any obsession, leads with a dialogue, something is pondering. He is tormented by doubts, memories, often associated with unfinished processes; the desire to commit an act or act that does not correspond to his ideas about the norm of public morality and behavior. Such desires (impulses) irritate the sick, cause mental anguish and fear that they can still give in to a rush, however, this never happens.

Patients are tormented by thoughts of close people or acquaintances connected with unreasonable aggression towards them, which frightens the patient. Obsessive memories are also painful, negative, accompanied by such memories of painful feelings about something shameful.

Obsessions in their pure form represent mental disorders, are experienced patiently subjectively, and motor disorders that accompany and are caused as a protective reaction to obsessive thoughts (compulsions) are included in the symptom complex of obsessive-compulsive disorder.

Phobias (fears) are also not an obligatory component of obsessions, however, patients often suffer from phobias. Most often they are afraid of dirt, germs, infections. Some are afraid to go out into the streets, plunge into the crowd, ride in public transport. This manifests itself in endless washing of hands, cleaning and cleaning of rooms, furniture, utensils, invented rituals before performing actions that cause rejection and fear. To overcome phobias, people have a whole system of ritual actions (compulsions), which they can, as they see it, ensure the successful fulfillment of undesirable actions if it can not be avoided at all.

Panic attacks can occur if necessary to perform a fear-provoking action. In addition to psychological symptoms, such seizures are often accompanied by a number of vegetative signs. The patient turns pale or red, sweats, becomes dizzy and short of breath, accelerates or slows down the heartbeat, there is an urgent need to visit the toilet.

Sometimes patients have hallucinations, but with this disorder it is extremely rare. They are observed in severe phobias, which no longer fit into the modern view of the obsessions.

With obsessions, there may be various impairments in perception. One of the most common manifestations is the so-called "mirror symptom" inherent in depersonalization. It seems to the sick that they are going crazy from the impossibility to get rid of obsessive thoughts, and they are afraid to consider their reflection, so as not to see in their own eyes a twinkle of madness. For the same reason, people with obsessions are hiding their eyes from their counterpart, so that he does not see signs of insanity there.

Obsessions differ from healthy thinking in that they are not the will of the patient and not only do not characterize him as a person, but are also contrary to his personal characteristics. With a clear consciousness, the patient can not cope with the besieging thoughts, but correctly perceives their negative context and makes attempts to resist them. Healthy thinking of the patient tries to reject obsessive thoughts, they are perceived as pathology.

Obsessions are directly related to the emotional state of the subject they are exposed to. They are activated at the time of oppressed, anxious consciousness, unrest before the upcoming events. Any stress factors stimulate the appearance of obsessions.

If the compulsive disorder syndrome is not associated with advanced mental illness, its presence does not affect the intellectual abilities of the patient and does not affect the development of thinking.

During the absence of obsessive thoughts, the patient remembers them, realizes their anomaly and retains a critical attitude towards them. At moments when obsessive thoughts and phobias are precipitated, the level of criticism can be greatly reduced and even completely disappear.

Distract from obsessive thoughts, to eliminate them by effort of will the subject can not independently, but he resists them. Resistance is of two types - active and passive. Active resistance is less common, it is considered more dangerous for the patient, because it is due to the deliberate efforts of the subject to create a psychotraumatic situation and to prove to himself that he can overcome it. The patient constantly provokes himself, for example, with an obsessive desire to rush down from a height, can periodically climb to high objects (bridge, roof of a building) and stay there for a long time, struggling with his desire. This causes unwanted reactions and greatly depletes the nervous system.

Passive resistance is more sparing, it is due to the fact that the patient tries not to get into situations that cause obsessions. Compulsions also apply to passive resistance.

Obsession during pregnancy

It has long been noted that during periods of increased stress on the body, reducing immunity and exhaustion, the probability of demonstration of obsessions increases or their exacerbations become more frequent. If, moreover, a woman has predisposing personality traits - anxiety, suspiciousness, then the appearance of obsessions is quite understandable. The period of pregnancy is also favorable for the manifestation of neuroses and more serious psychiatric pathologies, previously not manifested.

Obsessive thoughts that worry a pregnant woman are most often related to future motherhood - her and child's health, financial well-being, fear of childbirth, their complications, pain.

On this basis classical abstract obsessions blossom - a painful love for purity, a fear of becoming infected in such a critical period, compulsive rituals appear. Obsessive thoughts can concern any aspects, be aggressive, sexual or religious in nature.

A future mother may start to avoid crowded places, strangers, and sometimes acquaintances. Symptoms of obsessions are approximately the same and do not depend on pregnancy, just a woman waiting for a child, drug therapy is undesirable, but psychotherapeutic help will be very appropriate, especially since cases that are not burdened by mental illness are often enough.

[20], [21], [22], [23],

Stages

In the dynamics of obsessions, the following stages are distinguished. The first signs of the syndrome of obsessive states appear only under the influence of stress factors, when any objective situation really worries the patient. This is the initial stage of the process, given that it is associated with real anxiety, the patient seldom pays attention to obsessive thoughts. The second stage begins when the paroxysmal paroxysm begins at the mere thought that the patient may hypothetically end up in an alarming situation. In the third stage, it is enough for the patient to hear in the conversation only the word associated with his fears, for example, "virus", "dirty", "cancer" and so on. This, so to speak, "pathogenic" word starts the process of obsession.

[24], [25],

Forms

Classify obsessions have been tried many times and many authors. There is a separate opinion that such a classification does not make sense, in the same patient most often simultaneously there are different types of obsessions, in addition, with the presence of phobias and compulsions. Nevertheless, experts identify certain types of obsessions.

From the point of view of the physiology of psychiatric symptoms, obsessive ones belong to the disorders of central mental activity, and among these disorders - to associative, that is, to thinking disorders.

All authors consider the syndrome of obsessive thoughts to be productive, some schools of psychiatry consider it to be the easiest of them. According to A.V. Snezhnevsky distinguish nine productive circles of damage - from emotional hyperesthetic disorder to psycho-organic (the most severe type). Obsessions belong to the lesions of the third circle - it is between affective and paranoid disorders.

Domestic psychiatrists use the classification of the German psychiatrist and psychologist K.T. Jaspers, according to which two main types of obsessions are distinguished: abstract and figurative.

The abstracted obsessions have a more mild clinical form, are not accompanied by affect, have an objective background and manifestations resemble mania. These include:

• fruitless philosophizing (author's version), that is, a useless "mental chewing gum" that never flows into actions and does not have practical value;
• arrhythmia - the patient is engaged in constant counting steps on the stairs, lanterns, windows, paving stone elements, steps, houses, trees; remembers birth dates, phone numbers; Performs arithmetical operations in the mind; in severe cases - devotes all his time to only one of his understandable activities with digital material;
• some cases of obsessive memories - usually these are separate real cases from the life of the patient, but he imposes his memories on everyone (sometimes several times) and waits for the listener to imbue with the importance of the former situation;
• the patient puts phrases into words, words into syllables and individual letters aloud and sometimes repeatedly (a fairly common form in both children and adults).

A more severe form of the clinical course is characterized by imaginative obsessions. They appear only against a background of constantly eating sick anxiety, anxiety, are rigidly connected with negative mood changes and are caused by a biased perception of any events or by far-fetched non-existent causes. Negatively affect the psyche of the patient. To this type belong:

• obsessive doubts - the patient is never sure that he is acting or is going to act correctly, he is checking and rechecking, weighing all the options, detailing his memories or intentions, tormenting himself mentally, with the most common and usual everyday actions, ;
• obsessive impulses - the patient absorbs an irresistible desire to publicly perform an action that does not meet the norms of public morality, he repeatedly imagines how all this will happen, however, patients with obsessive disorders never decide on such an act;
• shaped obsessive memories (psychopathological experiences) differ from those abstracted by the fact that the patient is experiencing anew and brightly past events;
• mastering the patient's images - the images so master the patient's consciousness that his thinking completely switches to fictional reality, in this case the level of criticism is significantly reduced, compulsive actions, hallucinations, illusions are possible;
• contrasting ideas and thoughts - the patient is overwhelmed by desires and thoughts that contradict his worldview and moral and ethical principles (for example, blasphemous thoughts of a deeply religious person, denying the authoritative opinion that the sick person separates from the obsession, the ethical norms that he follows).

Obsessions are classified according to the development mechanism into elementary ones, the cause of which is obvious to the patient, since they arose immediately as a result of severe stress, for example, during a transport accident, and cryptogenic ones, the pathogenesis of which does not lie on the surface and is not taken into consideration by the patients, but nevertheless , cause-effect relationships can be established when conducting psychotherapy by causal scheme.

They also sing out excitations - ideas, desires, fears, and also - obsessions of inhibition, when the patient under certain circumstances can not perform certain actions.

Emotional obsessions

Obsessive ideas and associations, irresistible cravings that repeatedly arise against the mind of the subject, often unacceptable to him, have the character of coercion and in any case cause negative emotions.

Especially the emotional background suffers in imaginative obsessions, in such cases, even a moderate obsession is accompanied by a subdepressive state characterized by symptoms of oppressed mood, a feeling of inferiority and insecurity in one's own strengths. Often, patients have a syndrome of chronic fatigue, nervous exhaustion with signs resembling neurasthenia - the patient is irritated for any reason and at the same time - weak and apathetic. At moments when the patient obsesses obsessive ideas, noticeable restless motor skills and anxiety-depressive affect.

Psychiatrists point out that obsessive thoughts do not leave the patient until the strength and brightness of emotions associated with obsessions begin to subside.

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Sexual Assemblies

Obsessive thoughts from the sphere of sexual relations can concern the most different sides of it. Often they are associated with abnormal manifestations of sexual drives, which are condemned by social morality - incest, unisex love, zoophilia.

Sometimes people come up with the idea that they can make sexual intercourse with someone from strangers - the seller in the store, the policeman, the teacher of his child. If the obsessions are figurative, the patient sees the whole process in paints and images. Sometimes the patient is tormented by the fear that this has already happened.

Phobia often gives rise to the feeling that the action will still have to be done in order not to lose one's reason.

Sexual obsessions often arise on the basis of experiences, that the desired contact does not take place - the object of attachment does not come, refuses, will prefer another. Or, there may be an obsession about the negative outcome of sexual contact - unwanted pregnancy, illness. Such thoughts are manifested by constant talk about the ineffectiveness of contraception, the presence of microbes and others, and also create conditions for denying the very possibility of sex.

Aggressive obsession

This type of focus obsessive ideas causes in patients the most worries and fears. People who are exposed to such obsessions are afraid that their horrible thoughts will come true and they will cause tangible harm to innocent people, and these thoughts are really intimidating: up to sexual violence and murder, and they arise with an enviable periodicity. In these cases, patients often try to protect themselves with ritual actions from frightening desires. Even passive resistance obsessive impulses drain the nervous system, and if the subject actively resists, then the nervous tension goes off scale. His thoughts are horrible, he feels guilty for them, trying to hide his ritual actions from others, so as not to attract attention and not cause undesirable interest.

Aggressive and sexual obsessions are the most painful and often interspersed with each other - obsessive thoughts can be aggressive in relation to a sexual object.

[27], [28]

Obsessions in schizophrenia

The phenomenon of obsession is present in a small number of schizophrenics according to different data from 1 to 7%, however, is characterized by an adverse course, since schizophrenia is a severe progressive mental illness. Schizophrenics obsessive compulsions in most cases do not resist, but, on the contrary, try to rigorously execute "orders from above." Obsessions are characteristic for the onset of a neurotic-like form of the disease (paranoid subtype).

Obsessions in schizophrenics may coexist with other symptoms and psychotic automatism characteristic of schizophrenia. Basically, they are always accompanied by compulsions and phobias. The development of obsessive-phobic disorder in schizophrenics in the prodromal period is preceded by various sensory ideas, fascinations with pseudo-scientific research, an oppressed state with a predominance of apathy.

Obsessions with schizophrenia debut spontaneously, most often expressed in the emergence of doubts and representations, quickly accumulate compulsive rituals, very ridiculous and incomprehensible to an outside observer. Obsessions in schizophrenics tend to generalize.

If they were manifested by social phobias, the patient tried to avoid unfamiliar people, not to appear in crowded places. Phobias in schizophrenics are very diverse, ranging from fear of injections, broken glasses, diseases to emotionally colored panic attacks, which during the waiting for another attack were complicated by anxiety and vegetative disorders, although in general, with the progression of the disease, emotions are gradually lost.

With sluggish schizophrenia, patients for a long time remain critical of obsessive thoughts and fears, trying to cope with paroxysms, however, the threshold of criticism gradually decreases, and the struggle ceases.

Obsessions in schizophrenics differ from patients with neurosis-like disorders with greater force of obsession, more complex and ridiculous rituals, the fulfillment of which is devoted to a long time. Schizophrenics perform compulsive actions without embarrassment, sometimes they try to involve close people, in addition to neurotics, who try to hide their rituals from prying eyes.

In schizophrenia with obsessions, other mental disorders coexist, whereas in neurotic obsessions, in most cases, only the oppressed state is caused.

For schizophrenics is characterized by the appearance of suicidal thoughts and behavior, whereas in practically healthy people they are absent.

Patients with schizophrenia often can not do without guardianship in everyday life, avoid strangers, can not work and study, unlike people with neurosis, who usually do not lose their ability to work and sometimes create their own living and working conditions conducive to social adaptation .

Religious obsessions

A very common thematic view is obsession with religion, in a broader sense, this group can be attributed to multiple superstitions that imply the performance of all sorts of ritual activities that divert trouble - knock on wood, spit through the left shoulder and so on.

Positive and even soothing symptoms can be called such ritual actions as fingering rosary, wearing and kissing religious accessories, uttering prayer texts, ritual cleansing.

Negative emotions in a religious patient are caused by obsessive blasphemous thoughts and desires, sometimes having a sexual or aggressive coloring. They plunge the patient into horror and take a lot of energy to fight these desires, force them with great zeal to read prayers, observe fasts and other religious rituals in order to earn forgiveness.

Complications and consequences

With prolonged obsessional conditions, the person undergoes secondary changes in character: impressionability, suspiciousness, painful shyness, or a feeling of self-confidence, the phobia leads to the fact that the patient, trying to avoid disturbing situations, begins to leave the house less often, meet with friends, going to visit - falls into social isolation, may lose work.

Especially dangerous in this respect are the obsessions in schizophrenia, although they may be symptoms of various diseases and disorders. Timely appeal for medical help, and not an independent debilitating struggle with obsessions, will be relevant in any case and will help the patient to gain mental stability.

[29], [30]

Diagnostics of the assumption

The presence of obsessions in the patient is determined, first of all, with the help of psychometric methods - the doctor, having listened to the patient's complaints, invites him to pass the test for an obsession. Most often, the Yale-Brown scale is used to define obsessive states, named after the universities whose specialists developed its provisions. It consists of only ten items, five of which are devoted to obsessions, the other five to compulsive rituals. By the number of points scored by the patient, it is possible to determine the presence of compulsive thoughts and compulsions, the ability to resist them and the severity of the disorder. The patient can be tested several times, for example, during the week, which allows to assess the dynamics of the clinical course of the disorder.

Obsessive syndrome is a symptom of many pathological conditions, therefore additional studies are conducted to establish the cause of its appearance.

Studies are made depending on the expected causes and include general clinical and specific tests, instrumental diagnostics of the brain - ultrasound, electroencephalography, tomography.

[31], [32], [33],

Differential diagnosis

Differential diagnosis delimits obsessions and compulsions, theoretically obsessive thoughts can besiege the patient and not lead to any actions, just as obsessive actions (compulsions) can not be accompanied by obsessive thoughts. Obsessive movements that are not ritualistic, refer to the strong-willed, but they are so familiar to the patient that it is very difficult for him to get rid of them. However, in practice, usually the same patient has both symptoms, besides this, they separate phobias, although they also appear against the background of obsession, especially if it has an aggressive, sexual or frankly contrasting character.

Differentiate obsessions and panic attacks, which can also accompany obsessive-compulsive disorder, be one of the symptoms of neurosis or schizophrenia. However, episodic attacks of uncontrollable fear are not an obligatory symptom of obsessions.

The task of differential diagnosis is to delimit obsessive disorder from obsessive-compulsive disorder, schizophrenia, epilepsy, dissociative disorders, and other diseases in which the complex of symptoms may be accompanied by obsessive syndrome.

Prevention

Warn the emergence of obsessions, prolong the period of remission, you can eat well, fully resting, not nervous about trifles and training a positive attitude to the world.

Obsessive syndrome develops in people with a certain personality trait: suspicious, impressionable, timid and restless, doubting their capabilities. These are the character traits you need to try to correct. Independently - using techniques of auto-training, meditation, change your attitude to life or resort to the help of specialists in psychotherapy - attend trainings, group and individual classes.

[34], [35]

Forecast

Short-term obsessive disorders, which lasted no more than two years, did not introduce changes in the nature of patients. Therefore, we can conclude that the earlier you start the treatment, the more chances to change the situation without losses.

Long-term obsessions affect the character and behavior of people, exacerbating anxious-hypochondriac personal traits. Patients with long-term obsessive conditions, put different diagnoses. For example, an obsession with schizophrenia, have an unfavorable prognosis.

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