Types of obsessions: compulsive, emotional, aggressive

We have all, to a greater or lesser extent, become fixated on some thoughts or actions that at the moment seemed important to us, caused anxiety or irritation. They are usually associated with an upcoming fateful event or situation that can radically change our lives, so the obsession with such thoughts is quite understandable. An obsession is an uncharacteristic thought or idea that besieges a person against his will, arising periodically and involuntarily, with clear consciousness, from which he himself is unable to free himself by his own willpower. Sometimes these thoughts prompt a person to obsessive actions (compulsions) or give rise to irrational fears (phobias) that cannot be logically substantiated. These manifestations can complement obsessions, but modern psychiatry considers them separately.

The person's consciousness remains clear, logical thinking does not suffer, therefore fixation on obsessive, unhealthy thoughts alien to his consciousness and the inability to get rid of them causes negative emotions in the patient, up to the development of depression and neurosis.

Epidemiology

Statistics show that approximately 1-2% of the world's population suffers from obsessive-compulsive disorder. However, there are also neurotics, schizophrenics, people with other mental disorders who suffer from obsessions, and those who do not seek medical attention, not considering themselves ill, only because they are besieged by obsessive thoughts. Many researchers claim that the pathology is very common and is second only to phobias, addiction to psychoactive substances, and clinical depression.

In general, there is a gender balance among patients with obsessions. As a rule, the majority of those who first come with complaints of symptoms of an obsessive state are children, more often during adolescence (over 10 years old), and young people of active working age, but cases of the disease among mature and elderly people are not excluded. Among children, male patients predominate, women mainly fall ill at the age of over 20 years.

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Causes obsessive

At present, the etiology of the occurrence of obsessive syndrome has not been fully established. It occurs as an independent disorder and is often observed in the symptom complex of other mental and neurological diseases (schizophrenia, epilepsy, neurosis, personality disorders, encephalitis), the etiological factors of which are also still being studied. There are still many "blank" spots in the mechanisms of the process of higher nervous activity, however, there are several theories supported by research that explain the development of obsessions.

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Risk factors

Risk factors for the emergence of obsessive thoughts of various natures have biological, psychological and sociological origins.

The first group includes organic pathologies of the central nervous system, its morphological and functional features, disturbances in neurotransmitter balance, features of the autonomic nervous system, certain hereditary traits, and past infections.

The latter are related to constitutional and personal characteristics, accentuations, contradictions between aspirations and possibilities, the influence of childhood experiences and impressions, psychotraumatic situations, excitation inertia and inhibition instability on mental life and behavior. People with high intelligence, who have pronounced stubbornness, are prone to anxiety, doubts and excessive detailing, with the "straight A student syndrome" are at risk of developing obsessive-compulsive disorder.

Sociological reasons are associated with various conflict situations, excessively harsh upbringing, situational contradictions between the ideas of “how it should be” and “how you want it to be”.

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Pathogenesis

Pathogenesis, accordingly, is also considered hypothetically for now 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. Depth psychology sees the causes of obsessions in unconscious childhood sexual experiences (according to Freud); in the psychological contradiction between the desire for power, might and the feeling of one's own inadequacy (according to Adler) and subconscious complexes (according to Jung). These theories explain the appearance of obsessive syndrome in psychogenic disorders, but the biological causes are not revealed.
2. The followers of the school of Academician I.P. Pavlov developed his theory that the pathogenesis of obsessive states is similar to the mechanism of development of delirium, that is, at the basis of both processes lies an unusual inertia of excitation with the subsequent development of negative induction. Later, both Pavlov himself and many of his students considered the influence of extreme inhibition developing in the zone of inert excitation as one of the main links, as well as the simultaneous unwinding of both processes. The critical attitude of the individual to obsessions was explained by the low, in comparison with delirium, saturation of painful excitation and, accordingly, negative induction. Later, in the works of representatives of the school of this direction, it was noted that obsessive thoughts diametrically opposed to the character of the subject are associated with ultra-paradoxical inhibition, when excitation of the centers of the brain responsible for absolutely polar views occurs. It has been noted that in the process of an individual's constant struggle with obsessive states, processes in the cerebral cortex are weakened, and patients with obsessive disorders develop asthenia, which is reversible due to treatment. The exception is subjects with a psychasthenic constitution. The theory of representatives of this school echoes the modern neuromediator theory, describing damage to brain structures at the organismic level accessible in the first half of the last century. Nevertheless, this theory, with a fairly clear description of the activity of the higher parts of the brain during obsessions, does not indicate the origin of these pathological processes.
3. Modern views reflect neurotransmitter theories.

Serotonin (the most comprehensive) – links the occurrence of obsessive states with a disruption of the interaction between the orbitofrontal part of the gray matter of the brain and the basal ganglia. Hypothetically, in subjects with obsessive symptoms, the reuptake of serotonin occurs more intensively, which leads to a serotonin deficiency in the synaptic cleft, and because of this, some interneuronal transmissions are not carried out. The serotonin theory is confirmed by the effectiveness of drugs belonging to the SSRI class (selective serotonin reuptake inhibitors) in the treatment of obsessions. It also agrees well with the theory of hSERT gene mutation, explains the occurrence of obsessive states of a neurotic nature, as well as in personality disorders and partially in schizophrenia. However, it does not bring complete clarity to the origin of this pathology.

Dopamine (describes a possible special case) - it has been established that schizophrenics and people suffering from obsessive-compulsive disorder have an increased level of dopamine, a neurotransmitter of pleasure, in the basal ganglia. Neurobiologists have also established that the concentration of dopamine increases in any person with pleasant memories. These two whales are the basis of the theory, suggesting that some patients intentionally stimulate the production of dopamine, tuning in to pleasant thoughts. Dopamine dependence occurs, and over time, addiction. The patient requires more and more dopamine, he constantly evokes pleasant associations in his brain. Brain cells operating in hyperstimulation mode are depleted - long-term 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 hSERT gene (serotonin transporter) increases the likelihood of a genetically determined factor of anxiety disorders. This theory is currently being actively studied, in addition to the presence of this gene, it has been noted that the society in which the carrier of the mutated gene resides is of great importance.
2. Infectious diseases, particularly streptococcal infection, can cause autoimmune aggression of one's own antibodies, accidentally aimed at destroying the tissues of the basal nuclei of the brain. Another opinion, based on research, indicates that obsessive syndrome is caused not by streptococcus, but by antibiotics used to treat the infection.

Many researchers have long noticed that exhaustion of the body after infections, in women after childbirth and during lactation, led to an exacerbation of obsessive neuroses.

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Symptoms obsessive

Obsessions arise in a number of psychogenic, neurotic conditions or mental illnesses. They are manifested by the involuntary emergence of obsessive thoughts, memories, ideas and representations that are perceived by the patient as unpleasant, absolutely alien and foreign to him, from which the patient cannot free himself.

Psychological symptoms of obsessions - the patient constantly "digests" some obsessive thought, conducts dialogues with himself, ponders something. He is tormented by doubts, memories, often associated with unfinished processes; desires to perform some action or deed that does not correspond to his ideas about the norm of social morality and behavior. Such desires (impulses) irritate patients, cause mental anguish and fear that they may still give in to the impulse, however, this never happens.

Patients are tormented by thoughts about loved ones or acquaintances, associated with unfounded aggression towards them, which frightens the patient. Obsessive memories are also painful, negative in nature, such memories are accompanied by painful feelings about something shameful.

Obsessions in their pure form are thought disorders, experienced by the patient subjectively, and movement disorders that accompany and are caused as a defensive reaction to obsessive thoughts (compulsions) are part of the symptom complex of obsessive-compulsive disorder.

Phobias (fears) are also not a mandatory component of obsessions, however, patients often suffer from phobias. Most often they are afraid of dirt, germs, infections. Some are afraid to go outside, to plunge into a crowd, to ride public transport. This manifests itself in endless hand washing, cleaning and scrubbing of premises, furniture, dishes, invented rituals before performing actions that cause rejection and fear. To overcome phobias, people develop a whole system of ritual actions (compulsions), which can, as it seems to them, ensure the successful completion of an unwanted action, if it cannot be avoided at all.

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

Sometimes patients experience hallucinations, but this is extremely rare with this disorder. They are observed in severe phobias that no longer fit into the modern understanding of obsessions.

Obsessions can cause various disturbances of perception. One of the most common manifestations is the so-called "mirror symptom" inherent in depersonalization. Patients feel that they are going crazy from the inability to get rid of obsessive thoughts, and they are afraid to look at their reflection, so as not to see a spark of madness in their own eyes. For the same reason, people with obsessions hide their eyes from their vis-à-vis, so that he does not see signs of madness there.

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

Obsessions are directly related to the emotional state of the subject subject to them. They are activated at the moment of oppressed, anxious consciousness, worries before upcoming events. Any stress factors stimulate the appearance of obsessions.

If obsessive-compulsive disorder is not associated with progressive mental illnesses, then its presence does not affect the patient’s intellectual abilities and does not influence the development of thinking.

During the absence of obsessive thoughts, the patient remembers them, realizes their abnormality and maintains a critical attitude towards them. At times when obsessive thoughts and phobias besiege, the level of criticism can greatly decrease and even disappear completely.

The subject cannot distract himself from obsessive thoughts, eliminate them by an effort of will, but he resists them. There are two types of resistance - active and passive. Active resistance is less common, is considered more dangerous for the patient, since it is associated with the deliberate effort of the subject to create a psychotraumatic situation and prove to himself that he can overcome it. The patient constantly provokes himself, for example, with an obsessive desire to throw himself down from a height, he can periodically climb high objects (a bridge, the roof of a building) and stay there for a long time, fighting his desire. This causes unwanted reactions and greatly exhausts the nervous system.

Passive resistance is more gentle, it is connected with the fact that the patient tries not to get into situations that cause obsessive ideas. Compulsions also relate to passive resistance.

Obsession during pregnancy

It has long been noted that during periods of increased stress on the body, decreased immunity and exhaustion, the likelihood of manifestation of obsessions increases or their exacerbations become more frequent. If, in addition, 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 mental pathologies that have not previously manifested themselves in any way.

Obsessive thoughts that worry a pregnant woman most often concern future motherhood – her health and the health of her child, financial well-being, fear of childbirth, its complications, pain.

On this soil, classic abstract obsessions flourish – a morbid love of cleanliness, fear of getting infected during such a crucial period, compulsive rituals appear. Obsessive thoughts can concern any aspects, be of an aggressive, sexual or religious nature.

The expectant mother may begin to avoid crowded places, strangers, and sometimes even acquaintances. The symptoms of obsessions are approximately the same and do not depend on pregnancy, it is just that drug therapy is undesirable for a woman expecting a child, but psychotherapeutic help will be very appropriate, especially since in cases not aggravated by mental illnesses, it is often sufficient.

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Stages

The following stages are distinguished in the dynamics of obsessions. The first signs of obsessive-compulsive disorder appear only under the influence of stress factors, when some objective situation really worries the patient. This is the initial stage of the process, given that it is associated with real anxiety, the patient rarely pays attention to obsessive thoughts. The second stage begins when an obsessive paroxysm begins with the mere thought that the patient could hypothetically find himself in an anxious situation. At the third stage, it is enough for the patient to hear in a conversation only a word associated with his fears, for example, “virus”, “dirty”, “cancer”, etc. This, so to speak, “pathogenic” word triggers the process of obsessive condition.

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Forms

Many authors have tried to classify obsessions many times. There is a separate opinion that such a classification does not make sense, since one and the same patient most often has different types of obsessions at the same time, in addition to the presence of phobias and compulsions. Nevertheless, specialists distinguish certain types of obsessions.

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

All authors classify obsessive thoughts syndrome as productive, some schools of psychiatry consider it the mildest of them. According to the classification of A.V. Snezhnevsky, nine productive circles of damage are distinguished - from emotional-hyperesthetic disorder to psychoorganic (the most severe type). Obsessions belong to the third circle of damage - 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.

Abstract obsessions have a milder clinical form, are not accompanied by affects, have an objective background and their manifestations resemble mania. These include:

• fruitless philosophizing (author's version), that is, useless “mental chewing gum” that never flows into action and has no practical value;
• arrhythmomania – the patient is constantly counting steps on the stairs, lanterns, windows, paving stones, steps, houses, trees; remembers dates of birth, telephone numbers; performs arithmetic operations in his head; in severe cases – devotes all his time to activities with digital material that are understandable only to him;
• some cases of obsessive memories - usually these are separate real events from the patient's life, but he imposes his memories on everyone (sometimes several times) and expects the listener to be imbued with the importance of the past situation;
• the patient breaks down phrases into words, words into syllables and individual letters out loud and sometimes repeatedly (a fairly common form in both children and adults).

A more severe form of the clinical course is characterized by figurative obsessions. They appear only against the background of constant anxiety, worry, and are strictly connected with negative changes in mood and are caused by an objective perception of some events or far-fetched non-existent reasons. They have a negative effect on the patient's psyche. This type includes:

• obsessive doubts - the patient is never sure that he is acting or intending to act correctly, he checks and rechecks, weighs all the options, details his memories or intentions, tormenting himself mentally, and most often the most ordinary and habitual everyday actions, standard and practiced professional functions are subject to verification;
• obsessive urges - the patient is consumed by an irresistible desire to publicly commit an act that does not meet the standards of public morality, he repeatedly imagines how all this will happen, however, patients with obsessive disorders never dare to commit such an act;
• figurative obsessive memories (psychopathological experiences) differ from abstract ones in that the patient re-experiences past events vividly;
• ideas that take hold of the patient - images take hold of the patient's consciousness so much that his thinking completely switches to a fictitious 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 in a deeply religious person, denial of an authoritative opinion that the patient shares outside of the obsession, the ethical standards that he follows).

Obsessions are classified according to the mechanism of development into elementary, 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, the pathogenesis of which is not obvious and is not taken into account by the patient, but, nevertheless, cause-and-effect relationships can be established during psychotherapy according to the causal scheme.

There are also excitation obsessions – ideas, desires, fears, as well as inhibition obsessions, when the patient, under certain circumstances, cannot perform certain actions.

Emotional obsessions

Obsessive ideas and associations, irresistible desires that repeatedly arise contrary to the subject’s reason, often unacceptable to him, have a coercive character and in any case cause negative emotions.

The emotional background suffers especially in figurative obsessions; in such cases, even moderate obsession is accompanied by a subdepressive state, characterized by symptoms of depressed mood, a feeling of inferiority and lack of confidence in one's abilities. Patients often develop a syndrome of chronic fatigue, nervous exhaustion with symptoms resembling neurasthenia - the patient is irritated by any reason and at the same time - weak and apathetic. At moments when the patient is overwhelmed by obsessive ideas, restless motor skills and an anxious-depressive affect are noticeable.

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

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Sexual obsessions

Obsessive thoughts from the sphere of sexual relations can concern its most diverse aspects. Often they are connected with abnormal manifestations of sexual desires that are condemned by public morality – incest, same-sex love, zoophilia.

Sometimes people get the idea that they can have sex with someone else - a shop assistant, a policeman, their child's teacher. If the obsessions are figurative, the patient sees the whole process in colors and images. Sometimes the patient is tormented by the fear that it has already happened.

Phobias often give rise to the feeling that an action must still be taken in order not to lose one's mind.

Sexual obsessions often arise from worries that the desired contact will not take place - the object of affection will not come, will refuse, will prefer another. Or an obsessive thought about a negative outcome of sexual contact may appear - unwanted pregnancy, illness. Such thoughts manifest themselves in constant conversations about the ineffectiveness of contraception, the presence of microbes, etc., and also create conditions for denying the very possibility of sex.

Aggressive obsession

This type of obsessive idea orientation causes the most anxiety and fear in patients. People subject to such obsessions are afraid that their terrible thoughts will come true and they will cause tangible harm to innocent people, and these thoughts are truly frightening: up to sexual violence and murder, and they arise with enviable periodicity. In these cases, patients often try to protect themselves with ritual actions from the desires that frighten them. Even passive resistance to obsessive desires exhausts the nervous system, and if the subject actively resists, then the nervous tension goes off the scale. His thoughts terrify him, he feels guilty for them, tries to hide his ritual actions from others so as not to attract attention and not to arouse unwanted interest in himself.

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

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Obsessions in schizophrenia

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

Obsessions in schizophrenics may coexist with other symptoms and the mental automatism characteristic of schizophrenia. They are usually always accompanied by compulsions and phobias. The development of obsessive-phobic disorder in schizophrenics in the prodromal period is preceded by various sensory ideas, fascination with pseudoscientific research, and a depressed state with a predominance of apathy.

Obsessions in schizophrenia debut spontaneously, most often expressed in the emergence of doubts and ideas, and quite quickly become overgrown with compulsive rituals, very absurd and incomprehensible to an outside observer. Obsessions in schizophrenics tend to generalize.

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

In sluggish schizophrenia, patients maintain criticism of obsessive thoughts and fears for a long time, trying to cope with paroxysms, however, the threshold of criticism gradually decreases, and the struggle stops.

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

In schizophrenia, obsessions coexist with other mental disorders, whereas in neurotics, obsession in most cases only causes a depressed state.

Schizophrenics are characterized by the appearance of suicidal thoughts and behavior, while practically healthy people do not have them.

People with schizophrenia often cannot cope without care in everyday life, avoid strangers, and cannot work or study, unlike people suffering from neurosis, who, as a rule, do not lose their ability to work and sometimes create living and working conditions for themselves that promote social adaptation.

Religious obsessions

A very common thematic type is obsession based on religion; in a broader sense, this group can also include multiple superstitions that involve performing all sorts of ritual actions to ward off trouble - knocking on wood, spitting over the left shoulder, and so on.

Positive and even calming symptoms can include ritual actions such as fingering beads, wearing and kissing religious accessories, reciting prayer texts, and ritual cleansing.

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

Complications and consequences

With prolonged obsessive states, a person experiences secondary changes in character - impressionability, suspiciousness, painful shyness appear or increase, a person loses confidence in his own abilities, the presence of phobias leads to the fact that the patient, trying to avoid situations that disturb him, begins to leave the house less often, meet with friends, go to visit - falls into social isolation, may lose his job.

Obsessions in schizophrenia are especially dangerous in this regard, although they can be symptoms of various diseases and disorders. Timely seeking medical help, rather than an independent, exhausting struggle with obsessions, will be relevant in any case and will help the patient to gain mental stability.

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Diagnostics obsessive

The presence of obsessions in a patient is determined, first of all, using psychometric methods - the doctor, having listened to the patient's complaints, offers him to take an obsession test. The most common scale used to determine obsessive states is the Yale-Brown scale, named after the universities whose specialists developed its provisions. It consists of only ten points, five of which are devoted to obsessions, the other five - to compulsive rituals. The number of points scored by the patient allows one to determine the presence of obsessive 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 one to assess the dynamics of the clinical course of the disorder.

Obsessive-compulsive disorder is a symptom of many pathological conditions, so additional research is being conducted to establish the cause of its occurrence.

Research is carried out depending on the suspected causes and includes general clinical and specific tests, instrumental diagnostics of the state of the brain - ultrasound, electroencephalography, tomography.

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Differential diagnosis

Differential diagnostics distinguishes between obsessions and compulsions, theoretically obsessive thoughts can besiege the patient and not lead to any actions, just as obsessive actions (compulsions) may not accompany obsessive thoughts. Obsessive movements that are not ritualistic are considered volitional, but they are so habitual for the patient that it is very difficult for him to get rid of them. However, in practice, both symptoms are usually present in the same patient, in addition, phobias are distinguished, although they also arise against the background of obsession, especially if it is of an aggressive, sexual or frankly contrasting nature.

Obsessions are differentiated from 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 a mandatory symptom of obsessions.

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

Prevention

You can prevent the occurrence of obsessions and prolong the period of remission by eating well, getting enough rest, not getting nervous over trifles, and training a positive attitude towards the world.

Obsessive syndrome develops in people with a certain personality type: suspicious, impressionable, fearful and restless, doubting their abilities. These are the character traits that need to be corrected. Independently - using auto-training techniques, meditation, changing your attitude to life or resorting to the help of psychotherapy specialists - attending trainings, group and individual sessions.

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Forecast

Short-term obsessive disorders that lasted no more than two years did not bring about changes in the patients' character. Therefore, we can conclude that the sooner you start treatment, the greater the chances of changing the situation without losses.

Long-term obsessions affect the character and behavior of people, exacerbating anxious and suspicious personality traits. Patients who have been experiencing obsessive states for a long time have been given different diagnoses. For example, obsessions in schizophrenia have an unfavorable prognosis.

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