Category Archives: Obsession & Compulsion

Obsession or Psychosis?

The girl has been housebound for several months now. Though she managed to come to the clinic, but was seemingly restless and anxious, pacing the floor in the waiting area. She couldn’t see people using smartphones anywhere near her. She would think people are taking her pictures and use them for detrimental purposes. When she is in such situation, she experiences strong urges to grab the phone from others.

She does recognise those intrusive thoughts as irrational and could restrain herself from doing so. But like many other with OCD, she is staying home more and more to avoid such situations. When she first consulted a psychiatrist, it was about two years ago. She was quiet, introverted, sensitive, and repetitive in her speech, but wasn’t diagnosed as having OCD.

To really consider her current presentation, she seems to be having persecutory delusions (a common form of delusion in paranoid schizophrenia, where the person believes that ”he or she is being tormented, followed, tricked, spied on, or ridiculed.”).

So, how do you know or decide the diagnosis? Is it OCD or is it borderline psychotic of sorts?

Looking at the backgrounds, the mother who came with her said that she (the mother) has been “depressed” and taking psychiatric drugs for the past 10 years, it was mainly due to the stress caused by her daughter (only child). Though one of the mother’s symptoms, is compulsive washing(!), fear of contamination. It’s not difficult to imagine some OCD can be so severe and disabling leading to depression (the comorbidity rate is high anyway). But here through the mother at least a family history of OCD is exhibited.

In DSM-5, it is specified that OCD may be seen with: (i) good or fair insight, (ii) poor insight, or (iii) absent insight/delusional beliefs.  In all previous editions of the DSM, the criteria for the diagnosis of obsessive-compulsive disorder included the sufferer’s realization that their obsessions and compulsions are irrational or illogical. Now, absent insight/delusional beliefs can be part of an OCD diagnosis. Though we have all noticed that OCD sufferers’ levels of insight can change quickly, often depending on the circumstances and situations (e.g. the intrusive thought was felt completely real when she’s in the public noticing someone holding the phone VS when she’s at home thinking about that situation).

Some psychiatrists would prescribe both anti-depressants (serving as anti-OCD) and anti-psychotics. However, there were cases where OCD patients were first misdiagnosed as psychotic, and taking anti-psychotic very much worsened their OCD (though once they stopped the anti-psychotics and took anti-depressants at the right dosage, their OCD symptoms alleviated).

So time spent for detailed psychopathology and specific diagnosis would be of greatest importance. The presentation of suspiciousness (paranoia) as the main symptom suggested possibility of psychosis, however, the repetitive nature of the thought, which was stereotyped, causing severe distress, also the family history of OCD, pointed toward a greater possibility of obsessions. What is more difficult with this case is the absence of compulsions and reassurance seeking. And my final point, it’s not necessarily “either or”, it could be both! But still it takes much time and effort to really work that out.





  • 生活所有事都能肯定确定吗?有可能吗?
  • 对“确定性”的需要其实有多重要呢?有什么好处与坏处?
  • 你是否常常因为事情的不确定性而总是预测坏事会发生?这样合理吗?坏事以外的事发生的可能性不大吗?
  • 你所预测的事,发生的机率有多高呢?如果发生的机率很低,这样一直担心下去对你好吗?生活会快乐吗?
  • 你能尝试接受“不确定性”吗?能怎样做到船到桥头自然直的态度呢?
  • 问问你周围的人,他们怎么接受“不确定性”呢?


当你无法忍受“不确定性”时,你都把专注力放在“未来”。现在就要学习如何活在当下,对当下警觉注意,并接受这个“不确定性” -三个步骤:

  • 警觉:清楚自己目前的思维与感受。用呼吸的步伐来让自己感受当下。当你总是想要确定性时,它给你带来了什么感受或问题?
  • 放手:放弃这个对确定性的需要,告诉自己“这不过是个需要确定性的想法,我可以放手让它走”
  • 不批判性:让想法在脑海里走过,不要批判它,或尝试改变它。然后把注意力放回当下,体验现在,注意你周围的声音,身体的感觉,或你的呼吸,或专注于你现在需要做的事。


N.B. 在我看来,除了广泛性焦虑症(generalised anxiety disorder, GAD),不能接受“不确定性”(就是凡事都要百分百确定,不能冒一点险)也是强迫症(obsessive compulsive disorder, OCD)的一个明显特征,只是除了在脑中担心、不断思考,强迫症患者会对不确定性做出(反复的)行为反应。


You don’t have to see the whole staircase, just take the first step.

- Martin Luther King Jr.


She started picking hair since standard 5 in primary school, and the problems got worse over the years, especially when she was under pressure. She had seen a few counsellors, also skin specialist, and was given injection on the scalp and prescribed medicine. Finally her parents decided to take her to consult psychiatrist, and within two months she got better with some SSRIs and anti-anxiety drugs. She then stopped taking the medicine. Her hair was growing again.

Few days ago the mother called up, saying her problem is back. When she was sweeping her room, she could see hair all over her bed, pillows and on the floor. The mother asked if we could provide phone counselling to help her (without using medication, as it was causing drowsiness).

This kind of request is not untypical here. Asian people (including myself) tend not to take so much western medicine, and avoid it as much as possible. I can understand that. But the girl’s trichotillomania (hair pulling) problem has a biological components.

Most mental or psychiatric illnesses have a biological component, whether it’s depression, anxiety, OCD, psychosis (obvious!) etc. Sometimes it depends on the type of illness, sometimes on the individual, sometimes it depends on which episode (which means for the same individual, she could have a biological trigger last year but this time it’s a pure psychological triggered episode), sometimes it’s a mix of both. For a person who suffers from very bad OCD, medication can probably reduce his symptoms of 30-50%, but still leaving symptoms that would still interfere with his life, so for this part he would need psychological interventions.

So I explained to the mother that she needs medication, pure counselling may relieve her symptoms to an extend, but not all of it. Because when something is wrong biologically, she would need medication to help her, whereas psychological interventions can help her to reduce her anxiety and stress, and to learn to cope with stress, mood swing, etc.

The best treatment for her would be both medication and psychological interventions, and a good combination is in fact the best and most effective treatment for a lot of people and for many mental illness and psychological problems, unfortunately nowadays this is not the kind of service provided anywhere.








Introducing “Freedom From OCD: A Personalized Recovery Program for Living with Uncertainty”

By Jonathan Grayson PhD.

By Jonathan Grayson PhD.

I picked this book from Kinokuniya Kuala Lumpur in September (RM80.36), out of the desperate desire to really help the patients in the clinic and people out there with Obsessive and Compulsive Disorder (OCD). And I have to say this is really the book that I’ve been looking for; so much that I contacted the author Jonathan Grayson, got his permission and translated the materials into Mandarin Chinese so that it can help some non-English populations **.

The author is a definite advocate of Exposure Response Prevention (ERP) therapy. With his extensive experience working with people suffered from OCD since over three decades ago, his writing made you feel that he really understands you, your OCD and how you feel, BUT he gives you no certainty, no absolute answer, no 100%, in fact he provides almost no reassurance in his book, unlike many other OCD books that I’ve read. And this is why I like it about, and why I think it’s helping people.

Not just that, the book also contains various scripts and examples that you can record and listen to, and this is really important to help you in doing ERP. He also provides you with great details as of what to do when you’re in doubt, what to do if you slip during the treatment etc. For those CBT trained therapists, the book also tells us how we should adapt CBT to make it more workable and effective for OCD, and how traditional CBT may make the problems worse.

So whether you have been suffering from OCD, have a family or friend who suffer from it, or you’re like me, have been looking for a good OCD treatment book, this is definitely worth reading!

Are you willing to learn to live with Uncertainty? 

**For the downloads of materials, worksheets and tools in Chinese, please check here!

The English versions are available on the author’s website

Addiction to Speed (Fast! Faster!)

Are you hooked on fast?

Your Behaviour

  1. Do you want to slow down, but you cannot? Have you lost control?
  2. Do you keep adding activities without taking any away?
  3. Do you work longer and longer hours, but don’t ever finish?
  4. Do you treat other problems: sleep, anxiety, depression?
  5. Do you act first and think later?
  6. Do you check your email and reach for your phone first thing and last?

Your Feelings

  1. Do you feel internal pressure to live fast and act fast, which becomes a craving to “connect” more rapidly?
  2. Do you feel empty if you are not in constant action?
  3. Do you feel nervous without your tech gear in hand or pocket?
  4. Do you feel the beep of your phone as a comfort that gives you a shot of adrenaline?
  5. Do you feel you belong when you are rushing, stressed, and in action?

Your Beliefs

  1. Do you believe you have no limits and you are entitled to live without limits?
  2. Do you believe you should think, feel, react, and behave instantly?
  3. Do you believe you will fall behind if you slow down?
  4. Do you believe success equals fast and faster, and slowing down is failing?
  5. Do you believe you should only feel good, only feel high; other feelings are a sign of failure?
  6. Do you believe stress is the price of success and chaos is normal?
  7. Do you believe that the “new intimacy” is through technology; less time for off-line relationships is the price of success?
  8. Do you believe instant action is a virtue and you can overcome anything with enough willpower?
  9. Do you believe all change must be big to count?


Adapted from Speed: Facing Our Addiction to Fast and Faster – And Overcoming Our Fear of Slowing Down, by Stephanie Brown Phd.

So, How to Unhook from Speed?

Unusual Obsessions and Compulsions

Over the years I’ve come across a lot of OCDs in the clinic, some have more “normal” rituals, such as hand washing, reassurance seeking etc. Most people “stick” to their rituals over the years, sometimes better, other times (especially when they’re under great pressure, or facing major life events or life transiting periods) worse. Many of them have more than one or two compulsions, but they usually have similar underlying causes (obsessions).

Recently I was introduced to this man in his mid 50s. He has a brother who suffers from chronic schizophrenia. He is quite a sensitive person, very easily upset by remarks from others. Initially he was having obsessional ruminations, but responded well to the SSRIs. Subsequently he had a relapse, and started to always feel agitated, wanting to hit people and things he see. This recurrence with violent contents stay with him for quite a few years, however, he managed to function and work.

Over the years he has seen many psychiatrist doctors but to no avail. Then he came back again, still feeling anxious he might do harm to himself or others. Few months ago when he came, the violent content subsided a little, but he is now having this urge to swallow little things (e.g. coins, keys etc). And another two weeks later, it became less about harming people, but he still wants to smash things, especially glasses, big or small, so when he notices others’ smartphones (glass screen!), he gets really anxious with the urge.

Then few days ago, he said he’s been struggling to ride his motorcycles, because he keeps imagining driver/rider coming out from another junction/corner and he accidentally hit them or get hit! So he literally slows down or even stops in every junction, and was almost hit by a car following him. “Yet I’ve to stop!” he added, even knowing he might get hit from the back.

I tried to sit down and think how they are all related, what the underlying obsession is? – “fear of harming self/others/things” is what I concluded. What say you?


Previous entries about “unusual” OCD:

Learn about this man’s obsession (to do with his toilet habit)

Compulsive Voyeurism