Category Archives: Obsession & Compulsion

Does it make me an OCD if I can’t stand these?

So did you struggle to look at those pictures in one of my older post?

How about these ones?

kitkat
1. This is a no-no for a lot of people.

light
2. Some people don’t even notice what’s not right in this one. That’s good, maybe.

punchhole
3. Hate it!!! So what are we going to do with it now!

ringfolder
4. I thought it was only me who can’t stand this? It definitely has nothing to do with OCD.

smallcar
5. This is 99.9% not any obsession or compulsion. In fact, I drive a small car and I really like to park “deeply inside”. (No, it’s not for the sake of annoying others… It’s just ehmmm.. a habit!)

switch
6. What do you think?

tissue dispenser
7. Grrrrr!

toiletroll
8. Grrrrrr #2!! I could end up wasting a lot of paper just to make it “nice”.

toiletseat
9. Not acceptable. And it’s for hygienic reason!

wall
10. Not very professional.

waterdispenser
11. I’d rather not drink and stay thirsty.
bullytheblind
12. This is bullying!! And could be very dangerous.

coins
13. I never realized that I’d always stop it deliberately.

cutlery
14. Who did that?

doggies
15. So cute!! But can’t the two on the right switch their position??

Tips for Succeeding in Your OCD Treatment

Adapted from Fred Penzel, PhD “25 Tips for Succeeding in Your OCD Treatment” (to make it more suitable and applicable to Asian culture)

  1. Always expect the unexpected. You can have an obsessive thought at any time or any place. Don’t be surprised when old or even new ones occur. Be prepared to use your therapy tools at any time, and in any place. Also, if new thoughts appear, be sure to tell your therapist so you can keep them informed.
  2. Be willing to accept risk. Risk is an integral part of life, and as such it cannot be completely gotten rid of. Remember that not recovering is the biggest risk of all.
  3. Never seek reassurance from yourself or others. Instead, tell yourself the worst will happen, is happening, or has already happened. Reassurance will cancel out the effects of any therapy homework you use it on and prevent you from improving. Reassurance-seeking is a compulsion, no matter how you may try to justify it.
  4. Never analyze, question, or argue with obsessional thoughts. The questions they raise are not real questions, and there are no real answers to them.
  5. Try to not be a black-and-white, all-or-nothing thinker — don’t tell yourself that one slip up means you are now a total failure. The good news is that you are in this for the long haul, and you always get another chance. It is normal to make mistakes when learning new skills, especially in therapy. It happens to everyone now and then. Accept it. Even if you have a big setback, don’t let it throw you. Remember the saying, “A lapse is not a relapse.” This means that you never really go back to square one. To do that, you would have to forget everything you have learned up to that point, and that really isn’t possible. Also remember the sayings, “Never confuse a single defeat with a final defeat,” (F. Scott Fitzgerald).
  6. Remember that dealing with your symptoms is your responsibility alone. Don’t involve others in your therapy homework (unless your therapist tells you to) or expect them to push you or motivate you. They won’t always be there when you need them, but YOU are always there for YOU.
  7. Don’t get too impatient with your progress, or compare yourself to someone else. Everyone goes at their own pace. Instead, try to simply focus on carrying out each day’s therapy homework, one day at a time.
  8. When you have a choice, always go toward the anxiety, never away from it. The only way to overcome a fear is to face it. You can’t run away from your own thoughts, so you really have no choice but to face them. If you want to recover, you will have to do this.
  9. When faced with two possible choices of what to confront, choose the more difficult of the two whenever possible.
  10. If your therapist gives you an assignment you don’t feel ready to do, you can speak up and tell them so. As half of the therapist–patient team, you should be able to have a say in your own therapy. The goal is for the homework to produce some anxiety for you to get used to tolerating — not to overwhelm you with it and cause you a setback. On the other hand, don’t be afraid to stretch yourself a bit whenever you can.
  11. Don’t wait for the “perfect moment” to start your therapy homework assignments. Procrastination is a feature of many people’s OCD, so start your therapy homework assignments the day you get them. The perfect moment is whenever you begin doing them. When starting the homework immediately isn’t applicable or possible, at least plan an exact date and time to start it.
  12. Don’t be side-tracked by perfectionism. Perfectionism can be another feature of OCD. You may find your OCD telling you that if you don’t do your homework perfectly, you won’t recover. If you do find yourself obsessing about having to do your homework perfectly, you risk turning it into another compulsion. Watch out for having to do your homework according to the same rigid rules each time you do it. Also, don’t do your homework so excessively that it takes up your whole day. Remember that you still have a life to live.
  13. Don’t forget to go back to the old homework assignments you have done and materials you’ve read before. Don’t assume that you know them all and will not forget them.
  14. Give your homework your full attention, focus on what you are doing, and let yourself feel the anxiety. Try to not let yourself tune out when doing certain assignments, so that you don’t have to feel the anxiety. People sometimes let the homework become routine and do it in a very automatic way as a kind of avoidance. Also, don’t do homework while carrying out other distracting activities. You are building tolerance to what you fear, and for that to happen you have to be in the moment with it.
  15. When faced with a challenging assignment or an unexpected challenging situation, try to look at it as a positive. View it as another opportunity to get better instead of saying, “Oh, no. Why do I have to do this?” Instead tell yourself, “This will be good for me — another chance to practice and get stronger.”
  16. Try to not rush through your therapy homework so that you don’t have to feel as much anxiety. Take your time, and see if you can view it in terms of all the good it will do you. Getting it over with as quickly as possible is not the goal — raising a moderate level of anxiety and staying with it is the goal.
  17. If your homework doesn’t really give you any anxiety, tell your therapist about it. If your exposure homework doesn’t cause at least some anxiety, it isn’t going to help you that much. On the other hand, try doing all new assignments for at least a week before deciding that they don’t make you anxious. Some assignments can cause reactions later on, and it may take doing them a few times before the anxiety occurs.
  18. It is sometimes possible for OCD to try to make you doubtful about your homework. It may tell you that you are not in the right treatment, that your assignments cannot possibly make you better, or that you really don’t understand what you are doing and won’t be able to make it work. Remember that OCD was known as the Doubting Disease, and it will try to cast doubt on anything that is important to you. Don’t try to argue, analyze or question it, just continue what you have to do and over time you’ll find the answers.
  19. Never forget that you have OCD. This means that you will not always be able to trust your own reactions or the things you think and feel, especially if they seem to be telling you very negative and extreme things. If you are unsure if something is really a symptom, treat it as a symptom. Better to do a bit more exposure than not enough.
  20. Remember that in OCD, the problem is not the anxiety — the problem is the compulsions. If you think the anxiety is the problem, you will only do more compulsions to get rid of it (which will only create more anxiety). If you recognize that the compulsions are the problem, stop doing them, and stay with the fearful situation, then the anxiety will eventually go away as you build up tolerance.
  21. Always take a moment to be proud of your own efforts and recognize your successes. It’s a good way to help keep up your motivation. Look back at earlier assignments that are no longer challenging if you believe you aren’t making progress.
  22. Overall, never forget that OCD is very paradoxical and rarely makes much sense. The things that you thought would make you better only make you worse, and the things you thought would make you worse are the very things that will make you better.

A doctor who can’t doctor

A doctor (noun, a person), who can’t doctor (verb, to treat).

She’s on her 4th year of medical degree when she first came to the clinic with her parents. Once treated for OCD many years ago, she had recovered from it with some medication and never had any problem causing much distress since then.

She is brilliant academically since young, doing so well on most of the papers in the uni now. Now it’s towards the end of her medical degree, the problem rises.

The parents found that she’s always studying, doing revisions – but she’s already done so well and that’s not even the most important things to do now, as they should start with practices, attending to patients on the wards. She slowly disclosed that she is very afraid of meeting people, especially seeing patients. Her mind is occupied with herself misdiagnosing patients and failing to treat patients. So she wants to revise more, learn more about the theories (a good example of safety seeking behaviours – doing something to relieve her fear in the short-term, but in long-term what she does further reinforce what she couldn’t do – seeing patients).

The parents aren’t quite sure what to do. They don’t care if their daughter can never become a doctor, it’s not important, as long as she’s happy. But now her fear is killing her confidence, and they’re still hoping that she can at least complete the degree (and plan what to do subsequently, e.g. teaching, doing research etc). She doesn’t seem to be able to cope to complete her degree.

The parents can give her a gap year, “but the more she rests, does it mean the harder she can ever practice again?”.

“We can push her. But we don’t want her to think we’re forcing her then start to avoid us or lose trust in us.”

The parents were advised that what’s most important now is not whether or not she can become a doctor, whether she can graduate, but whether she can conquer the fear, have the courage and go for her practices despite the obsessional thoughts that she may fail. (Something that Acceptance and Commitment therapy could do, I’m kind of interested to know whether ACT can do better than CBT in this case.)

It is definitely not going to be easy, in fact it could be a long journey till she can manage that, but everything that can make that possible should be done.

Learn about this man’s obsession

WARNING: You may not want to read this while you’re eating.

At first it seems a bit difficult to diagnose what problem he has, other than not being able to sleep well for the past year.

He’s working in KL on his own while all his family are in Penang. He has one daughter and one son, both married with children. He said that he’s in good contact with all the family members, and he goes back to see them often, sometimes they would also come to see him. He is cheerful, and seems very sociable.

Apart from his sleeping problems (the reason he came to our clinic), he also kept mentioning that he has constipation. We’d have thought that this is not directly related to mental health problems, but he said he has had check up, test and scans, and was told that he’s absolutely fine. So why constipation?

When he started to talk about his problems in passing faeces in details, the answer slowly revealed. He said people should at least pass 1 kilogram of faeces every day, not anything less than that, “this morning I passed only 200 grams, that is not good enough, and that would keep me worried all day” (Please don’t ask me how he measures that, I hope he’s just checking his own weight before and after the business. And by the way, how does 1 kg of faeces look?). He does everything he can to improve his bowel movements, but still, he thinks he has constipation.

And it’s kind of difficult for him to have insight about his obsessions. Now he’s being treated for his insomnia, and secretly and hopefully, also for his OCD.

Though we have come across and read about all kind of obsessions, this is still quite distinct and… peculiar.

Paranoia? Anorexia? Body Dysmorphic Disorder?

It was first suspected that she has Othello Syndrome (morbid jealousy, case study here). When she came, she just split from her boyfriend and was having suicidal thoughts. The mother said she was constantly checking on the boyfriend, his phones, his whereabouts, his friends etc (similar to the case here). She was also hearing voices, very bad-tempered, having very unstable mood and insomnia.

Few days after she started taking anti-depressant and anti-psychotic medicine, she called up and asked if she could take weight loss pill “L*** B***”, she said it helps to lose body fat only, will not lead to diarrhea. So she was told ok to take this weight loss pill along with her medicine.

Few weeks later, the mother called and questioned us, why we allowed patient to take weight loss pills. Mother said patient has been taking the pills, along with laxative pills (for constipation) excessively, she could take over 20 tablets a day, and purging herself (to vomit). She’s in fact only 43 kgs when she first came to see us, she doesn’t need to lose any weight. But our position is to tell patient that the weight loss pill is safe to be taken with our medicine, but that’s obviously based on the fact that patient is taking it accordingly. It’s not our position to advice patient regarding her weight (we can do so, but we can’t stop her). It also important to note here that if the pill will cause diarrhea or vomit then it won’t be suitable to take with medicine.

So mentally she’s got much worse, as she wasn’t regular with the medication, plus all those means that she’s using to lose weight, her body probably couldn’t take in any of those medicine. She got more sensitive and paranoid, always thinks that people are talking about her, especially when she is out. At one point they had to admit her into hospital for drips as she was taking too much of those pills. After the discharge she finally realized what harms those pills are doing to her body and brain.

So she stopped purging and trying to lose weight. She’s given up on the idea of losing weight. But few days ago she came back for review, now she’s considering rhinoplasty (plastic surgery on the nose)! Almost obsessed about going for it…

Paranoia, anorexia nervosa and body dysmorphic disorder are undeniably inter-related and co-morbid, but does one move from one to another?

Body Integrity Identity Disorder (BIID)

If you were a surgeon and someone came to you asking you to amputate his leg, for how much he is suffering deeply due to this leg and for no physical health reason, what would you do?

The thing is if you don’t do it, they may DIY. One practiced first, he got rid of part of his finger as a prelude to amputating his leg. Another one laid on the train track and let the train run over his limbs. One more shot his legs off with a gun, etc.

Just like Gender Identity Disorder (GID), “body integrity identity disorder hypothesises that a normal function, which is your comfort in how your body fits together, has gone wrong.” When they envision themselves, the image is without the limb, the limb makes them feel “incomplete”.

Do they all desire an amputation due to BIID or a sexual fetish? An obsession with amputees and amputations?

Here was a perfectly healthy man with a perfectly healthy leg. Yet he went under the knife voluntarily, in a foreign country. He trusted a surgical team that worked under a cloak of deception. How much must a man suffer to come to this: lying by himself on an operating table, attended only by strangers, in a small, obscure hospital thousands of miles from his home in America?

Is amputation the only way out? Is it ethical?

Look at some case studies and the history of BIID here (a long read): This is what it is like to be at war with your body – the compulsion to be free of a limb is no imagery illness

Related study: Modular cognitive-behavioral therapy for body dysmorphic disorder: A randomized controlled trial