Search

The phenomenological distinction between delusions and obsessions has been the subject of much debate in psychiatry. Some authors feel these symptoms are distinct nosological entities, while others argue that they reflect manifestations of the same symptom and are distinguishable on the basis of the level of insight a patient displays. In this report we describe the case history of a lady who presented with an obsessional disorder. The symptom was resistant to standard treatments and subsequently became more delusional in nature. We review the literature in terms of the classification of obsessions and delusions and offer assistance to clinicians in terms of the diagnosis and treatment of cases where the distinction between these phenomena is not clear and offer alternative means of classifying these symptoms based on insight.

Traditionally, forensic mental health services have focused on the assessment and treatment of offenders with serious mental disorders. In recent years, there has been growing recognition that forensic clinicians have an important role to play for those offenders who engage in criminal acts driven by psychological or/and social problems, which may, or may not, occur in conjunction with a major mental disorder. This is especially true for specific offenses such as stalking and threatening. This article describes the innovation of the problem behavior model. This model uses a reductionist approach and the nexus between psychiatry and psychology to address the complex phenomena associated with specific problem behaviors that often culminate in offenses. The model is illustrated by describing the development of specialist clinics for the problem behaviors of stalking and threatening.

This review summarises the psychiatry of the puerperium, in the light of publications during the past 5 years. A wide variety of disorders are seen. Recognition of disorders of the mother-infant relationship is important, because these have pernicious long-term effects but generally respond to treatment. Psychoses complicate about one in 1000 deliveries. The most common is related to manic depression, in which neuroleptic drugs should be used with caution. Post-traumatic stress disorder, obsessions of child harm, and a range of anxiety disorders all require specific psychological treatments. Postpartum depression necessitates thorough exploration. Cessation of breastfeeding is not necessary, because most antidepressant drugs seem not to affect the infant. Controlled trials have shown the benefit of involving the child's father in therapy and of interventions promoting interaction between mother and infant. Owing to its complexity, multidisciplinary specialist teams have an important place in postpartum psychiatry.

The author begins by noting that the subject of obsessions and obsessional neurosis seems to have fallen out of favour with the analytic community in spite of the important part it played in the formation of Freud's theories, and notwithstanding the significance of its mechanisms in the maturation of the ego. He then discusses some theoretical considerations regarding the development of the taboo on touching and, by extension, contact. Attention is drawn to the parallels with autistic functioning emphasised by other authors. Particular importance is attached to the distinction between internal and external reality that arises during the anal-sadistic phase and that leads to polarisation and splitting in obsessional neurosis. Following a discussion of the transference-countertransference situation with obsessional patients and of their concretistic experience in the treatment situation, as also featured in the literature, an extensive case history exemplifies the author's contentions and shows how the patient concerned developed during the course of his analysis. After pointing out the importance of the avoidance of identifications as a mechanism of obsessional defence, the author concludes the paper with a brief comparison of obsessional and hysteriform functioning and a characterisation of the obsessional defence as the excessive recourse to perverted thought functions so as to ward off paranoid anxieties.

Stalking is a widespread phenomenon describing a pattern of intrusive and threatening behavior that leads to the victim's perception of being harrassed and rendered afraid. This paper summarizes relevant aspects of the current stalking concept and reviews its historical development. Furthermore, different typologies of stalking behavior, associated psychiatric diagnoses, frequency and demographic data, therapeutic approaches, and the psychomedical effect on victims are described and discussed. Stalking is not restricted to celebrities but can affect everybody. Members of the medical profession and other socially exposed people are especially potential victims of stalkers. Therefore, information on this topic is necessary in order to deal with it in a professional manner.

Building on two earlier experiments (Behav. Res. Ther. 34 (1996) 889; 39 (2001) 1439) the present study investigated the effects of neutralizing the consequences of an obsession-like thought in healthy participants. Just like in the earlier studies, writing out and thinking over such a thought generated anxiety. After this provocation, 40 of the 120 participants were instructed to neutralize the effects of the thought for 2 min, 40 participants did not receive a particular instruction, and the remaining 40 participants were instructed to do mental arithmetic aloud so as to prevent "spontaneous" attempts at neutralizing the thought. The no instruction group reported that they neutralized (spontaneously) to the same degree as the group that was instructed to neutralize. Within 2 min, anxiety decreased to near base line levels and there were no differences between the three conditions. When the groups were asked to bring the obsession-like thought back to consciousness again, anxiety increased slightly. Yet, contrary to expectation, this increase in anxiety did not discriminate the "neutralization prevention" group from the other two groups. Limitations of the paradigm as a model for clinical obsessions are discussed., (Copyright 2003 Elsevier Science Ltd.)

Over-valued ideas are truly a neglected area of psychopathology with few experimental studies published. There is a different emphasis in the USA and Europe regarding their definition. For authors in the USA an over-valued idea has become shorthand for 'poor insight' in the middle of a continuum of obsessional doubts to delusional certainty. Compared to negative thoughts, obsessions and delusions, they are often more resistant to any treatment. A better understanding of over-valued ideas is required if advances are to be made in therapy and for the development of appropriate measures to evaluate the efficacy of novel treatments. A cognitive behavioural model of over-valued ideas is presented which draws upon the philosophical distinction between beliefs and values. It is argued that over-valued ideas are associated with idealised values, which have developed into such an over-riding importance, that they totally define the 'self' or identity of the individual. Idealised values are also characterised by the rigidity with which they are held. Such patients are unable to adapt to different circumstances and ignore the consequences of acting on their value. This analysis leads to a discussion of predictions that can be tested and various strategies that can be used in cognitive behaviour therapy.

The present case study describes an adult male with a 28-year history of institutional care underpinned by a moderate intellectual disability (ID), and ritualistic behaviour congruent with features of autism or obsessive-compulsive disorder. The subject's ID was recognized early in life and he was provided with a special educational placement at 6 years of age, although his increasingly disturbed behaviour had resulted in several psychiatric admissions by early adolescence, and by the age of 20, his presentation necessitated long-term secure psychiatric care. The present report describes the application and ethical issues pertaining to a differential reinforcement of inappropriate behaviour (DRI) programme for the reduction of ritualistic behaviour and social isolation, the latter being a direct consequence of the former, one year after the subject was admitted to a medium-secure assessment and treatment residential facility. The results suggest that, although the treatment was successful in targeting ritualization and reducing social isolation, ethical concerns extended to care staff concerns about the reinforcer adopted for the programme and the lack of informed consent from the subject. The former resulted in inconsistent application of the programme and its eventual termination. A follow-up assessment of the subject's extent of social isolation and ritualistic behaviour suggested a return to a pre-DRI level of morbidity. Limitations and suggestions for the future treatment of such cases are outlined.

Wegner's (1994, Psychological Review, 101, 34-52) research on the paradoxical effect of thought suppression has been incorporated into contemporary cognitive-behavioural models of obsessive-compulsive disorder. However, findings on the effects of thought suppression on thought frequency have been inconsistent and few studies have actually examined the suppression of thoughts that are obsessional in nature. In the present study 219 nonclinical participants were randomly assigned to suppress or not suppress a neutral, obsessional or positive thought during an initial monitoring interval. In a second thought monitoring interval, all participants received instructions not to suppress their target thought. No paradoxical effect of suppression on frequency was observed for any type of thought, although suppression of obsessional thoughts was associated with greater subsequent discomfort and a more negative mood state than suppression of positive or neutral target thoughts.

This article considers the definition and impact of stalking behaviours, and describes recent examples, as well as the characteristics and behaviours of stalkers. Current legal frameworks and their application are reviewed, including recent changes in the law. Management and treatment issues as well as attention to minimising a violent outcome and general ethical matters are discussed.

Urinary and faecal incontinence present a considerable problem in people with learning disabilities, despite the general effectiveness of behavioural techniques in continence training. Children with learning disabilities and obsessional behaviour may be particularly resistant to toilet training, even where relatively cognitively able, and often despite a substantial degree of control over their eliminatory functions. Their resistance may be more appropriately regarded as a challenging behaviour and their incontinence better explained by factors other than a simple failure to learn. A 'stimulus-control' hypothesis proposes that the child's nappy (diaper)/potty/underwear has developed strong stimulus control over the elimination response. This report describes three case studies in which treatment-resistant children, aged between 8 and 12 years, with mild or moderate learning disabilities, were successfully treated for nappy-dependent nocturnal encopresis or diurnal urinary incontinence. The children were routine case referrals for whom previous attempts to train bowel or bladder control had failed. Behavioural techniques, such as 'shaping' (gradually increasing the proximity to the toilet), 'fading' (reducing the presence of the nappy), and rewards for eliminating, effected successful transfer of stimulus control over elimination from nappy to toilet. Treatment times varied, depending on the degree of the child's obsession and resistance to change.

We present two typical cases among five Japanese students who have complained of hearing music. They were found among 638 student case reports during 4 years at the mental health service center of a preparatory school. We diagnosed the complaint of hearing music as a symptom of obsession. Morita therapy was an effective treatment for this symptom. We discuss the characteristics of the symptom as an obsession and the therapy in the light of Morita theory.

It is proposed that obsessions are caused by catastrophic misinterpretations of the significance of one's thoughts (images, impulses). The obsessions persist as long as these misinterpretations continue and diminish when the misinterpretations are weakened. Evidence and arguments in support of the theory are presented, and the questions of vulnerability and the origins of the thoughts are addressed. A firmly focused treatment strategy is deduced from the theory.

The functional connection between unwanted intrusive hair growth and negative automatic cognitions is described and illustrated by case-material. Treatment by cognitive-behavioural therapy (CBT) is recommended as generally successful except when certain facts are denied.

This article examines the hypothesis that cognitive therapy (CT) is more effective than interpersonal therapy (IPT) for treatment of depressed patients with an elevated level of avoidant personality, whereas the reverse holds for depressed patients with elevated level of obsessive personality. This hypothesis was derived in part from the preliminary results of previous unpublished pilot work, which examined the course of dynamic and cognitive therapies for avoidant and obsessive-compulsive personality disorders. With the "completer" data set available from the Treatment for Depression Collaborative Research Program (I. Elkin et al., 1989), the expected significant interactions between treatment (CT vs. IPT) and avoidance and between treatment and obsessiveness were found. A significant interaction was also found between marital status and treatment, indicating that married patients did better after CT, whereas single and noncohabiting patients improved more after IPT. Similar patterns of results were found using the Hamilton Rating Scale for Depression and the Beck Depression Inventory. A matching factor formula of patients to CT vs. IPT is presented.

In young mothers an obsession of infanticide, that is, fear that they may murder their children, may be coupled with an obsession of imminent psychosis, that is, fear that the first obsession is a sign of approaching insanity. Sixteen mothers with this clinical picture were evaluated in interviews. Seven of them entered psychotherapy and improved. The causative factors in childhood and adolescence wich led to the later development of these obsessive difficulties are analyzed. Even when psychotherapy was not possible, as was the case in nine patients, they should be strongly reassured and explanations should be given about the nature of the problem, for such encouragement and clarification helps them to improve to a significant extent. The prognosis of patients who have systematic psychoterapy is good.

Progress in the cognitive-behavioral treatment of anxiety disorders is reviewed. Significant advances have been made in treating panic disorders and there are promising signs of an expansion of cognitive theory and therapy to other disorders, notably hypochondriasis, obsessional disorders and circumscribed phobias. Nevertheless, some difficult obstacles have emerged to present serious problems for the prevailing cognitive theory.

Despite impressive improvement in the behavioral treatment of obsessive-compulsive disorder over the last 15 years, progress has been slower for obsessional thoughts with few or no overt rituals. Encouraging case reports suggest that exposure to obsessional thoughts combined with covert response prevention is an effective treatment. Three cases are presented that required adaptation from the guidelines laid out by Salkovskis and Westbrook (1989). They provide clear evidence of the need to adopt a creative and flexible approach to exposure that enables access and activation of fear structures.

The aim of this study was to determine whether a group of 48 patients with obsessions and compulsions differed from a group of 26 patients with obsessions alone, on the basis of demographic variables, variables relating to obsessive-compulsive neurosis, psychological variables and treatment outcome. It was found that they differed significantly in the following areas: marital status, level of education, age at onset of complaints, psychoactive medication taken when admitted for treatment, severity of obsessive-compulsive complaints, depression and intelligence. No difference was found as far as treatment outcome was concerned. Patients suffering from obsessions alone, would appear to form a distinct sub-group within the group of obsessive-compulsive patients as a whole.

This paper presents clinical material from the psychoanalysis of a 12-year-old girl whose parents had divorced several years earlier. Material drawn from her analysis permits us to examine the question: given the intrapsychic demands of the prepubertal period, how was the experience of divorce registered, what aspects of intrapsychic functioning became distorted, and what, if any, remained uncontaminated? The impact of the parental divorce lay in an intensification and entrenchment of characteristic latency defenses which, as puberty approached, contributed to heightened internal conflict and an insistent turn to reality as both explanation for and solution of intrapsychic conflict.

The underlying psychodynamics are described on the basis of investigations undertaken with a total of 23 out-patients with self-inflicted lacerations of the skin. In many cases autoaggression was not the presenting symptom but was only mentioned by the patients in passing. The particular trigger factors and their effect is shown in two case descriptions. It appears that differences are possible between male and female patients. The character structure of the patients is usually narcissistic, the type of defence mechanisms being determined by the extent of borderline circumstances always present on first occurrence of autoaggression. Later, the original dynamics may become over-shadowed by obsessive behavior patterns. Self-inflicted wounds are seen to be part of a multiphase process which ultimately allows the patient to cope with narcissistic crises experienced as conflict situations. Withdrawal into a state of self-elected autarchy enables the patient to distance him/herself from the formerly idealized object now experienced as evil and disappointing. Pathological triangular relationships play a role here with the blood representing an important ersatz partner.

The author discusses the role of the father in early development through the concept of triangulation. Three male patients are presented who seemed to lack images and memories of their fathers and experienced them as absent, despite their physical presence during childhood. In these men, the oedipal phase appeared skewed and a dyadic relationship with the mother dominated the material. They reported a lack of a sense of masculinity and a phobic concern about the dangers of male violence, along with feelings of specialness and grandiosity. Analytic data suggested that the image of an absent father reflected a process akin to splitting of the ego, in which the significance of the father was disavowed and the patients fantasized a special role with their mothers; via projection, the fathers reappeared as dangerous intruders. It is proposed that this structure derives from a specific developmental situation in which a disturbed parental relationship has impaired the father's position as a "third" in the early triangle. The child's sexual and aggressive tensions cannot be contained in his fantasies of the couple and must be projected outside. The absent father returns in the transference, where the analyst is reexperienced as useless and absent and as a threat to the specialness of the dyad, thereby recapitulating the predicament of the child.

Time series analysis of more than a year of daily self-report of three subjects showed that self-imposed delay and response prevention was effective in decreasing obsessions and compulsions. The subject-controlled treatment had a varied effect on mood-anxiety decreased in two subjects, but depression increased in one. (A similar worsening of mood after elimination of obsessional behavior was found in a previous case study.) Apparently, successful treatment of obsessional behavior will not necessarily lead to an improvement in mood. Concurrent mood symptoms need to be targeted separately; and, plans should be made to deal with mood symptoms that may occur once obsessional behavior is removed.

Sleep deprivation therapy was used in 30 patients with protracted, resistant depressive phases within the framework of manic-depressive psychosis. All patients demonstrated some improvement, which lasted from several hours up to 3 days. Changes in the state were mainly expressed in mood swings and to a less extent to the sphere of thinking and motor acts. A course of sleep deprivation (6-8 nights without sleep with an interval of 2-7 days) was administered to 19 patients, of them 7 patients demonstrated a stable improvement. Recording depressive symptomatology by the scale of intensity showed significant positive changes according to the following parameters: mood, thinking, motor acts, interests, sociability. The highest effect was seen in patients with melancholic pictures and significantly worse in depressive-anxious and depressive-obsessional syndromes.

Peculiarities of the formation of the syndrome of obsessive fears originating in childhood and showing a favourable outcome are considered. Thirty-eight subjects (aged 17-24 years) taken off the psychiatric registry in connection with recovery were examined. A comparative analysis of 2 groups of patients with different clinical manifestations and age at the disease onset allowed the identification of conditions contributing to a favourable time course of obsessive fears. The author outlines the optimum therapeutic measures compensating neurotic disorders in children and adolescents with obsessive fears.

In this article, obsessions and phobic responses are examined in relation to the maintenance and development of a cross-generational coalition organized by a premise about exclusivity, as well as the specific, idiosyncratic "signature premises" characteristic to each case. It is suggested that the obsession develops when a developmental or situational crisis conflicts with the exclusive relationship definition (that is, coalition). Two forms of intervention for disrupting obsessions--the "conversation" and the "counter-obsession"--are discussed and illustrated. Both interventions conceptualize the obsession as an oscillation between remaining in the coalition and not remaining in the coalition, and both interventions challenge the signature premise that defines the coalition.

Obsessions are persistent, intrusive, unwanted ideas that are unproductive and anxiety-arousing. Although the magnitude of their importance in the workplace has not been established by acceptable scientific research criteria, they are in all probability a major source of inefficiency in jobs involving a high percentage of intellectual effort. The current body of knowledge of clinical psychiatry and behavioral psychology can provide rudimentary insights and hypotheses. The need is emphasized for further research to elucidate more precisely the extent of the problem.

Atropine-comatose therapy was performed in 18 patients with schizophrenia and disorders in the framework of an obsessive-syndrome. Improvement was seen in 11 of the 18 patients. A psychopathological analysis of obsessive disorders in this group of patients demonstrated that they were characterized by manifold traits, instability, abstract content of obsessions, a tendency towards their complication and expansion of obsessional disturbances. The absence of any effect was seen in 7 of the cases. They were characterized by montony, monomorphism, everday content and by their structure were near to constitutionally conditioned psychasthenic doubtfulness.

This paper is concerned with the strategic uses of paradoxical communication in therapy. Eight more or less distinct uses of paradoxical communication are described, and the proposition is put forward that the paradoxical interventions associated with the Milan group differ from those described by Haley and the Palo Alto group only in that they appear to be designed to influence simultaneously the behavior of several family members. The currently popular idea that such interventions should, or even can, be based on a systemic hypothesis, if "hypothesis" is understood in its usual sense as a statement amenable to empirical testing, is explicitly questioned.

A 49-year-old woman complained of pain and distortion of the facial skin of five years' duration. She had notable psychological depression, and the distortion she described was not apparent to others. She had sought relief for many years from many physicians and had tried numerous therapeutic regimens to no avail. After a diagnosis of "dysmorphic syndrome," haloperidol was prescribed at a dosage of 1 mg twice daily. With this regimen, the patient experienced a slow but steady improvement, although her compliance was erratic.