RxPG - Features of Obsessive Compulsive Neurosis

All are features of obsessive compulsive neurosis except:

1. Anxiety
2. Obsession
3. Normal thought
4. Suicidal tendency

This question was posted by tulip (RxPG Nick) in nagging questions forum. Since it has generated some confusion over the correct answer, especially regarding the last two options, I decided to have a look at it.

ICD classifies Obsessive Compulsive Disorder as an anxiety disorder and this classification (F40.2) includes Anankastic Neurosis and Obsessive Compulsive Neurosis. It is termed as "disorder" as ICD 10 avoids the term "neurosis". Since it is an anxiety disorder, the first option in the MCQ is obviously correct. Obsession is a feature of all obsessive compulsive disorders and the degree of obsession may vary depending on the subtype of Obsessive Compulsive Disorder i.e. predominantly obsessive Obsessive Compulsive Disorder or predominantly compulsive Obsessive Compulsive Disorder. According to ICD 10, there is no entity like purely compulsive Obsessive Compulsive Disorder, so the second option is also correct.

It was easy to rule out the above two options. The real confusion arises between option no. 3 and option no. 4. RxPG members gandalf and tulip were more inclined towards option 4 (suicidal tendency) being the odd one while shraddha argued about the possibility of low potential for suicide in Obsessive Compulsive Disorder. Tulip was of the opinion that since Obsessive Compulsive Disorder leads to secondary depression, there should be a risk of suicide. Gandalf referred to the fact that no psychiatric textbooks mention anything about suicidal tendency in Obsessive Compulsive Disorder. Shraddha's argument was that a person with Obsessive Compulsive Disorder never loses touch with reality and considers these thoughts as irrational, so the suicidal tendencies should be low. Draditithegreat and drsmita_s were sceptical about accepting normal thought as a feature of Obsessive Compulsive Disorder. According to drsmita_s, Obsessive Compulsive Disorder is a disorder of thought and hence they certainly do not have normal thought.

Well, to correctly answer this question, we will have to first think what examiner must have been thinking while setting it. Obsessive Compulsive Disorder is an anxiety disorder, but what is the striking difference between Obsessive Compulsive Disorder and other anxiety disorders. Obsessive Compulsive Disorder is a thought disorder whereas other anxiety disorders are not. Obsessional thoughts are never normal although they are self-identified as patient's own thoughts. ICD 10 defines it as "The essential feature is recurrent obsessional thoughts or compulsive acts. Obsessional thoughts are ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form. They are almost invariably distressing and the patient often tries, unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur. Usually, this behaviour is recognized by the patient as pointless or ineffectual and repeated attempts are made to resist. Anxiety is almost invariably present. If compulsive acts are resisted the anxiety gets worse."

This difference is quite important and the examiner is obviously testing your knowledge about this important fact. So option 3 is the correct answer.

But any explanation can not be satisfactory if we do not look at the other side of the coin. Some of you must be wondering now - what about suicidal tendencies? Well, firstly I should attract your attention to the fact that this option is about "suicidal tendency" and not "suicide" as such. Traditionally, the opinion is that people with Obsessive Compulsive Disorder have a lower rate of suicide than general population because of their inability to make decisions. Doubt is an important symptom of Obsessive Compulsive Disorder and that is true even in thoughts of suicide. This opinion is supported by statistical evidence (except in adolescent population). People with Obsessive Compulsive Disorder can have suicidal thoughts or tendencies, but as drsmita_s correctly identified (in the discussion thread), such suicidal thoughts would not be considered as patient's own (i.e. they are ego-dystonic) and the patient would try to resist them. This resistance will give rise to distress and anxiety and thence to the symptoms of Obsessive Compulsive Disorder. If the patient identifies that these suicidal thoughts are his or her own, then they are ego-syntonic thoughts (i.e. patient's own) and as a rule ego-syntonic thoughts do not exist in relation to Obsessive Compulsive Disorder. A patient with ego-syntonic suicidal thoughts should qualify for a diagnosis of depression and not Obsessive Compulsive Disorder. If the patient commits suicide due to a major depression secondary to Obsessive Compulsive Disorder (depression is co-morbid in one-third of Obsessive Compulsive Disorder cases and major depression constitutes two-third of such cases), then hierarchy of diagnosis will attribute that death to depression and not to Obsessive Compulsive Disorder. In light of all these facts we can safely conclude that although suicidal tendency can be a feature of Obsessive Compulsive Disorder, suicide itself is not. The option to be excluded from the above question is option no. 3 (normal thought) as it is clearly not a part of the Obsessive Compulsive Disorder spectrum.

The discussion thread for this question is located at http://www.rxpgonline.com/postt36703.html. Your feedback and any difference of opinion can be posted in this thread.