Obsessive compulsive disorder with associated hypochondriasisBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39555.608252.AD (Published 08 May 2008) Cite this as: BMJ 2008;336:1070
- Pamela Harrington, patient1
- Accepted 1 March 2008
I’ve seen it in their eyes. “Oh, God, not her again. I’ve got a waiting room full of patients and she’s back. I wonder what it is this time. I’ve told her a thousand times there’s nothing wrong with her. Why doesn’t she trust me? I’m the doctor. What does she know? Been looking stuff up on the internet again, I suppose.”
If only he would look into my eyes. Why can’t he see that this fear is destroying me? Why does he make me feel like a naughty child in the headmaster’s study? Why can’t he see that I am an intelligent woman? Why doesn’t he want to help me? Why can’t he see that the real illness is in my mind?
I am a hypochondriac. I know I am a hypochondriac. Actually, no. I suffer from hypochondriasis. It sounds better. I also suffer from obsessive compulsive disorder. It helps to have a name for it. I used to think I was just mad.
The fear of fear
I have noticed a definite pattern. First comes a period of prolonged stress. It could be anything—family relationships, stress at work, home life. It is always something where I feel I am not in control. Then comes the anxiety. At first it is generalised anxiety and then I’ll notice a symptom. I am always afraid that the symptom is the first sign of something really serious or very nasty. It is not so much the suffering, or even death, that I am afraid of, but the fear itself. I am afraid of the numbing, isolating, depersonalising fear.
Then I am afraid to go to the doctor. Afraid that he will be angry. Afraid that I’ve “cried wolf” so many times that this time he’ll miss something serious. I ruminate about it for days. I keep checking. I may even consult the internet. And then the intrusive thoughts start. This is the worst part. At this point I literally become afraid of myself. And then I don’t care if I die. When the intrusive thoughts first started I even planned to kill myself. I was so terrified of what was happening to me. And when I don’t care if I die, when I’ve reached the blackest pits of despair, the only way is up—and the cycle is broken.
So how did it all start?
I’ll begin by describing the “critical incident” that I believe triggered the clinical phase of my obsessive compulsive disorder.
I was 24 years old (I am 48 now) and my mum needed open heart surgery. We were all afraid she would die, but nobody said so. Instead of supporting each other, we fought each other. I was trying to cope and to stop the fighting, especially between my sister and my father and brother. The day of Mum’s operation, the tension exploded and I had a massive row with my sister. I completely “lost it” and was left sobbing uncontrollably. The next morning I was getting ready to go to the hospital when this thought flew through my head, “Maybe it would be easier if she died.”
I felt sick to my stomach. Where did that thought come from? I had grown up with a father who had a keen interest in the occult and I knew that some people believed in evil spirits. I did not know what I believed, but I was definitely afraid of the supernatural. So where did I think the thought about my mum came from? An evil spirit, of course. And if an evil spirit could make me think something I did not want to think, maybe it could make me do something I did not want to do. I was also afraid that if Mum died, I would have caused it by thinking about it.
What was happening to me?
Why do people do terrible things? Was I going to become an evil person? I thought of all the terrible things that people do and I asked myself if I could do them. I had never even considered such things before. Most people never think, “There, but for the grace of God, go I” when they watch the news or read the papers. I decided that if I was going to become evil, I’d rather be dead, so I planned to kill myself. At the very last minute, something happened that made me decide not to go through with it, but that is another story.
Since then, my journey has been a long and painful one. The more I tried not to think horrible thoughts, the worse they became. As anyone who knows about obsessive compulsive disorder will tell you, the thoughts can be violent, sexual, or blasphemous. For many years I thought the source of my problems was spiritual.
A long wait
It took 22 years to find out that I was suffering from obsessive compulsive disorder. It was spotted by a volunteer Christian counsellor. She referred me to some websites, so I looked at them with my husband. I sat there and sobbed tears of relief as I read about myself. I was not evil. I was not alone. I read that people with obsessive compulsive disorder are usually very caring and they never act on their thoughts. Even Florence Nightingale is supposed to have had the disorder.
So where am I now? My counsellor recommended that I seek specialist help from a cognitive behaviour therapist. I have also read several books and done research on the internet. It helps enormously to understand the problem that I have, and also to understand the underlying issues such as low self esteem. I firmly believe that low self esteem is a predictor for anxiety disorders, and this is not helped by general practitioners who make their patients feel like naughty children.
When I began having dizzy spells, I was afraid I might kill someone if I became dizzy while driving (my main fear is of harming people) and at this point I became so distressed at the dismissive attitude of my doctor that I reluctantly sought a second opinion. I was both surprised and delighted when it was suggested that I change my general practitioner if I was unhappy. I thought I’d just be labelled “trouble.”
Kindness and patience
The first time I saw my new doctor, I tried to explain what had been going on but I’m afraid I just sat and sobbed. Despite the patients piling up in the waiting room outside, at no time did he make me feel rushed or stupid or bad about myself in any way. He just looked at me kindly. And asked me to come back the next week. And the next week. He saw me for a double appointment every week for three months so that, he said, “I can get to know you in order to know what to do to help you.” And then he told me quite firmly that I was going to try a low dose of antidepressant. I didn’t want to do it. I was afraid of the side effects. And it felt like admitting defeat. I had tried so hard to help myself. But he was right. After two weeks on a daily dose of 10 mg of citalopram I was beginning to feel like a different person. I even began to have a new feeling. Happiness.
Now, over a year later, I am almost symptom free, both physically and mentally. It seems simple really. Long term unresolved stress (especially if combined with premenstrual symptoms), long dark days of winter, lack of exercise, or poor eating habits all conspire to reduce my serotonin levels. If they go too low, the hypochondria kicks in. The added stress of obsessing about my health then sends my serotonin levels even lower and the obsessive compulsive disorder kicks in. It still occasionally happens even when I take citalopram, but at least I recognise what is happening and can ask for help.
I don’t suppose I’ll ever know why I am like this. I can trace the roots back to incidents in my childhood, but all I can do now is continue to wrestle with and try to understand this condition and, in doing so, hopefully help others to understand it too.
What has helped and what has not helped?
Having a kind, sympathetic, and helpful general practitioner
Gaining a sense of ownership of my life, my body, and my thoughts
Dealing with stress, especially in close relationships such as family
Tackling low self esteem and setting “boundaries”
Being brave enough to tell others what is wrong so they can give their support
Learning about the condition
Ignoring intrusive thoughts and using diversion (such as by being engaged in an absorbing hobby or book)
Cognitive behaviour therapy with a therapist who specialises in obsessive compulsive disorder
Understanding myself through use of the Myers-Briggs personality type indicator with a trained professional
Has not helped
Having an unhelpful general practitioner
Being afraid to tell anyone about my struggles
Receiving well meant advice from people who do not understand the problem (especially those in the church who think the problem is purely spiritual)
“Friends” who tell you to “snap out of it”
Isolating myself and ruminating on my thoughts
A doctor’s perspective
I am an ordinary general practitioner. I have never done a six month psychiatric training post.
As with everything I meet in my work, when patients present with a disease pattern with which I am unfamiliar, I consider psychological or psychiatric conditions. I also see people more frequently rather than less in an attempt to get to the root of the problem, which can be difficult to ascertain, particularly if the presentation is chaotic.
Often, too, it is not possible to discern whether depressive symptoms are a cause or effect. Being an older general practitioner, I still occasionally prescribe tricyclic antidepressants. In the light of recent revelations about newer antidepressants, tricyclic antidepressants may be something we should reconsider. When I prescribe selective serotonin reuptake inhibitors, I warn the patient that they may at first feel worse rather than better and to expect good days and bad as the tablets begin to work.
My consulting style is often to let patients “talk themselves out” without interruption, reassuring them that I am listening carefully, trying to get to know a little bit more about them and to obtain a picture of their lives. If I am making no progress, I arrange to talk on a neutral subject. I also draw a family tree and ask about family history of related diseases. Probing about taboo subjects such as family, money, alcohol work, and sex may provide food for thought and an understanding of ideas, concerns, and expectations.
With this patient, I hope I admitted uncertainty at an early stage, and I encouraged a therapeutic trial of medication. Neither of us had anything to lose. Fortunately I had seen a similar pattern of illness before.
It is quite difficult to imagine being “inside” this particular disease with its physical manifestation of itches, twinges, and multiple symptoms of all types. Obsessive compulsive disorder, like depression, can give a feeling of being overwhelmed, absorbed, and trapped.
Selective serotonin reuptake inhibitors do seem to work well with obsessive compulsive disorder, but I don’t really know why. By being patient, we seemed to manage on low doses and to get some improvement in mood. This then allowed us to “see the wood for the trees” and a more normal life to return. The patient is aware that clinical symptoms may recur in the future, and long term and very long term medication may be what we will opt for.
Patrick Gray, general practitioner, Brampton Medical Practice, Brampton CA8 1NL
This is one of a series of occasional articles by patients about their experience of traumatic medical events that offer lessons to doctors. The BMJ welcomes contributions to the series. Please contact Peter Lapsley (email@example.com) for guidance.
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.