View Full Version : I think I have OCD IMHO.
I kind of figured that the retching I have been experiencing since 2011 could be a learned behaviour/ritual that I have taught my body to have to carry out as a way of releasing my anxiety and depressive feelings.
Any ideas?
It cannot be Gastrointestinal otherwise I would have deteriorated by now. Also alcohol helps ease my symptoms, that again doesn't suggest Gastrointestinal problems as alcohol would cause worsening of my symptom if it was down there.
:shrug:
Most of us on here think that too
Most of us on here think that too
:)
I need an anti-anxiety medicine which works in the same way that alcohol does so that I can feel calm and wean myself off of alcohol and also start feeling calm during the day the same way I do as when I have drank in the evening except without alcohol.
MyNameIsTerry
26-09-15, 04:53
Hi Calum,
You know that you use alcohol to reduce your symptoms and you know this is wrong, a problem. You posted a while back just like this where you believed it was anxiety and that you wanted to convince your doctors of it but then you went back into obsession over physical illness instead. It's really good to see you back at this stage where you are starting to believe it can be anxiety again. So, when those doubts creep in that make you want to seek out a physical explanation, try to challenge them with how you are feeling about it now. I think you would benefit from writing down how you feel in these more neutral times so that you can refer back to them when/if that obsessive cycle starts up again.
In terms of meds, it's one for a doctor here because you have a complex case of needing to remove the alcohol, which you may have not only a physical dependence but a mental one too, so without tackling the anxiety it will be hard not to revert to it. They can certainly prescribe several Benzo's to manage alcohol withdrawal symptoms as it's a documented strategy. Those could have an impact whereby they reduce your anxiety a bit too but it's a short term thing to get through the withdrawal, not a strategy to tackle your underlying anxieyt issues. Another option can be ones like Pregabalin for the anxiety side but they don't tend to prescribe it to people with substance misuse histories as there is a high abuse potential (like with Benzo's) so long term use of that could be an issue, another crutch or it could escalate. (again, thats one for a suitably qualified medical professional, unlikely a GP given the advice not to prescribe with substance misuse history) .
Beyond this you are talking about the usual pathway of SSRI's, SNRI's, etc. These can help you with your anxiety but they won't be giving you the alcohol effect. The trouble is though - you don't want that effect. It's a crutch, a safety behaviour and it will keep you in the cycle of feeling you need something to control your anxiety but thats not a long term strategy as SB's are unhealthy, it's Adaptive Behaviours that are needed, which are healthy. So, I suggest you re-evaluate how you feel about this because chasing an effect like alcohol is more the Benzo way and thats just another problem. Think how good it would be if you would handle this without? If you stopped the need to wretch? Thats the target, along with removal of the alcohol dependence. Removing the alcohol should be because you know it will only harm you, not to replace it with an equivalent. which I think is going to be difficult to find. I think we all have thoughts like this though until we come to terms with the fact we need to do the hard work to recover as opposed to being medicated to prevent anxiety.
However they decide to tackle the alcohol, please go with the professionals on this as they are objective and will use medically agreed methods. If they decide you need to be treated for anxiety before or along side, go with it, and if they decide to withdraw the alcohol first, go with it. Only their opinions matter here.
Your GP prescribed you a SSRI in the past but you wouldn't take it due to the risk of side effects. I think it was Paroxetine. I remember asking if your GP had told you that it's considered one of the two hardest to withdraw from and why he had chosen this one first? Was it because of the alcohol? Does he know about how you use the alcohol? Believe me, none of us want to go through the side effects but it's a cross we have to bare with these meds and doctors don't like giving out ones like Pregabalin early on as they are very costly and not even considered 1st or 2nd line meds for anxiety disorders. I think you need to be realistic here, it's likely to be a SSRI that is recommended to you and you will need to try them to see how they affect you.
In terms of what your actual anxiety disorder(s) is, it's unclear for me. You've never answered the question about who diagnosed your OCD and since you've not indicated a mental health professional, I felt it could be your GP. Whilst there are obviously disorders in play here, whether it's OCD is debateable for me and I think a diagnosis from a mental health professional would be a good idea.
I say that because your pattern of behaviour in chasing for all these tests fits very neatly into a Somatoform Disorder. One of them even mentions GI issues. Somatoform is the real HA as the medical people know it overhere. (it's different for countries that use the US derived diagnostic manual as they have Illness Anxiety Disorder within the OCD Spectrum Disorders, yet we use the WHO version in the UK which has a set under Somatoform Disorders and they are not connected to OCD)
But what actually drives the need to wretch in the first place? The use of alcohol, for me, is a safety behaviour as it lessens your overall anxiety levels and calms you down to not need to do it and people without OCD do that too. I don't think we have ever got to the root cause he to determine if the wretching is an anxiety physical symptom or whether you choose to do it because of obsession. Do you feel you need to do it to stop your anxiety or prevent something? Or does it just happen? I wonder what your doctor has seen to make the diagnosis because your threads don't confirm anything in my opinion so it's hard to know. Plus with the discussions not on the correct board, you are missing out on talking to others about it who may be able to help you work things out.
People with obsessive cycle style disorders like Somatoform also have ritualistic behaviours such as chasing for diagnosis to then find reassurance is short lived and they re-enter the obsession cycle again. It's very commonly seen on the HA board. People with certain forms of OCD also reassurance seek but it seems more limited to Pure O forms like ROCD, HIV/AIDS fears, fear of serious mental illness, contamination, etc and doesn't become a feature of the more physical forms like the checking. The diagnosis chasing fits very well to one Somatoform Disorder, the wretching could fit to OCD, etc. It's hard to know without real detail. Then you have also mentioned about anxiety over social issues so there is more in here to understand. Maybe there are comorbid conditions that are intertwined thus confusing things?
I need an anti-anxiety medicine which works in the same way that alcohol does so that I can feel calm and wean myself off of alcohol and also start feeling calm during the day the same way I do as when I have drank in the evening except without alcohol.
This is somewhat tricky case due to your alcohol dependence. Many anxiety meds don't mix with alcohol and can actually be detrimental to you if mixed. IMO, you need a strategy that allows you to wean off the alcohol and get on a med along with some therapy.
You make an interesting point in that what's happening is a learned behavior or habit that developed as a coping mechanism. A trained mental health professional would offer you the best avenue toward healing. I hope to see future posts indicating that you've taken those steps.
Positive thoughts
Hi Calum,
You know that you use alcohol to reduce your symptoms and you know this is wrong, a problem. You posted a while back just like this where you believed it was anxiety and that you wanted to convince your doctors of it but then you went back into obsession over physical illness instead. It's really good to see you back at this stage where you are starting to believe it can be anxiety again. So, when those doubts creep in that make you want to seek out a physical explanation, try to challenge them with how you are feeling about it now. I think you would benefit from writing down how you feel in these more neutral times so that you can refer back to them when/if that obsessive cycle starts up again.
In terms of meds, it's one for a doctor here because you have a complex case of needing to remove the alcohol, which you may have not only a physical dependence but a mental one too, so without tackling the anxiety it will be hard not to revert to it. They can certainly prescribe several Benzo's to manage alcohol withdrawal symptoms as it's a documented strategy. Those could have an impact whereby they reduce your anxiety a bit too but it's a short term thing to get through the withdrawal, not a strategy to tackle your underlying anxieyt issues. Another option can be ones like Pregabalin for the anxiety side but they don't tend to prescribe it to people with substance misuse histories as there is a high abuse potential (like with Benzo's) so long term use of that could be an issue, another crutch or it could escalate. (again, thats one for a suitably qualified medical professional, unlikely a GP given the advice not to prescribe with substance misuse history) .
Beyond this you are talking about the usual pathway of SSRI's, SNRI's, etc. These can help you with your anxiety but they won't be giving you the alcohol effect. The trouble is though - you don't want that effect. It's a crutch, a safety behaviour and it will keep you in the cycle of feeling you need something to control your anxiety but thats not a long term strategy as SB's are unhealthy, it's Adaptive Behaviours that are needed, which are healthy. So, I suggest you re-evaluate how you feel about this because chasing an effect like alcohol is more the Benzo way and thats just another problem. Think how good it would be if you would handle this without? If you stopped the need to wretch? Thats the target, along with removal of the alcohol dependence. Removing the alcohol should be because you know it will only harm you, not to replace it with an equivalent. which I think is going to be difficult to find. I think we all have thoughts like this though until we come to terms with the fact we need to do the hard work to recover as opposed to being medicated to prevent anxiety.
However they decide to tackle the alcohol, please go with the professionals on this as they are objective and will use medically agreed methods. If they decide you need to be treated for anxiety before or along side, go with it, and if they decide to withdraw the alcohol first, go with it. Only their opinions matter here.
Your GP prescribed you a SSRI in the past but you wouldn't take it due to the risk of side effects. I think it was Paroxetine. I remember asking if your GP had told you that it's considered one of the two hardest to withdraw from and why he had chosen this one first? Was it because of the alcohol? Does he know about how you use the alcohol? Believe me, none of us want to go through the side effects but it's a cross we have to bare with these meds and doctors don't like giving out ones like Pregabalin early on as they are very costly and not even considered 1st or 2nd line meds for anxiety disorders. I think you need to be realistic here, it's likely to be a SSRI that is recommended to you and you will need to try them to see how they affect you.
In terms of what your actual anxiety disorder(s) is, it's unclear for me. You've never answered the question about who diagnosed your OCD and since you've not indicated a mental health professional, I felt it could be your GP. Whilst there are obviously disorders in play here, whether it's OCD is debateable for me and I think a diagnosis from a mental health professional would be a good idea.
I say that because your pattern of behaviour in chasing for all these tests fits very neatly into a Somatoform Disorder. One of them even mentions GI issues. Somatoform is the real HA as the medical people know it overhere. (it's different for countries that use the US derived diagnostic manual as they have Illness Anxiety Disorder within the OCD Spectrum Disorders, yet we use the WHO version in the UK which has a set under Somatoform Disorders and they are not connected to OCD)
But what actually drives the need to wretch in the first place? The use of alcohol, for me, is a safety behaviour as it lessens your overall anxiety levels and calms you down to not need to do it and people without OCD do that too. I don't think we have ever got to the root cause he to determine if the wretching is an anxiety physical symptom or whether you choose to do it because of obsession. Do you feel you need to do it to stop your anxiety or prevent something? Or does it just happen? I wonder what your doctor has seen to make the diagnosis because your threads don't confirm anything in my opinion so it's hard to know. Plus with the discussions not on the correct board, you are missing out on talking to others about it who may be able to help you work things out.
People with obsessive cycle style disorders like Somatoform also have ritualistic behaviours such as chasing for diagnosis to then find reassurance is short lived and they re-enter the obsession cycle again. It's very commonly seen on the HA board. People with certain forms of OCD also reassurance seek but it seems more limited to Pure O forms like ROCD, HIV/AIDS fears, fear of serious mental illness, contamination, etc and doesn't become a feature of the more physical forms like the checking. The diagnosis chasing fits very well to one Somatoform Disorder, the wretching could fit to OCD, etc. It's hard to know without real detail. Then you have also mentioned about anxiety over social issues so there is more in here to understand. Maybe there are comorbid conditions that are intertwined thus confusing things?
Hi Terry,
My Gastroenterologist diagnosed me as anxiety and depression sufferer. He gave me Paxil but I wasn't told anything about side effects. He just told me it would take the edge off of things.
I have never seen a mental health expert and I have not been diagnosed with OCD. Is it right that a Gastroenterologist can diagnose anxiety and depression?
Also I don't really know what drives me to retch. I can only describe it as a sudden overwhelming urge to be sick but I don't actually feel sick and nothing ever materialises. The retching is horrific though and everything feels horrific and evil. I feel like my mind has split. I keep suffering from nightmares about walking on dirty pavements and I keep waking up with vertigo from time to time having been spinning around in my dream prior to waking up with vertigo.
Also I don't know if I am retching because I am anxious and depressive in nature or if I am retching due to a physical illness which in turn is causing me to feel anxious and depressed?
What on earth do you lot reckon???
---------- Post added at 08:54 ---------- Previous post was at 08:47 ----------
Hi Calum,
You know that you use alcohol to reduce your symptoms and you know this is wrong, a problem. You posted a while back just like this where you believed it was anxiety and that you wanted to convince your doctors of it but then you went back into obsession over physical illness instead. It's really good to see you back at this stage where you are starting to believe it can be anxiety again. So, when those doubts creep in that make you want to seek out a physical explanation, try to challenge them with how you are feeling about it now. I think you would benefit from writing down how you feel in these more neutral times so that you can refer back to them when/if that obsessive cycle starts up again.
In terms of meds, it's one for a doctor here because you have a complex case of needing to remove the alcohol, which you may have not only a physical dependence but a mental one too, so without tackling the anxiety it will be hard not to revert to it. They can certainly prescribe several Benzo's to manage alcohol withdrawal symptoms as it's a documented strategy. Those could have an impact whereby they reduce your anxiety a bit too but it's a short term thing to get through the withdrawal, not a strategy to tackle your underlying anxieyt issues. Another option can be ones like Pregabalin for the anxiety side but they don't tend to prescribe it to people with substance misuse histories as there is a high abuse potential (like with Benzo's) so long term use of that could be an issue, another crutch or it could escalate. (again, thats one for a suitably qualified medical professional, unlikely a GP given the advice not to prescribe with substance misuse history) .
Beyond this you are talking about the usual pathway of SSRI's, SNRI's, etc. These can help you with your anxiety but they won't be giving you the alcohol effect. The trouble is though - you don't want that effect. It's a crutch, a safety behaviour and it will keep you in the cycle of feeling you need something to control your anxiety but thats not a long term strategy as SB's are unhealthy, it's Adaptive Behaviours that are needed, which are healthy. So, I suggest you re-evaluate how you feel about this because chasing an effect like alcohol is more the Benzo way and thats just another problem. Think how good it would be if you would handle this without? If you stopped the need to wretch? Thats the target, along with removal of the alcohol dependence. Removing the alcohol should be because you know it will only harm you, not to replace it with an equivalent. which I think is going to be difficult to find. I think we all have thoughts like this though until we come to terms with the fact we need to do the hard work to recover as opposed to being medicated to prevent anxiety.
However they decide to tackle the alcohol, please go with the professionals on this as they are objective and will use medically agreed methods. If they decide you need to be treated for anxiety before or along side, go with it, and if they decide to withdraw the alcohol first, go with it. Only their opinions matter here.
Your GP prescribed you a SSRI in the past but you wouldn't take it due to the risk of side effects. I think it was Paroxetine. I remember asking if your GP had told you that it's considered one of the two hardest to withdraw from and why he had chosen this one first? Was it because of the alcohol? Does he know about how you use the alcohol? Believe me, none of us want to go through the side effects but it's a cross we have to bare with these meds and doctors don't like giving out ones like Pregabalin early on as they are very costly and not even considered 1st or 2nd line meds for anxiety disorders. I think you need to be realistic here, it's likely to be a SSRI that is recommended to you and you will need to try them to see how they affect you.
In terms of what your actual anxiety disorder(s) is, it's unclear for me. You've never answered the question about who diagnosed your OCD and since you've not indicated a mental health professional, I felt it could be your GP. Whilst there are obviously disorders in play here, whether it's OCD is debateable for me and I think a diagnosis from a mental health professional would be a good idea.
I say that because your pattern of behaviour in chasing for all these tests fits very neatly into a Somatoform Disorder. One of them even mentions GI issues. Somatoform is the real HA as the medical people know it overhere. (it's different for countries that use the US derived diagnostic manual as they have Illness Anxiety Disorder within the OCD Spectrum Disorders, yet we use the WHO version in the UK which has a set under Somatoform Disorders and they are not connected to OCD)
But what actually drives the need to wretch in the first place? The use of alcohol, for me, is a safety behaviour as it lessens your overall anxiety levels and calms you down to not need to do it and people without OCD do that too. I don't think we have ever got to the root cause he to determine if the wretching is an anxiety physical symptom or whether you choose to do it because of obsession. Do you feel you need to do it to stop your anxiety or prevent something? Or does it just happen? I wonder what your doctor has seen to make the diagnosis because your threads don't confirm anything in my opinion so it's hard to know. Plus with the discussions not on the correct board, you are missing out on talking to others about it who may be able to help you work things out.
People with obsessive cycle style disorders like Somatoform also have ritualistic behaviours such as chasing for diagnosis to then find reassurance is short lived and they re-enter the obsession cycle again. It's very commonly seen on the HA board. People with certain forms of OCD also reassurance seek but it seems more limited to Pure O forms like ROCD, HIV/AIDS fears, fear of serious mental illness, contamination, etc and doesn't become a feature of the more physical forms like the checking. The diagnosis chasing fits very well to one Somatoform Disorder, the wretching could fit to OCD, etc. It's hard to know without real detail. Then you have also mentioned about anxiety over social issues so there is more in here to understand. Maybe there are comorbid conditions that are intertwined thus confusing things?
Oh my GOD! Terry I have just googled Pure O and it is the exact same symptoms I had as a teenager in 2002 when I had some of those exact symptoms!!!!!!!
Do you think that in 2011 my Pure O returned this time in a physical form hence the retching and dry heaving???
MyNameIsTerry
26-09-15, 09:27
Hi Calum,
Well a GP could so theoretically they could too but neither is trained to make a mental health diagnosis. They certainly don't have the specialist knowledge of a psychologist/psychiatrist. They can however rule out the physical GI side for you which they must have done to get to this. It seems a bit concering that a gastro dishes out antidepressants when there are very clear guidelines that doctors should be monitoring people taking them and you are not going to be seeing that guy again and will be handed back to your GP. I would have thought he would have written to your GP to then move forward with medication for anxiety/depression.
So, there is no mention of OCD by doctors. OK, that removes any "trust the doctor" stuff and trying to understand their diagnosis. The gastro has made a very weak diagnosis anyway since anxiety means having a disorder type. GP's often say things like "general" or "chronic" neither of which are a real diagnosis and depression has many forms too as well as the fact they are not always comorbid in that anxiety may take preference for diagnosis and vice versa. This is why a proper diagnosis is useful.
If this were OCD, there would be something triggering it. Something this compulsion becomes an attempt at reducing the anxiety for. Can you say you do it for that reason? If not, it sounds less OCD to me. This urge to wretch as a compulsion would be for some level of relief or closure from an OCD point of view but it seems unclear to me from what you are saying. Your focus on it is to get it diagnosed as a physical issue and this is why I thought it may be more a Somatoform Disorder which is also an obsessive disorder, and in chasing for all these tests it's more like something seen on the HA board.
You can suffer from one form of anxiety for it to go and return as something else later due to new stresses in your life. It's also very common for OCD to be present in various forms or to "jump" to another form. So, it is possible you had an anxiety disorder that you managed to recover from and new stress has led you to what you have now but obviously we would need more information about what you went through to understand that.
After reading about Pure O, can you see anything in your behaviour which suggests you are performing compulsions? Are you checking things, touching, have tics, re-reading, repeating, anything like that? Reassurance seeking is also one of them but thats a major one for the Somatoforms too so it would be interesting to understand if there is anything to suggest a differential.
I think a lot of people have had the waking with vertigo. Sensations of falling and similiar are quite common. So, that may not be linked or could just be because of being more anxious?
Because of your alcohol involvement, this is complex and needs a multiskilled approach whether that means a multiskilled team (e.g. community mental health team), GP and alcohol withdrawal service or a combination. Thats for them to decide for you. Getting a proper diagnosis and plan of action to tackle these problems seems key to moving forward to me.
Hi Calum,
Well a GP could so theoretically they could too but neither is trained to make a mental health diagnosis. They certainly don't have the specialist knowledge of a psychologist/psychiatrist. They can however rule out the physical GI side for you which they must have done to get to this. It seems a bit concering that a gastro dishes out antidepressants when there are very clear guidelines that doctors should be monitoring people taking them and you are not going to be seeing that guy again and will be handed back to your GP. I would have thought he would have written to your GP to then move forward with medication for anxiety/depression.
So, there is no mention of OCD by doctors. OK, that removes any "trust the doctor" stuff and trying to understand their diagnosis. The gastro has made a very weak diagnosis anyway since anxiety means having a disorder type. GP's often say things like "general" or "chronic" neither of which are a real diagnosis and depression has many forms too as well as the fact they are not always comorbid in that anxiety may take preference for diagnosis and vice versa. This is why a proper diagnosis is useful.
If this were OCD, there would be something triggering it. Something this compulsion becomes an attempt at reducing the anxiety for. Can you say you do it for that reason? If not, it sounds less OCD to me. This urge to wretch as a compulsion would be for some level of relief or closure from an OCD point of view but it seems unclear to me from what you are saying. Your focus on it is to get it diagnosed as a physical issue and this is why I thought it may be more a Somatoform Disorder which is also an obsessive disorder, and in chasing for all these tests it's more like something seen on the HA board.
You can suffer from one form of anxiety for it to go and return as something else later due to new stresses in your life. It's also very common for OCD to be present in various forms or to "jump" to another form. So, it is possible you had an anxiety disorder that you managed to recover from and new stress has led you to what you have now but obviously we would need more information about what you went through to understand that.
After reading about Pure O, can you see anything in your behaviour which suggests you are performing compulsions? Are you checking things, touching, have tics, re-reading, repeating, anything like that? Reassurance seeking is also one of them but thats a major one for the Somatoforms too so it would be interesting to understand if there is anything to suggest a differential.
I think a lot of people have had the waking with vertigo. Sensations of falling and similiar are quite common. So, that may not be linked or could just be because of being more anxious?
Because of your alcohol involvement, this is complex and needs a multiskilled approach whether that means a multiskilled team (e.g. community mental health team), GP and alcohol withdrawal service or a combination. Thats for them to decide for you. Getting a proper diagnosis and plan of action to tackle these problems seems key to moving forward to me.
Hi Terry,
I have no compulsions accompanying the retching. I.E. I don't think that I have to count to 10 to make it stop or anything like that. That is a definite NO.
I do repeat words quite a lot around my family. I shout and copy phrases that have been said on films, etc. I don't really know why I do this but it makes me feel better by shouting and repeating the phrases. Whether or not this is just a silly habit I am not sure? Or maybe its a form of compulsion linked to having to retch uncontrollably? Who knows?
Thoughts can cause my retching. If I have to get in a car or in a lift or in a multi storey car park this WILL DEFINATELY set off a wave of unproductive retching which is horrific. I am limited these days to my home and work. Anything else is a complete no-no. However once again this was the case before the retching started.
I am also agoraphobic now due to the retching.
I also have Social Anxiety Disorder, Acute generalised anxiety disorder and depression. I had all these before the retching started. Most of these disorders have been present in me since starting school in 1992 so once again they pre-date the retching. SO it doesn't appear to me that the retching has triggered/set off these disorders, they were definitely in me from a very very young age.
Its horrible...
MyNameIsTerry
26-09-15, 12:10
Hi Calum,
Ok, thats good then, you can see definite triggers.
Repeating phrases isn't linked to the retching as you have described them but it could be that they are a separate compulsion. If you try to stop yourself doing them, how do you feel about it? Does tension build?
When you do the retching in a scenario like getting in a car, does the anxiety decrease because of it? Or does it just keep going? Usually compulsions are to make something "complete", to mitigate a possible outcome or just decrease anxiety. It doesn't always work like that but you would expect to see it some times at least. If there is no reduction or sense of "thats done now" then is it more a symptom of increased anxiety brought on by a stressful upcoming event?
What types of thoughts if you don't mind talking about them? Are we talking like in the Pure O stuff you read e.g. thoughts something bad will happen or that you may do something bad? And again, does the retching actually reduce the anxiety or make it feel like "thats that done"?
No, it doesn't sounds like the retching has set them off but it could be an increase in your anxiety that had created this new problem. It could still be OCD, need more info form the above really to understand the scenario better, but you will find many people talk about having OCD traits even though they don't have OCD which is because it has to be clinically significant in terms of how it affects your life. In your case this retching is obviously significant, so if does appear to be a OCD pattern, a diagnosis seems likely but there are many people with GAD that have intrusive thoughts that don't bother them enough to be considered a comorbid condition.
OCD usually presents early on but a lot of kids have it and it goes away. I can see some OCD behaviours in my childhood but my OCD didn't come until my mid thirties when my anxiety was intensified enough to bring it out of me. I still had some of the little habits inbetween but they didn't bother me.
Somatization disorder—a defensive waste of NHS resources
Leicester Royal Infirmary, 1Harplands Hospital, Newcastle-under-Lyme, 2North Staffordshire Hospital, Stoke-on-Trent, 3Staffordshire Rheumatology Centre, Stoke-on-Trent, UK
Correspondence to: A. Kinder, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK. E-mail: alisonkinder@dsl.pipex.com
Accepted December 19, 2003.
Sir, Patients with somatization disorder are high users of health care and often receive expensive, unnecessary tests and treatments. Current society expects doctors to diagnose and cure specific pathology. A failure to achieve this creates a psychological pressure of failure upon clinicians. We present one case that illustrates a common approach to a common condition with benign pathology which often presents to rheumatology out-patient departments.
This lady initially presented at the age of fourteen to ear, nose and throat surgeons with recurrent sore throats and underwent a tonsillectomy. Five years later during pregnancy she developed recurrent abdominal pain and despite extensive investigations no cause was found. She had a normal delivery of a healthy child. Since this time she has been referred to 16 different hospital specialities and undergone investigations for chest pain, breast pain, facial pain, ear pain, nasal stuffiness, irritable bowel disease, menorrhagia, urinary problems and dyspareunia. She has been referred to the rheumatology department on three occasions with back pain or multiple joint pains. Her symptoms have not improved despite surgery. A retrospective 30-yr review of her hospital case notes revealed she has had 29 operations requiring general anaesthetic, 10 MRI scans, three CT scans and 25 ultrasound examinations. She attended out-patients on 204 occasions with 52 in-patient stays totalling 411 days (Table 1 (http://rheumatology.oxfordjournals.org/content/43/5/672.full#T1)). She is now 44 yr old and under the care of neurologists, physicians and urologists.
View this table:
In this window (http://rheumatology.oxfordjournals.org/content/43/5/672/T1.expansion.html)
In a new window (http://rheumatology.oxfordjournals.org/content/43/5/672/T1.expansion.html)
Table 1. Investigations and attendances with costs over the last 30 years
The only pathology demonstrated is an incomplete peripheral tear in the middle third of the medial meniscus of the knee, an ulcer scar on the duodenal bulb, an intradermal naevus and an incomplete abortion that required a dilatation and curettage. Urodynamic studies indicated urge incontinence due to detrusor instability and a small bladder. This pathology is common in up to 10% of the general population and affects 40% of women who present for urodynamic investigations [1 (http://rheumatology.oxfordjournals.org/content/43/5/672.full#ref-1)].
We evaluated the hospital costs of this patient to the NHS by current reference costs for private patients at the trust in terms of out-patient visits, in-patient stays, procedures and investigations. The total cost came to £209 000. This does not take account of other potential costs such as primary care consultations, prescription costs, accident and emergency visits and attendances outside this trust. We are aware that she has had two consultations at other hospitals.
This patient fulfilled the diagnostic criteria for somatization disorder, which includes:
History of many physical complaints beginning before 30 yr of age that occur during a period of several years and result in treatment being sought or significant impairment in social, occupational or other important areas of functioning and
Presence of all of the following at any time during the course of the disturbance: (i) four pain symptoms; (ii) two gastrointestinal tract symptoms; (iii) one sexual symptom; (iv) one pseudoneurological symptom [2 (http://rheumatology.oxfordjournals.org/content/43/5/672.full#ref-2)].
Patients with somatization disorder have multiple somatic complaints for which no biomedical abnormality has been demonstrated. The current theory is that this is due to underlying emotional conflict the patient is unable to face [3 (http://rheumatology.oxfordjournals.org/content/43/5/672.full#ref-3), 4 (http://rheumatology.oxfordjournals.org/content/43/5/672.full#ref-4)]. The lifetime prevalence of somatization disorder is 0.1–0.2% but symptoms of part of this disorder are 100 times more common [5 (http://rheumatology.oxfordjournals.org/content/43/5/672.full#ref-5)].
This disorder needs to be recognized by all specialities and emphasized during training. It should be diagnosed at a relatively early stage before the illness becomes chronic and intractable [6 (http://rheumatology.oxfordjournals.org/content/43/5/672.full#ref-6)]. Extensive investigation only increases the burden of physical and psychosocial disability on patients and their relatives and is costly to the NHS, as demonstrated by this patient [7 (http://rheumatology.oxfordjournals.org/content/43/5/672.full#ref-7)].
The management of these patients should be consistent and unambiguous and coordinated by one speciality such as the chronic pain management team, psychiatrist or psychologist with involvement of the general practitioner. A programme should be agreed with the general practitioner that limits investigations and patients’ access to specialists. Cognitive behavioural psychotherapy and short-term intensive psychotherapy may help the patient understand the underlying conflicts and thereby reduce the symptoms and recurrent presentations. Pharmacological therapy such as antidepressants or anxiolytic medication may be helpful in some patients [8 (http://rheumatology.oxfordjournals.org/content/43/5/672.full#ref-8)].
This case demonstrates two learning points:
In a health service of limited resources improved training and management of somatoform disorders could produce huge national savings in time and resources as well as reduce morbidity in society.
The professional responsibility of the clinician is to judge the likelihood of doing good against doing no harm (Hippocratic oath). Extensive interventions and investigations put the patient at risk of iatrogenic harm and only increase the patient’s perceived burden of illness. Doctors must decide what investigations are appropriate based on the history and physical examination. It is unlikely that a patient (or doctor) will be reassured by investigations on demand which are not clinically indicated, even if the results are negative, because there will always be more that can be demanded. Eventually there will be at least one result outside normal limits, which will suggest the need for still more tests and exacerbate fears of a ‘missed’ disease. Sometimes it helps to negotiate in advance a ‘final investigation’ with the patient agreeing that if it is negative it will be the last [8 (http://rheumatology.oxfordjournals.org/content/43/5/672.full#ref-8)].
Signed consent from the patient was obtained for publication.
The authors have declared no conflicts of interest.
I had to post this as I had never heard of Somatization disorder before and might apply in this case.
Just read the first paragraph if it's too long for you.
Hi Calum,
Ok, thats good then, you can see definite triggers.
Repeating phrases isn't linked to the retching as you have described them but it could be that they are a separate compulsion. If you try to stop yourself doing them, how do you feel about it? Does tension build?
When you do the retching in a scenario like getting in a car, does the anxiety decrease because of it? Or does it just keep going? Usually compulsions are to make something "complete", to mitigate a possible outcome or just decrease anxiety. It doesn't always work like that but you would expect to see it some times at least. If there is no reduction or sense of "thats done now" then is it more a symptom of increased anxiety brought on by a stressful upcoming event?
What types of thoughts if you don't mind talking about them? Are we talking like in the Pure O stuff you read e.g. thoughts something bad will happen or that you may do something bad? And again, does the retching actually reduce the anxiety or make it feel like "thats that done"?
No, it doesn't sounds like the retching has set them off but it could be an increase in your anxiety that had created this new problem. It could still be OCD, need more info form the above really to understand the scenario better, but you will find many people talk about having OCD traits even though they don't have OCD which is because it has to be clinically significant in terms of how it affects your life. In your case this retching is obviously significant, so if does appear to be a OCD pattern, a diagnosis seems likely but there are many people with GAD that have intrusive thoughts that don't bother them enough to be considered a comorbid condition.
OCD usually presents early on but a lot of kids have it and it goes away. I can see some OCD behaviours in my childhood but my OCD didn't come until my mid thirties when my anxiety was intensified enough to bring it out of me. I still had some of the little habits inbetween but they didn't bother me.
I do the retching up to a dozen times a day. I have missed family holidays because I don't want to be in a car for up to 6 hours travelling across the country as I know that at some point a retching attack will occur and it feels dangerous if it happens when I am far from a place of familiarity and safety. Basically I cannot go anywhere or do anything anymore because if I do I retch uncontrollably. If I could find a cause to this disgusting affliction then I wouldn't mind going places.
The thoughts I have are like "If you go into that car you are going to retch to death" How will you escape? Everything feels really gloomy and evil as well nowadays. Certain places and areas that I used to enjoy visiting now make me retch even contemplating being in these places now. I do NOT KNOW what the hell has happened to me? I'm telling you it is serious whatever it is be it mental and/or physical or a combination of both.
I personally feel that I have every disorder across the spectrum. I.E. GAD, SAD, OCD, Depression, Panic attacks and Panic Disorder! Is this actually possible to be suffering from every disorder across the spectrum?
MyNameIsTerry
27-09-15, 11:42
I had to post this as I had never heard of Somatization disorder before and might apply in this case.
Just read the first paragraph if it's too long for you.
In the WHO ICD-10 there are the following main disorders in F45 Somatoform Disorders:
F45.0 Somatization disorder
F45.1 Undifferentiated somatoform disorder
F45.2 Hypochondriacal disorder
F45.3 Somatoform autonomic dysfunction
F45.4 Persistent somatoform pain disorder
F45.8 Other somatoform disorders
F45.9 Somatoform disorder, unspecified
F45.3 is a very interesting one for this thread since it specifically mentions GI issues. This was one I was thinking of when I saw Calum's threads. I could post the criteria for all of these but they would perhaps be a bit large for this thread?
F45.0 & F45.2 are probably the most likely common ones seen on the HA board.
You probably would know some of these called "psychosomatic" instead of "somatoform".
I was trying to learn more about HA a while back, came across the manual online and had a read of them. It made a lot more sense as I struggle with the general nature of the HA board and how GAD & OCD people are also potentially on there so it was useful to try to understand the differences. If you want the link, let me know, I'm not sure it's best to post it in Calum's thread as it contains ALL mental health issues. It's been useful for understanding more about dissociative issues and depression too.
---------- Post added at 11:42 ---------- Previous post was at 10:16 ----------
I know what you mean, Calum, it feels like you have everything there is. Trust me, there are a lot more disorders than we talk about on here and depression comes in various forms.
So, the thoughts are not intrusive but conscious thoughts you are having about the upcoming scenario/event? Then once you approach that scenario/event, the retching occurs? So, it's possible that what you have here are identifiable triggers that bring on a symptom. If the retching were OCD, you would be using it as a way to reduce anxiety yet you have fear of the retching in the same way someone fears a panic attack occuring in a similiar scenario.
It's true that in OCD you get more anxious by completing compulsions until you end the "loop" and then it should subside, but not always as you can feel quite frustrated with yourself and if you have a comorbid condition like GAD, it can just go off to that and keep the anxiety going and become a load of worry about what is wrong/why you do it, etc.
Personally, I think like others have said to you in the past, retching is an anxiety disorder symptom. It doesn't really scan as OCD to me. You just have a real focus on it and it is severely hampering your life. Your constant need to find an answer in a physical illness could be a Somatoform Disorder or just intensification of a current disorder (thats for a mental health professional to say).
One can speculate all day concerning what mental or physical illness is the root of their issue but at then end of the day, it's best to just leave it to the professionals.
The bottom line Cal, is that you have a choice. Do nothing and continue the way you are or do something, seek professional help and get a handle on your life. I truly hope it's the latter.
Positive thoughts
One can speculate all day concerning what mental or physical illness is the root of their issue but at then end of the day, it's best to just leave it to the professionals.
The bottom line Cal, is that you have a choice. Do nothing and continue the way you are or do something, seek professional help and get a handle on your life. I truly hope it's the latter.
Positive thoughts
I know Fishmanpa. It's just the stigma surrounding me. I mean how do you tell a specialist that going to town in a vehicle makes you retch? It sounds very odd and sinister.
I know Fishmanpa. It's just the stigma surrounding me. I mean how do you tell a specialist that going to town in a vehicle makes you retch? It sounds very odd and sinister.
Do you really think that a mental health specialist has not heard something similar or hasn't had their share of unusual, odd, sinister or difficult cases and scenarios?
It still comes down to you taking the positive steps toward healing.
Positive thoughts
Absolutely. It's no use speculating-you need to take some action. I sincerely hope you decide to seek help for both your anxiety and for your unhealthy coping mechanisms
Absolutely. It's no use speculating-you need to take some action. I sincerely hope you decide to seek help for both your anxiety and for your unhealthy coping mechanisms
Amen to that!
Positive thoughts
MyNameIsTerry
28-09-15, 06:23
Information is useful Calum, but it's not for everyone. My point in raising these is that you have a thread here about OCD and I have had years of many forms of it so I thought I could try to help you understand if it were OCD. There are people I have spoken to on here that have been panicking badly over OCD because they didn't understand it because they were used to their other disorder(s) but upon learning about it, they calmed down a lot. I know this can work because it did for me and a lot of other people I have spoken to. Thats part of the reason for forums like this, otherwise why bother with most of the threads on here? However, like I said, I doubt that is the case for you.
Regardless, you need someone to assess your needs and tackle both the alcohol and the anxiety disorder + main troubling symptom. You will have to accept it will be hard going and what you are thinking of as a med is unlikely to be what you will get. So, please speak to your GP and explain what you have said on this thread. The things you have said here have made more sense than your recent threads as you have talked more about why it is occurring. It's often easier for us to see things more clearly and give you some options to consider.
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