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Hello, My name is Charlotte H. I am 15 years of age and live in Manhattan.
Over the past months I have been having Intrusive thoughts of killing my mother, I know this seems awful but I would never harm her, or anyone for that matter. They are about strangling her, then killing myself. I am not insane, I feel emotions and I know I would never ever hurt anyone. But I would like to know what I could do about the guilt I feel?
The thoughts pass through my mind every now and again and I am disgusted but the more I try to force them away the more they appear. When I tell myself, you're sick, just don;t think about it, It comes back. I suppose it's like saying don't think of a taxi-cab; It will appear in your mind until you forget and thats the same for me. I have tried to do what Psychologists say and when you conjure up a thought just to let it pass and try not to dwell on it, but then I worry that I am not getting concerned by these horrific thoughts... Then I get more worried, Its a vicious cycle.
I have been told that everybody thinks these thoughts but most people can easily cast them away, but I seem to hold onto them and they become all I can think of. When I was age 11-12 I used to have urges to put coins in my mouth and let them go to the back of my throat to near where I could choke and then quickly spit them out, But my Father told me he used to have similar thoughts when he was my age and so did my older siblings...
Is there anything I can do? Or should I be more concerned?
Thanks, sorry for rambling :)

ask dr-robert

Hello, Charlotte--

The Diagnostic and Statistical Manual (DSM) which is used by many psychologists and psychiatrists contains a listing of so-called "disorders" each of which has a set of criteria used to decided if someone "has" the disorder or not. This logical listing can lead one to believe that emotional problems are like infectious diseases in that one either has them or not. But this is incorrect. Infectious disease is an either/or situation. One either has the disease or not. Take, for example, the sexually transmitted disease, gonorrhea. A person "has" gonorrhea even if that person has no symptoms at all, because the criteria for deciding whether or not someone has gonorrhea do not depend upon symptoms at all, but on whether or not the microorganism which causes gonorrhea is present in the body, according to the following criteria set:

1. Isolation of typical gram-negative, oxidase-positive diplococci from a clinical specimen, or

2. Demonstration of N. gonorrhoeae in a clinical specimen by detection of antigen or nucleic acid, or

3. Observation of gram-negative intracellular diplococci in a urethral smear obtained from a male.

In other words, if someone meets any one of those three criteria, that person "has" gonorrhea, ill or not, symptomatic or not.

The situation with emotional disorders is not like this. Take, for example, obsessive-compulsive disorder (OCD), a fairly common problem which brings many patients to psychotherapy. Unlike gonorrhea, if someone shows no symptoms of OCD, that person does not "have" OCD. This is because the criteria for OCD are entirely concerned with symptoms and behaviors. Here is the DSM definition of OCD:

Obsessive-compulsive disorder is characterized by either obsessions or compulsions:

Obsessions as defined by:

1. Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress

2. The thoughts, impulses, or images are not simply excessive worries about real-life problems

3. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action

4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

Compulsions as defined by:

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly

2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

--- AND: ---

At some point during the course of the disorder, the adult has recognized that the obsessions or compulsions are excessive or unreasonable (not applicable to children).

The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.

If another disorder is present, the content of the obsessions or compulsions is not restricted to it. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

ask dr-robert

I hope you are following this, Charlotte. It may seem that I am taking the long way around to answering your question, but I think this background will help you to understand your situation.

Now your thoughts about strangling your mother and then killing yourself certainly seem obsessive according to the three criteria above, but I don't think you really qualify for a diagnosis of OCD because, according to your account, "The thoughts pass through my mind every now and again. . . ," whereas a diagnosis of OCD requires obsessions or compulsions that "are time consuming (take more than 1 hour a day). . . ." Now to my ear, "every now and again" does not sound like "time consuming (take more than 1 hour a day)," so, I would hesitate to say that you "have" OCD. Nevertheless, your repetitive and disturbing ideas have the quality of obsessions. You cannot seem to avoid them no matter how hard you try, and they do cause you distress. One lesson here is that emotional disturbances are not like physical illness. Physical illness is, as I said earlier, and either/or matter, but emotional disturbances are best seen as a range or spectrum of symptoms which may vary from slight to severe.

To see this from another angle, all of us humans are more or less obsessive-compulsive. Some hardly at all, others severely. And somewhere along that spectrum—certainly not at the "slight" end of it, but not at the "severe: end either--is where you find yourself.

The fact that your father and older siblings report similar disturbing thoughts is highly suggestive as well, because OCD is known to be genetically based. Given this, I would say that although you do not meet the strict criteria for OCD, your situation should be treated as if you had a mild case of OCD. Please understand that at a distance and without a personal interview I cannot be certain of any diagnosis, so all of this is speculative.

However, assuming that your situation is best treated as a mild case of OCD, there are two possible effective treatments. The first is medication with one of the SSRI's (Selective Serotonin reuptake inhibitors) such as Prozac, Zoloft, Paxil, etc. These seem to work well for many people who are troubled by OCD. At this point, for many reasons I would discourage medication. Medication has side-effects, you are young and may change as you develop, and I would like to see first if the other treatment, cognitive behavioral therapy (CBT) would give you relief.

CBT is a formal name which really means changing the way you think and react to certain circumstances. Given your obvious intelligence, I think you may be able to carry out your own CBT without need for a psychotherapist. If you would like to try, here is what I suggest (thanks to Dr. Jeffrey M. Schwartz for this formulation):

ask dr-robert

Step 1. Relabel

Learn to recognize obsessive thoughts and compulsive urges - and do so assertively. Start calling them "obsessions" and "compulsions." Realize they are symptoms of your illness and not REAL problems. For example, if your hands feel dirty or contaminated, train yourself to say "I don't really think my hands are dirty; I'm having an obsession that they are. I don't really need to wash my hands; I'm having a compulsion to do so." After a while the brain learns to understand that these are just false alarms - false messages caused by a genetically caused chemical imbalance in the brain. You can't make the thoughts and urges go away because they are caused by this biological imbalance, but you can control and change your behavior response.

Step 2. Reattribute

"It's not me, it's my OCD." Learn to reattribute the cause of these thoughts and urges to their real cause. This will increase your willpower and enable you to fight off the urge to wash or check.

Step 3. Refocus

This is where the real hard work is done. Learn to refocus your mind on something else. Choose something pleasant like a hobby - listen to music, play sport, go for a walk, whatever it takes to make your mind think of something other than the obsessions and compulsions that it wants to think about. Say to yourself, "I'm experiencing a symptom of OCD. I must refocus and do another behavior."

Step 4. Revalue

Begin to realize that these thoughts and urges are a result of OCD, and learn to place less importance on them and less importance on the OCD.

Dr Schwartz writes (Brain Lock, 1997), "We who have OCD must learn to train our minds not to take intruding feelings at face value. We must learn that these feelings mislead us. In a gradual but tempered way, we must change our responses to the feelings and resist them."

Please give this procedure a try, Charlotte, and then get back to me to let me know how it is working for you.

Be well.

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