Current Medical Diagnosis & Treatment in Psychiatry

Abnormal Preoccupations & Impulses

Techniques & Settings • • Psychiatric InterviewSep 18, 05

A phobia is a morbid and irrationally exaggerated dread that focuses on a particular object, situation, or act (see Chapter 22). Phobias differ from generalized anxiety in their focused quality; although a diffuse anxiety state sometimes precedes a phobic disorder. The patient is aware of the exaggerated, irrational nature of a phobia and regards it as symptomatic. The patient often tries to avoid the phobic situation or is compelled to perform actions (such as hand washing) in order to eradicate the object of the fear, or atone for tabooed action.

An obsession is a persistent idea, desire, image, phrase, or fragment of music that cuts into the stream of conscious thinking. The patient recognizes the alien nature of the obsession and attempts to resist it, without success. The obsession often presses the subject to perform compulsive acts, to relieve anxiety. The key characteristics of obsessions are their persistent, irresistible, imperative nature; their ego-alien quality; and their repetitiousness. Obsessional symptoms have been reported after encephalitis. They occur in the premonitory phase of schizophrenia or as part of a major depression (eg, the patient may experience persistent ruminations that old tax returns were in error and that ruin will result). Obsessive-compulsive symptoms are most characteristic of the anxiety disorder that bears the same name.

Impulsions differ from compulsions in that the former are less likely to be resisted, and they are episodic rather than repetitious, although the distinction may be blurred at times. Impulsions tend to occur in externalizing personalities, whereas compulsions are more typical of inhibited, constricted people. Impulsions cause difficulty for others and may lead to legal entanglements. Impulsive acts often spring from an emotional setting of anger, anxiety, frustration, rejection, sadness, or humiliation, particularly when the subject is disinhibited by alcohol. Common impulsions include violent assault, fast driving, excessive drinking or eating, gambling, sexual assault, sexual exhibitionism, shoplifting, stealing, and fire-setting. Sudden, episodic, if not explosive, onset is the hallmark of these phenomena. The subject does not or cannot exercise inhibition or self-control. Feeling short circuits thought, leading to action without reflection.

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