Obsessions recur persistently and the patient experiences them as originating in the self, however irrational or repelling. These are accompanied both by a sense of compulsion and by a wish to resist.1 However, belief in the rationality of rituals such as decontaminating procedures varies from patient to patient, and resistance is sometimes slight. In ‘true’ obsessional states, compulsive rituals (like hand washing), checking (everything, endlessly) and rumination (‘Why am I? Why is the World?’ repeatedly) are the dominant symptoms presenting for treatment; others are compulsive slowness, and hoarding. Obsessional phenomena may also occur in patients with brain damage (after encephalitis or trauma), in schizophrenia and affective disorders: in one study, 24% of psychotic depressives were obsessional only when depressed.2 Treatment is then directed primarily at these major conditions.
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