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Ask the Mental Health Expert Archives 2001-2004

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Daydreaming OCD Person

Q. What label/term is used to describe the condition that causes someone to spend days rehashing how to solve a political situation or mentally rewriting a better script for a TV show or if in charge, how to solve a major world problem? Even though this person enjoys reading, he is not able to finish a book without great difficulty as his mind latches on to a particular thought and he "daydreams" about this thought. This person has been in treatment for 10 years with the general diagnosis of treatment resistant depression and is trying a combination of medications but thus far, nothing has helped. The latest medication combo is 100 mg Zoloft and 20 mg ziprasidone to help calm the obsessive thinking. How does obsessive thinking differ from obsessive compulsive disorder?

A. There is a good deal of confusion surrounding the term "obsessive" or "obsessive-compulsive". In the strict sense of the term, obsessive-compulsive disorder (OCD) involves intrusive, alien thoughts that the person resists--at least initially--and which he or she knows are exaggerated or irrational (at least initially). We speak of OCD as involving ego-alien thoughts or ideas that the person experiences as "not me". They are usually associated with a corresponding behavior or ritual which the person feels compelled to perform, in order to reduce the anxiety generated by the obsession.

This is all quite different from mere over-involvement in some project or daydream. If the individual experiences such intense involvement as either pleasurable or at least tolerable, it is hard to consider this a species of OCD, even if it interrupts other activities, such as reading. I have seen a few patients whom I might describe as suffering from the "Walter Mitty Syndrome". You may recall James Thurber's likeable but somewhat pathetic character, who constantly daydreams of great adventures and extraordinary feats.

These folks are usually not suffering from OCD, but from what--in the pre-DSM-IV days--used to be described as inadequate personality disorder. Typically, they are rather unassertive or repressed individuals, whose fantasies far outstrip their ego strength and coping skills. It's doubtful that medication for OCD would be very helpful for these individuals. Rather, long-term psychotherapy would be my treatment of choice, perhaps coupled with an assertiveness training group. This is not to say that such individuals are immune to bouts of major depression--far from it.

Your "person" may well be suffering from a treatment resistant depression, in addition to (and perhaps as a reaction to) whatever Axis 2 (personality disorder) problems he may suffer from. I would probably urge a second opinion from a clinician with extensive experience in treating personality disorders, and perhaps a psychopharm consult as well. I also suspect that cognitive-behavioral therapy could be very useful in a case like this.

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January 2002

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