Co-occurring Depression and OCD: A Student's Journey

Questions regarding the comorbidity of depression and obsessive-compulsive disorder (OCD)?

Dear Dr.
Ding,
I am currently a junior in college.
I have no prior history of mental illness or hospital visits.
This semester, due to a heavier course load and a research assistant position under a professor in my department, I have been experiencing significant stress from both academics and work.
My personality tends to be anxious and perfectionistic, which has led to prolonged stress and emotional tension.
Around mid-October (around National Day), I began to experience shortness of breath and chest tightness.
At the time, I didn't pay much attention to it, attributing it to my stress, believing it would improve over time.
Although the shortness of breath gradually resolved within 1-2 weeks, by mid-November (during midterm exams), I suddenly had violent thoughts of harming myself or my parents one night during the holiday.
I must emphasize to the doctor that when these thoughts occurred (which I did not want to have, and I felt very anxious at that moment), I did not experience hallucinations or delusions.
When I realized these violent and disturbing thoughts had invaded my mind, I was frightened and knew something was wrong with me.
However, I was also afraid to talk to the school counselor, fearing they would view me differently upon hearing such crazy thoughts.
A week later, these thoughts continued to intrude into my mind (occurring about 3-6 times daily).
They appeared suddenly in various situations, and upon recognizing these thoughts, I felt intense fear, anxiety, and concern, worrying that if I lost control, I might actually harm someone and end up on the front page of the news.
Finally, I mustered the courage to visit the counseling office and explained my situation to the counselor.
After the initial intrusion of these violent thoughts, I began to observe feelings of depression, suicidal ideation, and self-harm.
During my first meeting with the counselor on Monday, they recommended I see a psychiatrist immediately on Thursday.
Although I was reluctant, I understood that these violent thoughts were a significant issue and agreed to the psychiatric consultation.
During my first visit, my parents accompanied me.
The doctor conducted an initial assessment, during which I reported feelings of depression, anxiety, suicidal thoughts, sudden violent thoughts, and vivid dreams, although I couldn't recall the specifics of the dreams, only that they involved people.
My appetite was normal, but I experienced frequent diarrhea, going to the bathroom 3-4 times a day at times.
After understanding my situation, the initial diagnosis was a tendency towards depression.
During this first psychiatric visit, the doctor prescribed a new anxiolytic medication (Valdoxan), to be taken half a tablet at bedtime, with weekly follow-ups.
The side effect of this medication was mild headaches.
During the second visit, I reported to the doctor that the violent and harmful thoughts (occurring about 3-6 times daily) still intruded, disrupting my daily activities and exacerbating feelings of depression, anxiety, and helplessness.
I continued to have vivid dreams, my appetite remained normal, but diarrhea persisted.
The doctor prescribed the same medication (Valdoxan) but increased the dosage to one tablet at bedtime, maintaining weekly follow-ups.
The side effect remained mild headaches.

In the third visit, the situation was similar to the second week.
However, due to my impatience with the medication's effects after two weeks, I discussed adjusting the dosage with the doctor.
We agreed to keep the medication as Valdoxan but increased it to two tablets at bedtime (the maximum dosage for this medication).
The side effect was still mild headaches, but the intensity had noticeably decreased.

During the fourth visit, I had an initial consultation with a campus psychologist on the same Tuesday.
That day, while enjoying the warm winter sun, I suddenly felt an inexplicable sense of loss.
In the session with the psychologist, we discussed the increasing suicidal ideation.
The psychologist suggested that these thoughts might stem from stress and long-term repression (I have always dealt with my frustrations and sadness alone, never sharing them with my parents, and I find it difficult to cry).
I became aware that I sometimes had thoughts of jumping off the corridor at school, as if an inexplicable force was pulling me, but I did not perceive suicide as a release or think about how it would hurt my parents.
However, I recognized that there was a protective mechanism in place, as I would walk along the classroom side of the corridor to avoid the edge and sharp objects.
The counselor deemed my situation dangerous and said they would report it to the counseling office.
During the fourth visit, I mentioned to the doctor that my suicidal ideation had intensified, and I felt increasingly desensitized to the dangers posed by these thoughts.
My anxiety, depression, and low mood had worsened, and I continued to experience vivid dreams.
Starting that Sunday, I began waking up in the middle of the night (going to bed around midnight and waking up at 3 AM, unable to fall back asleep for 1-2 hours), along with appetite loss and persistent diarrhea.
After discussing with the doctor, we decided to adjust the medication: I would continue taking Valdoxan at bedtime but reduce it to one tablet, as increasing it to two had not improved my sleep quality.
We also added Venlafaxine (HCL) 75 mg extended-release capsules, to be taken in the morning with breakfast to mitigate nausea.
Initially, I felt nauseous on the first day, but this subsided by the second day.
However, I experienced more severe headaches than with Valdoxan.
By the fourth week, I was diagnosed with moderate depression.
After discussing with the campus counselor, I informed the doctor of my diagnosis.
Considering my safety, the doctor recommended I temporarily suspend my studies and take a 2-3 week break from academic pressures to rest at home, as well as pause psychological counseling.
We agreed to maintain the medication dosage from the fourth visit.
The headaches persisted but remained tolerable, and I was prescribed a two-week supply of medication.
During the seventh visit, my feelings of depression, anxiety, worry, and helplessness remained severe.
I continued to have suicidal ideation with a clear plan, and the sudden intrusive violent thoughts persisted (occurring about 3-6 times daily).
My sleep worsened, and I began to lose my appetite, experiencing increasingly severe diarrhea (3-4 times daily).
After discussing with the doctor, we maintained the dosage of one Valdoxan at bedtime and one Venlafaxine (HCL) capsule in the morning.
Additionally, I was prescribed a gastrointestinal relief medication to be taken three times daily, half a tablet each time.
I took this for the first two days, but after consulting with the doctor, I stopped because my diarrhea had improved.
During the eighth visit, my anxiety and low mood showed no improvement, but my sleep had improved (still vivid dreams, but less waking up frequently).
Suicidal ideation persisted, with clear plans but no attempts, and my appetite had somewhat returned, with food tasting better.
Diarrhea improved, but intrusive violent thoughts continued (occurring about 3-6 times daily).
The headaches also significantly improved.
After discussing with the doctor, we maintained the dosage of one Valdoxan at bedtime and one Venlafaxine (HCL) capsule in the morning, and I resumed psychological counseling.
In the ninth visit, my anxiety and low mood still showed no improvement, but sleep had improved (still vivid dreams, but less waking up frequently).
Suicidal ideation persisted, with clear plans but no attempts, and intrusive violent thoughts continued (occurring about 3-6 times daily).
My appetite returned to normal, diarrhea significantly improved, and headaches became less noticeable.
After discussing with the doctor, we maintained the same medication regimen.
During the tenth visit, my anxiety and low mood still showed no improvement, but sleep had improved (still vivid dreams, but less waking up frequently).
Suicidal ideation persisted, with clear plans but no attempts, and intrusive violent thoughts continued (occurring about 3-6 times daily).
My appetite returned to normal, and I no longer experienced diarrhea.
However, I began to feel sudden waves of loss and despair, becoming engulfed in low emotions for about 10-15 minutes.
After emerging from this emotional turmoil, I felt an inexplicable fatigue, lacking the energy to do anything else.
My mind felt dull, and I sensed a decline in my memory and a growing sense of disconnection from reality, feeling indifferent to good and bad, danger, and the care of my family (despite their constant support).
I felt my moral judgment was weakening, and my pace of doing things slowed down, with periods of blankness extending from 5-10 minutes before my illness to almost 20-30 minutes daily recently, during which I lost track of time and felt detached from the world.

I would like to ask you, Dr.
Ding, whether this is also a symptom of depression or OCD.
Is moderate depression considered severe depression? Given my young age at onset, will my risk of relapse increase, or is there a significant chance of passing this on to the next generation? Could my sudden intrusive violent thoughts be symptoms of another mental illness?
I apologize for the lengthy account of my experiences and the detailed history of my visits.
I have several questions I would like to ask:
1.
Are the recurring intrusive violent thoughts I mentioned (which I do not want to happen, as I have no motivation to harm my loving family or strangers) considered negative thoughts associated with depression (stemming from anger) or obsessive thoughts related to OCD? I experienced similar thoughts during middle school due to academic pressure, but they lasted only 2-3 weeks without any depressive feelings and then disappeared without explanation.
2.
My doctor (whom I have only seen once) told me I have comorbid depression and OCD.
Is this a serious condition, and is it uncommon in clinical practice? Will the coexistence of depression and OCD prolong treatment duration and lead to a less optimistic prognosis?
3.
Are patients with OCD who only experience obsessive thoughts considered rare in clinical practice? Are patients with obsessive thoughts less likely to recover or more prone to relapse?
4.
Are Valdoxan and Venlafaxine (HCL) addictive? Will these medications cause withdrawal symptoms?
5.
I have noticed that in the past two weeks, I have been entering a strange spiral of depression, often feeling sad at odd moments (e.g., while watching a comedy, I suddenly feel very sad and want to cry).
Does this indicate that my depression is worsening, or is it just a symptom of the depressive episode?
6.
Recently, I often feel mentally dull and find it increasingly difficult to grasp written text (e.g., needing to read a sentence multiple times or read it aloud to understand it).
I also feel a sense of detachment from reality, unable to perceive good and bad, danger, or my family's concern (despite their constant support).
I feel increasingly indifferent to the world, as if my moral judgment is weakening, and my pace of doing things is slowing down.
My periods of blankness have increased from occasional 5-10 minutes to almost daily 20-30 minutes, during which I lose track of time and feel detached from the world.
Is this also a symptom of depression or OCD?
7.
Is moderate depression classified as severe depression? Given my young age at onset, will my risk of relapse increase, or is there a significant chance of passing this on to the next generation? Could my sudden intrusive violent thoughts be symptoms of another mental illness?
I appreciate your attention to my questions, Dr.
Ding.

Wishing you all the best and peace.

Niming, 20~29 year old female. Ask Date: 2013/12/26

Dr. Ding Shuyan reply Psychiatry

Hello, I must commend your meticulous description of your psychological distress and the process of seeking medical help.
I believe you have already asked your questions to your physician and counselor.
However, as I mentioned in previous responses, if you are already seeing a doctor, asking other strangers online may not be beneficial.
The so-called experts on the internet have not examined you personally like your physician has.
While it may be acceptable to inquire about general medical knowledge, I would advise against seeking opinions on diagnoses and treatments that are specifically related to your personal health issues.
Additionally, consulting others outside of your physician may indicate a lack of complete confidence in your own doctor.
Even if you seek opinions from a second or third physician, the situation remains the same.
This may stem from your cautious nature and desire for precision and perfection, but it can lead to confusion in evaluating information.
Medicine is not a simple yes or no question; it involves comprehensive judgments based on numerous conditions.
If you ask many different people and their answers are inconsistent, whom should you trust? Ultimately, you must rely on your own judgment to determine which physician's advice makes sense.
However, the issue is that you may not feel confident in your ability to discern which medical information to believe or not.
Regarding your concerns about drug addiction or withdrawal symptoms, I believe you have asked your doctor more than once.
Continuously seeking reassurance or definitive answers to your concerns can lead to an endless pursuit.
We do not need to have a complete understanding of something to feel comfortable doing it.
Just as we do not need to be fully familiar with a computer's operating system to use it, we can still operate a computer.
Our understanding of cars may be superficial, yet we can still drive confidently on the highway.
Lack of understanding often leads to anxiety, but sometimes knowing more can become a burden.
Trusting your physician should feel as natural as trusting a chef when dining at a restaurant.
I believe that given your cautious nature, you have thoroughly vetted your current physician.
Trusting and cooperating with them can significantly reduce your psychological burden.
I know this is difficult for you, but you must learn to let go and empty your mind.
One day, when you recover, you will realize that the process of healing is not about fully understanding depression or obsessive-compulsive disorder, but rather that these issues no longer hold significance in your mind, and your attention and interests will return to daily life outside.
Thoughts of suicide can sometimes arise suddenly and without clear reason.
I want to emphasize that suicidal thoughts are absolutely abnormal; during those moments, it feels as if one is in a dream, which is not real, while life is undeniably precious.
In a distorted dream, no matter how sad or desperate one feels, it is ultimately an illusion.
When suicidal thoughts arise, it is better to do nothing and simply wait for the dream to end.
Everyone who has walked back from the brink of suicide is grateful they did not end their life at that moment.
Whether it is obsessive-compulsive disorder or depression, there will be some compulsive thoughts, especially negative ones, which can be very tormenting.
Your questions indicate that you are suffering greatly.
However, these feelings will pass; the pain will subside.
I am not trying to comfort you; this is simply the truth.
Wishing you a speedy recovery and all the best.
Sincerely, Dr.
Ding Shuo-Yan.

Reply Date: 2013/12/26

More Info

Understanding the complexities of co-occurring depression and obsessive-compulsive disorder (OCD) is crucial, especially for students facing academic pressures and personal challenges. Your experience highlights a significant intersection of mental health issues that many individuals encounter, particularly in high-stress environments like university life.

1. Nature of Intrusive Thoughts: The intrusive thoughts you describe—violent or harmful in nature—can indeed be characteristic of OCD, specifically termed "obsessions." These thoughts are unwanted and often cause significant anxiety. It's important to differentiate between these obsessive thoughts and depressive symptoms. While they can coexist, the key is recognizing that the distress from these thoughts is not a reflection of your desires or intentions. Instead, they are a symptom of OCD, which can manifest alongside depression, particularly when stress levels are high.

2. Severity and Treatment Duration: Co-occurring depression and OCD can complicate treatment, but it is not uncommon. The presence of both conditions may require a more tailored approach, potentially extending the duration of treatment. However, many individuals do find relief through appropriate therapy and medication. The prognosis can vary; while some may experience a longer treatment journey, others may respond well to combined therapies, including cognitive-behavioral therapy (CBT) and medication.

3. OCD Without Compulsions: It is indeed possible for individuals to experience OCD primarily through obsessive thoughts without the accompanying compulsive behaviors. This presentation can be less common but is still recognized in clinical settings. Those with primarily obsessive symptoms may face unique challenges, including a heightened sense of anxiety and distress, but with effective treatment, improvement is achievable.

4. Medication Concerns: Regarding the medications you are taking—Valdoxan (Agomelatine) and Venlafaxine—neither is typically associated with addiction in the way that substances like opioids or benzodiazepines are. However, discontinuation can lead to withdrawal symptoms, particularly with Venlafaxine, which is an SNRI (serotonin-norepinephrine reuptake inhibitor). It’s essential to follow your doctor’s guidance when adjusting or stopping medication.

5. Emotional Fluctuations: The emotional fluctuations you are experiencing, such as sudden sadness during typically enjoyable activities, can be indicative of depression. This symptom may not necessarily mean your condition is worsening, but it does warrant attention. It’s crucial to communicate these changes to your healthcare provider, as they may need to adjust your treatment plan.

6. Cognitive and Emotional Disturbances: The feelings of mental dullness, difficulty concentrating, and emotional numbness are common in both depression and OCD. These symptoms can significantly impact daily functioning and quality of life. They may also reflect the cognitive distortions often associated with depression, where individuals feel detached from their surroundings or experience a diminished capacity for emotional engagement.

7. Understanding Depression Severity: Moderate depression is a serious condition and can lead to significant impairment in daily life. Early onset of depressive symptoms can increase the risk of recurrence later in life, and while there may be a genetic component to mood disorders, it’s not deterministic. Your experiences and symptoms should be closely monitored by a mental health professional to ensure you receive the appropriate support and intervention.

In conclusion, your journey through these mental health challenges is significant and requires compassionate understanding and professional support. It’s commendable that you have sought help and are actively engaging in treatment. Continue to communicate openly with your healthcare providers about your symptoms and any changes you experience. With the right support, it is possible to manage these conditions effectively and improve your overall well-being. Remember, you are not alone in this journey, and there are resources available to help you navigate these challenges.

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