Tormenting Thoughts and Secret Rituals Page 10

  Patients must be thoroughly prepared before they begin exposure in the imagination because it can be startling and upsetting. They must clearly understand that the only purpose of the painful exercise is to make the mind get used to, habituate to, an awful image. Patients worry that picturing a terrible act could lead to doing it. As discussed previously, they must be reassured that OCDers never follow through on an obsession, that they are the last people who would ever harm anyone.

  Sherry used exposure in the imagination to treat several of her obsessions. Toward the end of therapy she wrote a script of her number one worst fear.

  Here goes! It’s winter and it’s ugly outside. I have been feeling down and have been unable to shake it. I’ve tried all day to concentrate on other things. It’s 4:30 P.M. and I’ve been to the grocery store and am feeling nervous. Life is so painful; nothing will ever be right. I’m putting things away in the kitchen, and I spot the carving knife. Megan is sitting at the table. The urge hits to slash at her. I shake with anxiety. The urge takes over. I am unable to control it. I sneak up behind Megan, and I stab her in the back, over and over. I see the blood spurting out. I think that I am out of control; that it’s really happening this time. Megan flops onto the floor, dead, into a pool of blood. I vomit hysterically. I’ve killed my daughter!

  Sherry recorded this scene on a cassette loop tape, and played it back to herself every day for twenty to thirty minutes, long enough to allow her anxiety level to drop significantly. She needed occasionally to step back from the scene and remind herself, “This is my OCD, it’s not me”; or, “This does not mean that I’m going to really do it, but I must learn to live with the idea of doing it if I want to overcome my OCD.” Such psychological distancing is usually necessary, but I encouraged her to minimize it, because the fuller the immersion in the frightful fantasy, the faster therapy proceeds.

  After twelve weeks of active behavior therapy, seventeen weeks total in treatment, Sherry had markedly improved. Her journal, in which she was now taking note of her attitudes as well as her obsessions, reflects her progress:

  Monday—Very mild obsessions. Ideas of knifing myself. Passed easily.

  Self-talk: “Oh, it’s a knife. I could hurt myself with that if I wanted to. Well, it’s dinner time. I could stab myself if I wanted to.” I took out a knife and used it easily for cooking.

  Tuesday—Rating: 8. Very mild obsessions. Was busy all day. Felt sad in the afternoon.

  Self-talk: “What a nasty illness. Why did it have to happen to me? Why couldn’t I have gotten help sooner?”

  Wednesday—Had obsessions off and on all day. Don’t know why. Got up in the morning and thought of knifing Bob in the stomach. Image first, then urge.

  Self-talk: “Oh, not you again. Stop bugging me, jerk. You’re bothering me, but you’re just an obsession.” Went away after a while.

  Thursday—Stayed busy all day. Some thoughts about hurting myself.

  Self-talk: “It’s just OCD. These thoughts can’t harm me.”

  Friday—Fleeting obsessions of knifing and running people over. Not bad.

  Self-talk: “Obsessions, I’m not scared of you any more! If I bear the anxiety, I know you’ll go away.”

  Saturday—Had two hours of a pretty bad obsession after an argument with Bob. Kept my anger in. Variety of thoughts. Knifing myself. Running car into overpass. Took a long time for them to go away. Crying. Why does this happen while I’m driving?

  Self-talk: “Come on, Sherry, shape up!”

  Sunday—Good day with family. Only a few obsessions all day. Very mild. Life can be good.

  Sherry’s most satisfying moment of all came a few months later. Not since age eleven had she carried a knife with the blade pointed outward when another person was in the kitchen. Instead, she always carried it pointed toward her belly, so that if she stabbed anyone, it would be herself. But one day while she was carving a roast, her daughter calmly munching snack food nearby, Sherry slowly and purposefully grasped the knife, held it pointed outward, and walked carefully, as if on slick ice, across the kitchen. At the finish of her journey, she put down the knife and gave her startled daughter a joyous, gasping hug. Sounds simple, but Sherry said it was like winning an Olympic gold medal.

  The treatment of Raymond and Sherry demonstrates the nuts and bolts of behavior therapy for OCD. The same basic techniques of exposure and response prevention were used to help Jeff, whose lust obsessions were discussed in Chapter 1. Jeff purposefully exposed himself to situations where his sexual obsessions occurred strongly, such as sitting close to other men. At the same time, he worked hard to prevent his mental rituals, such as repeating, “I am not gay,” over and over in his mind. Jeff’s formal behavior therapy lasted for approximately four months, and by the end of that time he was, like Raymond and Sherry, markedly improved.

  Melissa, whose religious obsessions were also presented earlier, was also treated with standard behavior therapy and responded well. Melissa systematically exposed herself to her nonstop obsessions of doubt (“Should I listen to non-Christian music?” “Should I wear dresses?” “Am I being a good enough witness?”) while limiting her compulsions to chant prayers, ask reassurance, and overanalyze situations. A couple of points about Melissa’s treatment deserve special comment.

  A theory on the cause of OCD that is especially good for explaining obsessions in the form of questions has been advanced by psychiatrist William Hewlett of Vanderbilt University. Hewlett’s theory holds that the basic problem in OCD is a broken “uncertainty system” in the brain. The uncertainty system, it says, is a mechanism that developed through evolution to help animals deal quickly and efficiently with danger. Suppose our prehistoric ancestor was walking through the forest and heard a twig snap. His uncertainty system would spring into action and cause the following: first, an uncomfortable feeling of doubt; second, fantasies of various possibilities to explain the twig snap; and third, an insistent demand to take some sort of action to resolve the situation. Such a chain of responses, it can be easily seen, could be very advantageous. But for a person with OCD, Hewlett suggests, the uncertainty system discharges for no reason at all. Spontaneous fits of doubt occur, similar, perhaps, to an epileptic’s sudden grand mal seizures. The OCD sufferer is then repeatedly overwhelmed by agonizing questions, fantasies of catastrophe, and powerful urges.

  When I explained this to Melissa, her eyes lit up. “If I were that caveman and heard a twig snap,” she laughed, “I’d look for a Bible verse that said all twig snaps are dangerous animals, and I’d say it over and over. But then I’d have the question ‘Does that mean a tiger or a bear?’ and I’d have to look for another verse.” This model helped Melissa to see that her tormenting questions were the result of a brain disorder and that her prayer rituals were simply acts she was driven to perform in order to turn off the questions.

  Another important point to be made about Melissa’s treatment is that her behavior therapy did not conflict at all with her religious beliefs. Many people, particularly Christian evangelicals, accuse psychiatrists of being opposed to religion. This criticism has some validity, unfortunately, since Sigmund Freud, the father of American psychiatry, did proclaim religion a “universal neurosis”; and many psychiatrists still do subtly, if not overtly, discourage people from their faiths. But it worked fine for Melissa to look on her obsessions as being caused by Satan; in fact, that view should be given a certain distinguished status because of the many great people who have held it, as discussed in the previous chapter. Furthermore, the fact that some of her prayers had turned into compulsions did not lessen the importance of true prayer for Melissa; her prayer life is now better than ever. And, finally, Melissa still attends the same evangelical church, where her pastor is now a believer in this form of psychiatric treatment.

  WHEN BEHAVIOR THERAPY FAILS

  Behavior therapy is not effective in all cases of OCD. Studies show that up to 30 percent of patients either refuse to try behavior therapy or quit it earl
y, and an equal number improve only minimally or not at all after a full course of treatment. My own experience is that at least one third of OCD patients will not be helped significantly by behavior therapy.

  Some types of OCD symptoms, it has been demonstrated, respond much better than others to behavior therapy. Luckily, clearcut washing and checking rituals—the most common symptoms of severe OCD—respond especially well. Most other types of rituals, along with episodes of avoidance, are also fairly easily treated as long as they can be clearly identified and thus readily targeted for exposure and response prevention. However, if compulsions and avoidance are not obvious, then behavior therapy becomes difficult.

  “Pure obsessionals,” people who are tormented by obsessions yet have few other obvious symptoms, have been identified as one group of patients who do very poorly with behavior therapy. Fortunately, increased use of the technique of exposure in the imagination (as was used with Sherry) has improved their prognosis considerably.

  OCD sufferers with “obsessional slowness” are another group known to do poorly with behavior therapy. Unfortunately, no new techniques have improved the outlook here. I see a middle-aged woman who spends two and a half hours dressing, bathing, eating, and getting out of the house every morning. Where does the time go? A few checking and washing rituals never take her more than ten minutes. Hours go by that simply cannot be accounted for. She is, it seems, just painstakingly slow. She will study every detail. She will move from one tiny task to the next only after thorough deliberation. To make anything happen, it is as if she must overcome a great inertia. Such slowness seems itself to be a form of compulsion—or more likely the result of hundreds of mini-compulsions. In any case, it is extremely difficult to target for exposure and response prevention.

  Severe depression also makes behavior therapy extremely difficult. Low energy, inability to concentrate, decline in interests, loss of motivation, and drab pessimism all rob a person of the ability to accomplish what is necessary for successful behavior therapy: a great deal of effort directed to exposure and response prevention. Depression must be addressed first, and only after that OCD.

  Another problem sabotaging the therapeutic effects of behavior therapy is a strong belief that obsessions are real. You will recall that an obsession is, as a rule, recognized in a moment of quiet reflection as senseless. When that insight is lost, behavior therapy becomes impossible. My clinical observation is that this apparent loss happens for two reasons. Some patients with schizophrenia-like disorders have obsessions that represent delusions, or fixed, false beliefs. In these cases, the main problem is not OCD but a brain disorder that interferes with the ability to know what is real and what is imagined.

  Other patients, though, suffer no such serious disorder, yet still insist on the truth of their obsessions. A student I treated recently insisted that her roommate really could catch her germs and die, and that scrubbing out the bathroom every day really was the right thing to do. She knew that no one else took such precautions. She even admitted that the chance of her roommate’s dying from her bathroom germs was less than the chance of her being struck by lightning. Yet she still defiantly claimed that it could happen and therefore that she should perform her cleaning rituals. There was no reasoning with her. It seemed to be a matter of her heart ruling her head, along with a good dose of bullheadedness. After many unproductive sessions, I strongly confronted her. She would never get better, I told her, unless she stopped being stubborn and started using her brain. I am hopeful that this helped but I don’t know because she terminated her therapy after that visit.

  Finally, perhaps the most common reason for behavior therapy failures is a lack of will to change. As pointed out at the beginning of this chapter, behavior therapy is the single best treatment for people who make the necessary effort. But some OCD sufferers, particularly those who have had the illness for many years, become accustomed to an impaired life; they call a truce with their rituals. I treat a middle-aged man, a chronic OCD sufferer, who works eight hours a day pumping gas and then returns to an empty house where he puts in two hours performing rituals. He understands the irrationality of his OCD; he was able to lay the groundwork for behavior therapy by keeping an accurate daily diary of his symptoms. But when it came to practicing exposure and response prevention, he could not get the job done. He would forget to do it, or there wouldn’t be time, or the assignment would be too difficult. After many unsuccessful attempts to make therapy work, he himself discovered the reason for his lack of success. “Well,” he said, “I guess I really don’t have anything better to do than the rituals.”

  SIX STEPS TO CONQUERING OCD

  It is a fact that minimal instruction in behavior therapy can be all that is necessary for dramatic improvement in OCD. This has been demonstrated by psychiatrist Isaac Marks of the University of London. Marks, widely regarded as the world’s leading expert in behavior therapy, demonstrated in 1988 that OCD sufferers taught the basics of behavior therapy could do just as well as patients who made frequent and lengthy visits to behavior therapists. Marks observed that the key to improvement was patients engaging in exposure and response prevention by themselves. This agrees with a common clinical observation: Once patients learn how to do behavior therapy, they don’t need to come in for regular visits any more. Raymond told me, “Once I got the hang of exposure and response prevention, I was able to handle things by myself.”

  This being true, I have no doubt that many cases of OCD do not require professional help. What is necessary is only to understand the principles of behavior therapy and to put them to use.

  You may benefit from a self-help approach if you are a self-motivated person and if your symptoms are relatively mild. You should consult a therapist, on the other hand, if your obsessions, compulsions, or avoidance are causing major distress or disruption to your life, or if your OCD resembles the cases described above in which behavior therapy is especially difficult. It may well be helpful, if you are going to attempt to treat yourself, to pick up a book that deals with self-help in greater detail than I do here. I often recommend When Once Is Not Enough by Stektee and White, Stop Obsessing by Edna Foa, Getting Control by Lee Baer, or Brainlock by Jeffrey Schwartz (see Appendix C).

  The following six steps cover the essential ingredients of effective behavior therapy for OCD. A note of caution: Isaac Marks comments that using self-treatment is far from a “glib exercise” in using willpower to face up to fears. Progress depends on mastering definitions and principles, then putting them to use in a systematic and disciplined way. That said, here is a bare-bones self-help program for OCD:

  Step 1. Understand that your OCD is a brain disorder. What you are fighting is a chemical problem that makes certain fearful thoughts (obsessions) stick tenaciously. The discomfort caused by these thoughts forces you to perform silly, repetitive acts (compulsions) and to limit your life (avoidance).

  Know these facts so well that you can explain them to others. Test yourself: What is OCD? What exactly are obsessions, compulsions, and avoidance?

  Step 2. Fully grasp the principle of habituation, nature’s way of getting rid of fearful thoughts. Your job is to put habituation to work through the use of exposure and response prevention.

  You will know that you have the main idea when you are able to comprehend this concise statement: “The problem with compulsions is that they chase away obsessions before a person habituates to them.”

  Step 3. Make a list, at least mentally, of your obsessions, compulsions, and avoidance. Give them a general ranking according to how seriously they interfere with your life. (If clearly identifying obsessions and compulsions proves very difficult, which it is in some types of OCD, then you should see a professional.)

  Step 4. Your goal is to learn to live with obsessions—even though you dislike them intensely—while combatting compulsions and avoidance. To accomplish this, do an exposure and response prevention task at least three times a week. Pick an instance of compulsion or avoidance
that is relatively mild, set up an exposure situation, and tolerate the ensuing anxiety until it decreases by at least 50 percent, which may take up to one to two hours. As you “get the hang of it,” move on to more difficult tasks. (If you find that your anxiety is getting worse rather than better, you may be sensitizing to your obsessions rather than habituating. See a therapist.)

  Step 5. Get support. You may be a lone-ranger type, but it is extremely helpful to have contact with other OCD sufferers and to keep abreast of new developments in OCD research. An excellent way to do this is to join the OC Foundation (see Appendix D).

  Step 6. Try out different strategies to assist in exposure and response prevention. My patients’ ten favorites are discussed in Chapter 6.

  5

  USING MEDICATIONS

  OCD sufferers are immensely fortunate that in addition to behavior therapy, a second treatment has recently been found to be markedly effective for obsessions and compulsions: medications. Medications can work when behavior therapy doesn’t; moreover, the combination of medications and behavior therapy usually works better than either remedy alone. Most OCD clinics, including my own practice, routinely employ a combination of these two proven treatments.