Tormenting Thoughts and Secret Rituals Page 18

  In my experience, perhaps one fourth of OCD spouses, for whatever reason, will have nothing to do with their partner’s disorder. They will attempt to ignore OCD, and when that is not possible, they will convey an attitude of disgust. They will discourage psychiatric treatment and refuse any discussion. Although such a response is unfortunate, it doesn’t have to be devastating. A number of my patients with severe OCD have been able to do very well in treatment despite getting nothing but a cold shoulder from their spouses. Raymond, whose case was presented in Chapter 1, is an example.

  Yet it is invaluable for a spouse to actively support treatment. OCDers are so guilt-prone and overly responsible that they can easily be turned away from therapy by the slightest intimation that they are wasting money, depriving the family of their time, or getting addicted to medications. Often it is extremely helpful for a spouse to take an active role in behavior therapy, helping the OCDer to carry out exposure and response prevention tasks. This sort of involvement does not require a great sacrifice of time or effort. Behavior therapy is such a powerful treatment that just a little help can make a great difference.

  The most important step for any family member to take is becoming educated about the disorder. Talking to someone about OCD isn’t enough. So much has changed in our conceptualization of OCD over the last decade that even mental health professionals may not be up to date. The Obsessive-Compulsive Foundation is an excellent source of up-to-date books and pamphlets on OCD. The foundation also sponsors numerous conferences. Perhaps the best introduction to dealing with OCD in the family is the pamphlet, “Learning to Live with OCD,” which contains the following helpful guidelines for all family members.

  GUIDELINES FOR OCD FAMILY MEMBERS

  1. Avoid personal criticism and angry outbursts. Deal with OCD as you would deal with diabetes. The sufferer should not be blamed for the symptoms.

  2. Support therapy. Make it clear that treatment is worth the cost. If the OCD sufferer hasn’t yet seen a competent therapist, take whatever steps are necessary to find one (see Appendix D).

  3. Be a medications advocate. Medications may be rejected out of a belief that taking medication is a sign of weakness, out of a fear of addiction, or out of an obsession that the medication is contaminated. All are equally false. “Talk up” medications, because they are usually a key to successful therapy.

  4. Renegotiate regularly how family members are to deal with OCD. Address specifics, such as when and how to intervene to stop rituals, as well as how family members can keep their lives normal.

  5. When confronting rituals, keep communications clear and simple. It is seldom helpful at this point to enter into a debate on the irrationality of a ritual. It is usually best just to say, “What I think is that this is an OCD ritual and it shouldn’t be performed.”

  6. Recognize “small” improvements. Don’t overlook the strong effort necessary to make even a little headway against OCD. Verbal praise is a strong reinforcer—particularly for OCDers, who tend to be permanently entrenched people-pleasers. Let the OCD sufferer know that his or her hard work is noticed.

  7. Be sensitive to moods and to sources of stress. Although it is extremely important to set limits on rituals, it is just as important to know when to back off. Bad feelings make OCD worse. Flexibility is the key.

  8. Avoid day-to-day comparisons. OCD runs a waxing and waning course, and comparing current symptoms to a day ago, or a month ago, or even a year ago, means little. Furthermore, overly sensitive OCDers often take comparisons as criticism. Limit comparisons to noting how much improvement there has been since the rituals were at their very worst.

  9. Avoid comparing an affected family member with another OCD sufferer. Some OCDers have the equivalent of lifelong insulin-dependent diabetes, which will always cause symptoms, whereas others have the equivalent of mild, adult-onset diabetes, which is easily cured.

  10. Keep the family routine as normal as possible. Disruption tends to occur when family members are either drawn into rituals or become overly protective toward the OCD sufferer.

  8

  MAKING SENSE OF

  SENSELESS SYMPTOMS

  Obsessions and compulsions seem uniquely puzzling. How can intelligent people allow themselves to be upended by thoughts that they know are senseless? And how can they waste hours and hours performing silly rituals?

  No other psychiatric symptoms are so mysterious. The imaginary voices heard by a young man with schizophrenia can be seen, without stretching the reasoning capacities too much, as a breakdown in a mechanism in the brain that separates true sensory perceptions from daydreams and fantasies. Similarly, the loss of capacity for enjoyment, decline in interests, and hopeless withdrawal of major depression can be seen as a failure in the mechanism that controls the amplitude of mood swings. The attacks of shaking, rapid heartbeat, and shortness of breath characteristic of panic disorder can be readily understood as excessive discharges of the body’s “fight or flight” response.

  But the senseless rituals and self-tormenting thoughts of obsessive-compulsive disease have defied a satisfying explanation. Particularly enigmatic are harm obsessions, such as Sherry’s terrifying impulse to stab her daughter, an idea that would not seem to have anything whatsoever to do with a normal mental process, however broken or distorted. Puzzling, too, are destructive compulsions, such as Raymond’s hours a day of checking. If Raymond recognizes it’s senseless and harmful to check so much, why can’t he stop?

  Freud, who called OCD the most fascinating of all mental disorders, admitted that it was also the one he never mastered. “I must confess,” the great psychoanalyst wrote in his celebrated 1909 article, “Notes upon a Case of Obsessional Neurosis,” “that I have not yet succeeded in completely penetrating a severe case of obsessional neurosis.… If we endeavor to penetrate more deeply into its nature, we still have to rely upon doubtful assumptions and unconfirmed suppositions.” Esteemed British psychiatrist Sir Aubrey Lewis went so far as to suggest, “It may well be that obsessional illness cannot be understood without understanding the very nature of man.” OCD has a self-destructive aspect that eludes analysis in terms of a normal, mechanistic process gone awry.

  In Western culture, the time-honored explanation for obsessions and compulsions has been that they are caused by attacks from the Devil. The psychologist and philosopher William James noted, “The lives of the saints are full of blasphemous obsessions, ascribed invariably to the direct agency of Satan.” This view, it must be admitted, does have a certain logic, since obsessions are, it is true, experienced as coming from outside of us and forcing themselves upon us. In any case, it was not challenged until the late 1700s, when psychiatric disorders first began to be approached from a medical standpoint.

  Early medical theories on the cause of OCD involved a certain “psychic energy,” which was thought to flow through the nerves just as blood flows through the veins. The most authoritative psychiatric textbook of its day, Henry Maudsley’s Pathology of the Mind, published in 1895, described obsessions and compulsions as resulting from “lowered energy in the inmost elements of the mental organization.” OCD was due to “sluggish molecular processes” that caused a “lack of nervous vitality.” Maudsley attributed the problem to heredity.

  At the turn of the century, the great French psychiatrist Pierre Janet published the most complete work ever written on obsessions and compulsions, the extraordinarily detailed and insightful two-volume Les obsessions et la psychasthenia. Janet hypothesized that OCD was caused by a selective loss of psychic energy in the highest mental functions, those dealing with will and attention. Such advanced capacities required more mental energy, he suggested, than lower functions such as emotions, memories, and muscle movements. Janet likened the various mental capacities to different types of machines: the more complicated, the more energy required to run them. Thus when mental energy ran low, a condition Janet termed psychasthenia, the capacities of will and attention were affected first. The result was exc
essive doubt and a loss of control over voluntary behaviors—symptoms of OCD. Janet’s observation that uncertainty is central to OCD was particularly astute. In France, OCD is sometimes still referred to as la folie de doute, the doubting disease.

  Yet it was Sigmund Freud’s psychoanalytic hypothesis of obsessive-compulsive disorder that became widely accepted in America. Freud published fourteen major papers on OCD, more than on any other topic, and he left us the most complete and famous case history of the disease, his 1909 analysis of “Rat Man,” which will be discussed in Chapter 11. Like his predecessors, Freud espoused the idea of psychic energy. To Freud, however, it was not an insufficiency in this regard that caused OCD; rather, it was that energy became bottled up in the unconscious and could not get out. Freud taught that OCD began in childhood when a boy or girl instinctively wanted to behave in a sexual or aggressive manner but was prevented by a parent from doing so. The resulting parent–child conflict, if not satisfactorily resolved, resulted in “repression” of the conflict, as well as of the conflict’s energy, into the unconscious. This energy, needing to be discharged, was finally released later in life through pathological attachment to various thoughts and behaviors, turning them into obsessions and compulsions.

  By the time I was in medical school, most psychiatrists favored a derivative of Freudian theory referred to as “ego psychology.” Developed by Heinz Hartman, George Vallient, and others in the 1950s and 1960s, ego psychology emphasizes the present rather than the past and stresses the importance of unconscious defense mechanisms—dynamic, basically adaptive mental devices that serve to keep people from being overwhelmed by conflicts between instincts, internalized prohibitions, and the real world. Ego psychology attributes OCD’s symptoms mainly to troubles with three defensive mechanisms: intellectualization, where an instinctual wish is let into consciousness without accompanying feeling; displacement, where feelings are redirected from the object that caused them to another situation or person; and reaction formation, where a person’s behavior is diametrically opposed to an unconscious impulse.

  None of these theories, in my opinion, gets to the heart of OCD’s mysterious, self-defeating nature. Those of us who have suffered OCD know from our own experiences that obsessions have less the feel of defensive maneuvers than of enemy attacks. In that sense, none of these medical hypotheses account for obsessions and compulsions as well as attributing them to Satan.

  Fortunately, the last twenty years have seen a burst of scientific research into the nature of obsessions and compulsions. Much of the work has been carried out by clinical and experimental psychologists using behavioral, rather than psychoanalytic, or Freudian-based, approaches. In general, what behaviorists study is that which can be readily observed and measured. Behaviorists avoid the unconscious—in fact, many do not believe it exists. These studies do not provide a final answer to the mystery of OCD, or even a single unifying theory for obsessions and compulsions, but the results from four very different areas of research do offer clues that, when taken together, add up to what I think, and my patients by and large agree, is an objective view of OCD that is useful and makes sense.

  CLUE 1: INTRUSIVE, UNACCEPTABLE THOUGHTS ARE COMMONPLACE

  To lay a foundation for making sense of OCD, it is first of all necessary to understand that the thoughts that plague OCD sufferers are not, by themselves, abnormal. In 1978, psychologist Stanley Rachman of the University of British Columbia, the world’s leading authority on obsessions and coauthor of the 1980 text Obsessions and Compulsions and the 1992 reference Obsessive-Compulsive Disorder: The Facts, asked 124 students, hospital workers, and nurses: “Do you ever get thoughts or impulses that are intrusive and unacceptable?” Fully 80 percent answered yes, they had such thoughts, usually at least once a week. Dr. Rachman and his coworkers then transcribed these “unacceptable thoughts” on paper and compared them with the obsessions of OCD patients. Guess what? The experts could not tell the difference between the unacceptable thoughts of average people and the obsessions of OCD patients.

  Take a look at a sample taken from Rachman’s classic study. These are intrusive, recurrent thoughts that people recognize as inappropriate and that they do not want to think. Yet most of us have at least one or two of them regularly. I’ve had four of these myself. See anything familiar?

  THE MOST COMMON UNACCEPTABLE THOUGHTS

  1. Urge to jump onto the rails when the train is approaching.

  2. Urge to disrupt peace in a gathering.

  3. Identifying with a person being executed.

  4. Image of family being greatly harmed by chemicals.

  5. Urge to be violent toward small children.

  6. Image of walking along and suddenly discovering you’re naked.

  7. Image of accident occurring to a loved one.

  8. Urge to jump in front of a bus.

  9. Urge to commit “unnatural” sexual acts.

  10. Urge to jump from the top of a tall building.

  11. Urge to crash the car when driving.

  12. Idea that harm has befallen someone near and dear.

  13. Wishing that someone close to you will be harmed.

  14. Urge to commit a robbery.

  The remarkable conclusion is this: The large majority of people experience thoughts that are exactly the same in content as obsessions. This has now been verified by over a dozen studies. For instance, a 1992 study detailed the percentages of all people who report fifty-two different types of unacceptable thoughts. Here is a sampling:

  • 55 percent of us have impulses to run our cars off the road.

  • 42 percent of us have urges to jump from high places.

  • 25 percent of us have ideas that our phones are contaminated.

  • 13 percent of us have images of exposing ourselves in public.

  • 13 percent of us have thoughts to fatally stab friends.

  • 8 percent of us have unwanted impulses to stab family members.

  Almost everyone experiences unwelcome thoughts—the guy walking down the street, the woman in front of you at the supermarket—it’s just that for most people these thoughts cause no problems. They are normal, and that single fact is for OCD patients often the most comforting insight gained from months of therapy.

  CLUE 2: INTRUSIVE, UNACCEPTABLE THOUGHTS ARE MADE WORSE BY TRYING NOT TO THINK THEM

  A well-known experiment makes clear an important mental law. The Russian novelist Leo Tolstoy wrote that when he was a child, his older brother once dared him to stand in a corner until he could stop thinking of a white bear. The difficulty involved in carrying out this challenge impressed the young Tolstoy greatly. Indeed, trying not to think of a particular object sets into motion a frustrating, and intriguing, mental procedure. Wherever you are, just stop reading, and for the next thirty seconds, TRY NOT TO THINK OF A WHITE BEAR.

  Done? Were you able to do it? Not likely. Psychologist Daniel Wegner devotes an entire, fascinating book (White Bears and Other Unwanted Thoughts) to the implications of this test. In a 1987 experiment at Trinity University in Texas, Wegner studied two groups of students. One group heard a talk about white bears, the other was told not to think about them. As you might guess, the group told not to think about white bears had bear thoughts throughout the day, whereas the other group rapidly forgot about bears. Not only that, but in a second phase of the experiment, when the two groups were both instructed to think white bear thoughts, the group who had previously been told not to think such thoughts had many more thoughts of bears.

  Other experiments have demonstrated similar outcomes. Researchers in England instructed a group of subjects to stop thinking troublesome, intrusive thoughts by switching their attention to another thought; then they compared these results with those of a matched group instructed to endure such thoughts. Later in the day, the group that had tried to avoid the intrusive thoughts experienced a much stronger recurrence of them.

  The point is, when you try not to think a certain thought, whether by putt
ing it out of your mind or by forcing your attention to something else, you only end up, eventually, focusing on it more intently. This psychological law explains a number of seemingly paradoxical findings: that people who try not to think about a deceased spouse take longer to get over their loss; that surgery patients who try not to think about an upcoming operation can become more upset afterward; that dieters who try to escape thoughts about food can be the most likely to go on binges and become overweight; and that incest victims who actively block out thoughts of their traumas are those most tormented by intrusive memories.

  Why do our minds bring back painful thoughts against our will? Studies of post-traumatic responses offer a hint. Pilots returning from combat missions, it has been shown, often replay a battle over and over in their mind’s eye before they can let it go. People who have witnessed a terrorist attack frequently suffer intrusive thoughts and nightmares until they adjust. Rape victims develop flashbacks until psychological healing occurs. It is clear that instant replays of traumatic events are somehow necessary for our adapting to them.

  The landmark studies on post-traumatic thoughts were done by psychiatrist Mardi Horowitz at the University of California in 1977. Students were shown grisly movies of industrial accidents, such as machine operators getting their fingers sawed off. Afterward, the students had intrusive unpleasant images of the accidents, images that recurred over and over, until gradually they began to lose their unpleasantness and fade away. Horowitz concluded from his experiments that some sort of “mental processing” is necessary for us to come to terms with traumatic memories.