Tormenting Thoughts and Secret Rituals Read online

  Horowitz hypothesizes that this processing is carried out through a computerlike, match-mismatch mechanism for assimilating and accommodating new information. When the memory of a traumatic event comes to mind, it is compared with preexisting wishes and fears and appraised in relation to coping capacity. If there is a match, if the memory harmonizes with preexisting associations about the self and the world, then the memory is quickly stored. But if there is a mismatch, if the post-traumatic memory does not fit with existing information, then a process is initiated by which additional associations are formed, integrating the new information with the old.

  Horowitz’s theory is used to explain a number of current therapies for post-traumatic stress syndrome. The widely publicized technique EMDR, eye movement desensitization and reprogramming, for instance, utilizing the idea that REM sleep is the prime time for processing of post-traumatic memories, seeks to speed up the processing by inducing eye movements similar to those of REM sleep. EMDR’s founder, psychologist Francine Shapiro explains: “When a trauma occurs, the processing mechanism gets disrupted. By inducing the eye movements, we accelerate the processing.”

  Most experts now agree that obsessions, like post-traumatic thoughts, repeat themselves again and again in order to be further processed. If you try to bypass this mechanism, to skip out on the replay of a painful thought, the result is that the thought is brought back again, and even stronger, so that next time you’ll let the processing be done. Harvard’s Pitman concludes in a 1987 review article, “The core problem in OCD is the persistence of mismatch.” It is a person’s inability to complete the processing of intrusive, unacceptable thoughts that lies at the heart of OCD.

  Thus, an obsession is a struggle between a part of the brain that wants to dismiss an unacceptable thought from consciousness and another part that wants to process it further. The word “obsession” is, after all, derived from “to besiege.” It’s a battle.

  CLUE 3: OCD SUFFERERS EVALUATE UNACCEPTABLE THOUGHTS WITH AN EXAGGERATED SENSE OF PERSONAL RESPONSIBILITY

  We have seen that it is normal for unacceptable thoughts to come to mind and also normal for them to recur and to increase in strength when people try not to think them. What, then, makes OCD sufferers turn these “normal” thoughts into self-tormenting obsessions? What makes them the people who fall into white-bear traps?

  Evidence mounts that a basic abnormality of OCD sufferers lies in the way they evaluate their thoughts. Pioneering researchers in cognitive psychology, including psychiatrist Aaron Beck and coworkers at the University of Pennsylvania, demonstrated in the 1960s and 1970s that there is an automatic, almost instantaneous, evaluative process lying outside our awareness that assigns different levels of importance, or attentional value, to intrusive thoughts. Researchers applying cognitive psychology’s findings to the development of obsessions have concluded that, as Stanley Rachman put it, “Intrusive, unacceptable thoughts become unduly significant only to the extent that the affected person attaches special meaning to them. The majority of people dismiss or ignore their unwanted thoughts and regard them as dross. However, once a person attaches important meaning to these unwanted thoughts, they tend to become distressing and adhesive.”

  Most people seem to approach their intrusive, unacceptable thoughts with an attitude something like: “There’s another nutty thought. I’m not going to let it bother me.” Dr. Rachman tells the story of a memorable subject, a young female psychology student who routinely experienced “outrageously promiscuous and violent unwanted images and urges.” Although they may have been shocking to the examiners, these ideas didn’t trouble the young woman at all. “Her tolerance for thoughts and impulses that most people would regard as antisocial or immoral,” the researcher noted, “was seemingly unlimited.” But that’s not the way it is for OCD sufferers.

  In the last decade, research by psychologist Paul Salkovskis of Oxford, England, and by other scientists in Cambridge, England, as well as in Canada, Australia, and the United States, has identified a single, specific abnormality in the way OCD sufferers evaluate their intrusive, unacceptable thoughts. As mentioned in Chapter 3, OCD sufferers tend to take excessive personal responsibility for the bad things they think might happen. Salkovskis puts it this way: “Obsessions occur when patients interpret the occurrence and content of an intrusive thought as an indication that they might be responsible for harm to themselves or others unless they take action to prevent it.”

  This theory—referred to by Rachman in a 1992 review article, “Obsessions, Responsibility and Guilt,” as the most significant advance in our understanding of OCD in a decade—seems so logical it’s a wonder nobody thought of it before. Consider the most common obsessions: contaminated hands, a stove left on, a forbidden sexual attraction, blaspheming God. All involve a negative consequence that might come about if the thinker doesn’t act to prevent it. Significantly, obsessions never involve fearful consequences that are beyond peoples’ control, like earthquakes and floods. And most compulsions—washing over and over, checking excessively—can be easily seen as irrational acts resulting from a need to take action personally in order to prevent a negative outcome.

  Only a few relatively uncommon obsessions seem to fall outside the area of personal responsibility for harm: a song, for instance, that keeps coming back into the mind despite repeated attempts to cast it out. Here, the OCD sufferer manages to turn what is initially innocuous into a cause for alarm. And although there are compulsions, such as counting, tapping, and arranging objects symmetrically, that are not obviously associated with preventing any sort of harm to self or others, most of these are driven by obsessions whose theme of preventing harm is readily recognizable. For instance, I see a young woman who, ever since childhood, has been compelled to tap her fingers in a ritualized manner at least several times every day because of a feeling, recognized by her as irrational, that if she doesn’t, harm will come to her parents.

  Salkovskis’ insightful hypothesis explains a number of puzzling aspects of OCD. Betsy, a homemaker and mother of three who suffered from depression and obsessive-compulsive disorder, was one of the first patients admitted to our new mental health unit at Centre Community Hospital in State College. After a week on the unit, she developed an irresistible compulsion to set off fire alarms and detonated an ear-piercing whistle several times a day. Betsy explained that a picture would flash into her mind of a cigarette starting a chair on fire and igniting a blazing inferno. She knew it was unreasonable to pull the alarms, and she apologized every time she did it; yet she could not be reasoned out of her compulsions. Eventually the fire alarms had to be relocated.

  That case will forever stick in my mind because, as director of the new mental health unit, I was that very week making promises to hospital administrators, and to the staff of the coronary care unit on the floor below, that our patients would never cause problems for the hospital. Our nurses and counselors, I assured everyone, could handle even the most agitated and boisterous patients without disturbing a single soul. But I hadn’t reckoned on Betsy’s irrational feelings of responsibility.

  Why did she continue to set off the alarm when she knew there was no fire? Salkovskis’ hypothesis helps us understand how the personal responsibility Betsy felt for preventing a possible disaster robbed her of a sense of perspective, took away her ability to assess the situation clearly. Betsy felt that if a fire did start, admittedly a one in a million chance, she would be responsible for the deaths of many people. She felt this as a deep, gut-wretching guilt comparable in intensity, perhaps, to a rage that overwhelms reason.

  The prominent role of feelings of responsibility and guilt in the genesis of obsessions helps explain another puzzle, which is why OCD sufferers have so much trouble expressing, even feeling, anger. People with OCD, as discussed in Chapter 4, tend to be timid and nervous, seldom hot-blooded or impulsive. The key is that: while anger is blame directed outward, a person with an excessive sense of personal responsibility directs blame w
ithin, producing guilt. OCD sufferers are hard-wired to feel a lot of guilt and little anger.

  But back to Betsy. Why did she wait a week before she started setting off those fire alarms? Actually, it is a common pattern. OCD symptoms are often mild during the initial part of a hospitalization. Salkovskis’ hypothesis, again, helps us to understand why. When Betsy first arrived on the unit, a strange place full of strangers, she took little responsibility for what happened. But as she made friends and became familiar with our unit, she slowly began to feel more and more accountable, and this soon led to obsessions.

  Typically, OCD sufferers do well in new places. On a short vacation, there may be a complete absence of symptoms. In a related way, OCD sufferers often fare much better when the responsibility for a troubling task is given to another person. Clinically, it can be helpful to transfer responsibility for, say, checking the doors at night to a spouse. Conversely, OCD sufferers do most poorly when personal responsibility is magnified. For this reason, the birth of a child, particularly a first child, sometimes sets off the illness.

  Putting together clues one, two, and three allows us to make some sense of obsessions. Intrusive, unacceptable thoughts are not the problem. Rather, it’s the way they are evaluated. A pathologically elevated sense of personal responsibility causes the OCD sufferer to bring certain thoughts back into consciousness again and again. Recognizing them as senseless, he or she tries not to think them, but in doing so, he or she falls into the white-bear trap, and the thought dismissed comes back stronger. It is a vicious cycle that escalates normal intrusive, unacceptable thoughts into pathological, self-tormenting obsessions.

  What about compulsions? Can sense be made of senseless rituals? Compulsions follow from obsessions—they are safeguards, attempts to neutralize, to put at ease, the irrational ideas, images, and urges for which OCD sufferers feel excessively responsible. As Salkovskis notes, “Compulsions are attempts to put things right, and avert the possibility of being blamed.” Yet since compulsions don’t work, and since they are time-consuming, demoralizing, embarrassing, and sometimes physically painful (as in the case, for instance, of excessive hand washing), why do people continue to perform them?

  One fact that has long been clear both clinically and experimentally is that compulsions are made stronger because in the short run they do lessen anxiety. Behavioral psychologists refer to this as “negative reinforcement.” OCD sufferers who are, for example, tormented by intrusive, unacceptable thoughts that the gas jet is left on will be temporarily relieved after checking it a certain number of times. And even though they recognize that the checking is senseless, the next time the same obsession hits they will check again.

  Yet, it seems improbable that negative reinforcement by itself would be strong enough to build up, against a person’s will, unbreakable and harmful habits. Furthermore, the principle of negative reinforcement does not explain why compulsions are so eerily stereotyped, performed exactly the same time after time. As psychologists Ricciardi and Hurley note in a 1990 review, “[The principle of reinforcement] cannot adequately explain the mysterious order that surrounds the apparent disorder within OCD.”

  CLUE NO. 4: COMPULSIONS CLOSELY RESEMBLE FIXED ACTION PATTERNS IN ANIMALS

  Female canaries reared from birth in cages containing manmade nests of felt will at certain times in their breeding cycles start methodically gathering any pieces of string that are placed in the cages and systematically weaving them together into nests. All female canaries will do this, whether they are raised in the wild or in complete isolation, and they will always do it exactly the same way. This is referred to as a nest-building ritual. Cats lick their faces and paws in just the same manner many times a day, an example of an auto-grooming ritual. Male fiddler crabs perform elaborate movements, invariable in form and timing, with one of their two claws before mating: a courtship ritual. Other common animal rituals involve defensive shows, elimination behaviors, and food gathering and burying. All are “fixed action patterns,” behavioral sequences that are always carried out in exactly the same way and that, once started, are carried out to completion.

  Nobel Prize-winning Austrian zoologist Konrad Lorenz first described such fixed action patterns more than fifty years ago. He observed that these rituals of behavior are performed at specific times: when they are helpful for the animal. They are adaptive, indeed essential, behaviors, as they allow important sequences of movements to be carried out automatically in a myriad of situations, enabling quick, appropriate responses. Lorenz concluded that fixed action patterns are instinctive, behavioral programs stored in the brain that are incorporated into the genetic makeup of animal species through the process of evolution.

  Of great interest is the fact that fixed action patterns may be set off when they shouldn’t be, especially in stressful situations. For instance, in experiments where rats are given inescapable foot shock, they may start auto-grooming—clearly a maladaptive response. Similarly, dogs under stress may, for no apparent reason, start compulsively licking their paws, a sometimes injurious response that can lead to painful, raw sores, a veterinary ailment called acral lick dermatitis.

  Do human beings have fixed action patterns? An untold number. Not only do we perform the equivalent of nest-building, auto-grooming, and many other animal rituals, but also, it turns out, many simpler muscle actions that were previously assumed to be chain reflexes are actually fixed action patterns, as well. Swallowing, for example, far from a simple reflex, involves a brain program that intricately times and coordinates contractions of at least eleven different muscles.

  Experts speculate that compulsions represent our own inappropriately discharged fixed action patterns. This theory is advanced by Dr. Judith Rapoport, among a number of other leading experts. In a paper titled “Hand-washing People and Paw-licking Dogs,” Rapoport suggests that both people and dogs groom themselves on the basis of fixed action patterns that are hard-wired into the brain and that compulsive hand washing in people and excessive paw licking in dogs occur when auto-grooming rituals are inappropriately activated. I like the simple way Harvard’s Roger Pitman puts it. There are two primary brain systems that drive behavior, Pitman says, an advanced memory system, which incorporates rational thinking, and a primitive habit system of fixed action patterns. Compulsions occur when the habit system overrides the memory system.

  What evidence supports this hypothesis? As mentioned, the similarities between human compulsions and animal fixed action patterns are striking, both in form and content. Both are carried out in uniquely stereotyped manners that, once started, have to be executed to completion. Both involve the same basic issues: showering, bathing, and toothbrushing compulsions correspond to licking and biting auto-grooming rituals; hoarding and collecting compulsions bear similarities to nest building; and checking compulsions resemble fixed action defensive behaviors.

  But there is further evidence beyond these surface similarities. Research reviewed in the next chapter proves beyond a doubt that the brain chemical serotonin is in some way involved in causing compulsions. Recently, at least three different research groups have found evidence that changing brain serotonin levels in animals results in changes in fixed action patterns. Furthermore, some veterinary diseases that are secondary to excessive fixed action patterns, such as acral lick syndrome in dogs and feather-picking disorder in birds, respond to the same medications, the serotonin reuptake inhibitors, that are effective in the treatment of OCD.

  Even more impressive evidence for the link between compulsions and fixed action patterns comes from studies showing that both responses are generated in the basal ganglia, a small, grapelike cluster of cells located in the center of the brain. Research linking OCD to the basal ganglia, reviewed in the next chapter, is so strong that some experts now simply refer to OCD as a “basal ganglia disease.” Animal studies in this area are also robust. Studies by a number of scientists, including noted brain researcher Paul MacLean, involving electric brain stimulation, selectiv
e surgical procedures, and drug experiments, prove the basal ganglia’s role in the development of fixed action patterns. For instance, electrical stimulation of the nerve fibers leading to the basal ganglia increases fixed action patterns, whereas lesions to the basal ganglia can completely eliminate them.

  The striking similarities of appearance in compulsions and fixed action patterns, the prominent role in both of the brain chemical serotonin, and the fact that both are generated in one small area of the brain add up to convincing evidence. Judith Rapoport concludes that compulsions most likely represent the inappropriate triggering of genetically programmed, fixed action patterns that are stored in the basal ganglia of the brain.

  It is now possible to make some sense out of OCD’s mysterious, self-defeating thoughts and senseless rituals. Consider Sherry, the young mother described in Chapter 1 who developed terrible obsessions to stab her child. We may theorize that her obsessions began when her imagination, quite normally, was generating intrusive thoughts about bad things that might happen. The thought came to her of stabbing her baby. Next came the OCD sufferer’s basic irrationality: Sherry felt excessively responsible for the harm that she might cause. An idea that others would have quickly dismissed as irrational and irrelevant filled her with panic. She tried to stop thinking it but got caught in a white-bear trap: by pushing the thought away before her mind had fully processed it, she only guaranteed that it would come back even stronger.

  Or consider the needle obsessions and mental compulsions I developed while in medical school. There I was, a stressed-out doctor in training with an overactive sense of personal responsibility, thinking about inserting needles into peoples’ veins. My imagination was throwing up various intrusive thoughts, and up comes one that the probe might slip in my hand and jab me. Soon, I was seeing an image of the needle jumping from my fingers and plunging through my skin. It didn’t make sense, and I knew that. Needles don’t jump. Nevertheless, the silly image caused a genuine feeling of sharp pain and was distracting. I tried to put it out of my mind. It kept coming back. I had an obsession.