Tormenting Thoughts and Secret Rituals Read online

  Like most OCD specialists, I routinely treat OCD with a combination of behavior therapy and serotonergic medications. Happily, the two cause no problems when used together. On the contrary, each seems to enhance the effect of the other. According to John Greist, M.D., OCD specialist from University of Wisconsin, “Medications and behavior therapy now are able to help 90 percent of people with OCD.” This in a disorder recently thought to be hopeless.

  My field of psychiatry—the branch of medicine that once brought you lobotomies and penis envy—has been getting things right lately. Tremendous progress has been made in the understanding and treatment of a number of syndromes, including schizophrenia, bipolar disorder, major depression, panic disorder, and attention deficit disorder. The advances in obsessive-compulsive disorder are the most impressive of all.

  A good case can be made, in fact, that no other disorder in the history of medicine has ever experienced such an explosive growth in scientific understanding that has led to such a revolution in how it has been viewed: from regarded as rare to recognized as common; from presumed psychological to proven neurobiological; from written off as hopeless to accepted as one of the most responsive of all mental disorders to therapeutic interventions. All this has happened to OCD in about twenty years.

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  FILTH, HARM, LUST,

  AND BLASPHEMY

  Obsessive-compulsive disorder can now be understood on a neurobiological level, yet its symptoms still seem altogether mysterious. How could I, in one of the best times of my whole life, suffer bloody images of stabbing myself? Sir Aubrey Lewis, the greatest English psychiatrist of the twentieth century, was struck by OCD’s apparent contradictions “between kindness and cruelty, logicality and unreason, fear and desire,” and by its overwhelming “variety of problems and the difficulty of stating them.”

  People who have never suffered the ravages of obsessions and compulsions can best get a sense of their puzzling power by examining clinical cases. This chapter presents four case histories, typical of severe OCD, that illustrate how the battle in the mind can come to rule peoples’ lives. Commenting on the extreme variety of obsessions, Lewis concluded in 1935 that most could be grouped under four general categories: filth, harm, lust, and blasphemy.

  OBSESSIONS OF FILTH: RAYMOND

  On a hot summer day in June 1993, I shook hands with Raymond and escorted him into my office. He was a short, broad-shouldered man dressed in rugged work clothes and a baseball cap; his heavily lined face and shabby gray hair making him look ten years older than his forty-two years. Despite a somewhat rough demeanor, however, he spoke in a soft, gentle manner, with an exaggerated politeness.

  “Doc,” he began, “I’ve dealt with awful fears for over twenty years.”

  He proceeded to describe in enthralling detail—he was, I soon discovered, an accomplished storyteller—his twenty-five-year struggle with obsessions and compulsions. Fears that his hands were infected had caused him to wash and scrub them until they bled. Doubts that he might have committed the “unpardonable sin” had led him to innumerable consultations with ministers and friends regarding the use of birth control. Bloody images of people lying injured by the side of the road had almost made him give up driving. “Have you ever driven to Harrisburg a hundred yards at a time?” he asked. One evening, after finishing the two-hour trip home from our state capital, he became so distraught by the idea that he might have hit someone along the way that he spent the rest of the night completely retracing his journey, stopping every hundred yards to check whether someone lay critically hurt by the roadside.

  Yet Raymond had conquered these and many other irrational fears by summoning all of his will power and standing up to them. He had forced himself to live with dirty hands. He had purposefully scheduled long drives every weekend.

  Now, however, Raymond was beat. “My mind is handing me a crushing vision that I can’t get rid of,” he said. “I’m physically worn out from fighting it.”

  This new vision had started, Raymond explained, when he had taken his family to visit Disneyworld during Christmas vacation. On the second day, while walking through the vast, darkened Met-Life pavilion, he suddenly had the thought, “What if a disaster were to strike here at Disneyworld?” With an immediate heightened, focused acuity he heard Hispanics speaking in front of him and Germans behind him—over a million people visited each year from all parts of the globe, he had been told. Surely it would be a worldwide catastrophe. At that exact moment, having just caught a glimpse down a long, crowded corridor, a dreadful vision “jumped,” as he put it, into his mind. In the middle of the corridor, a bucket, a jar—some sort of a container—was turning over and spilling contaminated material. Feces, germs, vile diseased substances, poisons that could cause devastation, were gushing along the floor.

  Raymond knew rationally that this vision was a figment of his imagination. It was his mind presenting him with another “killer fantasy.” The others had never come true, he tried to tell himself, and this one wouldn’t either. Yet the strength, intensity, and persistence of this particular image overwhelmed him. It was, as Raymond put it, an “enormous heart-burden” that took his breath away. If a spill had occurred, and if he was the only one who knew about it, then the lives of thousands of people depended on his locating it. This electrifying realization prodded him, propelled him into taking immediate action.

  Telling his family to wait by an exit, Raymond turned back to the corridor. He walked up and down, inspecting the carpet closely to make sure there were no telltale signs of dampness to indicate a poisonous spill. He wanted to get down on his hands and knees and go over it inch by inch, but he settled for kneeling down and touching the carpet a couple of times, rubbing it here and there, to make certain it was perfectly dry. Once satisfied, he returned to his family. A minute later, though, there was another long corridor, another vivid, fearful image, another reason to go back and check. The images kept coming, one dreadful spill after another.

  That night, as he lay in his hotel bed, the rest of the family asleep, tears flooded Raymond’s face. How could he slip away to check all these places? How could he live with himself if he didn’t? Disneyworld, he reflected, had turned into a den of horrors. He tried to calm down by telling himself that things would be better when he got home. Then he would be able to look back and see that all these fears had been imagined.

  But in the following days, gut-wrenching spill visions were continuously on his mind; when one began to fade, another took its place. Raymond fought to keep himself from checking. He was embarrassed by his excuses (“I need to get a drink,” or “I want to go back and see that last exhibit again”), especially when his wife fixed him with what he called the “oh-no-not-again look.” Yet the tormenting images drove him to glance furtively down every corridor, to walk back to scout for menacing spots frequently, to slyly brush floors with his hand, to nonchalantly, but firmly, rub carpets back and forth with his feet (this last ritual, Raymond realized, made no sense at all since he could not detect wetness through his shoes, but it somehow helped his mind to “click” and be assured that there had been no spill).

  Still, arriving home in Pennsylvania after the vacation, Raymond was optimistic. He prided himself on his mental strength. Hadn’t he kept his fears pretty much a secret for twenty years? Even his family was unaware of their true severity. Indeed, Raymond was known for his coolness under pressure in his job as railroad mechanic and as “Mr. Reliable” in his hometown of Altoona, Pennsylvania, where he was at once Sunday school superintendent, president of a fishing club, and leader of both an Explorer post and a Cub Scout den.

  Yet in the six months since his return from Disneyworld, spill visions had been relentless, and the rituals Raymond was driven to perform had become increasingly complex and time-consuming. By the time he came to see me, Raymond said, checking compulsions were taking two to three hours a day.

  A typical day would begin with clear and powerful spill fantasies charging into his consc
iousness at the ring of his alarm at 6 A.M. Someone had entered the house and urinated on the floor, or had poured out some poisonous substance. A rush of adrenaline would tense his muscles and speed his breathing. He had to check. If he didn’t, the intensity of these images would increase until he was shaking uncontrollably, hyperventilating with anxiety.

  First, Raymond would carefully inspect the outside doors, bolting and unbolting them several times until, as he put it, his mind “got to some high ground” from where he realized that it was very unlikely that somebody had entered the house during the night. The relief was only momentary. Attacked again by a vision, he would rush to his son’s room, painstakingly examine the bed, carpet, chair, dresser, touching, patting, rubbing to make sure there had been no spill. Before leaving the room, he would say to himself, softly, slowly, deliberately, to make himself stay convinced: “Okay, I’ve thought that one out flat. There’s no spill in the boy’s room.” Then he would walk quickly to the other bedrooms, the bathrooms, the basement, the living room, and take a glance in the kitchen.

  With the completion of these rituals, a “safe, warm feeling” would remain with Raymond for a while, allowing him to shave, dress for work, and eat breakfast in relative comfort. But once ready to leave his house, he would again be assailed by fears. Over by the toaster, was there anything there? No. Just the toaster. What was on the breakfast table? Any dampness? If the table top was clear, Raymond ran his hands across its surface systematically, covering every spot. (It was easier for Raymond if the table was crowded with objects because then he could focus on them. “Okay, Cheerios and yesterday’s mail,” he could tell himself and be satisfied. But if the table was empty, it was agonizing.) Finally, halfway out the door to work: “Did I check the corner of the living room? Did I look closely enough at the stove burners?” Most mornings, Raymond was out the door and back at least six times before finally being able to leave for good.

  The drive to work was filled with devastating spill fantasies, triggered by trucks “whooshing by” and kicking up dust. Suddenly, a menacing scrub bucket, a container of disease, was sitting in a hallway at his child’s school. Raymond would be jolted by an urge, an overwhelming responsibility, to check the school. He would fight the urge with all his strength, remembering that if he gave in he would be late to work. But then a conflicting agony would assault him, just as bad: “If I don’t check, how am I going to live with the pain of this fear all day?”

  At first Raymond had been able to deal with these particular fantasies by simply telling himself strongly that they were not real. When that strategy started to fail, Raymond found that if he shook his head, or whistled, he could distract himself from his scrub bucket fears long enough to turn his thoughts to pleasurable subjects, like hunting or car racing. When that, too, began to fail, Raymond found that if he promised himself to check the school later in the day he could keep from needing to check at the moment. When postponement stopped being effective, however, Raymond discovered that the only way to lessen the force of the visions, the only way that he could keep himself from running to the school, was to perform a complicated part-mental and part-physical ritual that he was initially too embarrassed even to mention to me.

  In this ritual, Raymond first confined the spill by focusing his imagination on a tiny, very specific place in the hallway of the school. He “tied it down,” as he put it, by repeating to himself slowly, “The whole spill’s right there on that spot.” Then he pictured as clearly and vividly as he could a huge vacuum cleaner hovering in the air over the spill and sucking it up in one huge gulp. To add emphasis to this counterimage, he made loud “whooshing” noises as he breathed rapidly in and out; and he flailed his elbows up and down as he held on to the steering wheel. That a passerby might observe him in the midst of this ritual terrified him. The cleansing tornado worked 90 percent of the time, but when it didn’t, Raymond had to turn his car around and go check.

  When he finally arrived at work, Raymond would be much relieved. The familiar routine at the railroad works and the small talk with his coworkers drew his mind away from his fears. He still took frequent glances down hallways, and on a bad day he might have to call his wife, risking her annoyance, to ask her to feel the bed in his son’s room, but these were relatively minor problems.

  Returning home after work, however, brought back crushing obsessions. “As soon as I walk in the door,” Raymond said, “I have the overwhelming sensation that the food in the refrigerator has been tampered with. I know it’s extremely unlikely that anyone could have entered the house, but I have to check anyway.” He would check the milk, the Kool-Aid, a half-full bottle of Coke, by carefully pouring a small amount into the sink to make sure there was nothing floating at the top. Then he checked for spills in every room in the house. If his wife was at home when he arrived the process was more difficult because he had to try to disguise and make excuses for the many rituals. Dinnertime meant sudden, piercing visions of disease organisms hidden at the bottoms of drinking glasses. Evenings brought more spill fantasies, worst of all when he had to leave his house for Scout meetings or church events, situations ripe for countless catastrophes. Raymond dreaded going out after dinner. He welcomed any excuse to stay home. Rainy days were good. Thunderstorms were great.

  Evenings finally brought on a new, excruciatingly embarrassing compulsion, the “last straw,” which led to Raymond’s coming to see me. The vision would strike of one of his children drinking something that had been poisoned or was “filled with disease.” Sitting on his daughter’s bed, he would ask, “What did you have in here to drink, Kristy?” “Nothing, Dad,” his daughter would reply. But Raymond would persist, “You’re sure there wasn’t anything sitting here on the bureau?” “I’m sure, Dad.” Relieved, Raymond would walk out, but no sooner did he get out the door than he would turn around and ask her again. “Come on, Dad!” his frustrated daughter would yell. Raymond badgered his children until they shamed him into leaving them alone, but later on, when the embarrassment had faded and the fearful image came back strong, he would hang his head and ask them again.

  “Raymond,” his wife told him at last, “you’re driving the kids crazy. You’ve got to get help.”

  OBSESSIONS OF HARM: SHERRY

  Sherry squeezed in her appointment with me between Catholic Mass, where she was a lector, and the Art Alliance meeting, where she was the secretary. Every minute of her day was filled with activity, and that’s the way she liked it—always helping others, the busier the better. Yet her overscheduled life was crumbling. She could no longer shove aside the horrors that were occurring in her own mind.

  Petite and blond, hippie-looking but stylish, in jeans and a shawl, she rushed into my office, yanked her chair up close, leaned in, and took a deep breath. “I’m so scared,” she confided. “I have terrible thoughts. I think of killing people. I think of stabbing my husband and my four year old, Megan. Driving over here I saw a little girl walking home from school, and I had the urge to swerve and hit her. Last night we drove by our old house, and my husband remembered that we still had the key to it. I started thinking: ‘Oh good, we could sneak in at night and stab everybody.’ I’m totally sick.

  “Some days I can’t think about anything else,” she said, speaking more rapidly. “No thought is too awful for me. Sometimes I get the idea of gouging my daughter’s eyes out. I used to think about throwing her in the microwave, but she’s too big for that now, thank God. This morning I was shaving my legs in the shower, and I felt like cutting myself, slashing my neck open with a razor. I saw the blood pouring from my neck.”

  She leaned back and gave me a glassy look. “God, this sounds so crazy. I don’t want to do these things I think about. At my worst moments, all I hold on to are God and Jesus. When will this hell I’m in end?” She sat quietly, wiping away tears.

  I asked gently when these upsetting thoughts had started. Sherry related that she had been tormented by obsessions since age eleven, when, while baby-sitting, she
had her first dreadful obsession. She was sitting on the kitchen floor, serenely watching her six-month-old niece rock back and forth in a swing set. Then, by chance, her eyes came to rest on a carving knife lying unsheathed on the kitchen counter. Suddenly, in her imagination, she grabbed it and slashed at the baby. Blood was everywhere. She froze in anguish and guilt. Her life was never the same.

  Each night for a week afterward she dreamed that an evil witch had cast a spell on her mind. Finally confiding in her parents, she was taken to a therapist. A year of psychotherapy aimed at uncovering conflicts helped her feel better about herself but did not stop the tormenting images. “Why me?” she thought.

  Knife fantasies continued to trouble her throughout junior and senior high school, and new obsessions cropped up as well. She learned to keep herself as busy as possible. As long as she was involved in an activity, the self-tormenting thoughts would usually leave her alone. If, however, she put herself under too much stress, then frightening thoughts would hit hard, like when she tried out for cheerleader and suffered terrifying urges to scream out obscenities at the top of her lungs. She made the team by keeping her teeth clamped together like steel traps; her jaw muscles ached for days afterwards.

  In college she majored in art after discovering that her obsessions disappeared when she was fully involved in a creative task such as painting. Yet most hours of the day tormenting, violent thoughts were her secret companions. Thoughts to commit suicide were often on her mind as well. Strangely, these were usually consoling in their effect. “If my awful thoughts get too strong,” she would think, “I can always kill myself before I murder someone else.”

  Her worst period ever followed the birth of her daughter. Overwhelmed by almost every awful harm obsession imaginable, including knifing, dropping, scalding, microwaving, and sexually molesting her infant, she developed a state of nervous exhaustion. She couldn’t eat or sleep and finally just stayed in bed, leaving caring for her daughter to others.