Tormenting Thoughts and Secret Rituals Read online

  By now the original question—Am I doing what’s right in God’s eyes?—had split into a number of more specific questions. Was it right to wear makeup? How about jewelry? As a woman, what was her greatest duty? Should she talk to non-Christians? How long should her hair be? Should it be worn up or down? Were curls all right? “I felt like digging at my skin,” Melissa explained. “I felt sick in my stomach. I felt as though everything would crumble, as though the ceiling would fall in.”

  The Bible verses began to lose their meaning for her, turning into mere incantations. Melissa noted this change: “It got to be silly stuff. I no longer went for what the verses meant. I just said them to block out the questions, to fill the anxiety.” Her choice of the words “to fill the anxiety” was interesting, I thought. It was as if doubt occupied her mind as an ominous void and rituals were the only thing that could give it substance.

  Choosing the right verse now depended more on rhythm and rhyme. Short verses were best. “Love one another” and “Be ye perfect” could be said to a good beat. Sometimes Melissa would consult different translations of the Bible to find the wording that worked best. “Fight the good fight” was better than “I have fought the good fight” because it had a better sound to it.

  After picking a verse she would repeat it over and over until she felt, as she put it, “sort of numb.” She would attempt to say it every second of the day. “People would try to talk to me,” Melissa explained, “but I was a zombie. I’d be trying to finish my verse.” Often in her dorm room she would pace back and forth repeating the verse; at night, she would rock herself to sleep with it.

  Not surprisingly, since the verses no longer held meaning, Melissa eventually began dispensing with them altogether and chanting other things. In the week prior to seeing me, she had started on numbers. She would secretly go to her room: “One and two and three and four and five,” she would chant, getting a good rhythm, sometimes rocking back and forth, sometimes walking in a circle, sometimes saying it faster and faster until she was saying it as fast as she could. At times this was the only way she could escape the anxiety.

  Also severe by the time she came to see me was another type of mental compulsion: the point-by-point, minutely detailed, over-analysis of conversations. Such prolonged trains of unproductive thoughts, done to chase away obsessions, are called compulsive ruminations. Melissa had always been sensitive to other people’s feelings and had for years had the habit of apologizing to people in an overly scrupulous manner for things she feared had come out wrong. By the time she came to me, however, she herself realized that her concerns were out of control. Melissa was picking apart every encounter to see whether she may have been boastful, arrogant, insolent, a gossiper, or a slanderer. She would completely relive the words she had used, her tone and delivery, the other person’s response, the order of speaking, and every other conceivable aspect of the conversation. It was a microscopic analysis that could easily go on for an hour.

  As her disastrous first semester drew to a close, Melissa accelerated her phone calls to ministers, friends, and family. Some days she would make twenty or more calls—not to socialize by now, or even to ask for help in dealing with her problems, but simply for reassurance. Had she fallen away from God? Was she being a good Christian? Had she committed slander? She needed reassurance so that her anxiety could be “filled” for a while. Her calling had become a compulsion, just like the repetition of verses, the counting, and the over-analysis.

  I admired Melissa for the way she had tenaciously struggled to find answers to her never-ending questions. I also respected a certain depth and potential richness in her religious quest. Indeed, it occurred to me that in the early part of her struggles, when, prodded by a vague uneasiness, she had turned to her Bible and prayer, Melissa could have been on a path to rich spiritual growth. Perhaps it is stretching the point too far, but Melissa’s struggles did bring to my mind Saint Augustine’s comment: “Our hearts are restless until they rest in Thee.” But whatever potential there was, it was devoured by obsessive-compulsive disorder. Her questions became foolish obsessions, and her answers were reduced to meaningless compulsions.

  The reader not familiar with obsessive-compulsive disorder may find the cases of Raymond, Sherry, Jeff, and Melissa extraordinary, or even incredible. They are, however, quite typical of the severe cases of OCD that are routinely seen in clinical practice.

  All four of these patients responded well to OCD treatments. The particulars involved in their behavior therapy, group therapy, and medication treatment will be discussed in subsequent chapters. First, however, it is important to understand exactly what mental health professionals mean when they say that someone suffers from obsessive-compulsive disorder.

  2

  DIAGNOSING OCD

  Obsessive-compulsive disorder is the simplest of all psychiatric disorders to diagnose. Unlike major depression, which requires the evaluation of nine symptoms (including depressed mood, diminished interests, weight loss, insomnia, and low energy), or panic disorder, involving the assessment of more than a dozen complaints (such as anxious mood, rapid heartbeat, and shortness of breath), obsessive-compulsive disorder requires the recognition of only two problems: obsessions and compulsions.

  Traditionally, OCD has been diagnosed when a person suffers either significant obsessions or significant compulsions. The most recent research demonstrates, however, that virtually all OCDers actually have both symptoms. A practical, concise, and up-to-date definition of OCD, then, is the following: OCD is diagnosed when obsessions and compulsions interfere significantly in a person’s life.

  WHAT IS AN OBSESSION?

  One major source of confusion must be cleared up right away: The term “obsession” has a totally different meaning for mental health professionals than it does for the general public. In magazines and on television, “obsession” has come to mean just about anything people want it to—as long as it has to do with thinking and carries a negative connotation. Most often, the word is used either for what is more accurately termed a preoccupation, like a coach’s “obsession” with winning, or for an addiction, as in a gambler’s “obsession” with horse racing.

  But these “obsessions,” clearly, have little in common with Raymond’s tormenting spill fantasies, Sherry’s heart-stopping knife thoughts, Jeff’s torturing sexual urges, Melissa’s mind-numbing religious interrogations, and my own thoughts to stab myself. What we suffered were clinical obsessions. This particular meaning of the word stays close to its Latin root, obsidere, meaning “to besiege,” as an army would attack a city for the purpose of forcing surrender. What clinical obsessions represent is, truly, a battle in the mind.

  The first good definition of clinical obsessions was provided in 1877 by the German psychiatrist Karl Westphal: “Obsessions are thoughts which come to the foreground of consciousness in spite of and contrary to the will of the patient, and which he is unable to suppress although he recognizes them as abnormal and not characteristic of himself.”

  A similar, precise definition is found in the official manual of American psychiatry (DSM-IV, see Appendix B): Obsessions are “recurrent and persistent thoughts that are experienced as intrusive and inappropriate and that cause marked anxiety or distress.”

  These definitions highlight the four main qualities of clinical obsessions. Intrusive, recurrent, unwanted, and inappropriate. Occasionally, not all of these characteristics are present, especially in children, chronic OCD sufferers, and OCDers with other psychiatric disorders in addition to OCD. In the great majority of cases, however, including those of Raymond, Sherry, Jeff, Melissa, and myself, all four are clearly recognizable. It is worth looking at each characteristic in some detail in order to become clear about just what an obsession is and what it is not.

  AN OBSESSION IS AN INTRUSIVE THOUGHT

  “Intrusive” describes the way a thought may pop into the mind, interrupting the normal flow. A person will be thinking along, one idea leading to another, when all
of a sudden—What’s this!—a new thought butts in unexpectedly, involuntarily.

  Intrusive thoughts are normal. Indeed, thoughts that show up suddenly and unannounced are often intensely creative. The French mathematician Henri Poincaré, perhaps the greatest scientist of his day, once described how he solved a particularly difficult problem just as he boarded a bus: “At the moment when I put my foot on the step, the idea came to me, without anything in my former thoughts seeming to have paved the way for it.”

  This quality of intrusiveness is acutely prominent in obsessions. Raymond, for instance, talked of crushing visions “jumping” into his mind and of his mind “handing” him terrible heart burdens. Since his obsessional thoughts bore no relationship to previous thoughts, there was no warning of their coming. Since they did not follow the normal flow of consciousness, there was the feeling that they somehow intruded on him from outside.

  Similarly, a psychology graduate student described her obsessions in this way: “I can’t stand to ride the bus any more, because awful sexual thoughts keep jumping into my mind—violent fantasies about men who sit next to me. I don’t want to have the thoughts, but they keep popping into my imagination, coming from out of nowhere. I can’t control them.”

  When I suffered from troublesome obsessions in medical school, I also had a disturbing sense of loss of control. Had my thoughts been leading logically from one to another, I could have intervened and halted the progression. But my obsessions—because they intruded suddenly and without warning into consciousness—seemed unstoppable.

  An obsession is not a sensation. The buzz of a refrigerator late at night can feel like an obsession: intrusive, persistent, and bothersome. But a sensory experience comes from outside your mind, whereas an obsession is a thought within it.

  AN OBSESSION IS RECURRENT

  An obsession keeps coming back again and again. This can continue all day long. Melissa described the recurrent nature of her obsessions as a “constant spinning that never stopped.” Sometimes an obsession repeats itself as a kind of undercurrent. Jeff, for instance, noted that his mind operated on two different levels at once. He could successfully teach a class while at the same time be continually tormented by unwanted sexual images.

  A student who had been attending my university health services group for some time introduced herself to a new group member this way:

  My name is Stephanie and I’m a grad student in mathematics. I’ve been having weird obsessions off and on for years. Sometimes I get strangulation visions and images of gory things happening to my body. I will imagine a belt going around my neck, or I will see a knife being thrust into my back, or I’ll see my ribs being cut open. These thoughts keep coming into my mind, over and over, sometimes all day long. Nothing stops them. Sometimes they really interfere with my work, which is bad, because I’m supposed to be getting my Ph.D. thesis done. This morning, thoughts were running through my head nonstop.

  An obsession is not a phobia. Phobias are very similar to obsessions, both being recurrent, irrational fears. The difference is this: A phobia is a fear of a particular situation, such as riding on an elevator, entering a shopping mall, or speaking in public; and avoidance keeps a phobia at bay. A person with a public-speaking phobia will be fine as long as he or she is away from the lecturn. With an obsession, in contrast, the focus is on a certain thought, such as knifing your daughter, crashing your car, or spreading germs. Avoidance doesn’t work with thoughts. My fearful fantasy of pricking myself with a needle was most intense not when I was actually drawing blood but rather when I was alone and needle-free in my apartment.

  AN OBSESSION IS UNWANTED

  An obsession is a gate crasher, an intruder in the night. The person afflicted with an obsession struggles mightily to resist it. This resistance can take up prodigious amounts of time and energy. Melissa said: “I try to stop thinking these thoughts but I can’t.… It’s like I’m involved in a battle with Satan, like he’s forcing them into my mind.” Jeff, sharing the OCD sufferer’s most typical refrain, said: “I fight them with all my might, but I can’t stop them.”

  Recently I saw a young mother who, like Sherry from Chapter 1, was having thoughts about harming her baby. Could there be any obsessions that are more unwanted? Hospitalized for exhaustion, thinking she had “gone crazy” and might actually harm her child, she told me:

  I was doing great until I got home from the hospital with my baby. All of a sudden, while I was feeding her, the thought came into my mind that I could choke her to death. I saw myself killing my baby. God bless her. I haven’t been free of that thought since. I don’t want my husband to leave me alone because I’m afraid of what I might do. I don’t let myself go to sleep because I might let my guard down. I try to stop these thoughts every second of the day with all my strength, but they don’t let up.

  The terrible irony is that, indeed, the more strongly you resist an obsession, the more strongly it comes back. The mind does not work like a computer screen, where an unwanted thought is simply deleted. Rather, as a student patient of mine once observed, an obsession is like Freddie, the character in the Nightmare on Elm Street movies. Every time people thought they were finally rid of Freddie, he came baaaaack even stronger.

  The strong resistance engendered by obsessions is probably their most defining characteristic. When I was in training at the University of Iowa, my chief of psychiatry, the noted researcher Dr. George Winokur, emphasized this point: “Look for how much the patient resists the thought—how much he or she fights it,” Winokur used to say. “That will tell you whether you’re dealing with an obsession or something else.”

  Again, to distinguish: An obsession is not a depressive preoccupation. A sixty-two-year-old man with intrusive, recurrent, and severely troubling thoughts was referred to me for “treatment-resistant OCD.” The usual anti-OCD medications and behavior therapy had been tried. Nothing worked. He presented as a worn-out, agitated gentleman who spoke of nothing else but his fears of going into bankruptcy and losing his farm—concerns that were, in reality, totally groundless. He did not, however, resist these thoughts or consider them unwanted. On the contrary, to him these were realistic worries that needed to be dealt with immediately. What tormented him were recurrent, depressive thoughts, not obsessions. The patient responded to a standard antidepressant medication, imipramine (Tofranil).

  An obsession is not an addiction. Degree of resistance also serves to differentiate obsessions from addictions. Obsessions are always unwanted—and not just 80 or 90 percent unwanted, but 100 percent. No part of a person wants an obsession. With an addiction, the unwanted urge carries a certain thrill. The gambling addict, for instance, gets a kick out of the action. A part of him looks forward to gambling, even while another part of him knows that he shouldn’t do it. With an obsession, there is no enjoyment at all.

  AN OBSESSION IS INAPPROPRIATE

  Given a chance to sit back and reflect for a minute, the afflicted person just can’t figure out why the tormenting thought would ever have occurred in the first place. There seems to be no earthly reason for it.

  Mental health professionals use the term “ego-dystonic” to describe this characteristic. The term means “against a person’s very nature,” a mismatch to a person’s sense of self. When I had my needle obsession, I knew it was irrational for me to be thinking such thoughts. They didn’t match with who I was. They didn’t fit in with my goals, my desires, or my fears. When an OCDer must check the light switch for the hundredth time, the reaction is: “Why am I thinking this crazy thought? This isn’t me.”

  Raymond knew very well that his spill visions were only “killer fantasies.” It was because he did that he went to such great lengths to hide his checking compulsions. A new student in our OCD group described her obsessions this way:

  I will fully admit right now that my worries are unrealistic and completely stupid. Like before I go to bed, I will keep having the thought that the door isn’t locked. I lock it and unlock it, lo
ck it and unlock it, a dozen times. But the thought still comes back: What if I didn’t lock it right? I will get up and go over and check the door again. It’s so crazy that I’m reduced to tears.

  An obsession is not a psychosis. Sometimes the recognition of the ego-dystonic quality of an obsession—realizing that a thought is violating who you are—causes people to think that they are “going crazy.” This is a common reaction to severe obsessions: “I should be locked up!” Jeff felt this way because he thought he was “hearing voices.” Even though he recognized that these “voices” came from his own mind and did not sound like real voices, still, because his tormenting thoughts were so inappropriate and senseless, so unlike himself, he mistook his obsessions for psychotic hallucinations.

  Melissa also feared that she was losing her sanity. At first, I myself wasn’t sure on this point. Her inner preoccupations and abrupt lapses in conversation gave her the appearance of a person who might be actively hallucinating; furthermore, her intense concern about Satan raised the question as to whether she might be suffering delusions. When I questioned Melissa, however, as to whether she was in fact hearing voices, she said no. And when I asked her about common delusions—such as the idea that other people could overhear her thoughts, or the idea that messages were being sent to her over the television or radio—she denied these as well. Her beliefs about Satan turned out to be shared by other members of her church and therefore were not signs of mental illness. It was soon clear that Melissa had OCD, not a psychosis.

  OCDers often feel like they’re going crazy because they experience a loss of control over their thoughts. Yet obsessions never—repeat, never—lead to a true loss of contact with reality, to a psychosis. People who are psychotic lack the ability to discern what is sensible. OCDers, on the contrary, are intensely aware that their thoughts don’t make sense. OCDers probably have less of a chance of going crazy than anybody else.