Tormenting Thoughts and Secret Rituals Read online

  The four qualities of intrusiveness, recurrence, unwantedness, and inappropriateness are what set clinical obsessions apart from the preoccupations, temptations, and worries of everyday life.

  An adolescent male, starry-eyed over a new girlfriend, is not really “obsessed.” He’s merely preoccupied. Likewise, the lady who has to grit her teeth and punch down on the gas pedal to get past the liquor store is not “obsessed with alcohol,” not clinically, at least. She is tempted, perhaps addicted. And consider what happened to me not long ago. I was fretting aloud about my ten-year-old daughter going away to college. Crime, cut-throat competition, men trying to take advantage of her.… My wife chided me, “Stop your obsessing!” But these were not unwanted thoughts that I resisted, nor were they completely inappropriate. It makes sense to be a bit fearful about your daughter’s future. These were not obsessions; they were simply worries.

  With ordinary temptations, addictions, and worries, there are ways to fight back—willpower, for instance, or thinking more rationally. But for obsessions there seems to be no defense at all. They are like body snatchers from outer space. A person will do anything to find relief. And that’s where compulsions enter in.

  THE NATURE OF COMPULSIONS

  The term “compulsion,” like “obsession,” has taken on a broad, which is to say vague, meaning. Popularly, it is used to indicate anything done to excess: compulsively eating Ben and Jerry’s ice cream, for instance, or compulsively planning one’s day. But again, the clinical meaning is much more specific.

  A clinical compulsion is sometimes defined simply as “a repetitive act that is performed according to rules that must be applied rigidly.” A better definition, however, is one that stresses the close relationship between compulsions and obsessions: A compulsion is a repetitive act that is clearly excessive and is performed in order to lessen the discomfort of an obsession.

  An obsession strikes, anxiety mounts, and repetitive acts provide a way out. Why compulsions are effective in the short run to alleviate anxiety is not completely understood. As will be discussed in Chapter 8, animals are known to perform many stereotyped rituals when under stress (monkeys in the zoo strumming the mesh of their cage, or rocking back and forth continuously). Many OCD experts believe that compulsions are related to these and involve genetically programmed tendencies.

  Compulsions can take an infinite number of different forms. Most often they are reasonable responses gone haywire, such as checking a gas stove a hundred times in a row for fear of a leak. They can also be acts that are completely foreign to reason, however, like jumping up and down eight times because of the thought that an accident will occur. But all compulsions have this property: Although they provide short-term respite from obsessions, in the long run they only make obsessions worse. Obsessions, in turn, make compulsions worse. It’s a vicious cycle.

  THE REMARKABLE CASE OF HOWARD HUGHES

  The best example of the depths of despair and disability to which this vicious cycle can carry a person is found, amazingly, in the case of a man who was once the richest person in America. Howard Hughes was a brilliant businessman, a pilot who set aviation records, a movie producer who courted beautiful starlets. Yet for the last twenty years of his life he lived as a complete recluse, spending his days in the darkened bedrooms of fancy penthouses with a small army of guards to insure his privacy. Newspapers portrayed him as an eccentric genius, but after his death in 1976 it was revealed that his strange behaviors were entirely due to compulsions run amok.

  As a young man Hughes was, indeed, eccentric. Perfectionistic and domineering, he wrote pages of memos on inconsequential items. Friends knew that he had irrational contamination fears; they were not allowed to even touch his private refrigerator. Nevertheless, despite such peculiarities, Hughes was enormously productive and successful. All this changed in midlife after he was severely injured in the crash of an air force reconnaissance plane of his own design and subsequently became addicted to the narcotics that were prescribed for the pain of his injuries.

  Thereafter, Hughes’ life was dominated by compulsions. Afraid to eat, drink, be touched, wear clothes, or leave his room, he made his staff follow senseless, intricate checking and washing rituals that took hours and hours to perform. A typical memo to his staff, instructions for the “preparation of canned fruit,” entailed no less than nine painstaking steps. Step 3, “washing of can,” for example, read:

  The man in charge turns the valve in the bathtub on, using his bare hands to do so. He also adjusts the water temperature so that it is not too hot or too cold. He then takes one of the brushes, and, using one of the bars of soap, creates a good lather, and then scrubs the can from a point two inches below the top of the can. He should first soak and remove the label, and then brush the cylindrical part of the can over and over until all particles of dust, pieces of the label, and, in general, all sources of contamination have been removed. Holding the can in the center at all times, he then processes the bottom of the can in the same manner, being very sure that the bristles of the brush have thoroughly cleaned all the small indentations on the perimeter. He then rinses the soap. Taking the second brush, and still holding the can in the center, he again creates a good lather and scrubs the top of the can, the perimeter along the top, and the cylindrical sides to a point two inches below the top. He should continue this scrubbing until he literally removes the tin protection from the can itself.

  Every other step is comparably detailed. From step 5: “While transferring the fruit from the can to the sterile plate, be sure that no part of the body, including the hands, be directly over the can or the plate at any time. If possible, keep the head, upper part of the body, arms, etc. at least one foot away.” The memo finishes: “This operation must be carried out in every infinitesimal detail, and I would deeply appreciate it if the man would follow each phase very slowly and thoughtfully, giving his full attention to the importance of the work at hand.”

  Hughes’ germ obsessions, paradoxically, drove him to hoarding whatever might cause contamination. His urine and feces was stored in large jars. He lived out his years in a tortured, solitary manner, his OCD relieved only by fixes of narcotic drugs.

  The case of Howard Hughes is, indeed, very strange. Not only were his compulsions extraordinary, but it is almost unheard of for a person to develop such a severe case after age fifty. The objective observer must wonder whether Hughes’ caretakers were purposefully keeping him disabled in order to take advantage of his wealth. His ability to cope with obsessions was certainly compromised when they helped him become addicted to narcotics. His OCD, it would appear, was also markedly worsened when they carried out what was in essence an “anti-behavior therapy” program, fully assisting in all of his wild rituals. Most tellingly, these assistants never tried to get Hughes any treatment. A physician remarked after his death: “He would have gotten better care if he were a penniless wino who collapsed on skid row. At least some passer-by would have called the paramedics.”

  TYPES OF COMPULSIONS

  The compulsions that crippled Howard Hughes, as well as those affecting his fellow OCD sufferers, can be divided into two groups: behavioral (observable acts) and mental (thought rituals).

  Behavioral compulsions include all the classic and well-recognized OCD rituals. Hughes was troubled primarily by washing and checking, the two most common types of severe compulsions. Another widespread behavioral compulsion is asking for reassurance. Other common examples include hoarding, repeating, tapping, and ordering.

  Washing

  Many experts think that washing is the single most prevalent type of behavioral compulsion. Judith Rapoport, M.D., of the National Institutes of Health, a top OCD researcher and author of the acclaimed book, The Boy Who Couldn’t Stop Washing, reports that more than 80 percent of the people who come to her clinic for treatment of OCD have been bothered at some time by washing rituals.

  At the root of washing compulsions, not surprisingly, is an obsession that a part o
f the body is unclean. Washing eases the feeling temporarily, but once the scrubbing is done, the thought returns. More scrubbing follows. Dermatologists are often the first to diagnose this disorder, as people frequently seek treatment for the skin damage caused by this excess.

  Handwashing compulsions are OCD’s most recognized symptom. They are, indeed, the hallmark of the disorder. A typical example is provided by a math teacher:

  I get to thinking that my hands are unclean in some way. It’s not that they look dirty. And it’s not that I imagine germs on them, either. It’s just that I have this feeling they’re unclean. So I’ll lather them up good, wash them for a couple minutes, and dry them carefully. But pretty soon I’ll touch something and then I’ll get the feeling again. Some evenings after work I wash my hands every five minutes. They’re in bad shape. I have to put medication on them and wear gloves when I sleep.

  The most famous description of excessive handwashing is found in Shakespeare’s Macbeth (Act 5, scene 1):

  DOCTOR: Look how she rubs her hands.

  GENTLEWOMAN: It is an accustomed action.… I have known her to continue in this a quarter of an hour.

  LADY MACBETH: Yet here’s a spot.… Out, damned spot! Out, I say!… will these hands never be clean?… Here’s the smell of blood still: All the perfumes of Arabia will not sweeten this little hand.

  Although this would seem to be a good description of compulsive washing, in the context of Shakespeare’s play it probably does not represent true OCD. Lady Macbeth’s handwashing occurs during sleepwalking, and her ritual is driven not by clinical obsessions but rather by depressive delusions or preoccuptations fueled by her guilt over Duncan’s murder.

  Checking

  Checking compulsions is also very common. A recent study of 250 consecutive patients from Harvard’s outpatient OCD clinic found that 63 percent complained of checking rituals.

  With this type of compulsion, a person must examine a situation over and over to make sure that no harm will come of it. Obsessions such as, “Is the gas shut off?” and “Are the doors locked?” drive the checking. A young wife described the torment and disruption that these rituals can cause:

  I stand there and turn the light switch off and on, off and on, off and on, off and on. I can’t make myself stop. It’s crazy. What happens is that I have the thought that maybe I didn’t completely turn it all the way off. Maybe the switch is somewhere inbetween the off and on position and a fire will start because of a short circuit. I know that this does not make sense. Still, I have to keep on switching back and forth until I get it just right. I might stay there for ten or fifteen minutes. One time the light switch started smoking. Now my husband swears at me and yells, “Leave the light switch alone or you really will start a fire!”

  Requesting Reassurance

  This type of compulsion tests the patience of family members more than any other. Here, a sufferer becomes obsessed that something terrible has happened and is compelled to coax a pledge from another person that everything is okay. “I didn’t hit anybody with the car, did I?” “That lump doesn’t mean I have AIDS, does it?” The OCDer asks over and over, unable to stop, knowing the answer she’ll get, but needing to ask again anyway. Reassurance must be endlessly provided. A newlywed explained how her marriage was almost on the rocks due to her reassurance compulsions:

  I love my husband more than anything. But I get the crazy thought that I might be interested in other men. I’ll be walking in the mall and I’ll notice a handsome guy, and afterward I’ll get to wondering if I looked at him too long, if maybe that means I’m interested in him. I’ll worry all day; I can’t stop myself from thinking that I might have had thoughts of unfaithfulness. Then, because I feel so guilty, I’m driven to tell my husband. I know it makes him feel bad, but I have to. He says that it’s okay, that he knows I’m not interested in anyone else. Then I feel better. But I’ve been doing this every day, and it’s driving him nuts.

  Hoarding

  Here, the natural tendency to save things is stretched to a pathological degree. A young man whose apartment was more than half filled, floor to ceiling, with magazines and newspapers explained that he was afraid to throw an article away because he might later remember that there was something critically important in it. Then, if he couldn’t find it, he might get so upset that he would have a nervous breakdown.

  Repeating

  When a routine action is repeated compulsively, and when—unlike in washing, checking, reassurance, and hoarding rituals—it bears no logical relationship to the obsession preceding it, this is called a repeating compulsion. One student, when struck by a harm obsession, compulsively repeated the action he was engaged in; this could be combing his hair, crossing his legs, or writing his name. Several quick repetitions usually sufficed to chase away the obsession. Repeating compulsions often must be performed a certain specific number of times. A young woman, in response to “a feeling of dread,” scratched her head, brushed her teeth, or chewed on Life savers four times, no more no less.

  Rubbing, Touching, and Tapping

  These common compulsions also defy logical analysis. A student with harm obsessions needed to tap her fingers ten times to prevent her tormenting thought from coming true.

  Ordering

  Here, items must be arranged so that they are “just so.” These rituals differ a bit from all others: They occur frequently in young boys, and their corresponding obsessions are often hard to identify. It has been hypothesized that ordering compulsions bear some resemblance to another kind of abnormal, repetitive action, the jerky movements referred to as “tics.” Ordering compulsions may represent a hybrid symptom between OCD and the related neurological disorder of tics, Tourette’s syndrome.

  MENTAL COMPULSIONS

  In Chapter 1, I mentioned that when I was in medical school I suffered the obsession of a phlebotomy needle suddenly plunging into my skin. It was a startling image that shook me to my bones, like fingernails raking across a blackboard. To lessen its effect I developed the habit of immediately bringing to mind a certain protective image: my skin being covered by a soothing, impenetrable cream.

  That was a mental compulsion, an attempt to escape an obsession by employing a special, counteractive idea. With mental compulsions, as with behavioral compulsions, something is done repeatedly, mechanically, for no purpose other than to lessen the discomfort of an obsession. As one person may repeatedly check the stove, another may habitually conjure up a corrective fantasy.

  Ten years ago, mental compulsions were not even known to most mental health professionals. The last edition of the official manual of American Psychiatry, the DSM-III-R, published in 1987, defined compulsions as “intentional behaviors that are performed in response to an obsession.” It is now recognized, however, that compulsions occurring in the form of thoughts are extremely common, probably even more common than behavioral compulsions. How far our knowledge of OCD has come in just a decade!

  Counter-image

  Perhaps the most prevalent type of mental compulsion is the type I developed in med school, the counter-image. In my OCD group, a student described her counter-images in this way:

  I get pictures in my mind of knives being stabbed into my grandmother. These thoughts cause me so much anxiety that I have to rethink them whenever they occur. I have to get a good image of my grandmother in my mind, one where she doesn’t have the knife sticking in her. So I see the knife going in, and then I have to pull it out. But as soon as I pull the knife out, it’s there again. So this goes on and on. I think a bad thought, then I have to think a good one.

  Repeating of Prayers

  Another common type of mental compulsion is the rote repetition of a prayer. The words no longer have real meaning, they have been reduced to ritualistic incantations performed exclusively to drive away an obsession. A Catholic woman in her fifties described her ritual:

  I say to myself “Holy Mary mother of God have grace on us sinners” over and over. It’s because an awf
ul thought keeps coming into my mind. A thought to stab Jesus. God knows why it happens. The prayer used to work to make it go away; but now I say it over and over, for hours, and the terrible thought keeps on coming back anyway.

  Counting

  This compulsion includes numbering objects as well as repetitively counting to a certain number. The key is that the compulsion is in the process of counting itself. A thirty-five-year-old man, totally disabled by OCD, needed to count anything in sight. In my waiting room, he counted the tiles in the ceiling. In my office, he counted the books on the bookshelf. He said he just had “an urge to do it.”

  Ruminations

  Although there is little written about this type of compulsion, it seems to be fairly common, especially in students. A rumination has been defined as “a train of thought, unproductive and prolonged, on a particular topic or theme.” Sometimes, ruminations clearly represent mental compulsions. An engineering student described his unwanted musings:

  I constantly over-think things. I’ll be out with my girlfriend, and suddenly I say to myself, “Oh no, here come the thoughts!” I know then that I’m going to get carried away with thinking things over. The thought comes that I’m not real. I’ll have to answer endless questions regarding whether my girlfriend and I are actually here or not. The metaphysical analysis goes on and on and on. I get an isolated, alone feeling. Then I may start questioning why I’m thinking these crazy thoughts in the first place. My whole evening will be ruined.