Tormenting Thoughts and Secret Rituals Page 6

  Mental compulsions, like behavioral compulsions, in the long run only worsen obsessions. A particularly devastating outcome is when the obsession itself starts to be triggered by the very images used to counteract it. A gentle, civic-minded man described how this happened to him:

  I’d kill myself before I’d harm a kid. I have kids myself. I’m a Scout leader, for God’s sake. Yet I will be walking along and I’ll see a little boy across the street, and then the thought will come into my mind to run over and strangle him. Nothing will get rid of the awful idea. I used to play a trick to try to get rid it. When the terrible idea would hit, I’d immediately imagine myself teaching the child how to play baseball. This worked for a while; but now things are even worse, because now whenever I see a baseball game on TV, it brings the terrible thoughts right into my mind.

  The compulsions mentioned above—washing, checking, reassurance, hoarding, repeating, ordering, and various mental rituals—do not exhaust all possibilities, but they are the types most commonly seen. All of them share one feature: They are defensive, done solely to lessen the torment of obsessions. Yet, from the extreme checking rituals developed by Howard Hughes, to my own more modest protective fantasies, compulsions in the long run only guarantee that the self-tormenting thought that caused them will return again and again.

  The diagnosis of obsessive-compulsive disorder presented no major difficulties in the cases of Raymond, Sherry, Jeff, and Melissa. All four had typical obsessions and common compulsions. Usually OCD is like that, very easy to diagnose. Anyone who has obsessions and compulsions that are interfering in their lives has obsessive-compulsive disorder, unless proven otherwise. Occasionally, however, there are times when it is not completely clear whether a person suffers from OCD or from another somewhat similar psychiatric disorder, such as hypochondriasis or body dysmorphic disorder, or from a related neurological disorder, such as Tourette’s syndrome. Phobias can also overlap with OCD. These more complicated situations will be discussed in chapters 9 and 10.

  To put the whole process of psychiatric diagnosis in broader context, it has been observed that medicine has three levels of diagnostic sophistication. The first stands on the recognition of specific symptoms (“pneumonia is a cough with a fever”). The second level founds diagnosis on measurable biochemical changes in the body (“pneumonia is congestion in the lungs”). The third, the highest level of diagnostic refinement, fixes diagnosis firmly on the ultimate cause of a disorder (“pneumonia is a bacterial infection of the lungs”). Psychiatry, for the most part, is still in the first stage, whereas the other branches of medicine have advanced to levels two and three.

  Later in the book it will become clear that psychiatry, in the case of OCD, is on the threshold of moving up one or two levels in diagnostic sophistication. For now, though, OCD continues to be diagnosed completely on the basis of the recognition of its symptoms, obsessions and compulsions.

  SELF-ADMINISTERED QUESTIONNAIRES FOR DIAGNOSING OCD

  There are several pencil-and-paper tests that can provide a fairly good idea of whether a person suffers from OCD. Taking these tests requires only sitting down and answering a number of multiple choice questions to determine whether common obsessions and compulsions are present. Although these tests do not take the place of diagnosis by a competent psychiatrist or psychologist, they can be effective screening devices.

  Below is the questionnaire that I find the most useful, the Padua Inventory, which was developed in Italy in 1987 and has been standardized on thousands of people here and abroad. I suggest you take this test. Apart from diagnostic considerations, reflecting on the questions contained in the Padua Inventory will increase your understanding of OCD, as these represent a fairly comprehensive list of the most common obsessions and compulsions. In them you will recognize the problems of Raymond, Sherry, Jeff, and Melissa. The test requires only about ten minutes of your time.

  THE PADUA INVENTORY

  Instructions: Reply to each question with a rating of 0 to 4: 0 = not at all; 1 = a little; 2 = some; 3 = a lot; 4 = very much.

  1. I feel my hands are dirty when I touch money.

  2. I think even slight contact with bodily secretions (perspiration, saliva, urine, etc.) may contaminate my clothes or somehow harm me.

  3. I find it difficult to touch an object when I know it has been touched by strangers or by certain people.

  4. I find it difficult to touch garbage or dirty things.

  5. I avoid using public toilets because I am afraid of disease and contamination.

  6. I avoid using public telephones because I am afraid of contagion and disease.

  7. I wash my hands more often and longer than necessary.

  8. I sometimes have to wash or clean myself simply because I think I may be dirty or “contaminated.”

  9. If I touch something I think is “contaminated,” I immediately have to wash or clean myself.

  10. If an animal touches me, I feel dirty and immediately have to wash myself or change my clothing.

  11. When doubts and worries come to my mind, I cannot rest until I have talked them over with a reassuring person.

  12. When I talk I tend to repeat the same things and the same sentences several times.

  13. I tend to ask people to repeat the same things to me several times consecutively, even though I did understand what they said the first time.

  14. I feel obliged to follow a particular order in dressing, undressing, and washing myself.

  15. Before going to sleep I have to do certain things in a certain order.

  16. Before going to bed I have to hang up or fold my clothes in a special way.

  17. I feel I have to repeat certain numbers for no reason.

  18. I have to do things several times before I think they are properly done.

  19. I tend to keep on checking things more often than necessary.

  20. I check and recheck gas and water taps and light switches after turning them off.

  21. I return home to check doors, windows, drawers, etc., to make sure they are properly shut.

  22. I keep on checking forms, documents, checks, etc., in detail, to make sure I have filled them in correctly,.

  23. I keep on going back to see that matches, cigarettes, etc., are properly extinguished.

  24. When I handle money I count and recount it several times.

  25. I check letters carefully many times before posting them.

  26. I find it difficult to make decisions, even about unimportant matters.

  27. Sometimes I am not sure I have done things that in fact I know I have done.

  28. I have the impression that I will never be able to explain things clearly, especially when talking about important matters that involve me.

  29. After doing something carefully, I still have the impression I have either done it badly or not finished it.

  30. I am sometimes late because I keep on doing certain things more often than necessary.

  31. I invent doubts and problems about most of the things I do.

  32. When I start thinking of certain things, I become obsessed with them.

  33. Unpleasant thoughts come into my mind against my will and I cannot get rid of them.

  34. Obscene or dirty words come into my mind and I cannot get rid of them.

  35. My brain constantly goes its own way, and I find it difficult to attend to what is happening around me.

  36. I imagine catastrophic consequences as a result of absent-mindedness or minor errors that I make.

  37. I think or worry at length about having hurt someone without knowing it.

  38. When I hear about a disaster, I think it is somehow my fault.

  39. I sometimes worry at length for no reason that I have hurt myself or have some disease.

  40. I sometimes start counting objects for no reason.

  41. I feel I have to remember completely unimportant numbers.

  42. When I read I have the impression I have missed something important and mus
t go back and reread the passage at least two or three times.

  43. I worry about remembering completely unimportant things and make an effort not to forget them.

  44. When a thought or doubt comes into my mind, I have to examine it from all points of view and cannot stop until I have done so.

  45. In certain situations I am afraid of losing my self-control and doing embarrassing things.

  46. When I look down from a bridge or a very high window, I feel an impulse to throw myself into space.

  47. When I see a train approaching I sometimes think I could throw myself under its wheels.

  48. At certain moments I am tempted to tear off my clothes in public.

  49. While driving I sometimes feel an impulse to drive the car into someone or something.

  50. Seeing weapons excites me and makes me think violent thoughts.

  51. I get upset and worried at the sight of knives, daggers, and other pointed objects.

  52. I sometimes feel something inside me which makes me do things that are really senseless and that I do not want to do.

  53. I sometimes feel the need to break or damage things for no reason.

  54. I sometimes have an impulse to steal other people’s belongings, even if they are of no use to me.

  55. I am sometimes almost irresistibly tempted to steal something from the supermarket.

  56. I sometimes have an impulse to hurt defenseless children or animals.

  57. I feel I have to make special gestures or walk in a certain way.

  58. In certain situations I feel an impulse to eat too much, even if I am then ill.

  59. When I hear about a suicide or a crime, I am upset for a long time and find it difficult to stop thinking about it.

  60. I invent useless worries about germs and diseases.

  To score the Padua Inventory, add up your ratings (0 to 4) for the sixty questions.

  The average result for unscreened groups of people (usually hospital employees and university students) is about 40. The average result for people in treatment for OCD is about 80. I took this test remembering back to when I suffered OCD in medical training and got a 72. Taking it now, I get about a 50.

  There are several other questionnaires worth mentioning. The Maudsley Obsessive-Compulsive Inventory, developed in 1977 in England, has been used more than any other test. Unfortunately, in light of our current knowledge of OCD, it is clear that the present version concentrates excessively on checking and washing compulsions. (A new, improved version of the Maudsley Inventory will be released soon.) The Leyton Obsessional Inventory and the Compulsive Activity Checklist are also excellent screening tests but are, perhaps, not quite as comprehensive as the Padua Inventory.

  The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), developed in 1989 by Yale and Brown universities, asks ten questions that assess the strength of a person’s obsessions and compulsions. It is a very useful and widely used test, but it was designed mainly to follow people’s progress in treatment, not to diagnose OCD. It is included in Appendix A.

  If you think that you might possibly have obsessive-compulsive disorder, please do take the Padua Inventory. OCD sufferers tend to walk through life in a sort of numb confusion, approaching their obsessions and compulsions like bad weather—to be lived through and then forgotten as soon as possible. They never come to grips with the fact that they have a real psychiatric disorder. This is a major mistake.

  Anyone who scores well above average on the Padua Inventory should consider that they may have obsessive-compulsive disorder. If you have it, you should treat it. There is no shame to having OCD. In fact, I am rather proud to be included in the company of the people discussed in the next chapter.

  3

  WHO GETS OCD?

  “They are mostly good people, for bad men rarely know anything of these types of thoughts.” That comment was made by English Bishop John Moore in 1692. Many similar observations have been made over the centuries by people, usually clergymen, called on to provide help to OCD sufferers.

  Contemporary helpers have largely agreed with these observations. Psychologist Stanley Rachman of the University of British Columbia, perhaps the leading expert on OCD over the last two decades, summed up the opinions of specialists in the area of obsessive-compulsive disorder in 1979: “Our clinical impression is that people with OCD are correct, upright, moral citizens who aspire to high standards of personal conduct.”

  In the 1980s, researchers began to study personality and OCD scientifically, confirming that people with OCD do share certain personality traits, specific life-long tendencies to think and act in particular ways. One research group suggests that OCD sufferers may be summed up as fearful, introspective, and depressive. Another group of investigators has found that there are three other qualities that are common to OCD sufferers: a tendency to avoid harm at all cost, a lack of interest in novelty, and a great need for approval from others. A third group of investigators finds that the core of OCD sufferers’ personalities is a tendency to take excessive personal responsibility for others. Indeed, it seems that people with OCD do make upright citizens.

  This chapter begins with a review of historical figures who have had symptoms of OCD. Then, taking these cases as examples, it will explore research into the unique personality traits of OCD sufferers.

  JOHN BUNYAN

  Author of the Puritan allegory, Pilgrim’s Progress, John Bunyan (1628–1688) has been called, next to Shakespeare, England’s most influential author. Coleridge referred to Pilgrim’s Progress as “the model of beautiful, pure, and harmonious English.” Rudyard Kipling labeled Bunyan “the father of the novel.”

  Bunyan had clear-cut, moderate to severe OCD; his case is our best historical example of the illness. As William James stated in The Varieties of Religious Experience, Bunyan had “a sensitive conscience to a diseased degree, beset by doubts, fears, and insistent ideas.”

  In his powerful autobiography, Grace Abounding to the Chief of Sinners, Bunyan vividly describes attacks of intrusive, tormenting thoughts. Most were obsessions of blasphemy. Nothing would stop the onslaught. “A very great storm came down upon me … whole floods of blasphemies, both against God, Christ, and the Scriptures, were poured upon my spirit, to my great confusion and astonishment.… I felt as if there were nothing else but these from morning to night.” Bunyan agonized over obsessional impulses to scream out profanities in public, urges that drove him to physically restraining himself: “The tempter would provoke me to desire to sin … if it were to be committed by speaking of such a word, then in so strong a measure was this temptation upon me, that often I have been ready to clap my hand under my chin, to hold my mouth from opening.” Bunyan endured other obsessions as well, perhaps murderous or sexual obsessions, which he considered too vile to discuss: “Many others at this time I may not, nor dare not, utter, neither by word nor pen.”

  Bunyan developed extensive compulsions, such as endlessly repeating certain phrases while rocking back and forth: “For whole hours together … my very body would be put into action by way of pushing or thrusting with my hands or elbows; still answering ‘I will not, I will not, I will not, I will not, no not for thousands, thousands, thousands of worlds.”

  In describing an obsession that a church bell would fall on him, Bunyan illustrates the torturing doubt that assails the obsessional:

  I began to think, what if one of the bells should fall? I chose to stand under a main beam … thinking there I might stand safely. But then I thought again, what if the bell fell with a swing, it might first hit the wall, and then rebounding upon me, might kill me, despite the beam. This made me stand in the steeple-door; and now, thought I, I am safe enough. But then it came into my head, What if the steeple itself should fall? And this thought did continually so shake my mind, that I dared not stand at the steeple-door any longer, but was forced to flee, for fear the steeple should fall upon my head.

  Through it all, Bunyan showed the insight of a true obsessional. He knew
his worries were irrational; he just couldn’t stop thinking them. “These things may seem ridiculous to others,” Bunyan notes, “even as ridiculous as they were in themselves, but to me they were the most tormenting cogitations.”

  SAMUEL JOHNSON

  Poet, playwright, biographer, and scholar, the greatest literary figure of his age, Samuel Johnson (1709–1784) once wrote, “Disorders of the intellect happen much more often than superficial observers will easily believe. Perhaps if we speak with rigorous exactness, no human mind is in its right state.” His interest in the subject was due to concern for his own sanity. In Young Sam Johnson, James Clifford writes that Johnson “would become oppressed, again and again, by the morbid obsession that he was losing his mind.” Johnson was a great admirer of John Bunyan. Historian W. Hale White notes that Johnson was “haunted by Bunyan’s specters.” That is not surprising, as Johnson, like Bunyan, clearly had obsessive-compulsive disorder.

  James Boswell, Johnson’s famous biographer, notes that his subject had “queer habits which amazed all beholders,” habits we now recognize as touching and repeating compulsions. Johnson “sometimes seemed to be obeying some hidden impulse, which commanded him to touch every post in a street or tread on the center of every paving-stone. He would return if his task had not been accurately performed.”

  Johnson also performed compulsive rituals before entering houses: “I have upon innumerable occasions,” writes Boswell, “observed him suddenly stop, and then seem to count his steps with a deep earnestness; and when he had neglected or gone wrong in this sort of magical movement, I have seen him go back again, put himself in a proper position to begin the ceremony, and, having gone through it, break from his abstraction, walk briskly on, and join his companion.” Similar compulsions are described by another Johnson biographer, Miss Frances Reynolds, who writes that upon entering a house Johnson “whirled and twisted about to perform his gesticulations; and as soon as he had finished, he would give a sudden spring and make such an extensive stride over the threshold, as if he were trying for a wager how far he could stride.”