Tormenting Thoughts and Secret Rituals Page 8

  PERSONALITY CLASSIFICATIONS AND OCD

  The DSM-IV diagnostic manual used by mental health professionals in the United States contains a set of diagnoses called personality disorders that are applied to people with long-term maladaptive patterns of thinking and behaving. Many of the labels are well known: paranoid, hysterical, psychopathic, narcissistic, and, yes, obsessive-compulsive.

  You probably recognize what obsessive-compulsive personality disorder is like. It represents the extreme of what in general parlance is referred to as obsessive-compulsive behavior. It describes the person who is perfectionistic, punctual, aloof, and inflexible, when severe obsessive-compulsive personality results in a sort of malignant fussiness. One patient of mine timed family members every time they showered, yelled when anyone put a fork in the dishwasher with the prongs facing down, and insisted on saving the carpet by having family members walk up and down the stairs on newspapers.

  Until recently, the unquestioned assumption among mental health professionals has been that obsessive-compulsive personality leads directly to obsessive-compulsive disorder. That is why, of course, they were both referred to as obsessive-compulsive in the first place. The two disorders were thought simply to represent different levels of severity of the same basic problem; the rigidity and inflexibility of obsessive-compulsive personality was thought to cause by unconscious mechanisms the obsessions and compulsions of OCD. When I was in training there was no doubt about this link. Yet, although this theory is still cited in newspapers and magazines, the fact is that experts in the field no longer believe it.

  First of all, researchers have found that obsessive-compulsive personality is not, after all, a necessary condition for the development of OCD. Recent studies suggest that obsessive-compulsive personality disorder is not even the most common personality disorder that is found among people who have OCD. A 1993 study by Russell Noyes and colleagues at the University of Iowa, for instance, found that although 80 percent of OCD patients suffer from personality disorders, it is dependent personality disorder—fear of decisions, under-assertiveness, excessive leaning on others—that is present in more than half of patients. This finding agrees with what is found in clinical practice. Instead of being detached and emotionally cool, as are people with obsessive-compulsive personality disorder, OCD patients are nervous and clinging.

  Secondly, the idea that OCD is caused by any personality disorder has been called into question. In a 1992 study at Harvard, Michael Jenike and his colleagues looked at seventeen patients who were diagnosed as having both OCD and personality disorders. Ten of these patients responded well to medications and behavioral therapy for their obsessions, and when tested again after treatment, nine of the ten no longer had their personality disorders. What these findings suggest is that when people with OCD have personality disorders, it may well be the obsessions and compulsions that are causing the personality problems, not the other way around.

  Studies such as these cause mental health professionals to question whether the diagnoses referred to as personality disorders are truly valid and reliable. Other approaches to personality may be better. One well-researched new scheme for describing personality is that introduced in 1987 by Dr. Robert Cloninger, chairman of the Department of Psychiatry at Washington University in St. Louis. I like Dr. Cloninger’s approach and so do my patients. It’s easy to understand, and it doesn’t involve negative labels, such as “hysteric” or “paranoid.”

  THE TRIDIMENSIONAL PERSONALITY THEORY

  In its simplest form Dr. Cloninger’s model suggests that most of the important differences between our personalities may be accounted for by three key qualities or dimensions: harm avoidance, novelty seeking, and reward dependence.

  “Harm avoidance” refers to the urge to escape from unpleasant experiences. People low in harm avoidance tend to be carefree, confident, relaxed, optimistic, uninhibited, outgoing, and energetic. Those who are high in harm avoidance, on the other hand, tend to be timid, inhibited, apprehensive, tense, shy, easily fatigued, and pessimistic about the future.

  “Novelty seeking” describes a capacity to be exhilarated by new experiences. Everyone likes excitement now and then, but people who score high in this dimension live for it. They are impulsive, fickle, quick-tempered, extravagant, and disorderly risk-takers. Daredevils fit here. Those who are low in novelty seeking are reflective, loyal, stoic, slow-tempered, and orderly. They’re good scouts.

  “Reward dependence” refers to the need to be reinforced by approval from others. Those on the low end of this personality dimension tend to be detached, emotionally cool, practical, and tough-minded. People high in reward dependence are sympathetic, eager to help, and sentimental. They’re people-pleasers.

  Consider some of the combinations. A person who is low in harm avoidance, high in novelty seeking, and low in reward dependence is fearless, impulsive, explorative, and doesn’t care what people think. In the extreme this is the criminal personality type. Think Charles Manson. If reward dependence is changed from low to high while the other two factors stay the same, then a person is impulsive and explorative but also emotionally vulnerable. He or she craves activity and excitement but needs positive feedback. This is the attention-seeking, dramatic, gullible individual; perhaps an example would be Marilyn Monroe. Each of the combinations of Cloninger’s traits corresponds to a recognizable character.

  OCD sufferers, according to Dr. Cloninger’s theory, are high in harm avoidance, low in novelty seeking, and high in reward dependence. Recent studies from the universities of Iowa and Toronto have confirmed the strong correlation of OCD to high harm avoidance and low novelty seeking. There is suggestive evidence tying OCD to high reward dependence. OCD sufferers are timid, sentimental, good scouts, people-pleasers. That description fits a surprisingly large number of my OCD patients.

  The term harm avoidant fits me to a T. Novelty seeking? When I was a child, my family visited New York City. My brother wanted to see Broadway; I wanted to stay in the hotel room and play cards. My brother is now in the foreign service; I’m living in my hometown. And reward dependence? I can’t remember even once making my parents mad at me. This is simply the typical personality pattern of the person who develops OCD.

  Of considerable value in Cloninger’s personality classification scheme is the fact that, for the first time, personality types have been connected to brain chemistry. Correlations are introduced between, for instance, harm avoidance and the level of the neurotransmitter serotonin; between novelty seeking and the neurotransmitter dopamine. This link allows patients to gain an appreciation of the interrelation between OCD’s psychological roots and the biochemical causes of the disorder.

  4

  OCD’S BEST TREATMENT:

  BEHAVIOR THERAPY

  Two treatments have been established effective in the majority of cases of obsessive-compulsive disorder: behavior therapy and medication. According to research studies, behavior therapy has the edge, markedly helping up to 80 percent of people who complete treatment, compared to medication’s 50–70 percent. Behavior therapy is also less costly than medication, and it causes no side effects. Behavior therapy is thus the premier treatment for OCD, indicated for all who suffer the disorder.

  From a theoretical point of view, behavior therapy is extremely simple. It requires no plumbing of the unconscious, exploring the distant past, or examining tangled motives. Instead, it stands on a basic, physiological property of the nervous system that is found in all animals from mollusks to man: habituation.

  If a snail’s head is lightly touched, it recoils quickly into its shell. If it is touched fifteen times in a row, however, it stops withdrawing. The snail, in effect, gets used to being touched. That’s habituation. The same type of response occurs in the infinitely more complicated case of a human who is afraid of a certain situation. Like the snail, if a person is presented with a noxious stimulus repeatedly and neither escapes from it nor is harmed by it, then he or she will eventually get used t
o it.

  Applying the law of habituation, behavior therapy has proven to be extremely effective in the treatment of simple phobias. Take, for example, a man who is afraid to ride in elevators. In order to get over his fear, he must first go into an elevator; this is called exposure to the anxiety-producing situation. Next, he must prevent himself from running off the elevator; this is called response prevention. Research shows that if the man places himself in elevators a sufficient number of times, and each time stays on the elevator long enough for his anxiety to diminish (as a rule, not longer than an hour), then eventually he will habituate to fear of elevators. He will overcome his phobia.

  The same principles apply when behavior therapy is used to treat OCD. A woman has obsessions that her hands are dirty and washes her hands compulsively. What she must do is expose herself to the anxiety-producing thought of dirt (the equivalent of going into the elevator) while resisting the response of washing (preventing running off). If she can do this often enough—twenty to thirty total hours of exposure and response prevention is usually sufficient—the idea of having dirty hands will no longer make her severely anxious, and she will no longer be driven to wash. She will conquer her compulsions.

  The gist of behavior therapy is found in an old adage that most people have heard all their lives, but too few OCDers have taken to heart: Face up to your fears. Behavior therapy simply takes this wise counsel and applies it systematically and scientifically.

  A number of different procedures may be employed in implementing behavior therapy for OCD. Usually, patients begin by recording in a diary the severity and duration of all obsessions and compulsions as they occur throughout the day. Situations that are being avoided because of OCD are carefully noted as well. Obsessions and compulsions are then ranked according to the degree of discomfort and disruption they cause. Specific symptoms are chosen for exposure and response prevention tasks. Progress is recorded daily in a journal or log.

  The meat of behavior therapy—the part of treatment where great gains are made—is in the tasks, or homework assignments, where patients must expose themselves to obsessional situations while preventing themselves from performing compulsions. Most commonly, the situations targeted for exposure and response prevention are the everyday triggers of OCD. A person with handwashing compulsions, for instance, may be asked to touch the toilet and refrain from washing her hands for two hours. An exaggerated measure of exposure may be encouraged: Touch the toilet then touch her clothes and furniture with her “contaminated” hands. Such exaggerated exposure, or “flooding,” speeds up the process of habituation, as it keeps a fearful thought prominently and inescapably in the forefront of a person’s mind. Sometimes, a therapist first models a task. For example, a patient might be asked to bring a “dirty” object into a session, and the therapist could rub it all over himself, demonstrating that it is not dangerous. Occasionally it is helpful for a therapist to accompany a client home and model an assignment in its natural setting.

  Exposure and response prevention can also be carried out in the imagination. Here, a patient is asked to bring to mind a fearful obsessional scene and to keep it in vivid awareness until the anxiety it causes begins to fade. For people who possess a strong capability in visual imagery (OCDers, it seems, usually do), this technique can be just as effective as exposure in real life.

  There are other techniques, as well, that help to implement exposure and response prevention. The popular form of psychological treatment known as cognitive therapy aims at changing people’s attitudes and outlooks toward their problems. We incorporate this approach extensively in behavior therapy for OCD. Putting a new spin on an obsession, taking a different view of it, can allow exposure and response prevention to be accomplished much more easily. A simple example would be helping a person to view an obsession as being like an obscenity shouted by a harmless drunk.

  Given the many different procedures that can be used in behavior therapy for OCD, one might think that this treatment is quite difficult, always requiring close professional supervision. Actually, however, twenty years of research into behavior therapy has led to a progressive diminution of the therapist’s role in its use. In the 1970s, for instance, it was thought that a therapist should always model exposure tasks and do home visits as well. Now it is clear that neither is necessary. What studies demonstrate is that the only absolute requirement for effective behavior therapy is enough exposure and response prevention to allow habituation to take place, and that this can be accomplished by a patient without the help of any therapist at all.

  In this regard, behavior therapy for OCD is much like physical rehabilitation for a shoulder or knee injury. Both can be accomplished without external help. More often than not, however, some assistance is essential. In the first place, just as it is not obvious that one should exercise a painful joint, it is not intuitively obvious that one should expose oneself to frightening thoughts. Secondly, exercising a knee, like preventing compulsions, is hard work. To extend the analogy further: If one has a minor shoulder injury, it may be fairly easy to devise and implement an exercise rehabilitation program. If the injury is severe, however, almost certainly a professional must be consulted in order to prevent exacerbating the injury with incorrect exercise. Thus, in milder cases of OCD, for the self-motivated person who has learned the principles of behavior therapy, no therapist may be necessary. Otherwise, however, it is wise to seek consultation (for information on how to find a behavior therapist, see Appendix D).

  This chapter will first illustrate professionally directed behavior therapy for OCD by following treatment of the cases of filth, harm, lust, and blasphemy that were introduced in Chapter 1. Then we will look at the special problems that arise when behavior therapy is ineffective. The chapter will conclude with a bare-bones, informal program of behavior therapy that will be sufficient to allow some OCD sufferers to help themselves.

  One more thing can honestly be said about behavior therapy in the treatment of OCD: Spectacular improvement is the rule. The cases of Raymond, Sherry, Jeff, and Melissa are not at all unusual. Most OCDers who follow behavior therapy programs through to completion will have therapeutic successes in the same range. They will not cure their OCD, but they will be able to live normal lives. And that qualifies as spectacular.

  AN EXAMPLE OF BEHAVIOR THERAPY: THE CASE OF RAYMOND

  Raymond’s case, introduced in Chapter 1, is instructive because he responded well to a very simple behavior therapy program. All that was necessary for marked improvement was for Raymond to systematically expose himself to his everyday obsessions while doing his level best to prevent compulsions.

  When Raymond first came to me, he was in the midst of a severe OCD crisis. He was unable to work. His days were filled with obsessions of poisonous spills, and he performed hours of checking rituals in order to prevent imagined catastrophes. Raymond thought that he had lost control of his mind, that his life was ruined. He fully expected to be hospitalized.

  Instead what happened was that Raymond worked hard at behavior therapy for six months, seeing me every one to two weeks for consultation. By the end of that time, his symptoms were more under control than they had been since he was a teenager. Antiobsessional medications were also quite helpful in Raymond’s treatment, especially in the beginning. Group therapy was very beneficial, too. But Raymond and I both believe that behavior therapy was the critical factor in his striking improvement.

  Raymond’s behavior therapy was divided into three stages. Our first four sessions together were educational. He learned the nature of OCD and how to clearly recognize his obsessions and compulsions. Sessions five through seven were concerned with assessment; here, we identified all of Raymond’s symptoms and ranked them by severity. Our last nine sessions formed the active behavioral therapy phase, during which exposure and response was accomplished.

  As is often the case, Raymond was greatly comforted right at the beginning of treatment when he learned that obsessions and compulsions are ca
used by a physical, chemical disorder. Like most OCD sufferers, he had never carefully considered the root of his symptoms but rather had blindly assumed that, somehow, he was to blame for them because of some mental weakness. Learning the truth about OCD began a revolution in the way he looked at himself. For twenty years, although he had been an excellent worker, citizen, and family man, he had thought himself mentally inadequate and half crazy. That he is neither of these things but instead the sufferer of a specific brain disorder continues to surprise him even now.

  Identifying obsessions and compulsions—the critical step in the early part of therapy upon which all further progress depends—presented no special problems for Raymond. His intrusive thoughts of vile and dangerous spills were classic, easily recognizable obsessions. Carefully looking for spills, feeling carpets, checking hallways, and conjuring up visions of vacuum cleaners while making “whooshing” sounds were obvious compulsions. With Raymond as with all OCDers, however, identifying obsessions and compulsions was easier when he was sitting in the office calmly discussing his symptoms than when he was in the heat of an OCD attack.

  In the assessment stage of therapy, the important work is to take a comprehensive inventory of obsessions and compulsions and then to rank them according to their severity. In order to accomplish this, I first asked Raymond to keep a daily diary of compulsions for three consecutive days. Here is a typical day of entries:

  DAILY DAIRY OF COMPULSIONS—JULY 22, 1993

  Even though Raymond’s symptoms were significantly improved by the fifth visit, his daily diary shows that compulsions were still taking up almost three hours a day. Obsessions, Raymond told me, were on his mind virtually every minute, except at work, when perhaps a half an hour would go by when he was completely free of them. The diary demonstrated that his obsessions were of two types: “spill fantasies,” in which he vividly imagined a container full of a deadly liquid ready to tip over and cause a disaster; and “poison fantasies,” in which he conjured up the image of a poison or diseased substance either accidentally present or deliberately planted in the food or drink of family members.