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in OCD, GAD, HC, BDD, depression, panic etc.
‘The portion of the brain responsible for OCD functions very much on the same emotional level as that of a two-year old. Trying to reason with either in the throes of a tantrum is senseless.’
‘Attempts at reassurance inspire the brain to automatically scan for any possible exceptions.’
Depression: ‘a deficit in the ability to suppress unwanted thoughts’.
(Wenzlaff, Wegner and Roper)
‘…you are always more than your feelings. At most they indicate to you where you need to grow.’
‘…depressed subjects were able to suppress unwanted negative thoughts by using negative thoughts as distractors. Depressed subjects found positive thought distractors a more reliable strategy, but negative distractors were used more often by these subjects as negative distractors were more accessible.’
(Wenzlaff, Wegner and Roper in Beyer and Hester)
‘Obsessive/compulsive disorder is now recognized as one of the most common causes of disability worldwide.’
‘To the sufferer, obsessions are what is known as “ego-dystonic” thoughts, refrerring to the uncomfortable experience of such thoughts as imposed and intrusive. Obsessions are to ordinary worries as migraine is to ordinary tension headache.’
(Duckro & Williams)
‘Nearly 60% of patients who are diagnosed with OCD are later diagnosed with depression.’
(Robins and Regier)
Much of the following work on OCD is based on excellent articles by Steven Phillipson Ph.D; some of which (see references) can be viewed on http://www.ocdonline.com. This does not mean that Anxiety Care follows all the theory and therapeutic practices advocated by Doctor Phillipson; or that Doctor Phillipson, or any other website or author quoted, would agreed with all, or any, of the sentiments, beliefs and suggestions as detailed in this booklet.
OBSESSIONAL THINKING IN OCD
Obsessional thinking is part of all OC problems, but here we will be looking at obsessive thought where it plays a primary role in the disorder.
There appear to be several types of OCD. Those most commonly brought to Anxiety Care can be gathered together under three main headings: ‘Classical OCD’ which involves the performance of rituals to reduce anxiety and may cover a very wide range; ‘Over-responsibility and guilt OCD’ where sufferers feel they are responsible for the welfare of others and are plagued with guilt about their inability to be able to do this successfully, or to be worthy enough to do this; ‘Obsessional thinking OCD’ where there is no overt ritual, but the sufferer experiences intrusive, persistent and alarming thoughts that may seem to come from nowhere.
A person may have aspects of all three types, but it is likely that one particular area will predominate or draw more extreme emotional reactions that the rest, as in; ‘I don’t mind the endless hand washing so much, it’s the fear that my mother will die if I don’t pray in the right way that is the main problem.’
It seems reasonable to assume that where these versions of OCD vary most is within the causes. That is, ‘classical’ OCD might be to do with a chemical or neurological imbalance where personality or early learning has little to do with the condition. The other two might be seen as having a predominance of personality and perceptual traits, where the sufferer’s view of him- or herself is the main trigger. Here, an initial sensitivity, like a chemical imbalance, might have begun the process, but the person’s susceptibility to feelings of over responsibility, worthlessness or personal ‘evil’ has been the catalyst to make the disorder a major problem.
Anxiety Care sees a lot of ‘staining’ within anxiety disorder sufferers. That is, once it is integrated into a person’s belief system that he or she is of low value, incompetent or potentially evil, many areas of life become threatening or the source of hovering disaster as self-confidence dwindles and doubt spreads like a stain into many areas of thought and perception. As one client said: ‘Once I could look at a problem and see fifty ways to deal with it and I’d pick the best one. Now all I see is fifty ways to do it wrong.’
As Phillipson points out, there is a non-conscious part of the brain that sends information to the conscious part if it deems this information significant to the person’s needs or well-being. This process also involves trawling for information that might indirectly (sometimes very indirectly) have pertinence to the person’s continued welfare. This process is a reflexive one and beyond our control – we cannot stop the information trickling (or blasting) through - but we do have a choice as to how we deal with it when it arrives.
Most people, those without obsessional thinking problems, discard the irrelevant and useless data and process only that part of it that is pertinent to their current situation. However, we all have preoccupations that might ‘colour’ this processing. For example, a charity client who has a problem with blood is so tuned in to the word that he is able to detect it being voiced amid several conversations in a crowded room. This can be likened to the ability we all have to respond to our names when spoken nearby, even by someone we were not consciously aware of as being within our hearing range, or even as being present at all.
‘…the part of the brain responsible for anxiety is not a thinking part, but only understands the experience of danger.’
This information-sorting part of the brain seems to be on duty at all times and certainly picks up a lot more information than we are consciously aware of. If we are tuned to a particular way of thinking or an area of current-sensitivity (like someone else’s footsteps on a lonely pathway at night, or the sound of a speeding car when we are crossing an apparently empty road) we are naturally going to process anything, like the above, that impinges on this.
Linking this to the way the brain can throw up tenuous connections, we are prone to jumping to wrong or ambivalent conclusions. This can be demonstrated by a method sometimes used in OCD groups. The leader says a word such as ‘jam’ and asks members to think about it and any thoughts it leads too, for thirty seconds. At the end of this time, ‘jam’ might have taken some people through scones, summer teas and happy holiday memories, while another is in a traffic jams on the M25 again and still another is cursing the cupboard door that never opens properly and wondering if he can afford a new kitchen.
In the above, no really emotive connections occurred, but if a person is in the habit of seeing him- or herself as out of control, weak, or ‘evil’ the summer holidays may be stained with self-contempt at not being able to sit on grass or sand for fear of contamination; the traffic jam underlines once again this person’s fear of killing somebody with his car; and the kitchen takes the last person back to fears of the knives in that kitchen drawer. In the latter situations, the super-sensitivity would probably take the sufferers back very quickly to frightening thoughts that grew out of one innocuous word.
‘There is no evidence that people who develop anxiety disorders change their basic thought patterns. What does appear to change is the intensity of the experience associated with what is perceived to be threatening thoughts.’
There are probably many areas and levels of ‘thinking’ with at least one having responsibility for holding every-day knowledge that we are not even aware generates thought. This knowledge might be our name, when asked, or which tool suits which job in our regular employment. In these cases and in many others, we don’t consciously think about the response, it is ‘just there’ in our minds when we need it. This is a very useful mental skill as it saves a lot of effort.
However, non-useful items can also be added to this internal list of time-savers – such as an obsessive response to an outside stimulation. Here it might become automatic, ‘without thought’, to avoid all pregnant or otherwise large women; to avoid all mirrors and reflecting surfaces; to count the pedestrians that one’s car passes. All these have been ‘responses without thought’ brought to Anxiety Care in the past year.
In these situations the stimulation has begun to generate an automatic response that might then be as hard to ‘forget’ as one’s own name. It also has the added anti-benefit of seeming to be as natural and necessary as are all the good automatic responses that make life simpler. Once this is explained, it can help sufferers to understand that the obsessive reaction is not normal and acceptable, but a dysfunctional response that has just ‘sneaked in’ among the useful ones. It is not ‘bad’ it just is. Whether it is a feeling of being out of control, potentially evil, responsible for other peoples welfare, or being guilty of all unsolved crimes in the region, it is just activity in the brain with no moral overtones or rationality.
Our need to make sense of the thoughts and feelings is part of the fear, the drive to understand and to be in control of our lives. It is nothing to do with the reality of the fears, because they have no reality.
When a sufferer is willing to believe that he or she is a bad person, that ‘only someone thoroughly evil could think these things’, the problem of ‘bad’ thoughts escalates and the effort to force them away again is intensified. However, trying to force a thought away or making efforts to avoid it’s recurrence – by staying away from situation that might cause it, hiding sharp objects, pills and potions etc – is far worse than useless as these huge efforts only ensure that the thoughts will grow stronger. Our anxiety keeps it’s mental fingers on our reactions at all times; it does not differentiate between real and imagined danger, its not bright enough for that, it just experiences the blast of feelings and labels this perception as super-serious and to be watched out for at all times. In such a situation, the more a person tries to hide and/or force the thoughts away, the stronger they become.
As with all anxiety conditions, the trick is not in reducing the times anxiety hits, it is reducing the response to these hits. Anyone who is undertaking a recovery programme will, inevitably, encounter the fears more often, which will involve more occasions on which anxiety blasts. This is an absolute requirement of the self-treatment. Anyone who judges relief by the amount of avoidance that he or she is able to undertake and the number of thoughts avoided is not recovering at all. Such a person is ensuring that the OCD owns them.
This can be very difficult to accept when these thoughts are hurtling around in one’s mind for many hours each day, or are hovering, apparently ready to ‘strike’, at the slightest jolt or reference to the feared situation.
When this occurs, it is tempting to try to ‘think the problem through’. That is, on the basic assumption that there just has to be a reason to be thinking like this, the person starts to work on detecting this reason. This is invariably disastrous because these thoughts don’t have a rational basis – they are obsessive and that is all they are. Once a person starts to look inside themselves for the ‘badness at the root of it all’ they will inevitably find something, because we all have areas within us that do not stand up well to close scrutiny.
We are all the product of everything we have ever thought and done and a solid proportion of this will be uncomfortable. Just looking back at ourselves as infants, children and adolescents, using young people of these ages that we know now, shows how self-involved, unkind and downright cruel we must have been at times. As one of Anxiety Care’s counsellors says, we all understand how a two-year old responds and accept it, but if that two-year old mind was put in an adult body, that person would be classed as dangerously deranged at the very least. So we all control the infant-inside, but it is still there.
‘’The more you laugh at the OCD, the more disrespect you give it. Hence, the less power it has.’
It simply isn’t possible to go through life without enduring malicious and self-serving thoughts. It is not possible to have children without becoming angry with them, resentful or, occasionally, wishing they weren’t around. We are emotionally involved with the people in our lives that we care about, but this caring doesn’t mean unbroken, unconditional love. It most certainly doesn’t mean that the slightest negative thought about these individuals is a betrayal and proves that we are ‘bad’. If anything, it proves that we are human and good at understanding people, because if we believe some individual is pure as the driven snow and totally perfect in every way, we are just showing that we are not good judges of people and situations, which is not a useful trait for an adult.
Take one of the most common fears of obsessive new mothers: holding a vulnerable baby and imagining dropping it on the hard ground. This is not a wish to perform the act, it is one’s mind flagging up the truth that babies are delicate and easily hurt; it is a thought about ‘not dropping it’, not a wish to harm the child. If we had no such thoughts, we might treat the baby like a bag of potatoes and forget our responsibilities and…woops! Most people experience the horrendous thought, see the tragedy in their minds, shudder and let it go. Obsessive people don’t. For the obsessive thinker, each shocking thought adds to the belief that he or she is ‘bad’ or out of control, or a potential monster. And these thoughts will be far worse if a tiny part of the mother mentioned above is angry, tired, fed-up and the thought of harm to the baby (and maybe resultant peace and quiet) wasn’t a total negativity for a fractional moment.
A charity worker states that, many years ago, his father used to spend night after night carrying his sister, the youngest child, around the first floor bedroom when her teeth were giving her a great deal of pain; and that after nearly forty-eight hours without sleep, he longed to toss the baby out of the window; that was all he could think about. This became a family joke, often repeated with relish over the subsequent forty years. At no time was there excessive guilt about the expressed feelings, and none was ever expected.
However, if these thoughts trigger terrifying responses about ‘personal evil’ and are then rattling round in the mind for hours each day, this person not only feels horror and fear but begins to think that he or she must be going insane. For most people, hovering insanity would prove that he or she is indeed almost ready to kill that baby; that he or she must be on guard against thoughts because they will soon reach a point where they are irresistible. This just isn’t true.
Charity workers who have been studying this field for more than twenty years can assure readers that there has never been one documented case when an obsessive actually carried out the feared harm. One doctor, when discussing this problem on a radio programme actually laughed at the question. He said that people with obsessive fear of their thoughts are literally the last people in the world to do such things. They have so many blocks and terrors between them and causing harm that it would be virtually impossible for them to carry out the actions.
This applies, in Anxiety Care’s experience, to both conscious and unconscious harm. People simply don’t drop poison into the baby’s milk or ground glass in their partner’s dinner by accident. Once the thought has occurred while undertaking food preparation, the chemical shock to the body and mind ensures that not only does the thought reoccur each time a similar action is undertaken (as we remember things best in the situation we learnt them, particularly if the learning was flagged up as vitally important which would be the case with obsessive thought), but that ‘casual’ or ‘thoughtless’ actions in that area become physically and mentally impossible. Basically, we are constitutionally incapable of performing the murderous act when it has been reinforced internally as hugely important not to. This would be in the same category as a bomb disposal expert forgetting he was in the process of defusing a bomb and whacking it with a hammer. It just doesn’t happen.
However, like the bomb disposal expert, nobody will give you a guarantee that it won’t happen – nothing is beyond possibility. As with everything in life, the obsessive person has to understand the likelihood of the consequences of any action. Getting out of bed in the morning can be dangerous - carpets fray, pets get under foot, bleary and only half awake we are not at our most careful. Having a shower or bath can be very dangerous – slippery surfaces, slippery soap, bath water deep enough to drown in, drowsiness, physical contortions to reach everything. Knowing the risks, what sensible person gets out of bed, or showers or bathes? The answer is, of course, all of us, because we have dealt with the dangers in our younger days and trust ourselves to do all this competently with the dangers stacked away neatly as understood but statistically viable.
We do not worry about something like this that has entered our thought processes as another time-saver that does not need conscious consideration, unless there is some special reason to do so, such as, with bathing or showering, an infirmity or bodily injury that requires special care.
This is just what happens in obsessional thinking. Our minds are telling us that there are ‘special/dangerous circumstances’ to consider and we are nor programmed to ignore such alarm bells. Absolute commitment and instant response to anxiety or fear-raising situations is a life-preserving trait that has served our small, soft bodied, blunt toothed, clawless species well for hundreds of thousands of years. It is a survival trait better than razor teeth and needle claws. As this is the case, we just cannot, genetically, ignore the signals it gives us.
So, there is no point trying to force the thoughts away, they don’t respond to that, they can’t. The trick is to process them differently.
‘An ordinary intrusive thought may be experienced as annoying or “weird”, but an obsession becomes an experience which is feared.’
(Duckro & Williams)
As Stout says, we have to accept all our thoughts – not that they necessarily tell us anything about ourselves, but that they exist and they are ours. They can be left at a pre-reflective stage, that is, with no interpretation or association with other things, or we can become involved in thinking about them. This is the quandary many obsessive thinkers find themselves in. ‘Good’ and ‘normal’ thoughts are dealt with at a pre-reflective stage, not given ‘thinking time’ – so a smile from another person is just accepted as a non-interpreted event and passes out our mind with barely a ripple. However, a frown from this person might mean (to the obsessive thinker) that his or her ‘badness’ is detected. A flash of anxiety and we begin to analyse the look and search within ourselves for the thought or action that ‘must’ have drawn it. In this way, normal and pleasant input that draws a simple recognition that it has occurred but no real reflective time, never balances the ruminations and anxiety that accompany any input and corresponding thought that we interpret as dangerous. In this way we come to perceive our world as full of danger and threat.
So the negative process begins as Stout describes for all thoughts: we identify the topic of the thought; we search our memories to determine whether we traditionally ‘like or dislike’ that topic. Based on the liking or disliking we experience desire or aversion (accept or avoid); we have a will to act on this desire; we work out through experience, reflex or intuition how to secure a successful completion of the activity the thought generated; we make a physical action to complete the task. This might by at a mindless, unconscious level (like scratching an itch) or consciously as the beginning of a major and life changing activity.
As Stout continues, and as all obsessive thinkers should grasp, once we are aware of the thought process we can begin to have an effect on it. This is best done at the point where we have ‘a will to act’ in the stages described above.
For the obsessive, this means he or she does not have to follow habit or a chronic, negative process. The obsessive can choose not to act as fear demands, or to act by putting the thought to one side with no real response. The person with obsessive thinking problems tends to experience the originating thought, with all its hangers-on of past misery, failure and fear, and then to try solve it, or placate it with ritual, or he or she tries to escape. In this way, the obsessive thinker becomes entangled with the thought as rumination. It cannot be solved or avoided but this does not stop the obsessive thinker trying. One charity client has been spending up to fourteen hours a day for the last eighteen years, trying to think his way out of this disorder. He has recently been persuaded to try another way.
This is not unusual and it does not reflect on a person’s intelligence or common sense. In fact, some highly intelligent people are suffering to some degree because of their mental abilities. In their experience, their unpleasant lives show nothing of value but their intelligence – that is, this intelligence is all they perceive they have to prove that they are viable human beings.
In this situation it is very easy to persuade oneself that the proper use of this intelligence is the only way out. The problem is, they are working with damaged tools. Their mind has decided that two and two is five, or the measure they are using is calibrated wrong. In these instances, the math or logic that follows the initial mistake may be impeccable, but it is inevitably leading to failure and will always be a failure because it is based on a false premise. Obsessive people cannot think their way out of their problems by the power of intellect alone.
‘When your brain sees that you are no longer running from the feared topics, a long-term consequence is that it will generally not bother transmitting the warning.’
For those who do not give mental activity great value, it is still very tempting to try to think oneself out of the problem or to become involved in mental ritual to damp down the fear. The greatest temptation of all is to give the thoughts credit. That is, the obsessive thinker cannot accept that a thought can be based in nothing of significance, that it is just a chemical or neurological misfire. Instead, this person clings to the view that any thought must signify a coming act, or at least a willingness or desire to perform such an act in the future.
‘…cross-national epidemiological studies have established that the proportion of cases of obsessive-compulsive disorder(OCD) in the community reporting obsessions only may be…up to 50-60%.’
(Weissman et al)
Within the groups, we suggest that anyone with a pictorial imagination can place themselves in any situation it is possible for them to imagine: this is better known as fantasy. There is nothing so wonderful or so disgusting that we cannot picture ourselves as undertaking it if we are so inclined. There are obviously areas that we avoid for social or cultural or family reasons, things that would be too distressing or embarrassing or illegal, or which would have too much of an impact on our fragile vision of ‘the self’ to consider consciously (see ‘sexual fears’).
However, many obsessive thinkers have very rigid parameters of thought. For example, one client was terrified of stabbing her young son and locked away all knives and forced the thoughts of knives from her head when they threatened to enter as they frequently did because she had flagged up the thought as so important. However, she had no worries about harming him in any other way and was comfortably able to imagine herself lighting a match and holding it near his duvet while he slept in the certain knowledge that she would never do this in real life.
That kind of process demonstrates the irrationality of obsessive thought and the tortuous flexibility of anxiety that can so irritate outsiders. That is, to non-sufferers, one is either murderous or one is not. They would find it hard to come to terms with someone who only perceives herself as dangerous in certain areas. They find it next to impossible to comprehend that a person can come to an arrangement with their obsessive thinking. That is, the fear of poisoning the baby’s milk has to stop when the obsessive thinker is down to the last few spoonfuls of powder (after throwing out the rest) because otherwise the baby goes hungry. The man afraid of contamination by proximity to gas pipes if he comes within a hundred feet of one outside, has to live near them in his own house because he has no other option.
To many non-sufferers this ‘proves’ that the obsessive person’s problems are not genuine. Unfortunately, it sometimes does the same for the sufferer. The doubt that even this living hell is not ‘real’ only makes the problem worse. Believing the problem ‘silly’ or ‘pathetic’ just undermines the will to counter it, for what is the point of trying to oppose something that doesn’t really exist?
Sufferers, carers and others who come in contact with obsessional thinking or, in fact, any severe anxiety disorder, have to understand that the problem will take up as much space in one’s life as it is allowed, and that it is pressing against these borders all the time. It has to be understood that such anxiety isn’t a rigid entity, but flexible and insidious. Most people have to maintain a certain level of ‘liveableness’ just to maintain their current place in the world. If circumstances were different they would love to throw out all clothes after one wear, dump the new carpet after the dog defecated on it, never again touch a door handle or any liquid or solid that could conceivably cause harm to another living creature; but this just isn’t possible for ordinary people. So sufferers come to an accommodation with their lives and their problem.
This is part of ‘balance’ which was discussed at length in ‘I know I’ve got to do it myself, but…?’ All our lives are about balance; whether or not we get out of a warm bed on a cold morning to go to work – comfort and much needed sleep against unemployment. Pigging out on adored chocolate – oral pleasure against weight gain and spots. Whether we throw yet another dinner in the bin for fear we have poisoned it – relief from anxiety against a partner’s condemnation and/or rage for wasting ill afforded money.
Seriousness (weight) of balances may be enormously different from case to case, the only requirement is that, in each individual case, one side just out weights the other. In many cases what constitutes the balance may be incomprehensible or invisible to outsiders. For example, in the case of a friend of the charity’s who is crippled with arthritis of the knees. Whether she drinks a cup of tea or not is much more to do with her ability to endure the pain of climbing the stairs to her lavatory in an hour’s time than how thirsty she is. This particular balance will only change when her need for liquid becomes more ‘weighty’ than her reluctance to endure severe pain; and this is a very simple, physical case, nowhere near as complicated (and probably humiliating which adds even more weight to the balance) as the choices of balance that an obsessive thinker must face many times every day.
For example, a female client is always late for work. Her OCD makes it extremely difficult for her to leave the house. When she needs to leave she is in front of her household appliances, checking and checking again, and cannot bring herself to go out through the front door. This situation continues until the balance of anxiety about leaving is out-weighed by the anxiety about losing her job. She is incapable of going out of the door until the need is extreme and this happens every working day. Living at this sort of ‘crisis’ level is very uncomfortable, exhausting and stressful, but many OCD sufferers do something like this every day of their lives.
This struggle, chipping away at the person’s dignity and self-esteem, is usually a lone battle fought out of sight (at least out of emotional sight) of even the closest and most loved family member. Sufferers feel lonely, isolated and usually freakish and sub-human. Very rarely do people suffering in this way understand the enormous victory they achieve every time they resist a compulsion or an obsessive thought.
One of the most important points Phillipson makes in ‘When Seeing Is Not Believing’ is that relief-seeking, looking for a way out from a perceived dangerous situation, is absolutely basic to human beings. It is a biologically programmed response to look for a solution, to obtain comfort and seek relief, when the anxiety centre of the brain (the amygdala) is activated. This means that the therapeutic requirement to resist this drive is going against nature.
This is small comfort of course. However, it does mean that the shame and guilt often voiced by the obsessive about being ‘weak’, ‘pathetic’ ‘not as strong as other people’ is misplaced at best. Anxiety Care workers agree that the continual battle they witness as sufferers struggle against this destructive disorder, is the site of more courage and determination than most people see in their lifetimes.
As said elsewhere and in various ways in this booklet, the answer, the way to deal with obsessive thinking, is to retrain the mind. It will never be possible to stop the amygdala responding to threat. If it were possible, we wouldn’t survive long as individuals; accident would claim us. In fact, were it possible, the species would have died out aeons ago. Anxiety as said before, is an essential survival trait.
The trick is to believe that the drive to find relief in ritual or thought is a way deeper into trouble and not the answer under any circumstances.
Many obsessive thinkers lose their place in the endless stream of thought that passes through the brain. That is, they lose the ability to differentiate between a random cognitive response that might have been fuelled by any number of physical, situational and biochemical activities, and their real selves. They simply begin to believe that everything that goes through the mind is significant. Even if, as is common, obsessives understand that such thoughts, pre-OCD, were ignored with a shudder at worst and at best were barely acknowledged and instantly forgotten, this often has no bearing on the way such thoughts are dealt with currently.
It should not be assumed, as many sufferers do, that obsessive thought is some new and strange way of thinking and the precursor to insanity or development into some kind of homicidal or sexual monster. As Phillipson says, OCD is an anxiety disorder, not a thought disorder. The vast majority of people think in just the same way as the obsessive; they simply do not give credit to the dross and the scary stuff – they accept it as the way the mind works and as having no pertinence to their character or cultural normality. They are fortunate in that the part of their brain that deals with anxiety does not label many pointless and irrelevant thoughts as vitally important, and/or the thinking part of their brain does not process every negative thought or impulse as a sign of badness.
The problem is, once doubt has entered the equation, obsessive people tend to try to be ‘super straight’; As with many areas of life, the greater the doubt about the self in certain areas, the greater the need to be seen, internally and externally, as culturally normal in these areas; (Which is almost invariably far to the ferocious right of being acceptably, humanly, ‘normal’). The sensitised obsessive begins to resist any thought that could not be voiced to his or her maiden aunt or the local bobby; and it is one short step from there to assuming that everyone else, not suffering in this way, must have similar internal cognitive processes that, by their obvious comfort with their minds, means they never think ‘bad thoughts’ at all.
This has the dual ‘benefit’ of making the sufferer a freak in his or her own mind, potentially a dangerous one, and therefore capable of virtually anything unless thoughts are rigorously controlled and guarded against.
‘People who start to listen to themselves usually encounter those painful emotions that lie just under the surface of consciousness: anger, shame, guilt, loneliness, depression, sadness, confusion…this is normal, so don’t let it scare you.’
Everyone represses the bad stuff. Repression is an unconscious mental process that pushes all the unbearably painful, frightening, shameful and otherwise personally unacceptable feelings out of the conscious mind, sometimes together with relevant memories (Molnos). As discussed in the booklet ‘Guilt and Shame’ these feelings and memories arise from conflict between our basic needs and drives and our internalised moral and social norms and standards (what we want against what family and culture demand). Trouble is, these denied events and feelings slosh around in our unconscious and continue to have an effect on our behaviour and our perceptions.
Most of us are vaguely aware of this psychological theory and many will recall the intense debate a few years ago about repressed memories of childhood, the supposed world-wide satanic abuse cults and the subsequent ‘false memory syndrome’ work. This hardly furthered the cause of science or improved the human condition, but it left many people with part-understood beliefs about the subconscious and the power of the mind. All of this fuels the obsessive thinker’s belief that he or she must control and explore thought.
However, as stated, most thought-stream activity richly deserves to be ignored – it has little or no value and is purely a response to outside stimulation that touches off irrelevant firings in the mind according to that person’s current physical and emotional condition: in short, a reflex.
‘It is important to note that one’s thought content and one’s genuine beliefs can be very different. People are not responsible for the ideas that occur to them through automatic cognitive processes’.
Sexuality is a prime example. Human beings have a broad, life-long, band of sexual interest that is artificially held to narrow, culturally imposed parameters in most countries. According to Allie, the western cultures were born out of ancient religions, pre-Judaism, Islam and Christianity, that held sexuality to be obscene and a curse; and the modern religions have integrated the stance, if not the actual rules, into their belief systems.
Fear and guilt is a good way to control a population and religious leaders of every epoch have not been slow in understanding this. So, religious teachings have always, notoriously, tried to control sexuality, but even the most prudish amongst us would (hopefully) find some of the Christian restriction on sex between married people, of a few centuries ago, laughable although they were culturally accepted at the time. Unfortunately, suppression of natural drives tends to distort their expression and even generates increases in them, which is something that these original teachers did not take into account.
As we all know, there are still many taboos and rules; some make sense, some don’t and ‘normality’ is often more to do with geography, social class and the century we are living in than anything more basic to the human condition. Unfortunately, we all tend to see the restrictions our particular culture places on us as ‘absolutely and immovably correct’; as if these rules were a law of nature rather than an artifice put up by people who felt they had the right to control others, and had a personal agenda for this control, and who (probably) integrated their own sexual hang-ups into the laws.
Within the last fifty years, homosexuality, for example, has changed from ‘official’ diagnosis as a mental illness to being, in the west at least, an acceptable (if still controlled to some extent) life style. So what changed? Did an immutable law of nature change or was it the laws of people catching up with reality? And why are there so many laws against so many sexual activities? If all this sexuality was really beyond the desires of normal people, as the media would have us believe (while lip-smacking over it), why the great need to control these ‘non-problems’ in the general population?
‘Inferiority was highly correlated with intrusive thoughts about perfectionism and sexuality.’
(Yao et al)
Men’s thoughts in particular easily drift into sexual avenues and the vast majority of normal men would admit, if they were honest, that a huge range of potential partners has drawn their sexual interest. Paedophilia is the current ‘shock/horror’ topic of choice and an interest that virtually all men would hotly deny.
It has been stated that calling somebody a paedophile is now the worst insult any person can lay on another and the hunt for transgressors is reaching a point in the UK that hasn’t been equalled since the hunt for communists in the 50’s in America and the witch hunts of this country in the sixteenth and seventeenth centuries.
‘…a sizeable minority of men in normal populations who have not molested children may exhibit pedophilic fantasies and arousal.’
(Nagayama Hall et al.)
An American survey (Briere & Runtz) has shown that over 20% of the normal male American college student subjects of this survey had had sexual feelings for children and that some would have involved themselves in a sexual relationship with a child if this were legal or if they knew they would not be found out.
Bradford, discussing the Crepault and Couture research, states that over 60% of their male subjects reported heterosexual paedophilic fantasies. And anecdotal and research evidence drawn from a wide range of sources, (notably Nagayama Hall et al.) suggests that occasional (not central) sexual interest in children is quite common in normal men and, at least from Anxiety Care’s experience, is far from being the sign of ‘degenerative monsterism’ that the media would have us believe.
This is not to say that adult/child sexual acts should be encouraged or condoned, or that any non-consensual sex is acceptable – we are talking about interest, sometimes fleeting and, in today’s cultural climate, almost invariably alarming and/or instantly repressed by the thinker.
Where does this leave normal men? We are the product of all our thoughts and experiences. Most of us will have memories of being sexually attracted, maybe totally smitten, in our school days, by classmates or other children in the school we attended or the clubs we frequented – teens and sub-teens. This is a normal part of development and these feelings reduce on sexual maturity, but our abilities to feel sexual interest in these areas is still within our experience and so part of ourselves.
Are we not to allow ourselves to think of this with pleasure as adults? Does being culturally correct mean excising these memories and being afraid because we once felt interest in (and still recall with nostalgic pleasure) someone who was below the age of consent, and this might mean the beginning of the slippery, slope to perversion? Does being attracted to a girl the day before her sixteenth birthday, make one a pervert, while being attracted to her the next day makes one a red blooded male?
As another example, the age of consent varies widely among American States, so it could be argued that it would be technically possible to be a normal male one side of a US road and a registerable pervert on the other after certain sexual activity.
‘The fact that millions of people believe a lie does not make the lie a truth.’
We cannot police our thoughts to extremes. We all have an inbuilt block against incestuous thoughts and activity as this is not socially or genetically useful to us as a species, although there is a very grey area at that time when we are ‘in love’ with our infant children; and more than one woman has suffered agonises of horror and self-loathing at being aroused by a suckling baby, which in itself can be just a physiological response.
Most of us also have culturally induced blocks against illegal activity of extreme sorts, such as rape (although research suggests that what constitutes rape in the minds of men and youths can vary hugely and not only from culture to culture). However, outside the more stringent and obvious rules, men’s feelings of affection and admiration easily slip over into sexual interest, the more sexually arouseable the man, the greater the chance of inappropriate sexual interest. This doesn’t mean anything. The idea that a momentary sexual awareness of a child or an ‘illegal’ teenager means an inevitable decline into molestation is ludicrous, but it is still being voiced by people who should know better and who want us all to police our thoughts – which might itself be seen as the ultimate, solicited self-abuse.
Anxiety Care has encountered several young men who are terrified of their sexuality. The problem is, one cannot be sexually aroused and very anxious at the same time, these responses are physiologically exclusive. So, if a man is in the habit of being made anxious by his sexual thoughts, it can become a chronic habit so that he cannot then even be aroused by what he might perceive as ‘normal’ sexual thoughts. Here lies the situation where young men trying to think ‘wholesome and normal’ sexual thoughts about women find they are not aroused because the chronic anxiety has sneaked in too, and so they then dive into the further terrifying thought that this must mean they are homosexual – more anxiety and a further guarantee that all or most future sexual thinking will involve a level of anxiety which will reduce sexual arousal, which will concentrate the thinking on homosexuality or other sexual fears, which…etc.
Some young men coming to the charity have found it impossible to think of a potential partner in a sexual way at all; they maintain such a close guard on their thinking that anything beyond the fantasy of a chaste kiss or hand-holding rings alarm bells. They are then trapped by their thoughts. If they have also adhered to the foolish teaching that masturbation is sinful or unhealthy, (ignoring or unaware of the fact that most people do it, and of the growing teaching that it is healthy and useful) and allow themselves no sexual expression, they are building up towards major problems.
Sexuality is part of everyone and its expression is a requirement that the body does not give up on easily. This does not mean imposing oneself on an unwilling partner, or forcing unwanted sexual acts on an otherwise consenting partner in the name of ‘good health’. It does mean that sex wants to express itself and won’t be denied. In the young (and sometimes the not so young) building up ‘a head of steam’ so to speak in the name of abstinence, leads to sexual expression at some point in spite of, not because of ones needs, and this can sometimes feel uncontrollable emotionally.
In the subsequent post-orgasmic state, the person is then free to be horrified at his or her ‘terrible uncontrollable lusts’, usually when the relief was self-induced and so no happy partner available to reassure him or her. This simply feeds into the obsessive fear of sexuality and the OC’s willingness to believe that he or she is a monster just waiting to be let loose on the world.
This inevitably aggravates the condition and the scene is then set for years of sexual doubt and mental and social isolation. Unfortunately, sexual obsession of this kind invariably leads to extra preoccupation with sex and a growing belief by this person that he or she is ‘sex-mad’ if not just plain mad.
Research suggests that normal men think of sex several times an hour. If a sexually obsessed OC is like other obsessive thinkers, he or she might be spending the greater part of the day ruminating about the problem – statistically, ten or more hours a day obsessing virtually full-time is not unusual for obsessive thinkers over thoughts that are not as persistent as sex. What then would this prove to someone afraid of his or her sexuality? Inevitably that he or she is potentially a sex criminal or so wanton as to be fit only for exclusion from civilised company. In this way, isolation and fear grows, and being afraid to talk about it ensures that the problem never finds a reasonable level within the thought processes and continually refuels itself. Linking this to the impossibility of becoming sexually aroused while extremely anxious, can lead to a person searching deeper and deeper within the self for his or her sexuality.
‘…one’s thought processes are altered or affected by the presence of shame.’
(Tangey, Wagner & Gramzow)
As has been said before, there are areas within all of us that are not comfortable to look at and our sexuality is right up there with the best of them. Emotionally healthy people realise that sexual fantasy need have little or nothing to do with a person’s actual sexual activity. Research says that both men and women have rape fantasies and many others that the law would frown on, or actually prosecute a person for performing in real life. These are the expression of a wish to be sexual (Fox) not a desire to actually perform the acts. Being attracted to the femininity or masculinity in another person of the same sex, does not necessarily involve ones sexual orientation at all, it can be simply an expression of feelings.
In fact it might be true to say that the more emotionally healthy the person, the broader the range of fantasies; but as the OC thinker is more interested in comfort and safety than health, it is almost guaranteed that his or her range or sexual fantasy would be heavily restricted. Digging deep to find arousal, even subconsciously, while armed with a mental stick to beat off everything that couldn’t be recounted to the maiden aunt, is a sure recipe for disaster. This will be additionally painful for the person who does not realise that his or her sexual fantasies were often formed in early childhood (Fox). As the focus here would probably involve immediate family it is then quite normal to find adults with incestuous or infant-like fantasies.
Sexual obsession, focusing on personal needs and fears, very easily translates the subject of desire into an object. That is, sexuality stops being an integral part of a full and rounded life and becomes life’s main focus where potential partners are not seen as such but as ways to relieve tension; crudely, for a male, as receptacles, for the totally obsessed, receptacles to avoid. With both situations, the partner is no longer a human being but another obsessional act.
Unfortunately, this state of mental affairs is common with OCD of all kinds. Obsessional problems easily present as another form of addiction – the driving need for relief at any cost. Family, friends and partners easily translate into just another resource for avoiding the overwhelming obsessional anxiety. This is not hard to understand – objectifying everything in the service of OCD – for anyone who has had the problem or who has had to live with a person suffering in this way. OCD easily becomes the only reality because it has its poisonous tentacles in every aspect of the sufferer’s daily life; just like addiction to proscribed drugs.
‘…one of the mind’s functions is to create habits…’
(James Harvey Stout)
It is like the master/slave syndrome. A master need know nothing about the slave, but the slave, to survive, has to know as much about the master’s needs as possible: In fact to be able to sense and meet those needs before the master himself is even totally aware of them. So it can be with OCD. Everything easily becomes lumped into two camps: obsessive problems and the rest. When mental survival seems to be in doubt, nothing else has real value. This is not a conscious choice of course. Like the master/slave situation, it can just be a reality of life.
Translated into a person’s sexual existence, it then becomes hard to view partners as people with needs and desires of their own. Orgasm may be the culmination of successful arousal against threatening anxiety, or proof that feared abnormality is not true, for a while. It can be (for men) a reinforcement of the belief that the sufferer is still a red blooded male or still able to perform ‘marital duties’. There may be very little space left for considering the partner’s wants and needs.
‘Within the fabric of each human being lies a basic drive to resolve emotional conflict when it reaches a heightened level.’
On the subject of proving masculinity, it is common to find male OCD sufferers very focused on their ability to have orgasms. As said elsewhere, when a man begins to doubt his masculine traits, not necessarily his sexuality, but his standing as a man among men, (common with men who suffer with anxiety disorders) sexual expression is often viewed as the fundamental proof of manliness. In this situation, it is not uncommon to find male sufferers giving up medicines such as SRI’s that have had a profoundly beneficial effect on their disorder, because their ability to reach orgasm has been restricted by it.
This might seem ridiculous to the observer (or the long suffering sexual partner) but it is another fact of obsessive life and one that has to be taken into consideration. Men with obsessions often feel less than manly, if not downright sub-standard and anything that holds their masculinity together in their own minds is powerful and necessary if this insidious disorder is not to own them.
Psychotherapy, as in an exploration of what constitutes manliness, might be in order here. However there is a more mundane response where this lack of orgasm has become a problem. Research suggests that it is possible to have a ‘medication holiday’ sometimes – reducing the dosage or leaving it off altogether before a weekend for instance – but this has to be done carefully and with the prescribing physicians guidance and approval. As with all areas in OCD, the thinking processes, used properly, will prevail over the powerful, but basically non-thinking obsessional part of the brain.
‘Analysts have actually known that their form of therapy is of no value to people with OCD for many years.’
CONTAMINATION AND THOUGHTS
According to McKay, the most common form of OCD is that to do with contamination fears. Obsessional thinking is obviously involved here as the sufferer, by definition, will be involved in irrational thoughts concerning cleanliness. McKay defines contamination as: ‘…a pervasive sense of having some undesirable object(s) still on one’s body, even after washing.’ He further states that: ‘ Many sufferers…report a ‘radioactivity effect’ such that mere exposure or incidental contacts with an identified contaminant results in total contamination.’
As with all obsessions, the more the rituals, in this case washing, are undertaken, the more this ‘proves’ to the mind that the perceived danger was real and the response vital.
When people fall into the belief pattern that only total cleanliness is acceptable, they have entered an area where the fear never ends; because there is always room for doubt and the mind is always keeping a look out for dangers: That open window, did germs fly in as I finished? Did I brush against that wall/towel rail/sink? How can I be absolutely sure I did not? The answer is, you cannot and you never ever will be certain of perfect cleanliness because this is an impossibility.
One charity client reports that this latter fear was always catching him out. As he was nearing a conclusion to the washing, he would sometimes ‘lose perspective’; that is, as he could see his hands with the wall/floor/sink behind them, they appeared to be touching one or other of these objects. To prove they were not, he had to move closer to the one focused on this time. Inevitably, this movement made him feel that maybe now he was touching, so he had to move again…etc. Eventually he would come in contact with the feared object and, mortified, the washing rituals had to begin all over again.
This client also demonstrated another area of the OC’s intolerance of uncertainty. He was incapable of accepting a ‘maybe’. Either planning an outing with friends or checking with someone that an activity had been completed properly, he had to have an absolute ‘yes’ or ‘no’ and it mattered little which it was. In this way, friends often stayed away because they knew that he could not accept tentative arrangements, and seeking reassurance on completions often lead to anger as few people would give a 100% guarantee that something was ‘clean’ or ‘safe’. A near-rational twist to the latter was that when he encountered people who patronised him by giving total guarantees in areas that, in more rational moments, he knew could not be true, he felt humiliated and betrayed and a need to find more ’trustworthy’ contacts for next time.
This kind of uncertainty is different from ‘pure’ obsessive thinking in that it is more an intolerance of doubt and, in this case, a fear of illness than a belief in being responsible for the safety of others, or being guilt based.
As McKay details, obsessional thinking becomes involved when a person with contamination problems fears harming others as in making them ill or even killing them with a disease he or she has been carrying inadvertently on body or clothing. It might also come into play where the person has irrational beliefs about cleanliness, that it is possible to be totally ‘clean’ and germ free, for example, or that everyone has a responsibility to try to reach this state of being. In this type of contamination problem, when starting recovery work, it would probably be of more value to deal with ideas and beliefs in this region before starting a recovery programme based on a simple reduction of the length of time involved in decontaminating.
‘Today, with or without a belief in religion and the supernatural, the notion of “evil thoughts” and “evil emotions” is overpoweringly pervasive in our culture. Its impact on mental health is devastating. On the one hand, it generates guilt; on the other, it sabotages men’s efforts at self-awareness. One cannot pursue self-investigation with a gun aimed at one’s head.’
Where washing or other forms of decontaminating are used to deal with ‘bad’ or ‘evil’ thoughts, this is almost invariably based in feelings of guilt. One client described his feelings of sexual guilt as presenting in the form of fears that words would flow out of his fingertips onto paper or other ink-friendly surfaces describing his ‘evil’ when he was not vigilant. This was never delusional; that is, he never really believed it, but based his finger licking response as being ‘better safe than sorry’. This might be described as another version of being unable to accept the slightest possibility of being visibly culpable linked to extreme guilt feelings.
While touching on the subject of delusions, it should be understood that it is not only the very seriously mentally ill who suffer in this way. ‘Normal’ people can also be delusional (Sheringham). In the description of work on the subject, Sheringham states: ‘Analysis of the frequency of delusions showed that nearly 10% of ‘healthy’ people had more delusional beliefs than the average score from someone with severe psychotic illness.’
In fact, looking at the range of human beliefs, it might be reasonable to suggest that we are all delusional about not being delusional.
‘When one gives in to a ritual, the brain’s sensitivity to the perceived threat is increased.’
McKay makes a very valuable final point in his excellent article when he points out that: ‘sometimes individuals simply cannot effectively engage in treatment related exercises. This problem manifests itself frequently when the fear associated with engaging in behavioural exercises is too high to be tolerated.’
As he mentions, and as charity workers would verify, therapists who insist on a programme that the client cannot maintain because of intolerable anxiety, are probably not the therapists that the person should have been talking to in the first place. Which doesn’t offer much comfort if they are the only ones available via the local NHS.
‘Although many sufferers recover from contamination OC, it is widely acknowledged that special attention must be paid to matters relating to staying recovered.’
RESPONSIBILITY AND GUILT
Aspects of this type of OCD were looked at in the booklet in this series, ‘Guilt and Shame’ however, here, we will be looking at obsessive problems where guilt and other responses aggravate feelings of responsibility.
The ‘greyness’ of this region manifests itself in washing and decontaminating generally. That is, Anxiety Care has encountered sufferers who wash both to reduce their fear of being contaminated and to prevent contamination occurring to others by their ‘negligence’. And as has been detailed above, clients with strong guilt feelings are very prone to excessive washing.
Phillipson & Gold in, ‘Beyond a Reasonable Doubt’, suggest that this type of OCD is distinguished from the others by the presence of guilt which is probably associated with the belief that a person’s worth as an individual is linked to the way he or she responds to such OC triggers.
In the charity’s experience, this can be a bit ‘chicken and egg-ish’; that is, clients have sometimes expressed confusion over whether their worry is to do with social concern, or anxiety/guilt over being responsible for the well-being of others, or fear that once they have become part of the problem (interacting with a ‘dangerous’ object) they will be perceived as responsible for the future harm potential of it.
‘I have yet to know a person with OCD to have been ruminating over a threat involving anxiety or guilt, which turned out to have any realistic significance.’
This was well demonstrated by a client who once became ‘stuck’ beside a broken bottle at a kerbside. He explained that he had pushed it off the pathway with his foot in order to prevent a child or other vulnerable individual tripping and hurting themselves on it, and this had been done with little anxiety or thought of any sort. He had then begun to worry about cars or buses that might puncture a tyre as they came into the kerb, but was prevented from placing the bottle in a nearby bin for fear that one of the vagrants in the area would harm himself when searching the bin for useables. He spent nearly twenty minutes agonising over his actions before he was able to walk (very anxiously) away.
He saw his intervention as making him part of the problem, which would not have occurred if he had simply walked past and left the glass where it was. During discussion he expressed the feeling that his fear of being responsible and open to punishment if detected, (so culpable might have been a better word) had quickly begun to outweigh his social concern for the safety of passers-by; that during the twenty minutes of rumination and regret he would have dealt with the guilt over an injured child in preference to the current feelings and the misery of culpability-doubt that plagued him for several hours afterwards.
This left the client unhappy with himself, putting his needs above those of a child, and regretting that this had proved to him that such a situation was possible. This client had been a life-long OC presenting with several variations of the disorder through contamination, guilt and checking ritual. He also had self-worth doubts that were simply aggravated by this episode.
This man is far from the only client who has presented with what might be called under-responsibility OCD. Over the years several checkers have expressed an inability to maintain their own households due to an inability to take responsibility for appliances, doors, windows etc. In most cases this has been linked to the person’s self-worth but in a flexible way where cognitive responses have been amenable to making responsibility someone else’s problem. (‘If you are last out and the door is left open, and we are burgled, it’s your fault, not mine.’)
It is debatable if this aspect of over-responsibility can be classed as just another area of the type of OCD, regarding obsessional thinking, we are discussing here. For example, a client who is finding it increasingly difficult to drive for fear of harming pedestrians and other road users, has no such fear when his partner, arguably a less able driver, is in control of the vehicle in these same areas. In such a situation, the feelings of responsibility are certainly irrational as, statistically, his partner is probably more likely to cause harm that he is. However, it is in his actions and the response to these actions he feels at risk, not within the rational area of deciding who is better qualified to do a certain job – which a person without OC problems would (probably) take more into consideration.
There might, of course, be an argument in this particular case for stating that the driver was being rational in that his aberrant behaviour while driving (looking in the mirrors too much for bodies behind him) made his theoretically less able partner a safer choice behind the wheel. This argument itself would fall down when discussing too much mirror work with this man as he would not see it as a problem, just a safeguard. So his focus of harm is on personal culpability, not the harm itself.
This area of over/under responsibility might be better viewed as an aspect of General Anxiety Disorder (GAD) where the overwhelming fear of life pressures and decisions leads to irrational behaviour; This is demonstrated by a client, working in a senior management post, who allowed a less able junior to make poor decisions on his behalf, secure in the irrational belief that he was then not responsible for the subsequent problems.
‘He who despises himself still respects himself as someone who despises.’
Phillipson & Gold describe the definition of responsibility OCD persuasively: that someone suffering in this way might be seen as feeling that he or she is able to cause harm by wishing it (even subconsciously), or can cause harm through their own ability to contaminate others unless scrupulous cleansing is undertaken. Basically, that he or she has too much ability to impact on another’s life, or has too much responsibility for protecting others. They state that: ‘this hyper-sensitivity to possible threats to others’ well-being is a feature that all individuals with Responsibility OC share.’
The area of under-responsibility is a difficult one with obsessional thinking. Experience within the charity suggests that those with an over developed feeling of self-doubt or hovering culpability are not prone to laying this off onto ‘power figures’ such as charity workers. That is, while doctors and psychotherapists might experience the situation where they are perceived as having given permission to the sufferer to give up responsibility (any disaster is then the ‘professionals’ fault if he or she has ‘forced’ the sufferer to give up some area of irrational, protective behaviour.); This has never happened within Anxiety Care.
No clients presenting with this type of obsessional thinking have shown the slightest desire to lay off their fears onto the worker, although this has often been discussed, or given any hint that such a proposition was even feasible. All have demonstrated that their feelings of responsibility were far more personal than that, very much locked in to their value as people or a need to believe that their irrational thinking demonstrated extreme caring and a proof of love.
There might be a case here for saying that such clients are not looking for relief and escape but a confirmation that their obsessive thinking is legitimate. Here, simple exposure work alone, attempting to reduce anxiety and dread by accepting the chance that harm will occur if ritual is not performed, is very unlikely to work without concurrent cognitive therapy and assistance with thought and self-talk changing.
‘Since the body and brain can periodically misfire and create unexplained feeling of peril, coping with and accepting these emotional events is more important than ensuring that they do not return or attempting to escape from them.’
As an example, one client has presented with a belief that he should be willing to sacrifice his life in order to save any other living person from death. When challenged on the reality of this belief, he does not respond with an extreme religious or humanist posture that might, just, be arguable, but with the feeling that he could not deal with the knowledge that by his inaction he allowed another person to die.
This is to do with anxiety and an unwillingness to experience it, perhaps also a very low self-valuation. It is not a laudable reverence for all life – it is never as simple as that. However, this does not (usually) prevent the person suffering in this way from hijacking a humanist position and presenting his or her obsession as a worthy trait. As obsessive thinkers are prone to thinking round the edges of a problem, involving themselves with the minutiae of the situation rather than the cold, straight facts, this is sometimes difficult to deal with and can lead to a great deal of directionless discussion.
We all need to understand what is going on in our lives, as has been discussed previously. It is a species trait. And the obsessive thinker tries more than most to make sense of his or her world: anything that reduces anxiety is grasped like the proverbial straw. In such a situation, it is common for a sufferer to find (and cling too) a coping technique, or therapeutic suggestion, that works once or twice, something along the lines of accepting the thought as ‘just a thought’ not a reflection of one’s life style or value as a person.
The problem is, if this is taken on in response to an outsider’s urging, much of the ‘power’ liberated might be that of the outsider. That is, the sufferer might be carried away by this outsider’s conviction or silver tongue on only a temporary basis.
‘…it may be comforting (not therapeutic) to know that the content of one’s obsessions does not characterize one’s true identity.’
Then often occurs the problem that relief is experienced without inner conviction that this is the way forward. The mantra, ‘It’s just a thought, it means nothing’, or whatever is used, becomes just more noise with no real belief behind it. Then a double problem is in place for the person does not experience much further relief, because the words are not really believed, and this person begins to search wildly for some other combination of thought and/or outside person to repeat the earlier ‘success’.
In this way, meaningless mantras are voiced, ‘proving’, by their failure, that accepting the anxiety is not the right approach and that some other outside force or power-person is needed to take the pain away. This stands alongside the willingness to give up responsibility for the problem as in the mantra: ‘It is not me, it is my OCD!’
While the latter may be useful as in the sufferer realising that he or she is experiencing erroneous responses on the basis of false perceptions of anxiety-borne information, it is more often used by people who are dissociating themselves from their thoughts. That is: ‘these are not my thoughts, they belong to the disease OCD which is inhabiting my brain.’
This frequently brings comfort but it is not therapeutically sound. All thoughts have to be accepted by the obsessive thinker if recovery is going to happen. These thoughts belong to this person. They are the result of a lifetime’s thinking, together with perceptions that have involved little thought. They are the result of every single external and internal action that has ever been processed by this body’s five senses. If they are distanced, if they are viewed as some malevolent invasion that has no part of the person they are ‘preying on’, then they can truly be seen as having power of their own. In such a case it is then one short step to believing that obsessional thoughts will lead to anti-social or illegal actions. Why shouldn’t they if they are not part of the reasonable and rational OC person and are taken on face value?
This can be a difficult concept to grasp, particularly if the person with obsessional problems is in the habit of repressing uncomfortable thoughts and feelings, or simply in the habit of denying the parts of him- or herself that are not liked. It is much more comfortable to see the things we hate in ourselves in other people. How much more reasonable then to view obsessive thoughts as a totally separate attack of misfiring brain chemicals that have no place in the sufferers mind. Like measles or a head cold, it could be seen as something that has come from outside and has invaded our body and we can do nothing about it but take medication and wait until it goes away.
When problems of responsibility are involved, it can be that much easier to see the obsessive thinking as an outside force. The weight of the responsibility can be huge; nobody suffering in this way ever takes pleasure from it even when, as said, they confuse it with a positive character trait. In such a situation, believing that the wounding or exhausting obsessional thoughts are not real but simply an illness, they lose some of their power to frighten, but they gain a disturbing independence that easily feeds in to feelings of being out of control should this be an aspect of the sufferer’s disorder.
‘Personal constructs are conclusions, convictions, attitudes…anything conceptual we use to make sense of our world. When rigid they become dogmatic filters over the eyes of awareness, thereby blocking our openness to new experiences, viewpoints, meanings. Allowing constructs to be ‘what I think or value or believe just now’, isn’t being wishy-washy; rather it’s a mature recognition that constructs are always working hypotheses constructed by an imperfect being who is always open to new learnings.’
One charity client, has become an expert at multi-layered thinking, having put literally thousands of hours to the service of his obsessions. He has become confused in that a thought might lead to a feeling, that might lead to a memory, that might lead to an impulse, that might...it goes on and on. His mind is an area of huge sensitivity where no thought is casual. Everything that comes into his mind is filtered through obsessive doubt.
This kind of situation easily lends itself to the belief that these thoughts are not of the person enduring them, but a disease-borne invasion that has to be repelled. As with any attacker that is seen as monstrously strong and potentially shattering, the subject is primed to fight back rather than to welcome. Unfortunately, trying to force away obsessive thoughts is a very good way to ensure their continuation and growth.
At the same time, very few normal people can accomodate the belief that something that is perceived as so malign and inimical to life can be internal without it also being the sign of imminent mental collapse.
Accepting that the thoughts are one’s own is a leap of faith that may be beyond many people starting out to work through a recovery programme. This is OK. As previously stated, a recovery programme has to be based in achievable steps, and the first one might be simply accepting the possibility that the above may be correct: ‘all thoughts are mine’; not necessarily swallowing it whole but entertaining enough doubt in personal perception to allow the belief room to grow.
As mentioned previously, this can be extraordinarily hard. Most severe obsessive thinkers will perceive all their energy as going into simply functioning, putting one mental foot in front of the other. If total denial of frightening thought is an energy saving technique in this process, then opening oneself up to more work and anxiety by accepting the truth about thoughts may be viewed as totally impossible. This is OK too.
All anyone can expect is that the sufferer will be willing to negotiate around this theory once the energy levels are better. As said, if the thoughts appear, to the OC, to be monstrously malign with a power of their own, it will be even more frightening to accept that they come from inside. This can then generate the situation where the sufferer accepts half of the theory. That is, he or she has been dealing (albeit badly) with the thoughts, using the comforting belief that they are just expressions of disease, like a runny nose or a measles spot, not part of the person; where watchfulness and caution are all that is needed to keep the disease from making the sufferer harm or molest others.
If a persuasive therapist (of any sort: professional or lay) over-turns this belief and manages to drive home the idea of personal responsibility for thought without helping to instil a belief that such thoughts are not precursors to actions, the sufferer is in trouble. In such a situation, the OC might feel as if he or she has been cut adrift as a bomb just waiting to explode. The thoughts have not lost their ominous threatening power within the sufferer, they have just been identified as a sign that this person truly is evil or a predatory monster.
‘Paradoxically, the chances of obtaining relief is increased the less one seeks it out.’
Someone with low self-esteem or a more than normally imperfect view of his or her ability to control personal actions might find a sort of perverse comfort in being self-identified as truly as bad as he or she fears. Hovering doubt is corrosive and debilitating – ‘am I, am I not?’ Anxiety wants to become fear or a resolution, so even a terrible truth is still a truth that leaves no more anxiety-raising doubt.
In such a situation, the misery and simple time consumption involved in multi-layered or questioning thought is gone and, with extreme obsessive thinking, any relief, even bad relief, is good news. The OC accepts the thoughts as belonging to him- or herself, but misses the qualifier that it is the perception of these thoughts, not the thoughts themselves that is doing all the damage.
As mentioned previously in this booklet and elsewhere, the simple power of such thinking can sweep a person away. One client suffering from extreme fears of harming and killing people, feels that he has to be aware of every thought at every moment, and be able to ‘play back’ every second of every activity. His perception is that, if he cannot recall literally every movement he has made during the day, the ‘blank spots’ are the times when he ‘blacked out’ and killed someone.
He does not subscribe to the belief that everyone has ‘blank spots’: that none of us can recall every action we take in a day because it is not physiologically necessary for us as a species to be able to do this under normal circumstances. He does acknowledge that, as a motorist pre-OCD, he did drive to places without conscious thought sometimes and was surprised when he arrived (we all have this auto-pilot capacity), but he cannot equate this with current circumstances; So any moment of relaxation is followed by checking his earlier progress for bodies when the terror hits again. He accepts that his extreme awareness of every painful second means that he should remember selecting and hiding the killing knife. And he is not divorced enough from reality to believe that the police have overlooked bodies strewn around the shopping precinct he frequents; but his hugely obsessive thoughts seek other answers – conspiracy, people protecting him – rather than the simple truth that these are brain misfires on top of a super-sensitivity to personal ‘evil’.
When a person is that afraid of his mind and it’s capacity to make him perform actions that are totally against his nature, it is then probably not a good idea to insist, at this time, that all thoughts are accepted as personal property. He is probably incapable of understanding that we all have violent thoughts and dismiss them (or even enjoy them). Any one of us who has been humiliated by another person, or who is looking after a child that is trying our patience to extremes, might find relief in fantasising about a physical response. However, the obsessive thinkers will have a whole stream of thought scenarios ready to click in as soon as the originating thought occurs. That is, for example, the urge to smack the naughty child’s bottom instantly develops into thoughts and images of losing control and battering the child to death. This is nothing to do with the person’s nature or violence levels; it is because such a thought process is scored into the brain by endless repetition, waiting only to fit round the next suitable generating thought.
We all have these ‘thought scenarios’ at some level. They might be viewed as fantasies if they were enjoyed. Some ‘normal’ people are appalled by their sudden flashes of rage and vengeance-thoughts and, as mentioned elsewhere, work hard at legitimising them; but they are part of life for all of us: we get angry and want to lash out, it is there within us as a species.
One charity counsellor who specialises in obsessive thinking problems states that he has a whole range of such scenarios of varying strengths that pop up in face of certain stimuli. For example, one client of his has a particularly colourful thought response whenever she hears a certain type of observation from friends or strangers. Whenever he hears this type of response himself, he thinks of the client and what she would have thought. He then does an internal shrug and lets the thoughts go. He can do this because he does not see the responding obsessive thought as significant, just as an understandable part of a thinking process; it was his thought, but the way it was processed depended on outside sources which had nothing to do with his value as a person.
This counsellor states that he has had many such scenarios in the past, generated by clients, but that all of them ‘dried up and blew away’ for lack of reinforcement. That is, as they were not personally important to him or relevant to ongoing mental activity they had no significance past an interesting event and disappeared completely once a particular client had gone.
This is common to all thoughts. Every thought leaves a certain residue in our minds according to its relevance – and this might be a good or bad relevance. This is part of our continuing self-education and growth. If we did not learn and change slightly all the time and have fractionally different responses due to this residue, we would adhere to outmoded responses and not develop into well-rounded adults always willing to learn.
However, when a thought is hugely terrifying, its residue is deep and muddy with a direct link to fear scenarios. So a thought of punching an ill mannered lout in the street, far from giving a certain relief to frustration, grows into thoughts of murder and graphic internal pictures of blood, guilt, family grief, trial and imprisonment. The OC is almost instantly a shaking wreck and the lout swaggers smugly away oblivious to the misery he has caused.
Such scenarios would naturally lead to extreme sensitivity to any angry thought and a need to monitor all strong emotion. This would inevitably grow over time into monitoring all thought so that even an interaction involving a friend, if not carefully thought through, has terrifying potential.
As with the client described above, who fears killing people, there are no safe moments when he is in a severely aroused obsessive state. Experience tells him that even the quiet times between ‘attacks’ are dangerous because, once the obsession has risen again, he will have needed to remember every action during that time of normality in order to prove to the roaring anxiety inside that he can account for every movement. That direction is towards exhaustion, huge pain and, often, a driving need for peace that sometimes only suicide seems able to promise.
‘Various parts of the brain present different levels of priorities or experiences of urgency. This duplicity of experience explains a key phenomenon: as the primitive part of the brain is misfiring biologically, the reasonable neo-cortex is confused by the false alarm.’
A sad point within this, relating to recovery, is that some OC’s, totally sensitised to their aggression, find it very difficult to take an aggressive stance towards their disorder once recovery is underway. That is, it can be important to be able to say to oneself in the situation above; “Yes, I probably killed that yob and buried him with all the others I’ve killed this week! Roll on the next one!’’ This is therapeutically healthy, but might be realistic for someone who has extreme anxiety in this area. An inability to indulge in such ‘gallows humour’ should not be looked on, by the sufferer, as yet another failure.
On this subject, it is also important to take an aggressive stance towards the thought processes during recovery if at all possible. This could involve encouraging the thoughts to do their worst and even looking for more extreme versions of the familiar, fear filled process as a pre-emptive strike – bringing them on deliberately before the thought scenario can click in – in order to circumvent the process. The part of the brain that wants us to feel extremely uncomfortable until we have dealt with the perceived threat then has nothing to do and the process of breaking down its stranglehold on our lives has begun.
The problem is, as mentioned, that when potential aggression has become terrifying to us, it is extremely hard to generate its chemical help to work against the disorder. Someone suffering in this way, as just said, might be so sensitised to aggressive feelings that he or she finds it impossible to use the same feelings to counter the obsessions. Then might be the time to talk through the whole idea of anger and rage with someone familiar with this field, outside the process of habituation and response prevention.
However, from Anxiety Care’s experience, this does not have to become a problem, as many clients seem to have been able to differentiate between obsessive fear of aggression and the more natural thoughts in this area. In fact, one client with extreme fears around violence was able to marshal much of the force involved to stand against the terrors. Basically he urged them to come and get him, which they naturally did not. He had managed to turn the focus of the violence away from the perceived targets (his children) onto himself which he was much more comfortable with. This did not solve the problem entirely, but his confidence grew enormously and he soon became able to push the thoughts away as ‘just inappropriate thoughts’ brought on by familiar thought scenarios, not the precursor to imminent murder.
This is a powerful tool within recovery – understanding that we have the ability to control our responses and move towards a positive outcome.
‘It is common for people to experience a diminution in the urgency to perform a ritual once they accept their willing collaboration and make the active choice to give in.’
COLLABORATION AND LIVING ON THE EDGE
A client who has had OCD since childhood reports that he finds it difficult to differentiate between relief gained by deciding to collaborate with the disorder (ritualise) and relief gained by deciding not to ritualise. He states that, at his worst, he would give in instantly when the urge to ritualise and check arose, even if this meant waiting for a period of hours (if he was away from home) until he could perform the calming rituals; just surrendering in his head seemed to be enough to reduce the anxiety to tolerable levels.
At one point, when he was away from home for over a week, he states that the need to check something that could only be done in his home simply stayed with him for that period, albeit at a less than critical level, until he was able to perform the ritual.
Now that he resists ritualising, he states that the equal and opposite decision not to collaborate gives him very much the same relief, but now he feels that this is a positive step rather than the humiliating surrender he saw his previous collaboration as being. “It owned me!” He said.
This client also developed a coping technique for long-term problems that involved him deciding that ‘anyone can handle this for a month’. He states that once the agony of indecision – should he or shouldn’t he – was removed from the equation he was able to look at the problem rationally. At the end of the month, he would decide whether or not to give in to the demands again and, invariably gave himself another month. In this way he states that he ‘staggered through six years, damn near successfully!’
The fact that collaboration brings relief can work disastrously to keep people trapped by OCD forever. This is sometimes seen within the charity where people have great responsibilities. Their perception is that they absolutely have to remain functioning so anything that allows this has to be accepted. Usually it is difficult to fault the perception if a person has large financial and family responsibilities and feels that he or she might ‘crack up’ and be unable to work and so lose everything if the disorder is opposed.
This enters the area of having enough ‘slack’ in one’s life to deal with trauma. Charity workers tell all clients that they have to ‘get away from the edge’. That if you live your OC life to the limit, metaphorically walking on a cliff edge, sooner or later that edge will crumble or something, or someone, will give you a push.
We all need enough emotional and psychical reserves to deal with the pushes that life inevitably gives us but, as discussed elsewhere, many OC’s perceive themselves as working flat out just to stay in one place, functioning as an adult with responsibilities. If this is the personal reality, it is exceedingly difficult to persuade people to oppose the disorder (additional and frightening activity) and so risk losing a great deal.
One client reported that he had a major argument with a therapist because he felt unable to accept the risk of contaminating certain irreplaceable work-related objects. He said that he could accept that this was the next logical step in his recovery programme as far as the therapist was concerned, but it presented to him as far too dangerous with the loss at failure far too great.
This particular situation seems more to do with the therapist’s poor perception of a structured hierarchy than anything else, but it does point up that many people who have to earn a living, feel that they cannot oppose OCD, this ‘ultimate blackmailer’, for fear of pushing themselves over the edge.
As said, charity workers try to help clients work out techniques to get away from the edge in such cases and remain very aware that capitulation, allowing the obsessions their way, is always a hovering alternative option when relief is perceived as essential. Far better to work at obtaining breathing space, slack, whatever an individual wants to call it, so that the problem can be dealt with, not integrated into the rest of one’s life; but to do this it has to be seen as a viable option.
Sometimes, medication is the only way. This does not necessarily reduce the perceived problems, but it usually enables the sufferer to see that he or she is able to invest some level of energy in resistance without the ‘certainty’ of failure. It gives a more accurate view of the true size of the difficulties. These might not take on the aspect of a ‘paper tiger’, but they might present as a less sprightly tiger than they appeared to be before.
‘It is critical to understand that relief-seeking is actually a biologically programmed response characteristic of human beings.’
Magical thinking is something we all do as children where wishes and reality can be indistinguishable. Chalquist sees aspects of this in adult relationships when we can swing between idealizing and despising a partner, expecting them to be perfect and totally nurturing and in touch with what we want from them; or totally dependant on us emotionally.
Molnos describes it as believing: ‘if I only think it strongly enough it will happen.’ And Penzel says that magic and superstition are as old as humanity and ‘represent a way for us to try to explain the normally unexplainable, and to try to control the seemingly uncontrollable’. The later might be a good definition of magical thinking within OCD.
James Alcock takes the position that some level of magical thinking is inevitable for all of us. He states that as evolution selects on the basis of reproductive success rather than with regard to reason or truth, it is sometimes more survival-friendly to think magically, to run on the basis of an erroneous magical coupling – ‘a rustling bush always means a large carnivore is hiding in it’ – than to hang around in total, rational control and find out for certain what that bush contains.
Of course, if such magical attribution stops the creature or person from ever approaching a bush again and the fruit and boughs of such bushes are a major source of food and protection, then this individual will similarly not live long. Therein lies the process of rationality and logic and plain ‘chance taking’ that has to be in existence to dilute our tendencies to think in extremes.
‘…memory is a constructive process rather than a literal rendering of past experience, and memories are subject to serious biases and distortions.’
It is true however, as Alcock points out, that we all have a tendency to link events and infer that the first caused the second, even when it does not; also that this situation is aggravated when the originating event is heavily loaded with emotion and finding a cause would offer relief from co-current anxiety.
Alcock states that ‘because of the nervous system architecture…we are born to magical thinking.’ The trick is, of course, to learn to put it aside as mentioned above. One excellent way is to accept the need for the magical thinking; that it serves a purpose by allowing us to feel in charge of our lives and fills the species-need to understand everything in our environment, but to put it aside anyway. Part of that response must always be to understand how easy it is for all of us to take a position and then dismiss all evidence to the contrary.
‘It is impossible to compute the magnitude of the disaster, the wreckage of human lives, produced by the belief that desires and emotions can be commanded in and out of existence by an act of will.’
Within many people’s perception, there truly is a yawning chasm waiting to open up if they dare to give up a set of beliefs or even one huge magical one, and enter the no-mans-land of seeking out new knowledge. The problem is, of course, that we are very hesitant to give up a belief if it works well enough to let us function, and at the same time offers that shadowy threat, as described above, of ignorance and fear if we do give it up. This ignorance and fear, as we tread between what we know and what we want to know, is common to everyone. Most people, not just obsessive thinkers, perceive giving up long-held beliefs as dangerous.
As Alcock points out, we all learn best from the association of two significant events – such as touching a hot stove and feeling pain. If we touch that stove again when it is cold, this does not mean we unlearn the first response as the cold touch has no significant effect on us; so the two events are not closely linked. This works just as well (or badly) with magical thought. Once we have reduced intolerable emotion by an undoing or placating thought, we are very likely to repeat this behaviour.
As we all have areas of life that we have to take on trust – religious beliefs being the main one for many people – we learn, as we grow up to bring a certain flexibility to words and events presented to us. Very few people can honestly say that there are not areas of their lives that they take on trust rather than on concrete proof of its truth or otherwise. Once this belief is established it will enter our belief system, rational or not, and we will tend to accumulate other information, from outside sources, sorting carefully, to confirm this. The stronger the emotion, (maybe very frightening feelings in OCD), the more unshakable the belief may become.
Many severe obsessives feel a very extreme form of this; that they are out of control and are experiencing a driving need to regain that which they perceive they have lost. This might or might not be a conscious process, but any compulsion will have an element of relief about its completion. However, magical thinking has a special place all its own.
‘…it is one of the great ironies of OCD…that it is in attempting to escape the anxiety- or guilt-producing thoughts that the greatest damage is done, because the thoughts themselves, while unpleasant, are survivable, whereas the attempt to escape – that is, the ritual – distorts the sufferer’s behaviour and affects his or her ability to function in the world.’
(Phillipson & Gold)
As Penzel says, with regard to magical and non-magical thinking in OCD, if the thought process was just one that resulted in very negative expectation from any action, it would be a ‘normal’ morbid thought. Magical thinking is quite different in that it attributes some form of unseen but very strong power to its occurrence. Sufferers may, for example, believe (as does one charity client) that simply thinking about a certain disease has the power to cause its occurrence within her or within a loved one. When such a thought occurs, this client feels compelled to perform ‘undoing’ rituals that might be described as a prayer or even a spell. She feels she has to repeat certain ‘healthy words’ a specific number of times, and if she is interrupted (by outsiders or her own wandering thoughts) she has to start all over again.
Another client has to perform certain actions in a precise form in order to ensure his family’s continuing health; and a third feels compelled to perform a complicated, mental ‘undoing’ ritual of words and numbers if he has sexual thoughts, in order to ensure that he does not stray beyond personally acceptable (very restrictive) sexual bounds; all of it mental rather than physical.
As will be noted, this ‘morbid-or-magical‘ thinking can be a grey area where a compulsion might quickly leap from ‘simple’ horror at one’s personal vileness, to a need to detoxify the thought by ritual.
When an OC thinker feels out of control and potentially dangerous, the belief that he or she can block the consequences of this perceived evil by some form of compulsive action might obviously be viewed as of great benefit. This can be understood with regard to a client who has problems with thoughts about harming his children when he sees a sharp knife. His response is a huge and overwhelming feeling of dread and horror with little attached thought. In his situation, the ability to ‘undo’ the feeling by some kind of magical thought would obviously meet the body’s need to reduce tension. He doesn’t do this and many clients and contacts in this general type of situation also show no inclination to adopt magical thinking as a response.
It is difficult to ascertain whether magical thinking is part of the disorder’s impact or part of the sufferer’s response to it. It might be logical to suggest that magical thinking, being part of all of us in our very earliest years, is a ‘last resort’ for anyone feeling totally out of control or helpless.
It might, of course be viewed as quite the opposite. The infant perceives everything as relating directly to him or her – the baby causes everything to happen in its own version of the world. Many OC’s coming to Anxiety Care would view this as the ultimate horror; it might be said that their need to have no responsibility is the opposite pole to the magical thinker who sees everything (within certain parameters) as his or her causation. Their ‘last resort’ would be to totally deny any kind or responsibility and ability to have impact on an obsessively perceived situation.
‘It is not that magical thinkers totally believe in their magic. They don’t. They do, however, experience serious doubts and need encouragement to take the risks necessary to see that their beliefs aren’t justified.’
It is not always possible to work out where the ‘normal’ obsessive thought response such as: ‘that was a terrible thought; only a worthless/evil person could have thought it’, stops and magical thinking begins. Some people use counting or the repetition of certain words, (mantras almost) to ease internal pressure. One client reported that thoughts he perceived as evil could be balanced by certain magical movements in another area. That is, when the originating thought response to outside stimulation (a pretty girl) made him feel like a potential rapist, his magical responses that (to him) kept his family healthy, which he would then do, proved his level of sensitivity and caring, which balanced the originating perception that he was a bad person. In this way he was able to keep two sorts of obsessive thought active and ensure his continuing dysfunction as a person.
Penzel offers a list of magical behaviours he has encountered which might be useful to readers and these are as follows:
· Repetitive praying or crossing oneself
· Counting up to or beyond certain numbers
· Reciting or thinking of certain words, names, sounds, images phrases or numbers
· Moving one’s body or gesturing in a special way
· Stepping in special ways or on special spots when walking
· Washing off bad ideas or thoughts
· Arranging objects or possessions in a special order
· Performing physical actions in reverse
· Thinking thoughts in reverse
· Repeating behaviour a special number of times, or an odd or even number of times
· Performing behaviours at special times or on particular dates
· Repeating one’s own words, or the words of others
· Repetitively apologising to another person, or God
· Gazing at certain numbers or words to cancel others out
· Touching certain things in a special way or a particular number of times
Anxiety Care has encountered many of these responses in people who would not even admit to being particularly superstitious, let alone obsessive.
As a further difficulty, Penzel notes that, with many people, magic has to be pure. That is, a few gabbled sentences or a half-hearted attempt at cancelling in the midst of other problems, might not be perceived as of any value. If a person with this problem adheres to the belief that the undoing words or rituals have to be exact, there lies in wait a great deal of anxiety and/or depressive feelings.
‘Feedback from the external world reinforces or weakens our beliefs, but since the beliefs themselves influence how that feedback is perceived, beliefs can become very resistant to contrary information and experience.’
All of us have an internal monitor concerning when we feel something is completed; with washing, for example, we all have different levels that we term ‘enough’ under different circumstances. In an obsessive washer however, this will be little to do with a rational response to a need for acceptable cleanliness.
As an example of normal differences, a charity volunteer states that when he is making a sandwich for himself, he may or may not wash his hands first, according to what he has been doing. However, he always washes his hands before preparing food for his children. His explanation is that he is happy to take his chances with contaminants in the name of laziness, but he would not force his children to do the same. In the case of his children, it would also cause him anxiety.
Another volunteer once sucked the fingers of his fourteen-month-old son when they were in a park and the boy had touched dried dog faeces. Encumbered with a pushchair and a bag, he was unable to prevent the baby from sticking his fingers in his mouth after the incident so took what to him, was the most sensible way out. (He does state that he would have given a lot for a peppermint sweet afterwards).
He has had obsessive problems, clinical and sub-clinical, and states that beyond the drive to keep his child safe, there was also a hovering feeling that he could not deal with the anxiety of waiting to see if the child had contracted an infection from the faeces. His own possible contamination was simply a ‘yes or no’ response – he either was infected or he wasn’t. No anxiety was involved, as he could do nothing about it.
As said, contamination OC’s will inevitably wash more than people without the disorder. Some will have an exact number of times that this has to be done, which might be termed ‘magical thinking’. Others will simply be tuned in to their internal anxiety levels and will cease washing when balance is achieved; and this, while invariably excessive, might be the result of a personal and solitary decision, or in response to family pressure, humiliation, exhaustion or even pain. (One client states that his washing is often curtailed when the hot water runs out and the subsequent pain of very cold water on his body becomes too much to bear).
If a person sufferers from magical thinking, the curtailing of such a ritual before perceived completion might cause much anxiety and depressive feelings. A magical thinker would probably not be able to rationalize the ‘pressures to stop’ as detailed above, as his or her balance between complete and incomplete would not be a vaguely internal response that varied according to the situation. Instead, it would be a rigid, unalterable need that had virtually nothing to do with the current environment.
‘…a view of the self that is dangerously mistaken and must be rejected: the notion that the self is some sort of “essence” within a person that is basically good or bad – and that a moral appraisal of a person’s thoughts and feelings will determine into which category his “essence” falls.’
As with all therapeutic responses to OCD, a magical thinker must, at some point, confront the need to take a chance: that they have to accept the possibility that harm may come to somebody if they do not ‘cast spells’. Regardless of how much this response to the OC prompt is perceived as necessary, it has to be acknowledged, sooner or later, that this version of the disorder is substantially interfering with the quality of this person’s life.
The problem is, magical thinking is very unlikely to be a conscious choice – people do not cast around for ways to deal with their OCD and pick the best one. Their response is going to have a lot to do with their nature, upbringing and culture. In this situation, the ‘mind-set’ of a person, the filtering process that determines how they perceive and process thoughts will be as natural to them as breathing, strange as it may seem to outsiders. As said elsewhere, when someone has internalised responses to life so that they become ‘truths’, as obvious and needing as little discussion as the difference between day and night, it is extraordinarily difficult to change this perception without a great deal of conscious activity and, often, faith in the person or person’s urging this change.
‘Scrupulosity is characterized by excessive worry, self-doubt, fear of taking risks, anxiety, embarrassment, intrusive thoughts, rituals, guilt, crippling indecision, problems in social and occupational functioning, and avoidance of the fullness of life.’
(Duckro & Williams)
Scrupulosity, as described by Duckro & Williams in their excellent article, has its beginnings in a ‘delicate conscience: the more delicate a conscience, the more it will be agitated by an inconsequential thought and excessively disturbed by some trifling matter. And this can cause great pain’ (Kolvenbach). Pedrick sees it as mainly a religious obsession but with hyper-morality and hyper-responsibility as major factors. And Cardinal O’Connor says that it always involves fear. He further states that ‘if anyone needs an awareness of the mercy, the gentleness, the love, the forgiveness of Almighty God it is a scrupulous person.’
For our purposes, we will look at scrupulosity as separate from general obsessive thinking that links to conscience; and define it as based in religious beliefs or a strong stance in that general region of personal life where ‘sin’ and ‘evil’ have an inappropriate amount of space in which to grow. And where sufferers are overwhelmed by a need to get everything in that area precisely right to the last detail; where they are extremely conscientious, hesitant, doubtful or uneasy and obsessive about deciding what is right or wrong.
According to Duckro & Williams, there are no reliable statistics on the incidence of this disorder, but they quote Ciarrocchi where studies show that (presumably in America) 25% of Catholic High school students and 14% of Catholic college students reported scrupulous behaviour. While the USA tends, as a general rule, to have a stronger and more fundamental approach to religion than the UK, their statistics in other areas of anxiety disorder and OCD do not vary much from the European, so it is reader’s choice as to what to make of these figures.
Van Orum’s book, “A Thousand Frightening Fantasies” as discussed by Cardinal O’Connor, would seem like a good place to start for anyone suffering in this way. Van Orum did a major survey of scrupulous people via the American organisation, ‘Scrupulous Anonymous’ and found that 50% of scrupulous people reported a severe or very severe effect on romance, while 54% noted a severe or very severe effect on marriage. This is not likely to come as a surprise to anyone with obsessional thinking problems.
Another interesting point from the research on scrupulosity, this time by Watkins, states that religious leaders within the Jewish and Roman Catholic faiths have writings on the subject of scrupulosity that brand it as a sin. One rabbi is reported as saying that it is idolatry in that devotion to a specific ritual to the detriment of good acts towards other people raises the act to a god-like status. Watkins seems to follow the path that a scrupulous person, concentrating heavily on one particular concern about sin, may easily neglect the more important aspects of his or her religion and so be moving away from a true and loving faith. She also makes the point that aggressive, sexual and religious obsessions sometimes occur together in the same individual. This, when it happens, is likely to make that person even more afraid, ashamed and perceiving his or her ‘evil’ as in total need of God’s forgiveness. To be a situation where only perfect prayers and excessive and obsessive religious activity can save this person from damnation.
Van Orum’s survey of scrupulous people, as quoted by Cardinal O’Connor states; ‘Internally…(many people) curse God…(They) radiate anger and bitterness towards God. Internally they curse their condition. They wonder why God selected them for torment…’ This would, naturally, only increase the sufferer’s fear and dread and ensure that the obsessive ritual continued.
It is easy for non-scrupulous people to see that any prayer ritual that depends on the (excessive and un-demanded) number of times a certain prayer is said, or a total commitment to the way in which it is said, with no room for mistakes of any sort is not about religious observation, faith and worship, it is about personal need and obsession. Those of us who have a belief in God are likely, in this country at least, to see that God as loving, compassionate and understanding: if we can forgive others, how much stronger and more complete must God’s forgiveness be?
However, if the scrupulous person sees him- or herself as evil, as a blight on society as many obsessive thinkers view their existence, then it is easier to understand a driving need to be ‘saved’. Perhaps like the ‘fire and brimstone’ religions of centuries ago in the UK (and not that long ago in other regions), where people were told that they were basically disgusting and worthless by many religious leaders, today’s scrupulous person will respond as these ancestors of ours probably did. This would be along the lines of a huge crime needing a huge punishment, or at least, a huge atonement.
Duckro & Williams point out that most religiously committed persons have experienced scrupulosity in some form, particularly in their younger years. Their reasons are that such people might have a period of increased religious fervour within which a need to be better than just good was paramount. They might also have interpreted a need for a more perfect union with God as coming from excessive rigidity of prayer. And as mentioned above, an awareness of personal sin, perhaps over-responsibility for perceived ‘wrongness’ might be fallow ground for excessive atonement and self-punishment where the fears gradually become more narrow and persistent and obsessive.
‘Depression is almost certainly caused by different factors, there is no single best treatment for depression’
(Greist and Jefferson)
These authors further point out that the scrupulous person usually seeks help from religious professionals first, rather than mental health professionals, and that by the time the mental health services are involved, such a person may well have developed depression – perhaps partly due to the withdrawal of support from significant others who have become intolerant of the repetitive religious behaviours. They further state that it is not unusual at this time to find the scrupulous person has withdrawn from religious practice and the religious community which had once brought some much peace and pleasure.
Duckro & Williams point out that many mental health professionals have no particular religious faith and some might have the tendency to try to ‘cure’ a scrupulous person of his or her beliefs. Anxiety Care has, in fact, encountered quite the opposite in the recent past, where two health professionals have, respectively, cited ‘finding Jesus’ as a cure and ‘the work of the Devil’ as cause when dealing with anxiety disorder in general.
Either end of this continuum, as a therapeutic intervention, would obviously be disastrous, adding an even greater complication to the scrupulous person’s life – particularly if this professional was being viewed as a ‘last chance’ when everything else had failed.
‘…there is good evidence that so-called self-defeating or irrational ideas may cause depression; there is also clear evidence that, once depressed, an individual often exhibits a variety of self-defeating or irrational ideas.’
Treatment for OCD usually avoids reassurance-giving and any intervention that reduces the sufferers’ need to face the problem ‘head on’. However, as Duckro & Williams point out, it might be essential for anyone helping a scrupulous person therapeutically to work with the person’s religious adviser and even assist while permission is given by such an adviser to undertake therapy that would reduce perceived religious ritual. That is, ‘to reassure the client that their challenge is to their own irrational beliefs not to God.’
Some clients coming to Anxiety Care have detailed very mixed messages coming from the various lay and religious professionals they have consulted about scrupulosity. It has also been common, as with most obsessional thinkers, for such clients to seek reassurance from group members and leaders that what they are doing is good and natural.
A response to this can be very difficult as most group members, even (maybe particularly) if not religious themselves, would hesitate to belittle even perceived extravagant religious beliefs, simply because they are about religion. This, from experience, has sat quite comfortably with the same group members helping other newcomers, with problems in a less delicate area, to face the irrationality of their thoughts by gently pointing out their thought processing errors.
The scrupulous person can then be in a no-man’s-land of seeing silence as agreement and then becoming tolerated but un-helped within the group because he or she presents as too uncomfortable for others to interact with.
Current Anxiety Care groups are London based and charity counsellors, even those who have been working within the service for many years, have no real experience of scrupulosity as it may differ when being presented within a deeply religious community where the majority of group members, whatever their other problems, would be expected to have strong religious convictions. Anecdotal evidence within the groups suggests that some sufferers have avoided discussing their continuing reliance on religious leaders in front of their peers, so it has not been possible to ascertain the level of useful support that has been obtained in this area.
However, as with any other help, if the support given is just reassurance that no sin has been committed – even if these words are spoken by a trusted priest or minister – the scrupulous person is likely to find a way round it. That is, within minutes or hours, the sufferer will have decided that the question was asked in the wrong way, or the adviser misheard, or insufficient information was given: anything that proves that the now returned anxiety has a good basis in reality.
This situation has recurred again and again within the charity over the years: however trusted, qualified or saintly the source of reassurance, the relief experienced never lasts, it cannot, the obsessive thought process won’t let it because nothing is being solved by the reassurance, it is being perpetuated. This rumination, doubting the religious advisor, can lead to additional guilt, particularly in the case of a scrupulous person who may perceive him- or herself as now betraying their priest or minister; or even observe themselves having angry or suspicious thoughts about him.
The best therapeutic approach to recovery, as discussed elsewhwere, is often a mix of medication (the Seretonin re-uptake inhibitors [SRI’s] or the tricyclic clomipramine are currently favoured), and cognitive-behavioural therapy that involves exposure and response prevention (ERP). The medication will enable the sufferer to manage symptoms; they will no longer loom as unstoppable, but it will not cure the disorder. It will lift mood, but will only bring the confidence that symptoms can be opposed, not remove them completely. This is needed to undertake the gradual exposure to manageable anxiety that not carrying out compulsive rituals brings as was discussed earlier.
When beliefs are never challenged, when the sufferer escapes via ritual before finding out that the anxiety would pass even if they did nothing, it is obviously very hard to accept that recovery using this method is possible. A good therapist will understand this and discuss it. He or she will work out a gradually increasing hierarchy of steps with the sufferer – only those agreed, no forcing or tricks – and will support the obsessive thinker as he or she undertakes these steps and works to resist the ritual that has previously been habitual. A very good therapist will also know when to ease off and when to talk about sticking points that might involve thought processes and self perceptions.
‘…depression is a complicated reaction to numerous events that contain cognitive (thinking), emotional (physiological), and environmental factors.’
Anxiety can generate depressive feelings and being depressed is very likely to make a person anxious. It can also co-occur as a specific mixed, anxiety/depression illness (be co-morbid as we say in the trade).
Depression may occur in many forms from the reactive – a fairly natural response to life stressors; through dysthmia, which is a mild form of depression that lasts at least two years, to major depression which might include being a personal trait in its antecedents. The various classifications are to do with severity of symptoms and the level of life impairment produced rather than different symptoms; and it is probably true to say that there are as many forms of depression as there are people suffering from it; and that no one treatment package is the answer to all (or most) types.
One major American classification model states that depressive mood brought on by bereavement should only last eight weeks, after which time a classification of depressive illness is warranted. This means that if you are still grieving over the loss of your nearest and dearest after two months, some clinicians might decide you were mentally ill! Most of us would query this, but, as said, classifications can be very different and arbitrary and are not, and never have been, etched in stone.
‘In a study by Roth et al (1972) the significant finding was that the anxious patient had such pervasive amounts of depression that they would also meet the inclusion criteria for depression.’
When depressed, it is frequently difficult to deal with, or suppress, negative or frightening thoughts, and some clinicians view depression as a form of aggression – turned inward towards the self rather than outward against others. So, the anxious and depressed person’s ‘mindset’ might be fixed firmly on a super sensitivity to all that is harmful or dangerous, or lead ‘naturally’ to a belief in personal inadequacy or personal evil and a preoccupation with death. This would be fallow ground for the development of obsessional thinking and a general OC condition.
Armstrong offers a clear comparison of anxiety and depression. He says that anxiety is about threat – to future happiness, self-esteem and a personal ability to make sense of the experience. And that depression is ‘a multifaceted state’, concerned with loss or a threat of loss. He further states that although both anxiety and depression involve ‘emotional, cognitive, behavioural and physiological components’, depression is more about avoidance, withdrawal and diminished activity. And anxiety and depression are both emotions ‘comprising more fundamental emotions’; that while not identical, they have similar components as in there being fear elements in depression and sadness elements in anxiety.
As mentioned in other literature, anxiety’s ‘fundamental emotions’ might be any kind of blending of anger, shame, guilt or sadness feeding in to the dominant fear (Izard ’77; Izard and Blumberg ’85). The individual’s ‘personal mix’ can obviously have unlimited variations and some of these would enable depression to take a fast and firm hold. When anxiety and depression are mixed, research suggests that this joint disorder will be more quality-of-life reducing than either disorder would have been alone. It also seems that even when the depression is ‘low-grade’ as in dysthmia, the sufferer will tend to invest the greater part of his or her available energy in work leaving little or none available for home, family and social life; with resultant family difficulties.
Several group members have recounted dramatic versions of this situation: children’s happy voices pounding the ears like klaxons; suggestions for outings or games in the garden processed as threats. One member told of the wonderful relief he experienced when driving away from his home and his beloved wife and children in the mornings – his only current interest being the ability to get through his working day without a total collapse.
Again, this is fertile ground for perceived alienation and the birth of anger against the family. A person suffering from obsessional thinking problems might quickly develop such feelings into a whole scenario of rage and personal evil where violence against family members seems more than a possibility.
The group member mentioned above described his feelings when looking at his family during the worst part of his anxiety/depression. He stated that there was no love, no real positive emotion at all, just the perception that they were one more impediment to his remaining a functional, working, ‘real’ man. Another point he made was that his depression reduced libido and he began to doubt his sexual orientation because he no longer perceived a sexual interest in his partner. At no time did he link his feelings with something ‘natural’ like depression. His focus was on personal weakness. He did not understand how anxiety and depression, alone or together, can generate feelings of worthlessness, or hugely aggravate existing doubts in this area.
‘Negative thoughts and thinking are characteristic of depression. Pessimism, poor self-esteem, excessive guilt and self-criticism are all common.’
Athens suggests that a person does not fully enter depression while he or she perceives there is the slightest chance that the life position can be altered for the better; that, while hope exists, the person will be moving in and out of depressive episodes. If this is true, it could explain the roller-coaster emotional lives of some obsessional thinkers.
Many people coming to Anxiety Care on a regular basis, present with very different perceptions of their problems from week to week. It is quite common for counsellors to be working with a client’s positive orientation towards the problem and the future for several sessions, only to encounter an almost complete reversal into despair and hopelessness a few weeks later; and then back again.
A nasty ‘twist’ to this is that some obsessional thinkers attempt to dampen down these despairing episodes by additional or more extreme ‘solving’ rituals and thoughts. Also, if this person has become involved in positive thinking and positive self-talk at the good times, the sudden cessation of positive response to this therapy, tends to ‘prove’ to him or her that the theory was always untrue or, worse, that he or she was always lying to the self and cannot be trusted with any good thoughts or beliefs.
Anyone who has experienced the poisoning weight of a major depression will understand that there are no good times within its grip – everything is and always has been pointless when in this mode. If the depression slows this person down, existence seems like too much trouble – eating, talking, thinking, even breathing. If the depression has an opposite effect, increasing activity, Athens suggests that this can generate overwhelming guilt feelings and anxiety.
Some people suffering in this way report body pain, with others events and people become sentimentalised; that is, normal perceptions give way to sadness and emotion. A sad song or a sad book takes on greater meaning and pain. TV programmes that once would have been dismissed as over blown and emotionally manipulative are interpreted as unbearably poignant and totally meaningful. A child’s sadness or temporary pain is seen as tragic and unbearable.
When these varying perceptions come and go as depressive episodes wax and wane, it is not surprising that the sufferer becomes emotionally exhausted and doubting of his or her ability to function in the world.
‘…clinical anxiety may progress to depression depending on the extent of one’s psychological and biological vulnerabilities, the severity of current life stressors, and the coping mechanisms at one’s disposal.’
(Brown re. Barlow)
The problem with depression is that when nothing matters, when there is no hope, a person does not have to try any more. A friend of the charity who suffered for many years with an acute disorder involving obsession, anxiety and depression, states that he felt safe during this time. Most of his behaviours and thoughts were self-defeating and self-involving. It filled his life with the minutiae of misery and sadness where everything had its place and nothing mattered enough to strive for, to put himself out for. He gave up working, socialising, interacting with people and operating within main-stream life in any meaningful way. He says that it was as if he put himself in solitary confinement for several years (punishment often appears in his descriptions of this time); where no positive cognitions were allowed to take root. There were no positive reinforcements to anything he did and, as Athens says, these are necessary as the building blocks of our self-esteem. Caught in this trap, the depressive has very little chance of breaking free – of having energy or desire enough to break free.
This friend also states that his crippling obsessional thinking went into remission at this time. His perception is that the hammering guilt and ruminations were ‘bought off’ by self-punishment; that his personal evil was being given the treatment it deserved so needed no more thought. He says that this was probably the worst deal he ever made in his life and that if he hadn’t been prescribed the tricyclic, clomipramine, he would probably still be there in his own private little hell.
‘…in many cases, the depressive symptoms appear after the anxiety symptoms, i.e. are secondary to depression but major depression can also precede the onset of an anxiety disorder or occur simultaneously.’
The World Health Organisation offers a list of erroneous beliefs that tend to contribute to a person’s depression:
· I should be happy all the time
· To be a good person, I have to be nice to everyone
· If someone is hurt by something I say or do, I am a bad person
· If I show emotion, it means that I am weak
· It is shameful for me to show any sign of weakness
· If someone does not like me, it means there is something wrong with me
· If I argue or disagree, people won’t like me
· If I am criticised, it means I am wrong
· If I don’t succeed, I am worthless
· I cannot handle it when things go wrong
Within the groups, people who think negatively, obsessively and depressively, are often challenged by leaders to give proof that life is as they see it; as in: ‘what proof have you got that what you just said is true?’
When this is said, people are often taken aback by the challenge, as if they had long given up questioning negative and depressive thoughts. This is not surprising as most of us are not in the habit of policing or even being consciously aware of a thought process; like much else in life, this process easily becomes a ‘truth’, it ‘just is’ – like night and day.
(OCD): ‘Depression – approximately 80% of OCD patients are currently depressed…(It is) fairly common for non-patients to have obsessional thoughts (80% in one study). Content of these thoughts is identical between patients and non-patients.’
When a person is helped to check on the reality of depressive thinking, much as he or she has to be with obsessional thinking, it may seem like just another problem to deal with: at least, previously, this person was not made to question the self about this misery, now outsiders have produced yet another way to be unhappy. At this point, it is quite likely that the depression sufferer will back away from further support of this kind.
But there is no real alternative to looking in this area. If the depressive element is to be countered, it first has to be acknowledged. This is often difficult as people with obsessional problems rarely want to believe they have another mental disorder as well – isn’t one enough, might be the perfectly reasonable thought? The answer is of course: yes, more than enough, but sadly this mixed anxiety/depression is a frequent fact of life that is doing it’s own negative part to maintain the primary OC problem.
It seems to be clinical practice to treat the OCD when a person presents with a mixture of obsessional and depression (and probably panic) problems. This does not mean that the depressive thinking won’t be severely aggravating the obsessions. Fortunately the new medications, the SRI’s, which are treatment of choice for OCD, are anti-depressants and usually have a profound effect on lifting mood.
As said earlier, reducing the perceived enormity of the fears and thoughts, is a good start to the work of dealing with them. However, while easing, this chemical help will not be altering ways of thinking. This takes personal work and, often, outside help. This outside help does not have to be professional – a friend or family member can often be of enormous value. If, however, the depressive thinking locks in to the difficulty of this work, and the inevitable failures bring on the ‘I am useless and always have been’ depressive response, then professional help in the area of supporting thought changes might be a good idea.
‘Dysthymia is morbid anxiety and depression accompanied by obsession.’
Many people coming to Anxiety Care with OC problems suffer from panic as well as obsessional thinking. One client described daily panic attacks that left him shaking and hysterical and begging for reassurance (and eventually resulted in his wife and children leaving him in sheer self-defence, he says).
Chandler offers two possible causes of panic attack: ‘CO2 Sensor Sensitivity’ and ‘Behavioural Inhibition’. He states that most researchers have found that panic attacks are caused by an abnormality in the part of the brain which tells how much Carbon Dioxide is in the blood. If the brain decides there is too much, it means that the person is not breathing fast enough, or there is too much Carbon Dioxide in the air, as with a stuffy (or smoke filled) room. The body then sends signals to increase breathing and a burst of adrenaline to make this easier.
Chandler goes on to say that it is possible that in a person who suffers panic attacks, this Carbon Dioxide sensor is too sensitive and gives the brain a false message that starts this alarming bodily reaction out of the blue. Here, a random adrenaline rush and fast breathing is almost certain to alarm the luckless victim. It is a short step from this point to believing that there must be something deeply wrong within the body. This almost inevitably leads to the setting up of a careful internal watch for more ‘signs’.
According to Chandler, the ‘Behavioural Inhibition’ is ‘a tendency to react negatively to new situations or things…roughly 15% of children will be shy, withdrawn and irritable when they are in a new situation or with new people or things.’ Chandler goes on to say that these children are much more likely than average to have a parent with an anxiety disorder and that this, together with adverse life conditions or stressors will make panic attacks more likely. He closes by stating that ‘it is thought that the majority of the genetic predisposition to anxiety disorders is expressed through behavioural inhibition.’
‘No experience carries a greater sense of urgency than a perception of imminent threat to one’s self or to a loved one.’
McNally and Lukach in 1992, made the interesting point that some panic sufferers met the then current classification criteria for Post-traumatic Stress Disorder (PTSD) subsequent to their most terrifying panic attacks. The intensity wasn’t reported as so great as for classic PTSD, which is the response to some heavily traumatising event such as warfare or a severe assault, but it was obviously bad enough. PTSD tends to bring the traumatising event back to mind in frightening ‘flashes’ and ‘recurrent and intrusive recollections of the event’, where guilt may occur too (Masters).
Obsessional thinkers who also report severe panics often mention the presence of the memory of a severe panic attack as extremely real and it can be seen from the above that the traumatising power of panic should never be under estimated. If guilt is also aggravated, as mentioned by Masters, then thoughts are going to be that much harder to deal with.
‘…there is some evidence that obsessional severity fluctuates markedly with the severity of depressive symptoms, whereas compulsions do not.’
(Ricciardi & McNally)
According to the ‘drkoop’ site, when panics occur within an OC disorder, it should not be assumed that this person also has Panic Disorder as a co-morbid problem unless these attacks occur ‘out of the blue’. A further indication that such panic is part of the OCD would be that the sufferer is not afraid of the panic attack as such (which, classically a Panic Disorder sufferer will be), but of the consequences of the cause, such as panicking at the sight of a blood stain or other feared contaminant on shoes or clothing that this person will believe is a precursor to death – his or her own or that of a loved one.
Drkoop also makes an interesting point about the difference between the ruminations of depression and the obsessions of OCD. This is that people with depression are usually concerned about realistic problems, at least things that non-sufferers would understand as the source of real unhappiness; such as feeling worthless or regretting past mistakes and lost opportunities. The difference between them and non-depressed people being that the depressed person’s perception of the enormity of these events or situation would be highly coloured by the depressive mood. The obsessive person would tend to be more concerned with problems in the recent past and averting future harm, and would probably not be able to successfully defend these obsessions as rational in the presence of non-sufferers.
‘Approximately 35% of non-clinical individuals experience at least one panic attack per year
(17% 1-2, 11% 3-4, 6% 5+)’
GENERALISED ANXIETY DISORDER (GAD)
GAD, sometimes called ‘free floating anxiety’ (Morgan) is another disorder where ‘thinking symptoms’ can be confused with OCD. GAD involves excessive and uncontrollable worry about life events over a period of at least six months where there are more worry days than non-worry days.
Family and finance seem to be the usual focus and there are likely to be strong feelings of threat involved and an internal readiness to acquire threatening information and to ascribe the most threatening scenarios to such information. It will probably also be believed that these situations are uncontrollable. Being preoccupied with the self (very understandable in such a situation) is likely to aggravate the experience. (Matthews and Mcleod 1987; Barlow 1991; Rapee 19991, various studies pages 79 & 83).
Onset is thought to be mostly in the early 20’s and gradual (Edelmann), although Rapee’s research (p.78) suggests that it can go back as far as a sufferer can remember. And Sanderson & Wetzler say that some GAD sufferers present with a lifetime history of anxiety, apprehension and physical symptoms. These authors also suggest that ‘patients with depressive disorders are more likely to have GAD as well than are patients with anxiety disorders.’
People with GAD will probably find it difficult to concentrate, they will have muscle tension, be easily fatigued and experience sleep disturbance (Dugas). They might also have physical symptoms such as trembling, upset stomach, sweating, dry mouth, flushes or chills (DSM-III-R) but, like OC’s and unlike people with Panic Disorder, they will understand that these symptoms are due to their own anxiety and are harmless. GAD sufferers might also wake up in the morning feeling anxious and be unable to pinpoint a direct cause. They might perceive themselves as harbouring this anxiety all day (Henning).
Rapee suggests, in an analysis of several research studies (1991 pgs. 87/8 and 288) that GAD involves a predominance of thought (verbal) activity rather than images and is conscious, attention-demanding and difficult to switch off. Dugas points out that this is one of the main differences between obsessional thinking and GAD thinking: people with GAD view their ruminations as consistent with their fundamental personality and beliefs, while people with OC thinking do not. Those with obsessional thinking problems also tend to involve more images in their thoughts than the mentioned verbal activity of those with GAD.
Dugas further points out that people with GAD are highly intolerant of uncertainty in that they may be discussed as having an ‘allergy’ to it, metaphorically speaking, where even the one-in-a-million chance of something happening is unacceptably threatening.
GAD sufferers may also use worry as a coping technique where this mental activity, rather than mental activity aimed at a solution, is used and reinforced by the feared event not happening, which could be put down to the worry being perceived as a positive activity (Edelmann).
According to one’s perspective, this might easily be classed as magical thinking and at least part way to obsessional thinking; although, as mentioned earlier, we are all prone to magical thinking at times – particularly those times when the forces we are up against seem to be hugely and unstoppably powerful, as they might be perceived by a GAD sufferer.
Freeston’s description of one area of OC sufferers’ ‘dysfunctional appraisal’ is ‘inflated estimates of probability and severity of consequences associated with feared events’. This can be difficult to separate from GAD thinking for some people.
One group member expresses a great deal of guilt about past activities concerning people and his home and worries excessively about dire (and unreasonable) consequences occurring because of this. He has suffered from a range of obsessive problems for many years, including checking, washing and contamination, but perceives himself now to be more aligned to GAD than OCD. Although many of his ‘guilty or incompetent actions’ involve over responsibility, he states that being given a ‘free pardon’ for everything he has ever done wrong would solve many of his guilt problems. However, he adds that he would have to have a very broad, catch-all pardon, because if it itemised his negative acts he would undoubtedly spend the rest of his life going through the list to see if he had missed anything.
This member involves himself in much reassurance seeking and avoids looking at items that are involved in his anxiety/guilt process. He is also capable of perceiving he has identified a problem (by sight or sound) when, in fact, he has not. (This does not intrude to a delusional level as he can be talked out of it). He agrees that his obsessive thoughts and guilt are unrealistically extreme, but he does not obsess about totally irrational situations, although his ruminations about actions that he possibly should have taken but didn’t, can occupy a great deal of reassurance seeking time as he goes through a wider and wider range of possible culpabilities.
He is aware that his thoughts, clinically diagnosable as obsessive or not, take up a great deal of his time; but he feels that if all possible culpabilities were removed, he would dig around until he found some more – because he views himself as ‘born to worry’. He further states that if most people have obsessive thoughts from time to time as research suggests, and that these thoughts are no different between an OCD sufferer and a non-sufferer, then it doesn’t really matter in which anxiety disorder ‘camp’ his thought processes place him, he only knows he wants to be free of them.
Charity counsellors working with this client have suggested that GAD might be the template of anxiety throughout his life that has prepared him to become ‘infected’ by a range of other problems like depression and OCD when stressors occurred.
Brown’s work suggests that, when people seek help, GAD is the most common disorder found to be co-morbid with anxiety and depression of various sorts, and with physical disorders associated with stress such as irritable bowel syndrome or chronic headaches (Brown & Barlow; Sanderson, Beck and Beck; Blanchard et al.)
Brown further states that it is hard to work out why GAD (as a trait or a general vulnerability) predisposes some sufferers to contract other disorders, while with others it becomes sufficiently prominent to warrant diagnosis and treatment as a distinct and separate disorder. This might be significant within thinking problems for many people – working out when (just about) rational worry becomes an irrational obsessive problem.
Worry tends to jump from subject to subject and because it gets in the way of processing this intrusive information successfully, it tends to increase the intensity and occurrence of such thoughts (Brown). Obsessional thinking can sometimes act much the same. Some OC thinkers express the misery of becoming highly sensitised to, caught up in, a spiral of such thoughts that are then more and more alarming.
It probably isn’t worth the effort to agonise over whether a problem is clinically GAD or OCD (and risk the chance of becoming obsessive over this); better to accept that it may be a bit of both, but that that does not mean that irrational OC thoughts then obtain the stamp of rational GAD approval.
‘Most frequent obsessional thoughts involve; subject of dirt or contamination (55%); followed by aggressive impulses (50%); sexual content (32%)’
HC is sometimes known as ‘illness phobia’. The American Psychiatric Association (DSM-IV) 1994 describes the core symptom of HC as the perception of having a serious disease based upon the misinterpretation of one or more bodily signs and symptoms (Neziroglu). The ICD-10 classification requires also the persistent refusal to accept the reassurance of several doctors that there is no physical illness (Howes). DSM-IV also requires that the disorder last at least six months and causes clinically significant impairment or distress. This would not be a delusional belief. Research suggests that HC occurs most commonly between the ages of thirty-six and fifty-seven and that a person might fear one or many illnesses.
Neziroglu points out that HC symptoms ‘mimic an obsession, and the constant reassurance-seeking and checking of the body for physical evidence resembles compulsions. Thus it seems that HC may be a variant of OCD.’ She further states that HC is probably ‘masked depression’ and that, while it is similar to panic disorder in some ways, the HC sufferer believes an illness will develop in the future, rather than immediately as panic sufferers almost invariably believe.
‘Estimates of the prevalence of HC range from 4% to 20% of the general population.’
‘Patients with HC have multiple symptoms in many different organ systems that tend to wax and wane over long periods of time. Most of the symptoms they experience are ones that occur transiently in normal healthy people.’ (Barsky and Klerman)
Lives have been ruined on the interpretation of that ‘most’. A person with OCD Spectrum problems relating to obsessional thinking, is never going to be satisfied with ‘most’. This will be particularly problematic, as the majority of HC sufferers do not perceive their problem as psychological and go to GP’s and specialists in physical diseases rather than the psychiatric services (Neziroglu). If those interviewing the HC sufferer believe in ‘reassurance/supportive therapy’, which involves medical testing, and which Neziroglu further mentions as a ‘widely utilized form of treatment’, the problem will never be overcome.
As anyone familiar with OC problems is aware, reassurance-seeking, while a major part of most obsessional disorders, is never going to cure the problem; if anything it makes it worse and always serves to maintain the belief that there is someone or something out there that will take the problem away. Like the drug addict, that ‘fix’ of reassurance, that temporary but wonderful relief, ensures that this will be sought again and again.
If obsessional thinking is involved; of the type that sees every bodily twinge (we all get many twinges every day) as potentially fatal or needing of instant response to stave off a painful death; then support within a change in thinking is necessary. This might require some chemical intervention (medication) first as, like many OC conditions, the perception of threat might be so enormous and be seen as so requiring of instant, outside intervention, that ‘talking treatment‘ would not be useful as an initial approach.
Neziroglu mentions wide-ranging research (p.5) that suggests anti-depressants are the intervention of choice and it seems likely that clomipramine or one of the many SRI’s would be worthwhile here.
‘(HC Causes:) Possibly a complication of other psychological disorders, but the cause is uncertain. It is more common in people who had a true organic illness in childhood or were closely involved with a sick relative.’
There are other disorders in this broad HC area: notably Somatization Disorder which involves ‘multiple physical complaints that suggest physical disorders without a disease or physical basis to account for them’; and Somatoform Pain Disorder which is ‘a persistent complaint of pain without a physical cause, or the impairment is greater than would be expected from the physical findings’ (Medilineplus).
Howes suggests that HC might be one end of a continuum where preoccupation with physical symptoms is at the other. He further suggests that HC symptoms are often secondary to things like depression and anxiety disorders and that the primary problem should be treated rather than the HC, which usually resolves the hypochondriacal symptoms when treatment has been successful.
The bio-behavioral website offer the following symptoms of HC:
· Preoccupation with bodily functions (heartbeat, sweating)
· Preoccupation with minor physical complaints (small sore, occasional cough)
· Numerous complaints about pain (headaches, stomach aches, back pains)
· Hypersensitive to any small physical changes in their body
· Concern with having a deadly disease such as AIDS or cancer
· Seeking repeated physical examinations, diagnostic tests, and reassurance from physicians
· Physician reassurance and medical tests do not decrease the concern
· Being alarmed if friends or family are diagnosed with a disease
· Seeking reassurance from friends and family about their physical symptoms
· Doing extensive research on the disease, such as reading medical journals
· ‘Doctor-shopping’ – Visiting numerous doctors who will ‘correctly’ identify and treat them
· Complaints that doctors and specialists were not good or were unable to find the problem
· Repeatedly checking own body for signs of disease, such as monitoring blood pressure, pulse, doing breast exams etc.
· Avoiding certain foods or activities thought to cause the disease.
‘It is important to understand that hypochondriasis is not a way of seeking attention from others by pretending to be sick. Individuals honestly believe that they are suffering from a medical condition and feel misunderstood. Most individuals are not concerned with the pain but rather with what the physical symptoms imply.’
The important area for talking treatment is to help the HC sufferer to accept alternate and more rational explanations for pain and to challenge the belief that any pain must signify a serious illness, or that it is essential to worry about such pains in order to fend off serious illness. It would also be vital to work through the inadvisability of reassurance-seeking and constant self-examinations, which feeds the cycle of anxiety and leads to greater arousal and more symptoms. A major area would also be helping the sufferer to accept the risk of everyday life – that there are no guarantees and that risks cannot be controlled magically or by extreme focus and vigilance; basically that there is a world of difference between healthy care and damaging obsession. Death is going to occur for everyone, the trick is to enjoy life to the full and not degrade it by constant worry about its end.
Obviously, ‘talking help’ that involved being told simply that ‘it is all in your head’ would be worse than useless. Any sufferer who is encountering that attitude from their medical advisor would do well to go elsewhere.
Howes discusses wide-ranging research (pgs.3-5) that suggests that the majority of people experience some of these physical symptoms on occasion; and ‘cpa’ notes that up to 20% of people experience intermittent fears about disease. This, again, would tend to work against HC sufferers for, as with anxiety and depressive disorders, everyone then becomes an expert via their own experience. However, this expertise – throwing off minor symptoms – tends to generate contempt in some people for those who cannot do this and who seem to ‘wallow’ in their ‘weakness’.
HC obsessional and/or magical thinking will be no different to any other kind. It is not a weakness or an affectation; it is a clinical disorder with the ability to destroy lives. Anyone who encourages a sufferer to believe that he or she should ‘just snap out of it’ with the implication that treatment or serious help is not required, is doing them a great disservice and encouraging the continuation of much misery.
‘It is important to remember that BDD is not a rare disorder, only an under recognized one. It affects children, adolescents, and adults, and it affects men as well as women.’
(Albertini & Phillips)
BODY DYSMORPHIC DISORDER (BDD)
BDD is a preoccupation with a nonexistent or minimal defect in appearance that generates significant distress or impairment in social, occupational and/or other important areas of life; and involves unrealistic beliefs in other people’s reactions to this ‘ugliness’. People with BDD put a very large emphasis on their appearance and believe that other people evaluate them negatively solely on the basis of this appearance. Whether this is as shallow as in: ‘pretty people equals nice people’, or has a darker side where becoming the subject of attention raises social fears or the perception that the ‘deformity’ is a visual signal to prove internal badness, will be to do with the individual. Research suggests that 29% of people with BDD have other obsessions and compulsions completely separate from their BDD handicap (Phillips et al. ’95) and that BDD might even be classed as a more severe form of OCD (McKay et al ’97). BDD should not be confused with vanity or normal concern with one’s looks and appearance.
‘Normal’ is, of course, a subjective term. Over the past few decades’, concern about appearance has grown in Western cultures alongside the availability of clothing and cosmetics to achieve changes and improvements and the financial resources to purchase these. At different times and at different ages we may all have an increase in our perceived need to ‘look perfect’ and many people have an ongoing dissatisfaction with their appearance that might stray into the regions of BDD on occasion. However, people with BDD will be spending at least an hour a day (and often very much more) checking in front of mirrors and other reflective surfaces (or avoiding these at all costs), camouflaging the perceived defect with excessive use of cosmetics, or inappropriate clothing such as scarves hats and sunglasses (inappropriate to the specific situation that is), avoiding social contact and suffering much internal torment and despair.
The University of Pennsylvania study on research within BDD (bpinsky3) is an excellent piece of work and much of this section is based on that article.
‘BDD preoccupations have been noted to structurally resemble obsessions in that they are distressing and anxiety producing, persistent recurrent thoughts that are difficult to resist or control.’
(Phillips et al. ’95)
Looking at the literature, it is difficult to gauge where a preoccupation enters the world of obsession and then, sometimes, delusion. All levels of obsessional thinking have a tendency in that direction. Many people have come to Anxiety Care with ‘absolute’ beliefs in certain things: the requirement to be perfect with only total loss of personal value as an alternative; a belief that a certain activity has caused irreparable harm despite endless proof to the contrary; a belief that only evil people have negative thoughts. It goes on and on.
Some service users have responded to alternative suggestions, or at least seemed to, although withdrawal from the service once the need for it is outweighed by the threat to a belief system, is an endemic problem with any work of this kind and leaves judging the extent of delusional beliefs a permanent and unfathomable problem within a community charity.
As delusions are fairly common in the general population (see earlier paragraph on delusions) it seems fair to conjecture that they are not an all-or-nothing concept; that (Eisen et al.) they exist on a continuum of insight that ranges from good through poor to absent altogether.
This might ease the minds of some people who come to the charity; people who visualise their obsessive disorder plunging into psychosis that, to most, is synonymous with raving madness. A further comfort should be that BDD does not respond to anti-psychotic medication, but does to the SRI’s, which are the medications of choice for OC disorders (Phillips et al.’94).
The whole area of: ‘My BDD, is it or isn’t it delusional?’ is probably not worth too much attention unless a sufferer allows such feelings to take them into extreme remedies such as ‘self-surgery’ (picking or trying to cut out a perceived blemish), total withdrawal or acute depression. Research seems to suggest that higher doses of one or other SRI would be indicated in these situations.
On the subject of surgery, the Penn U. article suggests that this is rarely useful. People with psychologically untreated BDD might then simply transfer to another bodily ‘abnormality’ or focus more on the surgically altered one, seeing it as still ugly and still in need of attention. Like OC problems in general, reassurance or practical alterations to the situation; in the case of BDD, activity that colludes with the perceived need to hide the ‘deformity’, are very unlikely to work. The combination of cognitive behavioural therapy involving exposure and response prevention, plus medication is the treatment of choice.
There are differences between OC thinking and BDD thinking. As with GAD, the BDD thinker may view the thoughts as relevant to his or her personality and beliefs; and, although severe and debilitating, a ‘normalish’ part of life. The OC thinker on the other hand will invariably view the thoughts as intrusive and alien, nothing to do with his or her perceived once ‘true’ personality, and is much more likely to experience images while the GAD and BDD thinker will experience the disorder more in verbal terms.
The latter is a fundamental and often very alarming (for the OC’s) variation when people with different OC Spectrum Disorders attend the same groups. That is, most of us appear able to deal with a verbal response to anxiety: ruminations, endless worry. Perhaps because it is ‘word-thoughts’ without accompanying pictures, it maintains an acceptable distance (which might also make it easier to accept as real of course). The OC thinker will almost invariably have ‘flashes’ of OC fear: pictures of him- or herself committing the feared deed. The majority of people coming to Anxiety Care, view this ‘flash’ response as proof that they are capable of committing the deed, or proof that they are going insane.
The OC thinker will also use ‘curing’ thoughts such as counting, thinking ‘good things’ etc. that are relevant to him or her but probably have little connection with the intrusive thought or thoughts that they are used to counter. The BDD thinker will invariably be focused on the perceived abnormality and all thoughts will surround this area and be totally relevant (to the sufferer at least) to the cause of preventing the abnormality being seen.
Then, although the BDD sufferer might indeed have ‘classic’ OC symptoms as well, the situation once encountered in a group can be understood. This was during a discussion about thought processes. Two people presenting with OC problems around thinking had both been asked to write down their thoughts by a therapist. The one whose thought processes were perceived as alien to his true character, had been horrified at the way one thought led to another. That is, as previously described, when writing the thoughts down and the inevitable happened: ‘The therapist is going to read this, I’d better not think anything worse, like…oops!’
This person was appalled at his ‘evil’ and completely missed the fact that a worsening of thoughts and images was unavoidable once a process aimed at not-thinking worse things had been slotted into place.
The BDD sufferer, on the other hand, quickly understood the situation and stopped writing the thoughts down when it became obvious to her that it was the fact that these thoughts were going to be read that was making them more and more alien and embarrassing, not the content of her character. A discussion then began about how this situation could have occurred, so different between two people with the perceived same problem. The answer was, of course, that they did not have the same thinking problem. The OC thinker was locked into ‘bad’ thoughts as a sign of personal evil and so was super sensitive too, and invariably subject too, a series of such thoughts that, in reality, had no end.
The BDD thinker was only sensitive to thoughts that revolved around her ‘deformity’. She was capable of processing some ‘evil’ thoughts as a sign of low personal value and inadequacy as a wife and mother, but beyond a certain point had rational beliefs in her character. In short, she saw herself as worthless in many ways, but not evil or potentially out of control, while the OC thinker saw himself as basically worthy but becoming progressively more evil and coming closer to the point where he would lose control.
‘Non-psychological therapy in people with BDD may do more harm than good.’
Another difference between OC and BDD thinking is that the OC thinkers ‘curing’ thoughts and rituals are used to reduce anxiety, while the BDD thinker’s thoughts are not used in that way at all. The BDD thinker will be hyper vigilant with thoughts focused entirely on concerns about the abnormality. These thoughts will, like the OC, be maintaining the disorder but in a different way. The OC’s relief by ‘curing’ a bad thought with another keeps the disorder active, while the BDD thinker does not cure the thoughts internally, but uses physical camouflage to hide the manifestation of the fear, which only maintains focus on the abnormality, the thoughts about it, and the anxiety that goes with the whole process.
Albertini presents a series of ‘clues’ to the presence of BDD which, while not required as part of a diagnosis, might be useful for anyone concerned that he or she or a family member has this disorder. Below is a slightly abridged version:
· Frequently comparing your appearance with that of others; scrutinizing the appearance of others
· Often checking your appearance in mirrors and other reflecting surfaces
· Camouflaging some aspect of your appearance with clothing, makeup, a hat, hair, your hand, your posture
· Seeking surgery, dermatology treatment, or other medical treatment for appearance. Concerns when doctors or other people have said such a treatment isn’t necessary
· Questioning others: seeking reassurance or attempting to convince others that you don’t look right
· Excessive grooming (e.g. combing hair, shaving, removing or cutting hair, applying makeup)
· Avoiding mirrors
· Frequently touching the defect
· Picking your skin
· Measuring the disliked body part
· Avoiding having photographs taken
· Excessively reading about the defective body part
· Exercising or dieting excessively
· Avoiding social situations in which the perceived defect might be exposed
· Feeling very anxious and self-conscious around other people because of the perceived defect
‘BDD usually begins during early adolescence, although it can occur in children and can also begin in adulthood. It appears to be a waxing and waning disorder this is generally chronic. Other disorders can co-exist with BDD and may be more obvious to…a casual observer than BDD itself, which may be hidden. These disorders include depression, social phobia, and obsessive/compulsive disorder, which may be closely related to BDD.’
(Albertini and Phillips)
Albertini and Phillips have also compiled a questionnaire to ascertain whether or not a person has BDD. This is not the place to present this in full, but it can be viewed on web page:
Basically, the questionnaire suggests that BDD is a possibility if ‘yes’ is the answer to the following questions:
· Are you very worried about the way you look?
· If ‘yes’, do you think about your appearance problems a lot and wish you could think about them less?
(Examples of disliked body area include: your skin, [e.g., acne, scars, wrinkles, paleness, redness]; hair; the shape or size of your nose, mouth, jaw, stomach, hips etc.; or defects of your hands, genitals, breasts or any other body part.)
· Has this problem often upset you a lot?
· Has it often got in the way of social activities?
· Do you spend more than an hour each day thinking about how you look?
Albertini and Phillips make the point that it can take as long as three months (or occasionally longer) for the SRI medication to work, as is true with all SRI medications, and that relatively high doses may be needed for BDD. They also point out that improvement of symptoms may be gradual so patience is essential. From Anxiety Care’s experience it is vital to talk to the prescribing physician if any side effects problems occur (and they will happen, if they are going to, before the benefit is felt) as many people, not totally convinced that medication is the answer, use temporarily unpleasant side effects as an excuse to abandon medication. These authors also mention the efficacy of cognitive behavioural treatment but suggest (gently) that this might useful only when ‘the person with BDD recognizes to at least some extent that their view of their defect is exaggerated.’
‘’Supportive psychotherapy serves to create a positive environment in which to apply other therapeutic techniques, but doesn’t seem to work by itself. Other psychotherapeutic approaches (for example, insight-oriented psychotherapy, diet and natural remedies) have not been shown to be effective for BDD.’
(Albertini and Phillips)
Phillipson and Stewart in ‘A Rose By Any Other Name’ make the point that another problem may fit in among the OC Spectrum disorders: olfactory obsessions. This involves the sufferer believing that some part of his or her body is producing an unpleasant and noticeable odour.
These authors suggest that the level of anxiety generated by social situations and the tendency to assume judgments of worth will be made by outsiders around the ‘fact’ of this smell, make it very close to BDD. Intense anxiety, hyper vigilance, shame and the need for reassurance are all similar to BDD with more similarities to this disorder than to classical OCD. The obsessional thinking will be very much to do with what is seen as a real and obvious personal problem, not as a sign of ‘badness’ or as imposed from outside as with OC thinking.
Phillipson and Stewart suggest that the treatment approach is much the same as for BDD. Sufferers must be helped to understand that their bodies will, occasionally, produce odours, just like everyone else’s, but that this is not a sign that the belief was true and that eternal vigilance should be maintained. Sufferers have to be helped to accept the disorder as a disorder, and to live with the possibility that the problem exists – nobody will guarantee them permanently freedom from bodily odour.
As mentioned earlier, our current culture puts much emphasis on looking good and this includes smelling good, so a minor level of olfactory worry may not be unusual. A recent episode of a popular television series featured a character, after being prevented from bathing for a modest period, stating that she smelt and that she hadn’t been aware that her body was capable of producing such an odour. This was obviously played for humour but was the more funny for portraying an almost-believable attitude in a certain type of person.
So olfactory obsession is, again, something that most of us might mistakenly believe we can relate too – we don’t like to smell. However this will be to an olfactory obsession as the proverbial tension headache is to a skull splitting migraine. People at the tension headache end of the continuum do not ruminate endlessly about the problem or spend much time trying avoiding social contact or watching surrounding activity (wrinkled noses, opening windows, ‘odd’ looks) for proof that the obsession is a reality.
As Phillipson and Stewart also say, sufferers will probably need to be helped to take practical steps such as reducing bathing, reducing excessive use of deodorants and gradually getting used to the idea that they can tolerate the possibility that they have an odour and that this is not the end of life as they know it. And, as always, the mark of recovery is not the extinguishing of the belief, but the perception that it doesn’t matter one way or another.
Like all obsessional thinking problems, the need for a 100% guarantee of immunity from fear is not the target, relief comes from accepting the response at whatever level it settles down to (maybe, with olfactory problems, you will always be a bit more concerned than most about your body odour) and understanding that this is just life and doesn’t stop it being liveable unless you choose to make it so.
OTHER PEOPLE AND OBSESSIONAL THINKING
Doctor Frederick Penzel has written a sensitive and thought provoking piece about the aftermath of OC problems: ‘What Do You Say After You Say You’re Sorry?’ that would be worth reading for anyone in the recovery stage of such a disorder (see references). I will attempt to précis the main points below:
Guilt and depression are often a major part of OCD, but the guilt and resultant depressive feelings that may come from an eventual acknowledgment of the stress placed upon one’s family, are a different, but probably not easier, type. Doctor Penzel lists a few situations that an average OC sufferer’s family might have been exposed too:
· Watching helplessly as you suffer with your worrisome thoughts, maddening compulsions and depressed moods
· Having to give up a lot of their personal time, and physical and emotional energy, if they are forced to take part in your rituals
· Enduring your anger if they interfere with or refuse to help you with compulsive routines, or answer hundreds of repetitive questions
· Being forced to severely limit the ways they are allowed to live or the places they can go to avoid triggering your symptoms
· Having to materially support you in your disability
· Having to take up your daily responsibilities for you around the house, doing chores, or functioning as wage earners or parents
· Putting their dreams and plans on hold in order to take care of you.
As mentioned, some people with obsessional thinking problems start to look on their families as an encumbrance, particularly if they begin to resent the presence of a member who is the source of frightening physical symptoms: a child who one fears one will harm for example. Others are so concerned with their own feelings that they become super-selfish and indifferent to the suffering they are causing; still others do care, and perhaps punish themselves for the anguish they are causing, but this does not stop them from performing the activities or demanding family cooperation and reassurance.
One recovering Anxiety Care client is haunted by his immaculate garden and now finds it very difficult to go out there, because his wife informed him that the reason it is maintained so beautifully is that it was the only place she could cry in secret when she needed to; and during that previous Summer this was all day, every day.
Facts like these hurt badly as do wary eyes from the family as they pretend not to watch for signs of relapse; and swallowed comments when they realise that they are talking about the pleasures they have missed, through no fault of their own, because of the illness.
For the recovered sufferer, it is then very easy to wallow in guilt and become self-obsessed again for all the wrong reasons. As Doctor Penzel says; ‘guilt is only useful if it leads to some kind of change’.
Nobody asks to become crippled by obsession. Undoubtedly life would have been better if it hadn’t happened, but it has and cannot be un-happened. No doubt the sufferer could have resisted more, worked harder and sooner at recovery; but his or her character, experience and the then current life situation made it happen the way it did – it wasn’t a conscious choice.
As one cannot change the past, the best way to deal with it is to accept it; not like it, just accept it. If it is not accepted, it will continue to have an impact on one’s current life, staining present and future events with regret and shame. Mistakes are still going to be made and the family are not always going to be viewed as perfect and worthy of any sacrifice, that is normal life too.
Acceptance must also include owning the fact that the obsession was a monster and may still, in times of stress, raise its ugly head again. Nobody with obsessive problems has ever thrown them off completely. The shadow of them will still be there on occasion. Trying to be super-person, all singing all dancing, not-a-care-in-the-world, is a recipe for disaster.
As is often mentioned in the Anxiety Care groups, recovery is a process that probably never ends. Compared to last year a sufferer may be a thousand percent better; but the odds are that compared to the person he or she was before the obsessions struck, there is still a long way to go. Comparative recovery feels wonderful, but its actual place in life must be accepted. Too many recovering people rush into a fully operational life before they are really ready and then wonder why they ‘run out of steam’. It is always tempting to do too much, to use all those freed-up hours to the full, but it can be dangerous. ‘Learn to walk again before you learn to run’ is still a good old saw; even if the ex-sufferer once ran at county level in his or her head.
‘You can change what you are (within reason), but you cannot change what you were.’
If recovery is accepted as a mourning process, as Doctor Penzel suggests, then the sadness and regret have a normal place to stay and any hovering depression and self-hatred can be kept at a safe distance. Feeling helpless, sub-standard and guilty is a fairly normal part of grieving, and this works just as well when mourning the lost years.
Doctor Penzel suggests that anger is often the first hurdle, anger against the OCD and the self; and that this is followed by extreme sadness. In the work of Hopson, the ‘life cycle’ of a change is detailed and this might also be useful for anyone involved in the huge shake-up that recovery from obsessional thinking might engender. The seven phases Hopson details are:
· ‘Immobilisation’ – feeling overwhelmed by the transition, unable to think or plan
· ‘Minimisation’ – coping by reducing or trivialising the transition, perhaps even experiencing a little euphoria in the process
· ‘Letting go’ – accepting that the transition has happened and cannot be un-happened. Feelings start to rise again
· ‘Testing’ – trying out new behaviours and situations. Plenty of energy available but a tendency to stereotype people and things – how they should be in relation to the change – and to become angry or irritable quite easily
· ‘Search for meaning’ – trying to understand how and why things are different now. Distancing somewhat from the transition to get a better look at it
· ‘Internalisation’ – absorbing and finally accepting the transition as part of life
This is not a rigid series. The transition caused by abereavement is likely to be on a different time scale and involve different levels of feeling to the transitions caused by anxiety disorder recovery. Similarly, people do not move neatly from one stage to the next. Some may become caught up in one stage or another and progress no further, while others may fall back into an earlier stage after a setback or further life changes that occur while they are working through this anxiety disorder transition. This is important to understand: as life is a series of transitions in many ways, more difficult or plain traumatic episodes are going to affect the rate of anxiety disorder recovery. Everything new in life affects the way the current life is lead, so it would be foolish to assume that obsessional thinking problems, during recovery, could not take a knock from a perfectly normal transition like illness, job loss or family problems. Because it was so bad and special does not exclude it from slipping back in the face of some comparatively minor problem. It is probably sensible to view the anxiety disorder, during recovery, as the old time miners did their canary – when the bird fell off its perch, that was the sign that gas fumes were rising in the mine. When the thinking problems feel aggravated, this is not the sign that treatment has failed, but is an indication that life is sneaking up on us, mostly unnoticed.
People also have different ways of responding to change. Even with the kind of change we are discussing, this might involve some mix of welcoming, resisting or fearing and anyone who has a tendency to respond in negative ways to new things might have additional difficulties and trouble their canary that bit more.
Anxiety Care workers have talked to many people who have recounted classic symptoms of bereavement – loss of appetite, sadness, depression, emptiness, loneliness, ‘life is meaningless’ feelings – when discussing losses of all kinds. The sad thing is, virtually none of them had allowed themselves to accept these feelings as natural but saw them as weakness that had to be fought, rather than part of a vital healing process.
‘…the origins of obsessional problems are best understood in terms of complex interactions specific to each individual.’
(Salkovskis et al)
Understanding the way life works is an essential element in recovery and recovery maintenance. The tendency to do too much has already been mentioned but there can also be a tendency to do too little.
Many people coming to Anxiety Care with obsessional problems have unrealistic beliefs that border on the edges of wishful thinking and fantasy. Expecting an instant answer is one, even if this expectation has been dashed many times before with many organisations, voluntary and statutory. Help with ‘The Quest’ is another. This is the belief that there is someone or something out there that will make the problem go away if only he, she, or it can be found. Both of these expectations are bound up in the need to be better rather than the need to get better.
If a sufferer is locked into such behaviour, personal efforts at recovery are going to be hard to undertake. If medication has had a huge effect and the problems have dwindled but this belief system is still in place, then recovery maintenance will be hard. This is because there is likely to be little perception that personal strength has been used to overcome the problem. And if the old erroneous thinking systems have not been challenged, then the cognitive difficulties that made this person’s mind such a good breeding ground for obsessional thinking are still there, ready for another seeding.
Some people are aware of this at a subconscious level and avoid getting back into normal life for fear of the stressors they know, at some level, they will not be able to counter. This is not to say that everyone who does not ‘jump in the deep end’ is part of such a process. Many people in recovery, sometimes well into recovery, are all too familiar with their internal workings and have faced the fact that they will not be able to compete on an even footing in the world for a while. Sometimes the old way of life will be accurately viewed as a major contributor to the problem and a more user-friendly way to earn a living has to be sought; this is not cowardice, it is common sense.
So, it will not be easy (maybe not useful) for the recovering or recovered person to get back into the old life. Only he or she, with the support of the family, will be able to work out which direction the rest of life is going to take. This direction will probably have a lot to do with how the disability was dealt with at its worst by the significant others in this person’s life.
HOW CAN THE FAMILY HELP AN OBSESSIVE THINKER?
Families tend to respond in a number of ways to obsessive problems in a member. Most commonly these are (changing Livingston & Rasmussen slightly):
· Becoming involved in the thoughts and rituals (if any) to keep the peace
· Not becoming involved but allowing them for the same reason
· Denying the existence of the problem
· Refusing to allow obsessive activity in their presence.
Even when the condition is denied, family tension is likely to be high. Experience and anecdotal evidence suggests that most families swing between assisting and attempting fairly negative or confrontational ways to stop it such as trying to shame this person into ‘growing up’, ‘snapping out of it’, or worst of all, ‘being a man’.
The lack of continuity of approach promises more trouble than success and is mostly to do with the caring person’s levels of patience, tolerance, ignorance, (of the disorder and possibly life strategies) and maybe love too. Swinging between collusion and denial is common and tends to prove to the sufferer that the disorder is not viewed as genuine – ‘We went along with your little difficulties until it affected us, now you have to stop!’; far better to acknowledge a major life problem but without agreeing to become part of maintaining it.
This is far from easy. Often one family member, usually the mother or partner, is elected as ‘guardian’ by the obsessive (maybe with the tacit agreement of the rest of the family). The sufferer is usually able to ‘push all the right buttons’ with this person in order to obtain maximum help; and much of this help, particularly in times of panic or other extreme distress, is going to be about avoiding anxiety, not dealing with it. If this ‘help’ is happening on a regular basis, the balance in the family is very likely to be upset with other members feeling marginalized and manipulated. Here everyone is having a miserable time with guilt, jealousy and helplessness mixing in a volatile cocktail that will make a family approach to the problem almost impossible.
‘My mother helped me until I couldn’t do anything for myself at all.’
Even if the family are convinced that the problem is based in neurological or biological dysfunction, this is not an excuse to allow the cared-for person complete freedom of action. As mentioned many times, the body’s chief aim when suffering from severe anxiety is to relieve the intolerable feelings and this response is unlikely to be recovery-focused. The obsessive person has to be helped to accommodate his or her actions to real life and family need, not attempt to change external situations to fit symptoms.
If a ‘helpless to resist’ attitude wins, the family simply become custodians and therefore part of the problem rather than assistants in the process of recovery. In other words, carers should support the person and recovery, not the symptoms and continued illness (Hurley et al).
A good way for the family to help is to organise a ‘recovery contract’. This is much easier where compulsions are concerned, as things like washing a few times less or for shorter periods are easy to agree and monitor. With obsessional thinking it is more complicated.
Anyone who has read this far will have a fair working knowledge of what obsessional thinking is about and should, hopefully, have an idea how not to aggravate the situation. He or she will be conversant with what kind of external activity keeps the thoughts alive – reassurance seeking for example – and can work out ways with the carer to reduce this over a set period. If the problem involves requiring the carer or other family members to perform (or not perform) certain tasks or activities, this too can be reduced gently.
Such activities could be very broad. One client is terrified of his children being close to any sharp objects; another feels compelled to take a tough, totally supportive role when anyone asks for help, however causal or unrealistic the request is; a third cannot pull his mind away from anti-social activities that his children might become involved in once they are out of his sight.
All of these can be worked through in response reduction ways: children, for example, allowed to handle sharp objects relevant to their age, or allowed to go out unsupervised and not cross questioned on return.
Whatever the family involvement, it must be consistent. If help is refused or withdrawn until the sufferer becomes totally needy, this only proves that the most extreme responses will eventually get him or her what is perceived as needed and will encourage such behaviour.
A contract has to be negotiated and this is always two-way. That is, the sufferer will tend to feel lacking in power and control and may over react to something that is seen to be enforced by the caring family. The two-way element might be the carer agreeing not to nag, punish with silence or in other ways express anger with obsessive activity that cannot, for a time at least, be avoided.
Even if recovery work seems impossible, for now, it is possible for the sufferer to ‘draw a line across his or life’ at this time. That is, getting better may not be an option at present, but getting worse is certainly not acceptable. This means that the contract might just involve not increasing help, or agreeing to point out increased obsessive activity, if this is noted by a family member.
Whatever the situation, it is vital for the carer to keep family needs in perspective. The fact that somebody has the loudest voice does not mean that he or she has the greatest need. Other family members may not feel they have the right to complain, but they may signal their displeasure, by withdrawing emotionally, or even physically, from the family.
Source material and references
Any author who feels that he or she has not been adequately cited in this article, should contact Anxiety Care with details of the required changes. Mistakes and omissions do occur and the Trustees of Anxiety Care offer apologies to any writer who feels under, or wrongly, acknowledged. Authors are also requested to note that this is a non-profit publication.
Ralph S. Albertini, M.D and Katherine A. Phillips, M.D., ‘Body Dysmorphic
Disorder: When Appearance Becomes an Obsession’
OCD & OC Spectrum
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