Chapter One
Obsessions
Obsessive-compulsive disorder is characterized by two
main categories of symptoms: obsessive thoughts and
compulsive behaviors. The terms obsessive and obsession are
used in everyday conversation to suggest a preoccupation. For
example, a person may be described as being obsessed with
money. The term obsession is frequently used to describe a
passion or strong interest. For example, "Golf is Howard's current
obsession." However, in discussing OCD, the term obsession
is used differently. Obsessions refer to intense thoughts,
worries, or images that are experienced as intrusive and
unwanted. These obsessions cause great anxiety for an individual
and often lead to the development of compulsive
behaviors or rituals designed to decrease anxiety. I'll discuss
compulsive behaviors more in Chapter 2. One of the simplest
ways to describe an obsession is an unrealistic or over-exaggerated
worry or concern about something. The person experiencing
an obsessive worry will frequently describe a thought
or concern that sounds magnified or "catastrophized" to others.
In other words, they will talk about a fear or worry that is
far beyond what most people consider "normal." In fact a person
with OCD can sometimes tell you that they realize that
their fears or worries are irrational or illogical. However, the
anxiety is very real and overpowering. I've talked with many
patients who tell me that they know their worries are irrational;
however, they can't control the overwhelming fear and
anxiety, that these obsessive thoughts produce. Obsessions usually
fall into one of several categories.
Contamination Obsessions
These types of obsessions frequently involve excessive concern
over germs, diseases, and other contaminants.
Tammy was a young girl who was fourteen years old when
her parents brought her to me. Her parents indicated that
they felt Tammy "worried too much." Worry is a common presenting
problem for people who suffer from OCD. Tammy's
worries included fears that something may happen to her parents;
fears that something may happen to her sister; and worry
about germs. Tammy was so concerned about germs; she was
unable to use any restroom outside of her home. Traveling
was terrifying for her. Even family vacations that were
designed to be fun and stress free became a source of tremendous
anxiety and stress for Tammy and her family. If the family
had to stay in hotels, Tammy would make sure that she
brought several cans of Lysol spray with which she would
immediately "disinfect" the entire hotel room upon arrival.
This would enable her to feel "safe" enough to at least be able
to use the restroom. At home, Tammy simply could not use
any public restroom. If she went out with friends to a movie,
she made sure that she would use the restroom just before
leaving. During an outing with friends, she was always careful
not to drink too much liquid so she would not have to urinate.
She timed her outings to make sure that she would never be
out longer than she could wait to use the "safe" restroom of
her own home. The biggest challenge she faced was from
Monday through Friday at school. While Tammy did use the
restroom before leaving home and restricted her fluid
intake, she could not make it through the entire school day
before she had to yield to the call of nature. Since she could
not use the school restroom, she would actually leave school
and return home to use the bathroom. Needless to say,
Tammy missed most of her afternoon classes. In fact, she
missed so many of these classes she actually failed two of
them.
While people who suffer from OCD often have a general
fear of germs, some people with OCD have specific fears related
to a particular disease. For example, many people with
OCD report a specific fear of contracting AIDS. Most of the
time, these individuals are not in any "high risk" group for
contracting HIV (the virus that leads to the development of
AIDS). However, their fear and anxiety is extraordinary. This
fear often causes them to ruminate endlessly that they may be
HIV positive. They are not comforted by reassurance that
there is no reason to believe they should be concerned (e.g.,
no unprotected sexual encounters; no blood transfusions;
etc.). They begin to describe irrational fears such as believing
that they might have had an undetected cut on their skin (the
hand, for example) and they wonder if they may have shaken
hands with someone who was infected with HIV thus resulting
in the transmission of the disease. This example illustrates the
type of thought processes characteristic of obsessive thinking.
Probabilities are greatly exaggerated and logic is stretched to
arrive at the ultimate conclusions. Many of these people will
have multiple medical tests to make sure that they aren't
infected. However, a negative test may lead to further rumination
and obsession. They may begin to wonder, "What if the
test was wrong; after all, they aren't 100 percent accurate.
Perhaps I should be retested." Some OCD patients will
receive repeated tests for a disease that they are at virtually
zero risk of contracting. Others will do the opposite: they are
so terrified that they may have the disease they will refuse to
receive a test to assuage their fears. They reason, "If I am HIV
positive and find out, I won't be able to carry on. It's better to
not know." While HIV isn't the only specific disease OCD sufferers
worry about, it is a common one.
Another frequent obsessive worry is that of getting cancer.
Jeff was a young man who read an article about testicular cancer
and became terrified that he would develop this disease.
Consequently, he worried almost incessantly about having the
disease. This was a bright young man who functioned at a very
high level. He was at the top of his graduate school class in his
studies, and everyone found him fun to be around. However,
he was almost constantly tormented by obsessive thoughts that
he had testicular cancer. He described experiencing "sensations"
in his scrotum. He read that while the disease is often
symptom free in the initial stages, there may be a "heavy feeling"
in that area. He began to imagine that he felt a "heaviness"
in this area which further fueled his anxiety and
concern. At times, obsessions can involve an imagined physical
sensation. These are known as somatic obsessions. The
only time he was not assaulted by these thoughts and fears was
when he was mentally engaged in a task, or when he was distracted
by something he thoroughly enjoyed. He found that
he was almost anxiety free when he drank alcohol.
Consequently, he began to drink more. OCD can be a precipitant
to abuse of substances. Many OCD patients described
using alcohol, marijuana, or other drugs to "self-medicate," or
to decrease the anxiety caused by the obsessive thoughts.
People who suffer from OCD are particularly at risk of
developing obsessive worries that they may have a disease after
reading about the symptoms of a particular disease. Some
OCD sufferers will see a television show or read an article
about an obscure disease or illness and begin to worry that
they may have the symptoms of that malady.
For some people with OCD, the obsessive worry is not of
contracting a specific disease, but rather a pervasive fear of
any germs that they may come in contact with. This may
become so extreme that they fear touching doorknobs
(because myriad other people have touched them) or handling
money. Their persistent worry about germs causes anxiety
in almost any public arena. Efforts to avoid being
"contaminated" with germs can lead to the development of
significant compulsive behaviors (discussed in Chapter 2).
While some individuals obsess about contracting an illness,
others may obsess about contaminating others. These concerns
range from mild (a man who worries excessively that he will
spread germs if he coughs in public) to more severe (a woman
who fears that her past sexual indiscretion may have caused her
to contract a sexually transmitted disease that she will pass on to
innocent others by simply rubbing against them).
Some individuals worry about being contaminated not
by germs, but by other "contaminants." Many individuals
report a fear of being harmed by ordinary household cleaners.
Bobby was a teenage boy who was terrified of household
cleaners. When his mother would spray the kitchen counters
with a normal household product, he would experience
severe anxiety (bordering on a panic attack). He avoided all
cabinets and rooms where cleaning supplies were stored.
Other individuals report anxiety over the possibility of environmental
contaminants. These may include chemicals such
as pollutants and pesticides. Some individuals refuse to allow
their homes to be sprayed for pests or their lawns to be
sprayed for weeds for fear of being harmed by the toxins used
in these types of treatments.
The Need for Symmetry or Exactness
Many people with OCD describe the need for things to be
"evened up." This refers to the need for things to be symmetrical.
For example, some people go to great extremes to make
sure things in their environment are even on each side. They
may arrange their rooms or offices so that things are aligned
in perfect symmetry including pictures on walls, items on
their desks, or books on a shelf. These individuals may also
report the need for things to be symmetrical on their body.
I've spoken with several individuals who described tying and
retying their shoes in order to make sure they were tied with
the exact same tension on each foot. I worked with a young
man who had to make sure that if he saw something out of the
corner of one eye, he also viewed it with the other eye. This
became quite cumbersome as he worked to make sure that
things were always "even." While these behaviors would be
considered compulsive (which we will discuss in detail in the
next chapter), it is the obsessive need for symmetry that drives
the behavior.
A similar type of obsessive thought is the need for exactness.
This refers to a need for certain things to be "just right."
A middle-school student was failing in classes involving a
great deal of writing. This was perplexing to her parents and
teachers since she was such a bright and capable student. She
was originally referred to me in order to see if she suffered
from some biologically based attention problems (such as
attention-deficit hyperactivity disorder) or some type of specific
learning disability (such as written expression). I performed
a complete neuropsychological evaluation in order
to examine all areas of cognitive functioning. Testing revealed
a young woman who was highly intelligent with
achievement scores to match her intellect (indicating no
areas of learning disability). She also manifested no obvious
signs of attention difficulties, and teacher and parent reports
indicated no significant difficulties in these areas. However,
in completing the testing, I observed that she took an inordinate
amount of time to complete written tasks. An analysis of
her performance determined that she was obsessed with
forming letters on the page perfectly. Her handwriting was
impeccable and letters looked as though they were formed by
a printer rather than a human. She made frequent erasures
in her efforts to make the letters perfect. This need to make
her written work perfect caused her to take at least 5 times
longer in completing work. This was causing her to miss
handing in assignments at school because she could not complete
them in time. Homework became so arduous; she
would become frustrated and quit. This case is an example of
how students who suffer from OCD are often suspected of
suffering from other disorders such as attention-deficit
hyperactivity disorder (ADHD) and learning disabilities.
For others, the need for exactness involves positioning
things in their environment. One young woman I worked with
described spending hours making sure the fringe of her
oriental rug was "perfectly straight on all sides." She also
described becoming very anxious if a guest moved one of the
pillows on her couch from its "perfect position." I had one
patient who told me she could not concentrate on our session
until she straightened every diploma and picture on my walls
and lined up the items on my coffee table so they were precisely
positioned.
Aggressive Obsessions
Many OCD sufferers are tormented by intrusive fears that they
may suddenly and violently act on angry or violent impulses.
Typically, these individuals have no history of violence or trouble
with aggressive behavior. However, they are terrified that
they may suddenly engage in some violent act as though it is
outside of their control. I worked with a woman who became
panic stricken around babies. When I asked her why she was
so anxious around infants, she described with great difficulty
the fear that she may suddenly rip the child from the parents'
arms and slam the child to the ground. This woman was a
highly skilled and very successful paraprofessional. She had
no history of any aggressive or violent behavior in her 40+
years of life. In fact, she loved children and was deeply saddened
that she could not be around her nieces and nephews
because of this paralyzing fear. Her anxiety was completely
irrational, and she knew this. However, she was disturbed that
these thoughts were even in her conscious mind. She
described how she was haunted by images of seeing herself
being handed an infant. She talked about how she would see
herself raise the small baby above her head and throw it to the
ground with all her might. She then talked about how she was
traumatized by seeing the image of the child lying on the
ground, bleeding and dead from the blow. These images were
so gruesome and clear, so terrifying and traumatic, that they
were debilitating to her. She was so horrified by these thoughts
that she went to great lengths to avoid having them.
Unfortunately, this primarily meant avoiding her sister, nieces,
and nephews.
I've spoken to several individuals who experienced significant
anxiety around knives. In fact, I've known a few individuals
who had to remove all knives from their house (which
made cooking difficult). If these individuals saw a knife, they
were bombarded by horrific images of taking the knife and
sticking it into their eye. Again, none of these individuals had
any history of self-harm. However, these horrific images and
the fear of their possible aggressive impulses were terrifying.
For others, these obsessions take the form of violent images
alone as opposed to fears of violent impulses. I spoke with a
teenager who described riding by a house on his way to school
when he observed a man mowing his yard. The teen was blindsided
by a sudden image of the man falling under the lawnmower
and having his leg severed by the mowing blade. This
image was extremely upsetting to the young man.
Continues.
