Sthe compulsions that crippled Howard Hughes, as well as those affecting his fellow OCD sufferers, can be divided into two groups’, behavioral (observable acts) and mental (thought rituals).Behavioral compulsions include all the classic and well-recognized OCD rituals. Hughes was troubled primarily by washing and checking, the two most common types of severe compulsions. Another widespread behavioral compulsion is asking for reassurance. Other common examples include hoarding, repeating, tapping, and ordering.
Washingmany experts think that washing is the single most prevalent type of behavioral compulsion. Judith Rapoport, M.D., of the National Institutes of Health, a top OCD researcher and author of the acclaimed book, The Boy Who Couldn’t Stop Washing, reports that more than 80 percent of the people who come to her clinic for treatment of OCD have been bothered at some time by washing rituals.At the root of washing compulsions, not surprisingly, is an obsession that a part of the body is unclean. Washing eases the feeling temporarily, but once the scrubbing is done, the thought returns. More scrubbing follows. Dermatologists are often the first to diagnose this disorder, as people frequently seek treatment for the skin damage caused by this excess.Handwashing compulsions are OCD’s most recognized symptom. They are, indeed, the hallmark of the disorder. A typical example is provided by a math teacher:
I get to thinking that my hands are unclean in some way. It’s not that they look dirty. And it’s not that I imagine germs on them, either. It’s just that I have this feeling they’re unclean. So I’ll lather them up good, wash them for a couple minutes, and dry them carefully. But pretty soon I’ll touch something and then I’ll get the feeling again. Some evenings after work I wash my hands every five minutes. They’re in bad shape. I have to put medication on them and wear gloves when I sleep.
The most famous description of excessive handwashing is found in Shakespeare’s Macbeth:
doctor: Look how she rubs her hands.gentlewoman: It is an accustomed action. … I have knownher to continue in this a quarter of an hour. lady Macbeth: Yet here’s a spot. . . . Out, damned spot! Out,I say! . . . will these hands never be clean? . . . Here’s thesmell of blood still: All the perfumes of Arabia will notsweeten this little hand.
Although this would seem to be a good description of compulsive washing, in the context of Shakespeare’s play it probably does not represent true OCD. Lady Macbeth’s handwashing occurs during sleepwalking, and her ritual is driven not by clinical obsessions but rather by depressive delusions or preoccuptations fueled by her guilt over Duncan’s murder.
Checkingchecking compulsions is also very common. A recent study of 250 consecutive patients from Harvard’s outpatient OCD clinic found that 63 percent complained of checking rituals.With this type of compulsion, a person must examine a situation over and over to make sure that no harm will come of it. Obsessions such as, “Is the gas shut off?” and “Are the doors locked?” drive the checking. A young wife described the torment and disruption that these rituals can cause:I stand there and turn the light switch off and on, off and on, off and on, off and on. I can’t make myself stop. It’s crazy. What happens is that I have the thought that maybe I didn’t completely turn it all the way off. Maybe the switch is somewhere inbetween the off and on position and a fire will stat because of a short circuit. I know that this does not make sense. Still, I have to keep on switching back and forth until I get it just right. I might stay there for ten or fifteen minutes. One time the light switch started smoking. Now my husband swears at me and yells, “Leave the light switch alone of you really will start a fire!”
Requesting Reassurancethis type of compulsion tests the patience of family members more than any other. Here, a sufferer becomes obsessed that something terrible has happened and is compelled to coax a pledge from another person that everything is okay. “I didn’t hit anybody with the car, did I?” “That lump doesn’t mean I have AIDS, does it?” The OCDer asks over and over, unable to stop, knowing the answer she’ll get, but needing to ask again anyway. Reassurance must be endlessly provided. A newlywed explained how her marriage was almost on the rocks due to her reassurance compulsions:1 love my husband more than anything. But I get the crazy thought that I might be interested in other men. I’ll be walking in the mall and I’ll notice a handsome guy, and afterward I’ll get to wondering ifI looked at him too long, if maybe that means I’m interested in him. I’ll worry all day; I can’t stop myself from thinking that I might have had thoughts of unfaithfulness. Then, because I feel so guilty, I’m driven to tell my husband. I know it makes him feel bad, but I have to. He says that it’s okay, that he knows I’m not interested in anyone else. Then I feel better. But I’ve been doing this every day, and it’s driving him nuts.Hoardinghere, the natural tendency to save things is stretched to a pathological degree. A young man whose apartment was more than half filled, floor to ceiling, with magazines and newspapers explained that he was afraid to throw an article away because he might later remember that there was something critically important in it. Then, if he couldn’t find it, he might get so upset that he would have a nervous breakdown.Repeatingwhen a routine action is repeated compulsively, and when— unlike in washing, checking, reassurance, and hoarding rituals—it bears no logical relationship to the obsession preceding it, this is called a repeating compulsion. One student, when struck by a harm obsession, compulsively repeated the action he was engaged in; this could be combing his hair, crossing his legs, or writing his name. Several quick repetitions usually sufficed to chase away the obsession. Repeating compulsions often must be performed a certain specific number of times. A young woman, in response to “a feeling of dread,” scratched her head, brushed her teeth, or chewed on Life-savers four times, no more no less.Rubbing, Touching, and Tappingthese common compulsions also defy logical analysis. A student with harm obsessions needed to tap her fingers ten times to prevent her tormenting thought from coming true.Orderinghere, items must be arranged so that they are “just so.” These rituals differ a bit from all others: They occur frequently in young boys, and their corresponding obsessions are often hard to identify.It has been hypothesized that ordering compulsions bear some resemblance to another kind of abnormal, repetitive action, the jerky movements referred to as “tics.” Ordering compulsions may represent a hybrid symptom between OCD and the related neurological disorder of tics, Tourette’s syndrome.*13/338/2*
Archive for the ‘Anti-Psychotics’ Category
an obsession is a gate crasher, an intruder in the night. The person afflicted with an obsession struggles mightily to resist it. This resistance can take up prodigious amounts of time and energy. Melissa said: “I try to stop thinking these thoughts but I can’t. . . . It’s like I’m involved in a battle with Satan, like he’s forcing them into my mind.” Jeff, sharing the OCD sufferer’s most typical refrain, said: “I fight them with all my might, but I can’t stop them.”
Recently I saw a young mother who was having thoughts about harming her baby. Could there be any obsessions that are more unwanted? Hospitalized for exhaustion, thinking she had “gone crazy” and might actually harm her child, she told me:
I was doing great until I got home from the hospital with my baby. All of a sudden, while I was feeding her, the thought came into my mind that I could choke her to death. I saw myself killing my baby. God bless her. I haven’t been free of that thought since. I don’t want my husband to leave me alone because I’m afraid of what I might do. I don’t let myself go to sleep because I might let my guard down. I try to stop these thoughts every second of the day with all my strength, but they don’t let up.
The terrible irony is that, indeed, the more strongly you resist an obsession, the more strongly it comes back. The mind does not work like a computer screen, where an unwanted thought is simply deleted. Rather, as a student patient of mine once observed, an obsession is like Freddie, the character in the Nightmare on Elm Street movies. Every time people thought they were finally rid of Freddie, he came baaaaack even stronger.
The strong resistance engendered by obsessions is probably their most defining characteristic. When I was in training at the University of Iowa, my chief of psychiatry, the noted researcher Dr. George Winokur, emphasized this point: “Look for how much the patient resists the thought—how much he or she fights it,” Winokur used to say. “That will tell you whether you’re dealing with an obsession or something else.”
Again, to distinguish: An obsession is not a depressive preoccupation. A sixty-two-year-old man with intrusive, recurrent, and severely troubling thoughts was referred to me for “treatment-resistant OCD.” The usual anti-OCD medications and behavior therapy had been tried. Nothing worked. He presented as a worn-out, agitated gentleman who spoke of nothing else but his fears of going into bankruptcy and losing his farm—concerns that were, in reality, totally groundless. He did not, however, resist these thoughts or consider them unwanted. On the contrary, to him these were realistic worries that needed to be dealt with immediately. What tormented him were recurrent, depressive thoughts, not obsessions. The patient responded to a standard antidepressant medication, imipramine (Tofranil).
An obsession is not an addiction. Degree of resistance also serves to differentiate obsessions from addictions. Obsessions are always unwanted—and not just 80 or 90 percent unwanted, but 100 percent. No part of a person wants an obsession. With an addiction, the unwanted urge carries a certain thrill. The gambling addict, for instance, gets a kick out of the action. A part of him looks forward to gambling, even while another part of him knows that he shouldn’t do it. With an obsession, there is no enjoyment at all.
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Drugs, however, not only create other diseases, but seem to be erratic in dealing with relapses associated with highly emotional environments and difficult life situations. In Introduction to Psychopharmacology (Lader, 1980, p. 58) we read that assessment studies on maintenance therapies (antipsychotic medication which suppresses chronic symptoms such as hallucinations) show that ‘drugs made a demonstrable difference to patients in low EE homes.’ An EE home is one where the closest relative at the time of the schizophrenic’s admission was low on the number of critical, hostile or emotionally overcharged comments. ‘Life events also seem important and tend to cluster in three weeks immediately before, relapse.’ Drug maintenance therapies seem relatively ineffective in preventing such event-related relapses, especially when life events are major.
There are other problems connected with medications besides their inefficiency. Many patients go off ‘meds’ not only because they found something of value in even the most nightmarish mental conditions, but also because they cannot tolerate either the drug’s effects or the social implications of being drugged. These patients are disturbed about the overall effects drugs have or do not have on their, lives.
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