People do not usually realize that OCD (obsessive-compulsive disorder) is a serious disorder and that serious cases of OCD can lead to suicide. Last year, a man came into my office and said he had a psychological problem that I would not understand. The man was 50 years old, an accountant, married with children. He said that his long-standing relationship with his wife had deteriorated and as of five years ago they stopped being intimate. About two years ago, the man started having unwanted, intrusive images in his mind at work and at home. These images were about harming women by touching them. He did not like thinking that he may have done something wrong, but his problem was that he couldn’t decide if he committed these acts.
I told the man that his symptoms were typical for Intrusive Thought OCD. OCD is an anxiety disorder, and anxiety manifests itself in an infinite number of ways. Some of the types of OCD are:
1) Contamination OCD: The person is afraid of catching germs, so they clean endlessly or wash their hands until they bleed or take showers for hours on end.
2) Just Right OCD: Objects must be placed “just right” or words must be pronounced “just right,” otherwise the anxiety does not stop.
3) Intrusive Thoughts OCD: Unwanted intrusive thoughts about sexuality or harm enter the mind spontaneously, and a physical action must be done, such as tapping one’s foot 100 times, in order to make the images and anxiety go away.
4) Counting, Checking OCD: The person feels anxiety until they check faucets, light switches, doorknobs, the oven a certain amount of times otherwise the anxiety does not stop.
5) Reassurance OCD: The person asks for reassurance endlessly about things that are of no concern, e.g., a child might ask their parent to reassure them that they did not just eat poison ivy. The parent says, “Of course not, I was watching you.” The child says, “But how do you know? “The parent says, “Of course I know; I have been watching you.” This repeats itself at home regarding something else. Until the child feels reassured his anxiety does not stop.
The man who was my client would pass an elderly woman on the train and suddenly suspect that he might have touched her. On the one hand, he did not think so because she had not said anything to him. The police had not been notified. Still, since he might have, he thought about the possibility all the way home. He knew he never acted that way, but still, who knows? He would consider this possibility in his mind until it went away. The entire thing befuddled him.
Once my client told me that he was on the subway platform and saw a man waiting for the train. Suddenly, my client was not sure if on another day he had pushed this man onto the tracks. The man was standing right there, my client was never charged, and it had not been on the news. But who knows? My client felt it could have happened.
OCD can be understood as an illness of doubt. My client doubted whether he can trust his own senses and his own experience because he has a doubt whether he harmed women, despite knowing that he did not. A person with Checking OCD might doubt whether he turned the faucet off, despite knowing that he did, so he checks it again. The doubt makes him too anxious. The problem is that the compulsive action which makes the obsessive doubt go away only does so temporarily, until the doubt enters the person’s mind again, when the cycle begins again.
Treating adults and children with OCD is different. Adults usually understand that what they are experiencing requires professional attention. Children do not understand this. Children often hide their OCD from others because they feel so terrible about it. What is a child supposed to do if they have unwanted thoughts of killing their family? They do not act on these thoughts, but the thoughts terrify them and make them feel guilty.
My client and I worked for a year on these intrusive (ego-dystonic), annoying, unwanted images and the doubt that accompanied them. In typical presentations of OCD, the person usually has thoughts that make them anxious (obsessions) and behaviors that help calm the anxiety temporarily (compulsions, e.g., tapping, counting, washing). My client had no behaviors to help calm his anxiety regarding his worry that he may have harmed someone sexually or physically. He was already on Clomipramine, an anti-anxiety medication specifically approved by the FDA for the treatment of OCD. After SSRIs prove unsuccessful (e.g., Prozac), Clomipramine is the drug of choice. Since the current dose of Clomipramine was not quelling his anxiety-driven symptoms, we used a combination of techniques to manage them.
The first technique was to use slow breathing to calm the client’s hysteria when he first “realized” that he may have touched a woman without her consent. He had to calm himself before logic could hope to be effective. Once he was calm the client was instructed to use logic to analyze the situation and determine if it was possible that these things never happened.
Once the client accepted the possibility that these events may not have occurred, he was instructed to hold ice in his hand for five minutes. The cold distracted him, and my client found holding the ice helpful. The combination of breathing plus logic and ice brought relief.
After working with the client for a year, the intrusive OCD images stopped, without any increase in Clomipramine. He was happy about this but said that he had another kind of OCD, which had become more intense lately. Whenever the client used a faucet or turned off a light switch and left the room, he would go back into the room to check that it was indeed off. At work, when he wrote a memo, he would check it four or five times for errors. Once he reported that he spent four hours checking memos.
Both these cases are instances of Checking OCD. After Contamination OCD, Checking OCD is the most common type. Checking repeatedly, despite wanting to stop, can cause people to lose jobs for being late. We did not want to raise the dose of Clomipramine until all other methods proved ineffective, so we approached the Checking OCD with a behavioral approach, as a first step.
The client said that he checked a maximum of four times. We decided that he would check a maximum of three times and walk away. If he became anxious, he could try breathing to calm his anxiety. If that did not work, he could go back and check one more time. The purpose of this exercise was to show the client that he was not helpless in the face of OCD. If he believed this, we would lower his checking until we extinguished his need to check. The client later reported that he was able to limit his checking, which made him hopeful.
The therapy treatment of choice for most forms of OCD is exposure and response prevention (ERP) which is an outgrowth of cognitive behavioral therapy (CBT). ERP is a way of desensitizing the person to the feeling of anxiety so that they do not respond to it. If a person can learn to sit with their anxiety, the feeling of anxiety will peak and then go down quickly. It is like jumping into a cold pool. If you stay in for a few minutes you acclimate to the temperature of the water and become comfortable, although the water temperature stays the same.
By combining various techniques including medication, relaxation, logic, ice and ERP, my client’s OCD is becoming manageable. The client still comes once a week for therapy and is now working on his marriage, which causes him stress that makes his OCD worse. Like any illness, OCD is made worse by stress. For that reason, limiting stress is always a good idea when trying to protect one’s mental health.
Jonathan Bellin, LCSW has been in practice over 25 years. He is accepting new patients in his tele-therapy practice where he treats anxiety and mood disorders, ADHD, trauma, PTSD and relationship issues. Please email Jonathan at [email protected]
