Obsessional Thinking

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.’
(Phillipson)

‘Attempts at reassurance inspire the brain to automatically scan for any
possible exceptions.’
(Phillipson)

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.’
(Craig Chalquist)

‘…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.’
(Khouzam)’

‘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.’
(Phillipson)

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.’
(Phillipson)

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.’
(Phillipson)

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.’
(Phillipson)

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.’
(Craig Chalquist)

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’.
(Phillipson)

SEXUAL DIFFICULTIES

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.’
(Erich Fromm)

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.’
(Phillipson)

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.’
(McKay)

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.’
(Branden)

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.’
(Phillipson)

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.’
(McKay)

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.’
(Phillipson)

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.’
(Nietzsche)

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.’
(Phillipson)

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.’
(Phillipson)

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.’
(Chalquist)

AGGRESSION

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.’
(Phillipson)

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.’
(Phillipson)

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.’
(Phillipson)

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.’
(Phillipson)

MAGICAL THINKING

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.’
(Alcock)

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.’
(Branden)

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.’
(Penzel)

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.’
(Alcock)

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.’
(Branden)

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

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.’
(MHi)


Treatment

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.’
(pathways)

DEPRESSION

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.’
(Armstrong)

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.’
(PIO)

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.’
(Westenberg)

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.’
(lonigan)

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.’
(Anderton)

PANIC

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.’
(Phillipson)

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+)’
(lonigan)

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%)’
(lonigan)

HYPOCHONDRIASIS (HC)

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.’
(Neziroglu)

‘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.’
(HealthGate)

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.’
(bio-behavioral.com)

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.’
(bpinsky3)

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:

http:/www.worldcollegehealth.org/031199.htm

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)

OLFACTORY OBSESSIONS

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.’
(Penzel)

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.’
(anonymous client)

    
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.

* * * * *

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responsibility beliefs in obsessional problems: possible origins and implications
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Sanderson William C. and Wetzler, Scott (1991) Chronic Anxiety and Generalized
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Jessica Sheringham, ‘Research finds delusions prevalent in the general
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http://www.schizophrenia.co.uk/news/news_articles_20.html

William Van Ornum, Ph.D, (1997) ‘A Thousand Frightening Fantasies: Understanding
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‘Are You Scrupulous?’ and Duckro & Williams (see ref.)
Cardinal O’Connor’s Homily:
http://www.cny.org/archives/ch031199.htm

Carol E. Watkins, MD, ‘Scrupulosity: Religious Obsessions and Compulsions’,
http://www.baltimorepsych.com/scrup.htm

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Journal of Personality and Social Psychology, 55(6) 882-892 (1988)

H.G.M. Westernberg, ‘Basic mechanisms of panic and depression: Are They
Separate?’
Anxiety Research Unit, University I-Iospital, Utrecht, The Netherlands
http://www.psicoterapia-palermo.it/depressione/treatment_panic_depression.htm

WHO Guide to Mental Health in Primary Care, ‘Dealing with depressive thinking’
(World Health Organisation)
http://cebmh.warne.ox.ac.uk/cebmh/whoguidemhpcuk/leaflets/07-3.html

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Unite de Traitement de l’Anxiete, CH Neurologique de Lyon
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