Obsessive-compulsive disorder is characterized by two main categories of symptoms: obsessive thoughts and compulsive behaviors. The terms obsessive and obsession are used in everyday conversation to suggest a preoccupation. For example, a person may be described as being obsessed with money. The term obsession is frequently used to describe a passion or strong interest. For example, “Golf is Howard’s current obsession.” However, in discussing OCD, the term obsession is used differently. Obsessions refer to intense thoughts, worries, or images that are experienced as intrusive and unwanted. These obsessions cause great anxiety for an individual and often lead to the development of compulsive behaviors or rituals designed to decrease anxiety. I’ll discuss compulsive behaviors more in Chapter 2. One of the simplest ways to describe an obsession is an unrealistic or overexaggerated worry or concern about something. The person experiencing an obsessive worry will frequently describe a thought or concern that sounds magnified or “catastrophized” to others. In other words, they will talk about a fear or worry that is far beyond what most people consider “normal.” In fact a person with OCD can sometimes tell you that they realize that their fears or worries are irrational or illogical. However, the anxiety is very real and overpowering. I’ve talked with many patients who tell me that they know their worries are irrational; however, they can’t control the overwhelming fear and anxiety that these obsessive thoughts produce. Obsessions usually fall into one of several categories.
These types of obsessions frequently involve excessive concern over germs, diseases, and other contaminants.
Tammy was a young girl who was fourteen years old when her parents brought her to me. Her parents indicated that they felt Tammy “worried too much.” Worry is a common presenting problem for people who suffer from OCD. Tammy’s worries included fears that something may happen to her parents; fears that something may happen to her sister; and worry about germs. Tammy was so concerned about germs; she was unable to use any restroom outside of her home. Traveling was terrifying for her. Even family vacations that were designed to be fun and stress free became a source of tremendous anxiety and stress for Tammy and her family. If the family had to stay in hotels, Tammy would make sure that she brought several cans of Lysol spray with which she would immediately “disinfect” the entire hotel room upon arrival. This would enable her to feel “safe” enough to at least be able to use the restroom. At home, Tammy simply could not use any public restroom. If she went out with friends to a movie, she made sure that she would use the restroom just before leaving. During an outing with friends, she was always careful not to drink too much liquid so she would not have to urinate. She timed her outings to make sure that she would never be out longer than she could wait to use the “safe” restroom of her own home. The biggest challenge she faced was from Monday through Friday at school. While Tammy did use the restroom before leaving home and restricted her fluid intake, she could not make it through the entire school day before she had to yield to the call of nature. Since she could not use the school restroom, she would actually leave school and return home to use the bathroom. Needless to say, Tammy missed most of her afternoon classes. In fact, she missed so many of these classes she actually failed two of them.
While people who suffer from OCD often have a general fear of germs, some people with OCD have specific fears related to a particular disease. For example, many people with OCD report a specific fear of contracting AIDS. Most of the time, these individuals are not in any “high risk” group for contracting HIV (the virus that leads to the development of AIDS). However, their fear and anxiety is extraordinary. This fear often causes them to ruminate endlessly that they may be HIV positive. They are not comforted by reassurance that there is no reason to believe they should be concerned (e.g., no unprotected sexual encounters; no blood transfusions; etc.). They begin to describe irrational fears such as believing that they might have had an undetected cut on their skin (the hand, for example) and they wonder if they may have shaken hands with someone who was infected with HIV thus resulting in the transmission of the disease. This example illustrates the type of thought processes characteristic of obsessive thinking. Probabilities are greatly exaggerated and logic is stretched to arrive at the ultimate conclusions. Many of these people will have multiple medical tests to make sure that they aren’t infected. However, a negative test may lead to further rumination and obsession. They may begin to wonder, “What if the test was wrong; after all, they aren’t 100 percent accurate. Perhaps I should be retested.” Some OCD patients will
receive repeated tests for a disease that they are at virtually zero risk of contracting. Others will do the opposite: they are so terrified that they may have the disease they will refuse to receive a test to assuage their fears. They reason, “If I am HIV positive and find out, I won’t be able to carry on. It’s better to not know.” While HIV isn’t the only specific disease OCD sufferers worry about, it is a common one.
Another frequent obsessive worry is that of getting cancer. Jeff was a young man who read an article about testicular cancer and became terrified that he would develop this disease. Consequently, he worried almost incessantly about having the disease. This was a bright young man who functioned at a very high level. He was at the top of his graduate school class in his studies, and everyone found him fun to be around. However, he was almost constantly tormented by obsessive thoughts that he had testicular cancer. He described experiencing “sensations” in his scrotum. He read that while the disease is often symptom free in the initial stages, there may be a “heavy feeling” in that area. He began to imagine that he felt a “heaviness” in this area which further fueled his anxiety and
concern. At times, obsessions can involve an imagined physical sensation. These are known as somatic obsessions. The only time he was not assaulted by these thoughts and fears was when he was mentally engaged in a task, or when he was distracted by something he thoroughly enjoyed. He found that he was almost anxiety free when he drank alcohol. Consequently, he began to drink more. OCD can be a precipitant to abuse of substances. Many OCD patients described using alcohol, marijuana, or other drugs to “self-medicate,” or to decrease the anxiety caused by the obsessive thoughts.
People who suffer from OCD are particularly at risk of developing obsessive worries that they may have a disease after reading about the symptoms of a particular disease. Some OCD sufferers will see a television show or read an article about an obscure disease or illness and begin to worry that they may have the symptoms of that malady.
For some people with OCD, the obsessive worry is not of contracting a specific disease, but rather a pervasive fear of any germs that they may come in contact with. This may become so extreme that they fear touching doorknobs (because myriad other people have touched them) or handling money. Their persistent worry about germs causes anxiety in almost any public arena. Efforts to avoid being “contaminated” with germs can lead to the development of significant compulsive behaviors (discussed in Chapter 2).
While some individuals obsess about contracting an illness, others may obsess about contaminating others. These concerns range from mild (a man who worries excessively that he will spread germs if he coughs in public) to more severe (a woman who fears that her past sexual indiscretion may have caused her to contract a sexually transmitted disease that she will pass on to innocent others by simply rubbing against them).
Some individuals worry about being contaminated not by germs, but by other “contaminants.” Many individuals report a fear of being harmed by ordinary household cleaners. Bobby was a teenage boy who was terrified of household cleaners. When his mother would spray the kitchen counters with a normal household product, he would experience severe anxiety (bordering on a panic attack). He avoided all cabinets and rooms where cleaning supplies were stored.
Other individuals report anxiety over the possibility of environmental contaminants. These may include chemicals such as pollutants and pesticides. Some individuals refuse to allow their homes to be sprayed for pests or their lawns to be sprayed for weeds for fear of being harmed by the toxins used in these types of treatments.
Many people with OCD describe the need for things to be “evened up.” This refers to the need for things to be symmetrical. For example, some people go to great extremes to make sure things in their environment are even on each side. They may arrange their rooms or offices so that things are aligned in perfect symmetry including pictures on walls, items on their desks, or books on a shelf. These individuals may also report the need for things to be symmetrical on their body. I’ve spoken with several individuals who described tying and retying their shoes in order to make sure they were tied with the exact same tension on each foot. I worked with a young man who had to make sure that if he saw something out of the corner of one eye, he also viewed it with the other eye. This became quite cumbersome as he worked to make sure that things were always “even.” While these behaviors would be considered compulsive (which we will discuss in detail in the next chapter), it is the obsessive need for symmetry that drives the behavior.
A similar type of obsessive thought is the need for exactness. This refers to a need for certain things to be “just right.” A middle-school student was failing in classes involving a great deal of writing. This was perplexing to her parents and teachers since she was such a bright and capable student. She was originally referred to me in order to see if she suffered from some biologically based attention problems (such as attention-deficit hyperactivity disorder) or some type of specific learning disability (such as written expression). I performed a complete neuropsychological evaluation in order to examine all areas of cognitive functioning. Testing re-vealed a young woman who was highly intelligent with achievement scores to match her intellect (indicating no areas of learning disability). She also manifested no obvious signs of attention difficulties, and teacher and parent reports indicated no significant difficulties in these areas. However, in completing the testing, I observed that she took an inordinate amount of time to complete written tasks. An analysis of her performance determined that she was obsessed with forming letters on the page perfectly. Her handwriting was impeccable and letters looked as though they were formed by a printer rather than a human. She made frequent erasures in her efforts to make the letters perfect. This need to make her written work perfect caused her to take at least 5 times longer in completing work. This was causing her to miss handing in assignments at school because she could not complete them in time. Homework became so arduous; she would become frustrated and quit. This case is an example of how students who suffer from OCD are often suspected of suffering from other disorders such as attention-deficit hyperactivity disorder (ADHD) and learning disabilities.
For others, the need for exactness involves positioning things in their environment. One young woman I worked with described spending hours making sure the fringe of her oriental rug was “perfectly straight on all sides.” She also described becoming very anxious if a guest moved one of the pillows on her couch from its “perfect position.” I had one patient who told me she could not concentrate on our session until she straightened every diploma and picture on my walls and lined up the items on my coffee table so they were precisely positioned.
Many OCD sufferers are tormented by intrusive fears that they may suddenly and violently act on angry or violent impulses. Typically, these individuals have no history of violence or trouble with aggressive behavior. However, they are terrified that they may suddenly engage in some violent act as though it is outside of their control. I worked with a woman who became panic stricken around babies. When I asked her why she was so anxious around infants, she described with great difficulty the fear that she may suddenly rip the child from the parents’ arms and slam the child to the ground. This woman was a highly skilled and very successful paraprofessional. She had no history of any aggressive or violent behavior in her 40+ years of life. In fact, she loved children and was deeply saddened that she could not be around her nieces and nephews because of this paralyzing fear. Her anxiety was completely irrational, and she knew this. However, she was disturbed that these thoughts were even in her conscious mind. She described how she was haunted by images of seeing herself being handed an infant. She talked about how she would see herself raise the small baby above her head and throw it to the ground with all her might. She then talked about how she was traumatized by seeing the image of the child lying on the ground, bleeding and dead from the blow. These images were so gruesome and clear, so terrifying and traumatic, that they were debilitating to her. She was so horrified by these thoughts that she went to great lengths to avoid having them. Unfortunately, this primarily meant avoiding her sister, nieces, and nephews.
I’ve spoken to several individuals who experienced significant anxiety around knives. In fact, I’ve known a few individuals who had to remove all knives from their house (which made cooking difficult). If these individuals saw a knife, they were bombarded by horrific images of taking the knife and sticking it into their eye. Again, none of these individuals had any history of self-harm. However, these horrific images and the fear of their possible aggressive impulses were terrifying.
For others, these obsessions take the form of violent images alone as opposed to fears of violent impulses. I spoke with a teenager who described riding by a house on his way to school when he observed a man mowing his yard. The teen was blindsided by a sudden image of the man falling under the lawnmower and having his leg severed by the mowing blade. This image was extremely upsetting to the young man. After this, the teen was unable to ride by the same house (because of the anxiety this image created for him) and asked his mother to take him to school via a different and less convenient route.
Many others live with agonizing thoughts and fears of something terrible happening to loved ones. They may have images or fears of loved ones dying in motor vehicle accidents or plane crashes. Others may experience extreme anxiety caused by thoughts of loved ones being attacked and assaulted.
For many, these fears of something terrible happening to loved ones is accompanied by the belief that if they do something (e.g., recite a certain prayer or engage in a certain ritual), they can protect the loved ones from harm. The feeling of responsibility for protecting their loved ones is overwhelming and can cause great distress.
Because I frequently work with Christians, I see obsessions involving religion frequently. One of the most common religious obsessions is the fear that the person has “committed the unpardonable sin.” Others describe the fear that they have “blasphemed the Holy Ghost.” When asked what they think they may have done to warrant eternal condemnation, the answers vary. However, they are convinced that they may have done something to deserve eternal separation from God. Because of the confusion in the Christian community over this and other religious obsessions and compulsions, I’ve devoted an entire chapter to this topic (see chapter 5).
Some people with OCD find any type of sexual thoughts and feelings unacceptable and extremely anxiety producing. This is particularly true of adolescents suffering with OCD. Eric was a young man who experienced an episode of sexual acting out early in his pre-puberty years. The incident was handled appropriately by his parents and was in the past. However, the teen harbored extraordinary feelings of guilt and shame over the incident. He later associated any and all sexual feelings with this incident and had tremendous difficulty accepting his normal sexual development. He would become extremely distressed upon waking after having had a nocturnal emission. He also described seeing a television show in his basement which caused him to become sexually aroused. Because of his difficulty with accepting his normal sexual feelings, he began to view the T.V. and eventually the entire basement as “contaminated.” By the time he came to see me, he could not go into the basement of his own home. In fact, anything that was in the basement was viewed as “contaminated” and was at risk of contaminating the remainder of the house. He would not wear his favorite clothing or listen to his favorite CD’s because they were in the basement.
I recall another young man who was tormented by the fear that he would become attracted to other males. The curious fact was that he never had the slightest attraction to other males. In fact, the thought of this actually repulsed him. However, he was so preoccupied by the fear that he may someday find another man attractive, he would go to great lengths to avoid establishing any close relationships with other male friends.
While it is true that some individuals can become obsessed with sexual thoughts and feelings in an almost addictive way, the type of sexual obsessions I am referring to here are different. Sexual obsessions associated with OCD refer to extreme discomfort with normal and healthy sexual thoughts, feelings, and impulses.
Some individuals with OCD find themselves constantly questioning their own behaviors. For example, they may wonder if they locked doors or turned off appliances. I worked with a man who was late for work every day. I don’t mean a few minutes late, I mean very late. The only reason he wasn’t fired from his job was because he was a terrific guy and a valued worker. The reason for his tardiness was his inability to leave the house due to his fears that he may not have unplugged the coffee pot or closed the garage door. He described returning to the kitchen repeatedly to make sure the coffee pot was un-plugged. He would also stare for long periods of time in order to “make sure” it was unplugged. He reasoned that if he stood and stared long enough, he would surely remember that it was unplugged. However, after being gone for a few minutes, his doubts would return and he would have to go and check again. He also described sitting in the driveway for a prolonged period of time staring at the garage door in order to make sure it would not somehow reopen. After leaving the house, his doubts would return and he would have to return to the house in order to check again.
Some people with OCD are referred to as “pack rats” because of their inability to throw anything away. These people will save any and all items (regardless of how useless they may be). They often realize that they may be running out of space to store things. However, when they are faced with the need to make a decision to throw something out, thoughts run through their mind such as, “What if I need that item some day?” These thoughts are so strong they stop the individual from being able to discard even useless items. Consequently, they begin to gather and collect piles of useless junk. Imagine the distress this causes family members.
This last category of obsessions is a bit difficult to describe. However, if you suffer from OCD, you will know exactly what I am describing. Many people with OCD feel that certain things must be done in a certain way. They may have trouble explaining what that way is or why it must be done that way. However, they know that it must be done “just so.” A man described one such obsession to me and demonstrated with his hands. He stated that he often had the urge to take his hands and position them so that the fingers of his left hand touched the tips of his right hand at precisely the ends of the finger. He stated, “I’m not sure how I know when they are touching at that particular spot, but it has to be exact. I know when I’ve done it because it feels right. Then I can stop and go on to whatever I need to do.” This man was a successful executive for a Fortune 500 company. He told me that he could do this in a business meeting and no one had a clue that he was engaging in the behavior. Again, I am describing an example of a compulsive behavior. However, it is the obsessive thought of having to have it “just so” that drives the behavior.
These are examples of a few types of obsessions. Obsessions are a hallmark symptom of OCD. They are thoughts, worries, images, or impulses that torment the individual and feel out of the person’s control. Typically, obsessions are irrational and illogical and may be recognized as such by the individual. However, they cause debilitating anxiety and distress and usually result in the development of compulsive or ritual behaviors which I will discuss in the next chapter. It is important to understand obsessions so that the person can recognize when they are being plagued by obsessive thoughts or images. Identification of these obsessions is essential to proper understanding, diagnosis and treatment.