Compulsive Acts: A Psychiatrist's Tales of Ritual and Obsession

George was special from day one. I can still remember Dawn, my clinic clerk, paging me at 1:45 p.m., three quarters of an hour after his first scheduled appointment, to warn me: "Oh, Dr. A., you're gonna love this one!"

"Please don't tell me the patient just showed up," I said. "How am I supposed to do a full intake in the remaining fifteen minutes?"

"I know," Dawn answered, "but I couldn't just let him go. I don't know what to say, but he's-how should I put it?-he has his reasons for being late ... He's special, even by our standards in this clinic, and even after nine years of doing this! I had to go out into the parking lot to check him in. That should give you an idea ...

"You went to the parking lot to check him in?" I asked. "Outside?"

"Yes, outside," Dawn answered. "He can't come in, he says. Our door isn't wide enough for him."

"Our door isn't wide enough?" I queried, wondering whether I was the right doctor for this patient. "Did he mistake us for the gastric bypass clinic? How heavy is he?"

"Oh, he's not heavy at all," Dawn answered. "In fact, his wife tells me he hasn't eaten in a few days. He's just ... I don't know ... Something about his nose ... He won't let anyone or anything close to it ... He was so worried about his nose, he wouldn't even get into the car this morning."

"How did he make it to our clinic, then?" I asked. "I thought he lived in Belmont. That's fifteen miles away."

"He does," Dawn said. "He walked here. His wife drove, but George walked."

"He walked?" I asked in disbelief. "All the way from Belmont?"

"All the way from Belmont," Dawn repeated. "That's why I can't simply send him back and ask him to reschedule. Anyway, he is checked in now and waiting for you over in the far corner of the parking lot, exactly three feet from the dumpster, where, I might add, his wife spotted your old, squeaky office table and asked me to help her pull it out and put it in her trunk. I'm no doctor, but she's not right, either ... What use could she possibly have for that table? Anyway, what would you like me to do now?"

"Well, I guess my only choice is to come right down," I said. "Meet me by the dumpster."

"OK, just remember not to get too close!" Dawn warned. "You might frighten him. And by the way, your two o'clock is here, too."

"Great! Is my two o'clock at least waiting in the waiting room?" I asked.

"Yes, she is," Dawn answered. "And I told her it was going to be a long wait ..."

* * *

I walked toward Dawn, who was standing in the far corner of the parking lot. Nearby, in a vacant handicap spot by our recycling dumpster, stood George. In the adjacent spot, having managed with Dawn's help to squeeze my old filing cabinet into her trunk, stood his wife, now trying unsuccessfully to push the trunk door shut.

George was a lean twenty-something, with wide green eyes and a sunburned face and neck, probably from having walked a very long distance in the midday sun to come to my office. His grooming and hygiene left something to be desired, and his dirty fingernails and caked hair indicated more than just the wear and tear of one day's walkathon.

His wife started the conversation. "Dr. A., thank you for coming out here to see us," she said, still intent on shutting the trunk, despite one leg of my old office table clearly sticking out. "I know this is not standard practice, but it's very difficult to get him through doors anymore. I read up on obsessive-compulsive disorder, so I know how to diagnose it. Heck, I may even have a touch of it myself ... We're here because we were told you were a specialist in OCD. It's urgent, Doctor! Things have gotten completely out of control since it's grown to three feet. Three whole feet!"

I was intrigued by the three feet but realized that I had not yet introduced myself to George. However, before I could formally do that, George preempted my handshake.

"I don't mean to be rude, Doctor," he said apologetically, "but please don't stick your hand out. I can't do handshakes."

"That's OK, I understand," I said. "I'm pleased to meet you anyway. Your wife just mentioned that 'it's grown to three feet.' What is it that has grown to three feet, George?"

"The radius around his nose," his wife answered, the quiver in her voice betraying her anxiety. "He needs that much clear space around his nose at all times. In the good old days, it used to be that nothing could come within a foot of his nose, and we could joke about it. But when the radius grew to two feet, it was anything but funny, and we started needing to make lifestyle modifications: having to sit alone in the backseat of the car, trying to sleep standing up like a horse, not to mention-if I may go there in your parking lot-the challenging sex ..."

I could see Dawn's face tense up at the idea of "going there." The sexual comment was clearly in poor taste for her and went against deeply ingrained prohibitions on discussing private sexual matters even in clinical conversations-that is, if you can really call a parking lot discussion a "clinical conversation." Dawn soon found an outlet for her anxiety, however: she strode over to the trunk, broke off the old table's leg, threw it inside, and snapped the trunk closed with a satisfying thud.

The sound of the trunk shutting and the thought of securing the old cabinet for her home also dissipated George's wife's anxiety, and a relieved smile made its way to her face.

"But then," she continued, more at ease, "even two feet weren't enough. It had to grow to three feet, and at three feet, it has been, well, impossible to accommodate!"

Steering the conversation back to the principal patient, I asked, "How long has this been a problem for you, George?"

"Oh ever since ... I don't know ... It sort of crept up on me," he answered.

"Ever since his brother died," his wife interjected.

"When did that happen?" I asked.

"Two years ago," George answered. "He died in a skiing accident."

"I'm very sorry to hear that," I replied.

If sex had been difficult to discuss in the parking lot, death would have been even more so, so I asked George, "I know this is hard for you, but can you try once more to come up to my office so we can continue this important conversation in private?"

"I can't. I'm sorry," George answered, cautiously shaking his head. "Doorways are difficult for me. Hallways are challenging. And elevators are out of the question."

"Nothing personal, Doctor," George's wife added. "His father was visiting from Europe, where he lives, last month. We hadn't seen him in two years. Well, George wouldn't even give him a hug! All he could do was wave hi from a safe distance when he arrived at our house and wave goodbye when we dropped him off at the airport."

Seeing that the entire first meeting would probably have to be conducted outside, I wanted to make myself more comfortable. I went over to his wife's car to lean against the door, moving only slightly in George's direction. George responded briskly, stretching his arms out and twirling in a 360-degree circle, his arms fully extended. The move resembled a disc rotating on its axis; its purpose, I surmised, was to make sure the required radius of safety was not violated by my sudden movement and that I did not put his nose in any danger.

Sensing that I may have inadvertently increased George's anxiety, I tried to give him a little break by addressing my next question to his wife.

"You said you might have a touch of OCD, too," I said. "Tell me about it."

"Well, it's really just a touch," she said. "Nothing like this! I don't worry about injuring my nose, although I should! I broke it twice already, once in a car accident and once in a diving injury. My OCD, if we may call it that, actually makes sense ... It's about making sure I don't run out of important things. 'What if I need it one day?' I always ask myself when I consider, or George makes me consider, throwing something out. And this simple question is usually enough to make me save the item, whatever it is. You can understand, then, how I built up my collection of pots and pans and cooking magazines and the tables I hope to stack them on. Did I mention cooking magazines? That is probably my biggest weakness!"

"Indeed," George agreed, gently nodding his head in agreement. "She has so many cooking magazines all over the kitchen, she can't make it to the stove to cook!" he added with a smile.

"That's right," his wife agreed. "I honestly can't remember the last time I cooked a meal for this poor man."

"But despite the mess in the kitchen," she continued, "we still eat well-or ate well, I should say-until his symptoms began. When he was at one foot, he couldn't use utensils, so I would buy him pizza, which he ate alone in his office. We lived on pizza for months because it didn't require a fork and knife. I would ask him, 'George, how come the pointy end of a pizza wedge is OK, but you can't use a knife and fork?' and he would say that something about metal approaching his nose was much scarier than the pointy end of the pizza wedge. Well, I thought it was kind of tragic, especially for someone who loved to eat and appreciated food so much. But oh, how I miss those days now! You see, when the radius grew to two feet, he couldn't even eat pizza, so he started insisting on soups and fluids, served in plastic bowls without a spoon. Later, when the radius grew to three feet, he started avoiding coming home altogether. He thought it was too much of a hazard, with all my stacks of cooking magazines and other stuff strewn all over the house. He didn't want to fall and hurt his nose, he said. So now he rents a studio nearby and eats-oh, I don't know what he eats, or if he eats ... Look at how thin he's gotten!"

George did appear thin, but more than his low weight, it was his disheveled appearance that marked him as unhealthy, so I asked him, "What about basic activities of daily living besides eating? Toileting and hygiene, for instance?"

"This is really embarrassing, Doctor," George answered, looking down and away from me. "I can't shower anymore. I feel the showerhead is about to attack me. We even had a plumber come in to replace it. He said he would have to install the showerhead in our neighbors' kitchen if he adhered to my specifications of how far it should be from my head when I'm standing in the tub! I know it's crazy, Doctor, but I really can't help worrying about it."

"Worrying about things that don't make sense and constantly checking to make sure one is safe are common symptoms in OCD," I said. "It doesn't mean you're crazy. It means you have OCD, and that is only a small part of who you are. The good news is that for many patients OCD is quite responsive to treatment, so I'm glad you made the decision to come here today."

It is important during a first psychiatric meeting to try to get a fuller sense of the patient than his symptoms alone, so I inquired about George's hobbies and work experience next. Unfortunately, the conversation always came back to OCD. "What do you enjoy doing in your free time?" I asked. "Tell me more about the part of you that doesn't have OCD."

"Well, I used to sing in church," George answered, "but I've had to give that up, too. The idea of getting a microphone close to my nose is enough to make me mute with anxiety!"

"How about work, George?" I asked.

"I used to work in a large advertising firm," he answered. "I had to give that up, too. My cubicle got too small for my nose ..." George smiled at the visual-an expanding nose in a shrinking cubicle-and I smiled, too, appreciating this young man's stubborn sense of humor, still evident despite the obvious stress he was under.

But many pieces of George's life and history were still unknown to me, and I could feel a hundred questions racing through my mind, all begging to be asked. By that point, though, I was very late for my two o'clock appointment, who was still patiently waiting for me, so I left George and his wife in the parking lot after getting their promise to return the following day so we could continue our "first meeting."

I did not leave them alone, though. I left them with Dawn, hoping that her powers of persuasion would be sufficient to get George inside the car.

"If I can get that old oversized table into your wife's trunk and manage to shut the door, I can get you into the car, too," she said to George as I walked away. As I overheard her ordering George's wife to open the sunroof, I cringed at the thought of what she might have in mind for George's trip home ...

* * *

We all have our peculiar habits and bizarre superstitions, but most of us don't suffer from OCD. Obsessive-compulsive disorder, the clinical condition, afflicts 1 to 2 percent of the population, and males and females are about equally likely to get it. For most sufferers, OCD is a chronic problem that will continue to negatively impact their lives, although the intensity of their symptoms may vary over time.

The fourth edition of the Diagnostic and Statistical Manual, or DSM-IV, the "bible" used by mental health professionals for diagnosing mental illness, defines OCD as the presence of obsessions or compulsions. To be clinically meaningful and meet DSM-IV requirements for a psychiatric diagnosis, the obsessions or compulsions must take up at least one hour daily and interfere substantially in the person's life. The DSM-IV criteria for diagnosing OCD are listed in on page 10.

Typically, OCD includes both obsessions and compulsions. Obsessions are unwanted thoughts, images, or impulses that come into the patient's mind in a repetitive way and that the patient experiences as bothersome. Common obsessions in OCD include contamination fears, such as fear of catching an infection or fear of pollution; "pathological doubt," especially about whether safety checks at home or in the car have been performed; symmetry obsessions, like the need to preserve things in perfect order; "somatic" obsessions about particular body parts or body functions, such as unjustified worries about one's nose or fear of fecal incontinence; and disturbing thoughts of a blasphemous or incestuous nature, as might be seen in a patient with no history of, or desire for, incestuous relationships, who has distressing mental images about having sex with a parent.

Compulsions are rituals performed by the person with OCD to neutralize the obsessions and reduce the anxiety they cause. Common compulsions include frequent checking of doors, windows, stoves, car locks, or body parts; excessive cleaning, either of one's body or one's environment; hoarding of useless items in case they are needed in the future; and a need to repeatedly ask for reassurance or to confess perceived mistakes. Compulsions need not be observable behaviors and can be mental acts that the person performs, such as praying in rigid, preset ways, counting in silence up to a predefined number, or repeating certain words or sentences to oneself in fixed patterns "until it feels right."

Some compulsions cluster naturally with particular obsessions. For instance, excessive cleaning or hand-washing (the compulsion) often goes with contamination fears (the obsession), and frequent checking (the compulsion) often goes with pathological doubt (the obsession). Other obsession-compulsion pairs are not related in any "rational" way. For example, Sean, a pleasant young athlete I see in my clinic, experiences obsessive incestuous thoughts involving his sister. He is absolutely disgusted by these thoughts and has never had any desire or intention to act on them. For Sean, the compulsion that helps neutralize the anxiety accompanying this obsession consists of tapping his inner thigh five times every time the thought intrudes on his mind.

Of all compulsions, excessive checking is the most common and is seen in over 60 percent of people with OCD. Some checking compulsions take the form of exaggerated everyday behaviors that in normal individuals are automatically and quickly performed-examples include checking to make sure the doors are locked or that one did not accidentally hit a passerby while backing out of the driveway. A person with OCD, however, may spend several hours a day checking and rechecking, often in complex, uncompromising patterns.

(Continues...)

Excerpted from Compulsive Acts by Elias Aboujaoude Copyright © 2008 by The Regents of the University of California. Excerpted by permission.
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