I was standing in an open field, looking back into the forest and brush, watching the others struggle their way out. It was raining. I had purposely taken everyone off trail through trees and undergrowth so densely packed that forward movement was a slow process of stepping over and through bushes and being on guard for branches snapping back from whoever was in front of you. Melanie, the fourth person to emerge into the freedom of the clearing, shouted, “I’m having a great time!” The photographer documenting our trip for People magazine snapped a picture. Seeing Melanie’s joy, it was hard to connect this woman with the one I’d met seven months earlier at my former center, The Anxiety and Agoraphobia Treatment Center in Philadelphia.
When I met Melanie at our first session, she was an extreme suicide risk— all medications in her home, even aspirin, had to be locked in a safe. Her parents wouldn’t permit her to carry more than two dollars at a time, fearing that access to more money would enable her to commit suicide with over-the-counter medications. She was an attractive and articulate twenty-nine-year-old with a fifteen-year history of both obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). Her OCD focused on issues of perfection. When taking notes during class, if there were any cross-outs, stray marks, folds, or creases in her notebook, she would feel compelled to discard the page. Similarly, she wouldn’t tolerate any such marks in her textbooks and would cope with such “imperfections” by not using the text. Though she found school a nightmare of anxiety, Melanie did well in the courses she managed to complete. But many of her attempts to go to school resulted in anxiety and depression severe enough to require psychiatric hospitalization.
Melanie also felt as though she was horribly ugly—so repulsive that she believed it was a burden for those around her to tolerate her presence. This is what it feels like to have BDD, a form of OCD in which sufferers can’t stand their own appearance. She spent endless hours agonizing over her hair and makeup, trying to get ready to go out, but often wouldn’t be able to leave the house. For more than fifteen years, she had no memory of ever being free from her anxiety and despair.
Yet here she was on a camping trip. And not just any trip, but one that I’ve been running almost every year for more than two decades as a therapeutic journey for OCD sufferers. Even non-sufferers might find it difficult to spend a weekend sleeping in tents, using latrines without the benefit of running water, and taking torturous hikes through the mud and muck. For the OCD sufferers I treat, especially those with contamination fears, the accomplishment of making it through such an experience is often nothing less than a tremendous breakthrough in their recovery.
This camping trip is just one of the approaches I’ve found to be of use in working with OCD sufferers during the last twenty-five years. Earlier in my career, as a faculty member in the Department of Psychiatry at Temple University’s School of Medicine, I was part of a research team studying the treatment of OCD. Though our research excelled at delineating the mechanics of treatment—our results and findings regarding the behavioral techniques known as exposure and response prevention are still the core of today’s treatment for OCD—I felt the need to go beyond the actual treatment process.
I wanted to address issues our research was ignoring, such as relapse prevention. So in 1981, with an OCD sufferer named Gayle Frankel (who was then the current president of the Philadelphia Affiliate of the Obsessive-Compulsive Foundation), I started the first OCD support group in the country. Called GOAL (Giving Obsessive-compulsives Another Lifestyle), our group was more than a place for sufferers to share their stories. Its purpose from the beginning was to help sufferers understand their OCD and to make and maintain treatment gains.
Helping people understand their OCD is the key to my treatment approach. One of the greatest problems for those of you who suffer from this disorder is the disparity between your inner world and the outside. For all of us, the person we show the world is not exactly who we are; we all have our private thoughts, opinions, and secrets. But, for you, the gulf between your private and public selves is greater. No matter which aspects of your OCD everyone else sees, you and I know it is only the tip of the iceberg. You understand the pain and frustration of being locked in a strange world in which you know that your thoughts and behaviors make no sense. It is as if you have simultaneously lost your mind and, at the same time, are so sane that you are a witness to the loss. You are an expert at knowing what OCD feels like, but fully understanding your plight is another story.
You may have heard many explanations for your OCD—it’s a chemical imbalance, it’s a learned behavior. These are explanations, but they are no better than saying a car works because it has an engine. Knowing that a car has an engine doesn’t tell you how to fix a car that’s not running. For you to fully understand your OCD, a meaningful explanation needs to be more than logical and scientific. It must address your feelings and experience and answer questions such as: I’m staring at the stove and can see that it is off. Why don’t I know that it is off? If an explanation touches you, and you can’t help exclaiming, “That’s me!” then you understand.
If you suffer from OCD, you have probably seen many different professionals, tried numerous medications, and read any number of books dealing with anxiety and OCD. This book, however, is different. It is not simply a cookbook explaining how to recover from OCD, because overcoming OCD requires more than simply following instructions. Treatment without understanding is like painting by numbers; there will be some improvement and symptom reduction, but you want more.
To go beyond symptom reduction and stop OCD from controlling your life, I believe you’ll do better as a master artist. The “master artist” has the understanding to create and fashion his or her own work. This book offers the self-guided version of the treatment program used at my center, where helping sufferers understand their OCD is the crucial first step to recovery, because they can’t truly agree to therapy if they don’t understand their OCD and the treatment process.
Your success depends upon your becoming an equal partner in designing your recovery program. As you’ll find in this book, with understanding you won’t follow a treatment protocol, you’ll design your own. Copies of the forms, worksheets, and other materials found in this book are also available for free download from www.FreedomFromOCD.com.
Part 1 of this book, Understanding Obsessive-Compulsive Disorder, will help you to truly understand your OCD experience. You will begin to answer the questions that plague you—for example: How can I not know what I know? Why can’t I stop ritualizing? In making sense of your OCD, you will begin to realize that this disorder doesn’t set you apart from the rest of humanity. You will come to recognize that the difference between you and non-sufferers is a matter of degree, not unlike the differences between social and problem drinkers. In the case of drinking, getting drunk isn’t the problem; it is how often and how much it interferes with your life. For OCD, it is not rituals, seemingly irrational thoughts, or anxiety that differentiates the sufferer from the non-sufferer, but how much these interfere with your daily life. This section will also address the role of medication in recovery and the cognitive behavioral techniques that you will use in your OCD program.
In Part 2, The Foundation of Your Program, I will demystify the process of OCD assessment and treatment, allowing you to design a recovery program for yourself that you can understand and believe in. Then I will guide you through the initial steps of assessing your OCD.
Your newfound understanding will be transformed into practical knowledge as you use the tools and instructions I provide to further assess your OCD and prepare the materials you will need in your self-guided recovery program. The most important of these will be the “scripts” you will be creating to keep up your motivation, fight discouragement, and overcome difficult hurdles. These scripts will help you address one of the greatest difficulties in carrying out a self-guided OCD treatment program: the absence of a therapist to provide you with support specifically targeted and appropriate to your needs of the moment. Although a book can’t replace an experienced therapist, sample therapist scripts are provided, along with directions that will enable you to adapt them to your own needs or to create your own. These scripts will appear throughout the book. Ideally, your recovery program should be a collaboration between you and an experienced OCD therapist. This book is meant to be used as an adjunct to therapy or at times when you can’t find a therapist.
Part 3, Personalizing Your Program: Treatment Guidelines for Your Specific OCD Concerns, is the heart of this book and focuses upon the different manifestations of OCD. Each poses special challenges that need to be addressed when designing a recovery program, particularly if most of your OCD symptoms seem to fall into a single category, such as obsessions focusing on contamination or violent thoughts. The chapters in Part 3 will provide guidance for modifying and individualizing your recovery program through examples, adjusted treatment guidelines, and scripts.
Even when your obsessive concerns seem to have a single focus, they may affect your life in more ways than you realize. For example, if you have contamination concerns, you may find that, in addition to washing your hands, you check the environment for contaminants and mentally ruminate about what you have or have not touched. Or if violent thoughts are your focus, you may spend your time both trying to figure out what it means that you have such thoughts and trying to find ways to prevent the thoughts from coming into your mind. Because of this, you will discover advice throughout Part 3 that you will want to incorporate into your recovery program.
Part 4, Recovery and Beyond, will help you complete your recovery. Working alone on your recovery can be hard. I provide you with guidelines for using family and/or friends as helpful supports during treatment. However, sometimes you will want help from someone who knows exactly how you feel. For this purpose, I also provide instructions for setting up an effective GOAL support group.
Your recovery program doesn’t end when you feel you have overcome your symptoms. Maintaining your gains is a process that requires continued effort. In the last chapter, you will discover why “slips” are normal and how, when you prepare for them, they don’t have to lead to a complete relapse.
The good news is that, while OCD can be a devastating and debilitating psychological disorder, surprisingly it is one of the most treatable. Current research holds that 70 percent of those suffering from OCD will significantly benefit from a treatment involving exposure and response prevention (the treatment of choice for OCD). This should be a time of hope and optimism for finding treatment.
The key, though, is finding therapists who are truly experienced in treating OCD, who know how to properly use exposure and response prevention instead of offering traditional talk therapies or nothing more than medication. When Melanie, my camping trip client, first came to me, I found that her psychiatrist had been underprescribing the SSRI (Selective Serotonin Reuptake Inhibitor) antidepressant she had been taking. When this was rectified, she went from being an extreme suicide risk to a moderate one. Her OCD and BDD, though identified early in her previous therapies, had never been properly treated. Her course of treatment with me included exposure and response prevention, and seven months later she was camping and having a great time. One year after that trip, Melanie was no longer controlled by OCD, BDD, and depression; had completed two semesters of school with ease; had spoken at the annual national conference of the Obsessive-Compulsive Foundation about her recovery; and had gone on her second OCD camping trip.
Too often I am faced with seeing another Melanie—someone who has needlessly suffered for years. Freedom from Obsessive-Compulsive Disorder is my solution. I believe that OCD, when properly understood, is not a disorder of hopeless torment but one that can be overcome. Conquering OCD is hard work, but not as hard as what OCD sufferers already go through every day. So, I invite you, like my campers, to find the hope and courage to journey with me to a better place.
A few years ago, I was in a doughnut shop, waiting to be served. A well-dressed woman was sitting at the counter next to me. When her server—Jared, according to his name tag—brought her doughnuts, she had a special request. “Would it be okay if I pay you after I eat?” she asked. “I’m not going to run out or anything, but I just washed my hands, and if I go into my purse to touch money, they will be dirty and I’ll have to wash them again.”
“Do you realize how dirty money is?” she continued. “Money is handled by so many people that anything could be on it. That’s why they don’t allow cashiers to both handle money and serve food. In fact . . .” She went on for quite some time, ignoring or pretending not to notice Jared’s expression, which silently said, What is wrong with you? Fine, pay later—just let me get back to work.
The answer to Jared’s unspoken question was obsessive-compulsive disorder (OCD). And the woman in the doughnut shop—to my trained eye, an OCD sufferer—is not alone. I am often struck by how many people I pass on any given day—driving my car on the highway, walking through a mall, sitting in a movie theater—who likely have OCD as well. Statistically, for every forty of the thousands of faces I see, one is suffering or will suffer from OCD. When I was in graduate school in the late seventies, I was taught that OCD was a rare and hopeless disorder that only affected about .05 percent of the population (1 in 2,000). However, in the early eighties, I quickly realized that these figures had to be wrong. At that time, I was working at Temple University’s School of Medicine with Dr. Edna Foa, who was on the first of her many National Institute of Mental Health (NIMH) grants that researched and pioneered today’s treatment of OCD. Everyone I discussed my work with seemed to know of someone who exhibited OCD symptoms (significant symptoms, like those of the woman in the doughnut shop, not the little habits and rituals all of humanity engages in on a daily basis). I wondered, How could OCD be simultaneously rare and yet so common that everyone knows someone with it? Since then, worldwide studies have found lifetime prevalence rates for OCD to vary between 2 and 3 percent—about one in every forty people.
For the most part, OCD sufferers are able to remain invisible. There are exceptions, of course: those of you who make no effort to hide your compulsions, whose suffering is obvious, if in nothing else, in your inability to function. The billionaire Howard Hughes, for example, suffered from OCD so severely that his life was reduced to a tortured and limited existence. His seemingly bizarre habits and lifestyle, coupled with his wealth and fame, attracted the media like a magnet.
The way OCD looks to outsiders is a far cry from what OCD really is. To outsiders, the disorder is what the press shows us—extreme cases of people who claim they have to do things that make no sense to themselves or others. But the truth is that when you have OCD, something is happening to you, you are not crazy, and there is something you can do about it.
Why doesn’t the outside world have a better understanding of OCD? One problem is that many of you are experts at hiding all or almost all of your rituals, so you appear to have, at worst, a minor problem. Colleagues at work just think of you as a neat freak, or as that man with the odd but harmless habit of circling his car a few times in the parking lot after locking it. You function in the world, and you don’t appear to be in obvious distress. Unlike the extreme cases publicized in the press and on talk shows, your OCD doesn’t seem to be much of a difficulty to live with. There are a number of reasons you may strive to hide your fears and rituals. For many of you, concealing your problem is necessary to keep your job and preserve your relationships. Another reason you may try to hide OCD is that you simply want to avoid the humiliation of being labeled “crazy.” So even if you engage in a few small rituals—enough to have others label you a neat freak—you make sure no one sees how anxious you are underneath that “neatness.” This ability of yours to successfully function under stress has a special name: competence.
Anyone who is successful in the world has this ability. Imagine coming to me for treatment. If, during your first session, you found me shaking, stuttering, and discussing a terrible problem I was having at home, you’d quickly decide you were in the wrong place. You’d expect that whatever problems I might have, I would pull myself together and do my job. There is only one difference between me and you: I don’t rely on using this competence as often as you do.
Competence works both for and against you. On the one hand, it allows you to function in the world. There are many accomplished individuals whose OCD we’d never know about if they hadn’t admitted to the problem publically. Actor-director Billy Bob Thornton, as well as former host of Nickelodeon’s Double Dare show, Marc Summers, are both very forthright about their OCD and have managed to find ways to have successful careers. It is important for you to recognize this strength in yourself. Some of what I will be asking you to do later will seem very hard, but what you are doing now is also very hard. How many of your colleagues and friends who don’t suffer from OCD could function as well as you if they were under the same constant level of anxiety and stress? Bravery is not a feeling; bravery is how you behave when you are scared. You are among the bravest people I know. The strength and competence you are accustomed to using in order to get through your daily life can help you succeed in treatment.
But competence can also work against you. It has led many of you to delay seeking treatment. After all, if you are trying to hide your problem, seeking treatment might be a flag to others that something is wrong. If your OCD started when you were a child or an adolescent, you may have felt especially afraid that adults, if they discovered your secrets, would confirm that you were going crazy. Jessica, for example, came to my center at age sixteen after having hidden her OCD for five years. During the previous school year, she had begun to obsess about harm coming to her family and felt the need to protect them with numerous rituals involving movement and symmetry. Every time she went through a doorway, she felt she had to touch the left and right sides of the doorway to protect her family. She would continue to do this until it “felt right.” Her OCD only became evident to her teachers and family when her anxiety became so intolerable that she no longer felt capable of hiding her pain and rituals. In “crashing,” she was one of the lucky ones. She worked very hard in treatment and was able to overcome her OCD. I have worked with sufferers who successfully hid their OCD for twenty years or longer.
Where does this leave you? Trapped with anxiety, painful thoughts, rituals you feel you can’t control, and the frustrating knowledge that you logically know your fears and compulsive actions make no sense. You don’t understand what is happening, and you are surrounded by people who understand even less about it than you do. Often your friends and family are aware of your OCD and will try to offer helpful advice: “You don’t have to wash your hands again—they are clean.” “The door is locked, we can leave now.” “Yes, for the fiftieth time, I’m sure you didn’t hit anyone on the way home; you can stop asking.”
Most of the time, you don’t listen to the advice. Others tell you not to worry, because your fears make no sense. You already know this. Their exhortations merely confirm your suspicions that you must be losing your mind. So you desperately try to hide your symptoms, because who wants to be thought of as crazy? Though you may succeed in appearing “normal” to the outside world, you know something that non-sufferers don’t: You know how anxious you feel.
Your family would like you to stop ritualizing, but you know they have no idea what stopping will do to you. Indeed, there have likely been occasions in which you tried to resist ritualizing. Even though your most feared disaster didn’t occur, your anxiety probably increased. In the end, you may have gone on a binge of ritualizing that lasted far longer than usual. And as anyone with OCD knows, five hours of handwashing isn’t simply washing your hands over and over. It is a hell in which every repetition is accompanied by mounting frustration and anxiety: Why can’t I stop? Why don’t I know my hands are clean when I know they must be? How long is this going to last? On such occasions, you didn’t stop ritualizing because you finally felt you got it right; you stopped because of exhaustion. The whole process felt crazy and out of control.
No matter what disaster you may fear with your OCD—illness, death, or whatever—usually the feeling that “I can’t take another second” or “I will lose control or go crazy” is almost certainly present. In the previous Diagnostic and Statistical Manual of Mental Disorders-IV, the psychiatric handbook for diagnosing mental disorders, OCD was listed as an anxiety disorder. This probably comes as no surprise to you. Although OCD has been given its own category in the DSM-V, we know that anxiety is the driving force behind OCD: an anxiety that feels overwhelming and endless, an anxiety that spirals out of control as attempts to reassure and neutralize fail over and over again. So, even if your obsessions and compulsions are literally attempts to avoid potential disaster, they are also attempts to make your anxiety stop. In order to avoid intolerable out-of-control feelings, to avoid going crazy, you ritualize. Ritualizing may not make sense to your friends and family members, but they don’t know what will happen to you emotionally if you stop. Given all they don’t know about OCD, listening to their advice really would be crazy!
Despite its crucial role in OCD, anxiety is not the defining feature of OCD. OCD has many different faces—contamination concerns and handwashing; repetitious checking of doors, stoves, and locks; concern about violent or sexual thoughts. How can so many different manifestations all stem from the same problem? What ties them together? What is the core of OCD and the source of the painful anxiety it evokes? In preparing to write this book, I created a survey questionnaire that asked sufferers and their families to describe their experiences with OCD. It was disseminated at my center and over the Internet.
Ira, a forty-eight-year-old man, has suffered from OCD since he was nineteen years old. The following excerpt from his survey response provides us with an answer:
I work in the city, and it’s such a filthy place. If I could have my way, I wouldn’t go there, that way I wouldn’t have to go near so many dirty people—people sneezing, coughing, touching everything—but that’s where my law firm is. During the day, I’m not too bad. I have dirty clothes for wearing outside and decontaminated clothes for home. I make sure to keep my hands away from my mouth during the day, and I’ll only go out to lunch at certain clean restaurants.
But when I get home, that’s when the ordeal begins. I make everyone in the family come into the house through the laundry room. That way they can take their clothes off down there, go straight to the downstairs shower to wash, and then put on house clothes. I have everyone keep house clothes separate from going-out clothes. The going-out clothes have to be washed three times before I feel they are clean. After I’m done with them, I run the empty washer two more times to get it clean enough to wash the house clothes.
My laundry procedure is as follows: I take a shower and put on gloves to take the going-out clothes to the washer. I carefully put them in and then put the detergent in and turn the machine on. I then take the gloves off, throw them away, and wash my hands. When the cycle is finished, I get another pair of gloves, put the detergent in, and start the machine. Then I throw away those gloves and wash my hands. Then I do this one more time. When the final load of the night is done, I clean the outside of the machine with ammonia during each of the two cleansing cycles.
We go food shopping on Saturday. All cans and packages that can be washed are. For boxed goods, I put on gloves and carefully open the top of the box and peel it away, so that nothing inside could possibly touch the outside. Then I put the contents in decontaminated Tupperware containers. The kids’ school books and papers used to be a problem—I didn’t want to let them into the house, but I knew I couldn’t do that, so we have a special homework room and homework clothes for them. I hate this problem and what it’s done to me. I have a great family; they put up with me, even though I put them through hell. I know none of it makes sense, but you don’t know what it feels like, trying to be so perfect to get things clean that you know don’t really have to be. No one else does this, but then I think about getting AIDS or my family getting it. And what if I was the unlucky one to somehow get it from something someone with AIDS touched. What if . . .
In Ira’s description, you can see all of the many defining features of OCD: anxiety, painful thoughts, rituals he feels he can’t control, and the frustrating knowledge that his fears and compulsive actions make no sense. But it is in the last line of the excerpt that he provides us with the answer to our question about the source of anxiety in OCD: “What if?” The intellectual and emotional uncertainty of “what if” is, I believe, the root of most OCD symptoms. By intellectual, I am referring to our ability to question any aspect of our lives, for example, wondering if the door is locked or how you will do on tomorrow’s test. Emotional uncertainty refers to our feelings about unpredictable events, usually things that in some way threaten us or the people or things that are important to us.
The core of OCD is trying to get rid of uncertainty in our lives in an attempt to be 100 percent certain. Everyone, sufferer and non-sufferer alike, knows what certainty feels like. There are numerous aspects of our lives for which we take this feeling for granted: My car is in the driveway; I am sitting on a sofa at this moment, reading a book; the sun will rise tomorrow. However, while all of us feel certain about many things, the truth is that the absolute certainty we feel is an illusion. An event may be probable or improbable, but neither is an absolute. The inability to feel or be certain is reasonable. My car may have been stolen and may no longer be in the driveway. Rather than reading a book on the sofa, perhaps I’m actually in a state mental institution experiencing a very realistic and remarkable hallucination. Do I have any evidence to the contrary? No, after all, by definition if I’m delusional and hallucinating, my senses are not to be trusted. Certainly no one around me can answer the question—my wife might be part of my delusional system, merely saying what I am making her say. As for the sun rising, some cataclysmic cosmic event might destroy the sun tonight, in which case there will be no dawn tomorrow. Improbable is not impossible.
To better grasp the deceptive nature of certainty, take a moment to imagine someone you love who is not in the room with you right now. Is this individual alive? If you answered yes, how do you know? Even if the two of you spoke to each other ten minutes ago, isn’t it possible that he or she has had an accident, or a heart attack, or has been physically attacked in those ten minutes? And yet, if this isn’t the focus of your OCD concerns, you still feel certain that your loved one is alive. Despite the fact that your feeling is based on probability, not truth, despite the effect the loss of this person would have on you, you have no urge to rush to the phone to make sure your loved one is alive. You are coping in a “normal” way: regarding your feeling of certainty as truth and not planning to act otherwise unless you receive a horrible phone call informing you of disaster. With your OCD symptoms, you do the reverse—rather than waiting for disaster to occur, you want immediate answers to your obsessive questions.
Having OCD doesn’t mean that you are consumed by a driven, all-pervasive pursuit of certainty in every aspect of your life. That urge to be certain is restricted to your OCD fears and concerns. Some might suggest that OCD concerns are unreasonable as opposed to reasonable concerns. They would argue that washing your hands for two hours to avoid contamination or driving around the block fifteen times to make sure you haven’t hit someone is not as reasonable as worrying about a terrorist attack in the city you live in. My response to this is, “How could anyone argue that concerns about death, disease, or causing an accident are unreasonable?” Reasonable vs. unreasonable is not the issue. Non-sufferers might also argue that the issue is not only the type of event but also the likelihood that it will occur—that non-sufferers can live with uncertainty without anxiety for what we would identify as low-probability events, that is, events not likely to occur.
But this isn’t true: Everyone becomes concerned with low-probability events at times in their lives. Imagine being the parent of a teenage girl who is going out on her first date with a boy you don’t know who has only had his driver’s license for five months. The odds are heavily in favor of her safely returning home, but how many parents would be unconcerned? How would they feel if she was late? Consider the anthrax scare that followed the destruction of the World Trade Center on September 11, 2001. Although very few people contracted anthrax and even fewer died, many people were terrified about opening their mail. From a statistical point of view, it was more likely that they would be maimed or killed in a car crash than contract anthrax, but they were still anxious. Why? After all, you don’t hear people asking, “Do I really need to risk being injured in a car crash just to go shopping at the mall?”
The fact is that we all live with risk. We drive cars to and from work. We cross streets. We go to sleep secure in our belief that if a fire starts, our smoke detector will wake us in time. And we all take precautions that are unnecessary or don’t make sense. Parents of newborn babies will often look in on their baby before going to bed. If asked why, they would tell you how much they just love looking at their baby, sleeping so peacefully, but they would also admit that they would feel uncomfortable going to bed without checking. Let’s look at this objectively. If you put your baby to sleep at 8:00 p.m., there are about three hours between then and your bedtime for something terrible to happen. At 11:00 p.m., when you go to bed, you check the baby, and now there is a whole night during which tragedy could occur. In reality, this is a ritual check that may make the new parents feel better, but it doesn’t protect their baby.
If this concern were the focus of your OCD, you’d frequently check your baby throughout the night. Your OCD wants you to be 100 percent certain (who wouldn’t want this?). But there is a problem: Uncertainty is making you feel anxious, and because of this you make the mistake—from literally not knowing any better—of trying to alleviate your anxiety by obtaining absolute certainty. You try to use logic to change your feelings, and that doesn’t work.
The reason we try to use logic to change feelings is that we are used to believing what our feelings tell us—some things feel so obvious that questioning their veracity seems unnecessary (e.g., your certainty that your loved ones are alive). You experience feelings of certainty for the non-OCD parts of your life. Because of this, when confronted by OCD fears, you seek to feel the comforting illusion of certainty you feel in those unaffected parts of your life. You desperately try to use what you logically know to change these feelings—it seems as though experiencing certainty should be easy and within reach. Armed with logic, you pursue the feeling of certainty, sending yourself round and round in endless circles: I know I don’t want to hurt my wife, but if I don’t want to hurt her, then why did the thought of hurting her pop into my head? Maybe I have a secret urge to hurt her that I don’t know about. So maybe I will hurt her. But why would I want to do that? I love her. Everyone knows I wouldn’t hurt a fly. I’ve never hurt anyone. . . . It’s an endless circle, a vicious spiral of frustration and anxiety. As you have discovered, for every logical answer there is a what-if.
What you need to learn is that logic doesn’t change feelings. For example, imagine that pizza is one of your favorite foods. Think about how wonderful it tastes. Now suppose you discover it is no longer safe for you to eat this food, that your cholesterol is very high, so you can’t have any more cheese in your diet. Would knowing that cheese is dangerous for you make cheese taste bad? Unlikely.
Logic doesn’t change your feelings. It provides you with reasons to listen or not to listen to your feelings. I may deprive myself of cheese because of my cholesterol problem, but I will still love pizza. What most people don’t realize is that what they experience as a certainty is not a fact, but a feeling. Frequently, our feeling of certainty correlates with reality; that is, most of the time our car isn’t stolen, the sun rises, our loved ones have not been shot, along with so many of our other expectations, that we come to believe that this certainty emotion is a fact. If this were true, then how can Democrats and Republicans both have certainty about their beliefs. Similarly, how can two people who are devoutly dedicated to different religions both be certain? In both of these cases at least one group has to be wrong. And although the odds of the sun not rising are slim, cars do get stolen and people do get shot. Rather than representing a factual reality, the feeling of certainty, at most, represents a probability and not necessarily a high one. Despite this, we cling to trying to feel certain, not only because it is so often reinforced by the environment, but because we are wired to pursue this feeling.
So logic fails as it must. For some of you, the failure of logic and the resulting vicious circle of endless questioning and anxiety have left you feeling that you are no longer able to discern whether or not something is safe: that not washing your hands really may harm your family, that you did run over someone on the way to the office, or that you don’t know whether or not the door you are staring at is locked. You know what you are feeling, but you don’t understand why. The words you use in an attempt to capture your emotional experience haven’t been accurate with regard to what is actually happening. You tell yourself and others that rituals can’t be resisted, so you can’t stop washing your hands, or that your judgment is impaired, because you can’t tell whether or not your hands are clean after two hours of washing. It is hard to separate how you feel from what you know, when you don’t have the language to communicate what is happening inside. As a result, both you and therapists inexperienced with the treatment of OCD can end up focusing on the wrong goals.
So, are your perceptions accurate? Do you know anything for certain? Can you get better without knowing? The answer to the last is yes. Knowing is too difficult. Therefore, let’s focus not on what you “know,” but on what you guess. Throughout this book, I will be asking you to make your best guess about different situations. Coming up with a best guess means you don’t have to be sure of your answer. This can be very hard, because you want to feel that your guess is right. If it were right, it wouldn’t be a guess. To help you guess, you can use a method that I call the Gun Test.
The next time you are having trouble making a decision, think of the following scenario. Imagine I have a gun pointed at you and your loved ones, and I am going to give you a single guess about your concern (for example, Will this particular contamination kill your children? Is the front door open?). You will only have one guess, and if you guess wrong, you and they will be killed. You don’t have to be confident in your guess, but you do have to guess, because if you don’t, everyone will be killed. What is your guess?
To date, everyone makes the “right” guess. I put right in quotes to denote that it is not so much right as it is merely the same guess that those who aren’t suffering from OCD would make. The Gun Test is an aid to help you distinguish between what you intellectually and logically know from the emotional feeling of certainty you want. It won’t, however, make your guess feel right—if it did, you would be done with OCD. Learning to guess and to live with the consequences of guessing will play an important part in your self-guided program.
Obviously, the program you will be designing for yourself in the coming chapters will be built on more than just guesses. In thinking about your program, ask yourself if the ideas in this chapter have begun to change your thoughts about recovery. You probably started with the general goal of wanting to overcome OCD, wishing your thoughts and rituals would stop and your anxiety would go away. It seemed that getting better would put an end to painful doubting. You may have even heard of OCD referred to as the “doubting disease.” But I hope that after reading this chapter you have come to realize that this is wrong—doubt is normal. OCD is the problem in which you try to eradicate all doubt—and that is impossible. As near as we can tell the only people to possess absolute certainty are stupid—something that you are not! Non-sufferers may tell you that they are definitely certain about some things. The truth is that they feel certain when the odds are not absolute (either 100% or 0%). Technically, they are comfortable with uncertainty just as you are in the parts of your life unaffected by OCD. To achieve your desire of overcoming OCD, you now know that learning to live with uncertainty needs to be one of your goals.
Can you do this? I think you can. You’ve seen how you have already successfully lived with many uncertainties every moment of your life. The idea is to learn how to cope with your OCD uncertainties the same way you cope with life’s other uncertainties. To achieve this, you need to understand why you have greater difficulty with uncertainty than non-sufferers; in other words, why do you have OCD? To answer this question, in the next chapter we will look at the factors that gave rise to your OCD.
No one likes uncertainty, but why is coping with it harder for you than for non-sufferers? Is there something different about your biology? Did you somehow “learn” to have OCD? The answer to these questions is yes: OCD is both a learned and a biological disorder, and these two factors interact with each other. The experience of one of my clients, Mary, is a good example of the interplay between biology and learning. Mary had an eight-year history of severe contamination rituals. She was afraid of germs and illness, particularly hepatitis, and was fearful of making herself and her family sick. Simply leaving the house was an ordeal. Her husband did all the food shopping, because she didn’t want to touch anything at the supermarket. Doctors and nurses, who may have had contact with hepatitis, may have been there touching everything. For the same reason, she had not bought new clothes for years. Her husband and children had to engage in cleaning rituals when they came home from work or school. In discussing history of suffering, Mary said she felt like “absolute hell” during some of those years. There were other years in which she wasn’t functioning, but they somehow didn’t feel as bad.
After going through an intensive treatment program, Mary became basically symptom-free. During the year that followed treatment, she would periodically call me when she found herself slipping. We’d make an appointment, but Mary always canceled it, because in the week between her phone call and our scheduled appointment, she did everything I would have suggested she do, and her symptoms abated. Then, a year after her treatment, she finally came to an appointment. Although using the techniques she had learned in treatment helped her to keep functioning, she continued to be plagued by painful urges. After a few weeks, her psychiatrist and I decided to put her back on an SSRI antidepressant, and shortly thereafter, her OCD urges ceased.
I believe the dysfunctional years that felt like absolute hell to Mary before her treatment represented times when her OCD was a function of both biology and learning. For the other pretreatment years when she felt unable to function even though she didn’t feel as bad, I believe her OCD was being maintained purely on the basis of learned responses. After treatment, she experienced two kinds of slips: slips based on learned factors that were overcome with techniques she had learned in therapy, and slips resulting from a shift in her biology, which necessitated the use of medication to return to symptom-free functioning.
Though we may never agree on whether the chicken or the egg came first, when it comes to OCD we do know that biology precedes learning. Research suggests that a person will not develop OCD without having a biological vulnerability to it. This means that people don’t cause their own OCD. It is not the result of some character weakness on your part or something that your parents did to you.
Let’s look briefly at the biology underlying OCD before turning to the learned factors. What you most need to know about the biology of OCD is not the nitty-gritty biochemistry and neuroanatomy, but how the underlying biology is related to your emotional experience of OCD.
OCD and Neurobiology: It’s Not All Learned
OCD is a neurobiological disorder—that is, the differences between you and non-sufferers are reflected in the biology of your brain. Many of you find these words comforting: They are proof that you have a real problem—you aren’t just being willfully difficult or controlling. At the same time, it’s terrifying to think that something really is wrong with you. However, it would be wrong to accept the neurobiological aspect of OCD as a complete explanation of the disorder. Unfortunately, many people, including professionals, make this mistake. When treatment decisions are based on this misunderstanding, the result is incomplete treatment. To understand the underlying neurobiology of OCD is to only partially understand OCD.
At present, scientific evidence suggests that OCD is genetically transmitted. This means that the biology you were born with made you more vulnerable to developing OCD. Some of you may protest and say your OCD started not in childhood but later in life. But because the control our genes have over our lives is very complicated, developing OCD later in life is not evidence that genes don’t have a role in OCD. Encoded in our genes is what age we will hit puberty, when our hair will turn gray, and how susceptible we may be to heart disease.
The biological component of OCD is not always active. As Mary’s history illustrates, OCD sufferers can experience periods during which symptoms are less severe or even absent, even without treatment. Some of you may experience symptom-free years followed by a return of old or new OCD symptoms, while others may experience a predictable cycle of symptoms increasing and decreasing in severity. Still others may have symptoms that are ever-present. These kinds of variations can also be seen in other psychiatric problems, such as depression, and in part can be accounted for by an activation and deactivation of the neurobiological components of OCD.
At this point in time, the factors that cause the “OCD genes” to turn on are unknown. Scientists assume that stress and learning, as well as biological mechanisms, play a role in activating the genes. Again, we see this kind of phenomenon in other health problems. Individuals with a predisposition to migraine headaches will develop them in response to a variety of triggers. These include external stressors, as well as internal ones, such as hormonal changes. For individuals without the genetic vulnerability, there are no triggers that will cause a migraine headache.
Upon reading that there is a genetic component to OCD, some of you may be concerned about having children. I hope no one would use this information as a reason not to have children. If you have OCD, there is a one in four chance that your child will have it. Important results from OCD twin studies find that there is not a 100 percent concordance for OCD in identical twins, that is, for a sizable number of the twin pairs, only one member had OCD. Having a genetic vulnerability for OCD is not the same as saying you will develop OCD.
Knowing that OCD has a genetic component tells you nothing more than there is a reason you have OCD. But how does this component lead to your experience of OCD? The next step would be to explain that genes and other factors lead to a chemical imbalance in your brain. The most studied theory of this sort regarding OCD is called the serotonergic theory. Brain cells communicate with one another through neurotransmitters, and serotonin is one of many chemicals that the brain uses as a neurotransmitter. This theory does not suggest, as many mistakenly believe, that OCD sufferers do not have enough serotonin in the brain. The research indicates that they have enough serotonin but that it is not as available as it needs to be for certain brain communications to take place.
How does this lead to OCD feelings and urges? The brain is not a simple organ; it has many different parts, each with its own special tasks and functions. For those suffering from OCD, the problem isn’t simply the unavailability of serotonin throughout the brain; instead, it is the unavailability of serotonin in specific parts of the brain. The structures of the brain that are affected by OCD—the orbital cortex, basal ganglia, striatum, caudate nucleus, and thalamus—are interconnected and form a circuit where, researchers suspect, OCD symptoms originate. Messages that are ignored by non-sufferers keep intruding on consciousness and require conscious effort to be suppressed by those suffering from OCD.
At this level of explanation, the theories begin to evoke your experience; you know the feeling of intrusive thoughts all too well. A clearer explanation of the role these brain structures may play in your experience of OCD has been offered by William Hewlett, a researcher from Vanderbilt University. What appears here is a simplified version of his ideas. He suggests that one of the functions of the brain structures involved in OCD is responding to uncertainty with discomfort. From an evolutionary point of view, this makes perfect sense. Imagine primitive man walking through a jungle and hearing a noise behind him. His chances of survival will be enhanced if he feels nervous enough to turn around and check the jungle behind him for danger. Being uncomfortable with uncertainty is normal and can be healthy.
Another function of the brain structures involved in OCD suggested by Hewlett is responding to task completion with satisfaction—parts of our brain drive us to complete what we start. Again, this is normal and healthy. From an evolutionary point of view, you don’t build a complex civilization like ours if there is no motivation to complete anything. This is the deficit that you’ve come to fear and hate, this is the biology underlying your experience of, “I know I did ‘x’ (check the locks, wash my hands, etc.), so why don’t I know that I did ‘x.’” Again, the logical facts we are aware of and the emotional feeling of certainty are two different events. And just as you can’t instantly make yourself happy, sad, or mad, you can’t make yourself experience emotional certainty on command.
Having OCD may mean that you have a lower threshold for these responses, so you feel more anxious in response to less uncertainty, and when an action is completed, you don’t experience the feeling of completion. It’s not that you’re overwhelmed by every potential uncertainty in your life. For example, you may have a moment like many of us do: Did I set the clock? What was that bump in the road? Look how cute and helpless that baby is—it would be so easy to hurt. Most people respond to such thoughts by checking the clock, looking in the rearview mirror, and turning their thoughts away from what they could do to the baby. But the brains of OCD sufferers, Hewlett suggests, are better at learning avoidance responses. The very fact that you so strongly avoid the discomfort elicited by uncertainty makes you more likely in future confrontations with similar situations to experience anxiety and a desire to escape that situation.
In this model, biology sets the stage for learning. You feel greater anxiety in response to uncertainty and try to avoid it. However, for every logical solution you put forth, you find a way to question it. Obtaining absolute certainty is impossible: I touched the faucet knobs after washing my hands—maybe they are recontaminated. And what about the doorknob? Maybe the last person who touched it didn’t wash their hands. What am I going to do? This is further exacerbated by not feeling the normal satisfaction of completing an act. If you have OCD, you know the frustration of engaging in a ritual and knowing you have done it, but at the same time feeling like you haven’t—more agonizing uncertainty: I’ve been checking the stove for an hour; I can see it is off, but it doesn’t feel like it is off.
What this tells us is that the different presentations of OCD are the result of biology setting the stage for learning OCD responses. Your specific checking rituals or violent obsessions are the result of a complex mix of your cultural background, personal history, environment, and state of mind at the onset of your OCD symptoms. Thus, the range of OCD symptoms is the result of the disorder’s learned component.
OCD and Learning: It’s Not All Biology
Learned emotions, as we know, can be very powerful, very resistant to change, and, most important, are not altered by medication. After all, when you take medication, you don’t forget how to add, where you live, your feelings of love for your family, or, unfortunately, your OCD concerns.
When we think about learning, we usually think about choosing something we are interested in and then making an effort to learn it. Given this, why would anyone choose to learn obsessive-compulsive behavior? The answer is simple: by accident. You didn’t and couldn’t know that what you were doing at a given point was going to lead to OCD. At some moment when your biological vulnerability to OCD was active, your brain was more sensitive to uncertainty. Compared to non-sufferers, you would have felt more anxiety in response to less uncertainty. You may have been confronted by something that triggered your anxiety—perhaps a violent thought, a dirty bathroom, or a homework assignment you wanted to do a good job on. Your initial response to this anxiety was to try to remedy the situation—by avoidance, perhaps, or reassurance. You would likely repeat the behavior that worked in that situation the next time you found yourself in that same anxiety-provoking situation.
As an example, imagine that I’m afraid of cats, and I know I won’t feel anxious if I can successfully avoid them. One of my coping techniques might be to have my cat-owning friends lock up their pets when I visit. This would work, except you know how cat owners are—they don’t take your fears as seriously as you do. So every now and then, the cat might escape and run across the room. There is that horrible startle when I first see the cat, and then I’ll feel terrible anxiety until the animal is put away. Eventually I’ll come up with a new strategy: My cat-owning friends can come to my house, or they can meet me in a public place, but as long as they have a cat, I’m not going to their house. And while I’m on the subject, what about those people who live three blocks from me, who let their cats run loose? Whenever I walk by their house, I have to cross the street. But then one day I think to myself, Why walk down that street at all? If I keep progressing along this path of avoidance, I will get to the point where walking out of my front door is difficult, because a cat might be close by. My descent might be in small gradual steps—so small that it is not noticeable. Similarly, OCD does not usually occur suddenly; that is, an individual isn’t washing their hands normally one day and then washing them for five hours the next.
According to psychologists, there are two kinds of learning: classical conditioning and operant conditioning. Classical conditioning is the association of emotions or feelings with cues and stimuli. Take eating, for example. Besides wanting food when your body needs nourishment, you may feel hunger at other times: at noon, because this is your regular lunchtime, or when someone brings a box of doughnuts or chocolates to work. You have learned to feel hunger in conjunction with these nonbiological stimuli. This kind of learning has little to do with what is rational or what you know. With OCD, this simple conditioning accounts for much of the nightmare and seemingly irrational frustration of OCD fears, when a sufferer feels anxious about a situation or thought that seemingly has no rational connection.
Imagine, for example, that I attach an electrode to your hand, and every time I ring a bell, I administer a shock. After a number of trials, you would begin to jump at the sound of the bell before the actual shock came. Now imagine that I remove the electrode. Logic tells you that nothing will happen when the bell rings. But when I ring the bell, you’ll still jump. This is what has happened with your OCD—you have accidentally conditioned yourself to respond to certain situations with anxiety. When you are confronted with these situations, it doesn’t matter what you logically know; your body still “jumps.” Until you go through treatment, your body will continue to respond with fear—whether or not it makes sense.
While classical conditioning explains how our feelings come to be associated with different stimuli and situations, operant conditioning accounts for how we will behave in response to different stimuli and situations. Through operant conditioning, we learn to pursue whatever is reinforcing—that is, works—in the short run, whether it be going after something positive and pleasurable like food or avoiding something negative like anxiety.
So operant conditioning won’t explain why you feel hunger, but instead it reinforces any action that alleviates hunger. That action is likely to be repeated in future situations involving hunger. But eating doughnuts is also reinforcing, because they taste good. Given this, operant conditioning suggests that when doughnuts are available in future mornings, you will be more likely to eat them just for the taste—even if you aren’t hungry.
Operant conditioning also explains avoidance behavior. Let’s return to the bell-and-shock example, except this time, rather than take the shock electrode off, I’m going to give you a button that prevents the shock if you press it as soon as you hear the bell. It isn’t difficult to predict that you will soon be pressing the button every time you hear the bell. Avoiding shock is reinforcing. In the early stages of developing OCD avoidance, you probably felt less anxious after engaging in a ritual or avoidance: the ritual worked. Operant conditioning does not tell us how you will feel in a situation; it tells us how you will act.
These two kinds of learning work together. Imagine a sufferer-to-be whose OCD will focus on contamination. Perhaps he is in a public restroom, looking at a disgustingly filthy urinal, when thoughts about AIDS arise. Because of his underlying biological vulnerability, he feels more anxious about this compared to someone with less vulnerability. He washes his hands the way he usually does, but is still thinking about AIDS when it occurs to him: Some people don’t use soap when they wash their hands; some people don’t even wash their hands, so the restroom door might be contaminated, and maybe I could get AIDS. I’m going to use my elbow to open the door, just in case. The avoidance works, and he feels less anxious. He may continue to have some discomfort with thoughts of the bathroom and AIDS throughout the day, but that probably won’t be enough to foster new rituals. The next time he is in a public restroom, he is likely to feel anxious (classical conditioning) and, because it worked before, he will want to use the same avoidance technique when he leaves (operant conditioning).
Through classical conditioning, this sufferer’s fear of contracting AIDS has begun to be associated with bathrooms. When he needs to go to a public restroom, he will feel some anxiety and will be a little more careful than he used to be. He will become conscious of other places in the bathroom that might be too “dangerous” to touch. He will continue to use his elbow to open the door. Why not? It isn’t a big deal, it doesn’t take much time, and this way, he won’t have to worry about his hands becoming contaminated. Without realizing it, though, his problem is getting worse. Over time he is conditioning himself to feel more anxiety and to find more ways to avoid his fears.
It is important to remember what is driving the behavior of our sufferer: the fear of the possibility of contracting AIDS. Fear, not the practical threat of contracting AIDS, is the sensation that drives behavior. Fear is upsetting in its own right; you engage in rituals in an attempt to alleviate your anxiety as much as to avoid the feared consequence itself (for example, I might contract AIDS). If you think about the differences between your good days and bad days, it is not that the world was safer on good days (the public restroom isn’t any less contaminated on good days). On good days, you felt less fearful about your OCD concerns.
Possibility—the possibility of a feared consequence happening—is merely another word reflecting uncertainty. As your OCD grows in severity, the intensity of your anxiety will increase and your tolerance for your particular uncertainty will decrease. Finding a way to know, to be absolutely certain your fear won’t be realized, seems like the only possible escape from fear. But there is always another what-if. More and more stimuli—people, places, and situations—become frightening, as classical conditioning associates these stimuli with fear. Through operant conditioning, the ways you choose to avoid anxiety will also multiply. Over time, using your elbows to open the door in a public restroom may lead you to completely avoid public restrooms and engage in special cleaning rituals once you’re home. The list of places and people to be avoided and rituals to be engaged in grows.
To make matters more complicated, behavior is not only driven by reward but also by the possibility of reward. The result of this is like gambling—engaging in behaviors that are unlikely to pay off. In other words, people pursue hope, even false hope.
Imagine playing the slot machines at a casino. Like everyone else, you know the slots are there to make money for the casino. You already know that if you start playing, you will probably lose money. But what happens when you are standing in front of a slot machine? You think about how incredible it would be to hit the jackpot. You have wonderful fantasies about how to spend your winnings. It could happen; some people do win. You want this so badly, it is as if it wouldn’t be fair if you lost. So you put a quarter in—three if you are really serious—pull the lever, and then . . . shock! Exactly what you would have predicted happened: You lost. You stand there in disbelief; it feels wrong, as if you deserved to win. Do you walk away? No, you put in another quarter. Every now and then you do win—not enough to offset your losses, but enough to keep you playing. If you have a gambling problem, you won’t stop until you run out of money.
You do the same thing with your OCD. Your rituals often don’t work, you say, but once you get started, you feel unable to stop. And, like the gambler, when faced with an accidental exposure, you are faced with a choice: You can walk away and suffer all day, or if you can just get this ritual right, you’ll be free for the rest of the day. So you gamble on the ritual. And, as with the gambler, your prediction comes true—either you get lost in endless rituals, stopping only when you give up out of exhaustion, or, just as bad, the rituals work, but just enough to keep you hooked on chasing them.
These two types of conditioning form the basis of our understanding of the learned components of OCD. Do learning and biology combine to make your fears and rituals irresistible? Many of you have come to believe this. But it isn’t true: You don’t have to ritualize. Saying you don’t have to ritualize is not the same as saying the choice is simple and painless. The decision is a difficult one in which you are weighing the pain of engaging in or resisting rituals against your expectations of the possible consequences and how you will feel afterward. Before treatment, you feel like the choice is between painful rituals that might work and anxiety and obsessions that feel as though they will never end. Before treatment, you may believe this is no choice at all.
There is another version of the Gun Test that can help you realize that ritualizing is a choice. Imagine I’m holding a gun to your head or to the heads of your loved ones. I tell you that if you ritualize, I’ll shoot. I’m not leaving, so this is not a matter of waiting. Under these circumstances, will you engage in your rituals? If the answer is no, that you would resist, then you are admitting it is a choice. Again, it may be a very difficult choice, but it is a choice nonetheless. Now suppose I asked you to float three feet in the air under your own power for thirty seconds to prevent me from shooting. Outside of a miracle, you won’t float, because you can’t, even when threatened by death. This is an example of having no choice. You may argue that all of this is a contrived scenario and that in real life there is no weapon pointed at your head, but you are wrong. There is one: It’s called OCD, and every time you give in to your rituals, you and your family lose another piece of your life.
We all make choices depending on the rewards and punishments we expect to receive. Since you don’t make decisions to ritualize with guns pointed at your head, is there any proof or real-life evidence you can point to that demonstrates how ritualizing is a choice? Yes. Many OCD sufferers ritualize more in private than in public. Recently I met a new client, Jane, at my center. I held out my hand for her to shake and, for the briefest of moments, she hesitated before taking it. I was not surprised to find out that her OCD focused on contamination. But she made the choice to touch my hand despite her fear of physical contact with others. At that moment, the discomfort of embarrassment was greater than her fear. If rituals were truly irresistible, this couldn’t happen.
All of our behavior takes place within a context—a complex set of cues and stimuli determining what we are likely to feel and how we are likely to respond at any given moment. These are learned through complex interactions between operant and classical conditioning. For Jane, part of the context included the fear stimulus of my extended hand with its many possible contaminants. Her taking my hand wasn’t a function of her feeling safe. Her contextual environment also included being in my center’s waiting room and, perhaps more important on this occasion, the presence of an unknown person and how this person might judge her. For many of you, the fear of public humiliation in response to your rituals is worse than the fears driving your urges to ritualize. For the rituals you do perform in public, you may often believe that no one will notice or that they don’t look too bad. Or the obsessive fear driving your urge may be greater than your fear of embarrassment.
Broadly defined, context is simply a description of anything and everything associated with the performance of a behavior. This concept is very powerful in its ability to predict behavior. A rat, for example, can be trained to press a lever to obtain food. Suppose there is a red light and a green light in the rat’s cage. When the green light is on, if the rat presses the lever, he will be reinforced with food, but when the red light is on, food won’t be available and pressing the lever won’t do anything. The rat will quickly learn not to waste his time with pressing the lever while the red light is on. The green light, though, becomes part of the rat’s context for lever pressing.
How does this relate to OCD? Many of you may have discovered that your OCD isn’t as severe when you are away from your normal work and home life—perhaps on a vacation, despite the fact that you may still be confronted with triggers that usually result in ritualizing. For those of you for whom this is true, the vacation environment is not part of your contextual environment for ritualizing, and as a result you feel less anxious. I have met some sufferers who have made the mistake of deciding that the best way to cope with their OCD was to move to a new place. If this really did work, it would be an ideal treatment. Unfortunately, without treatment, the problems that sufferers have will inevitably gradually reassert themselves in the new location.
Does everyone initially experience relief when he or she goes on vacation or moves to a new area? Of course not. Everyone is an individual. Just as the range of OCD fears and rituals is limitless, so too are the myriad ways context will play a role in a sufferer’s behavior. For some of you, your OCD is so “portable” that you never have any relief. For others, you will feel as though different environments vary in safety.
Context is more than simply your environment. Your own behavior is a part of the context that controls your emotions and behaviors. Your rituals are both a response to your OCD fears and a part of the context that triggers further rituals. You have probably found that as your OCD progresses, rituals that used to work for you begin to fail to alleviate your anxiety and discomfort. When this happens, you repeat the ritual with the same disappointing outcome. What is happening?
Consider the thoughts you have when you worry about ritualizing: I hope this isn’t one of those times when my rituals get out of hand. This is not a comforting thought. Your emotional response to it will likely be an increase in anxiety, which makes your ritual less likely to work, since a main goal of the ritual is to decrease anxiety. If you do repeat the ritual, your anxiety will further increase: Oh no, is it happening? Is this going to be one of those times when I lose control? With each repetition, your anxiety rises—the opposite of your goal. Your suffering, anxiety, and frustration mount. Your rituals have become a part of your context for failing. You stop performing them, not because they worked but because you gave up out of exhaustion. On such occasions, ritualizing feels like being in a hole and trying to dig your way out—unfortunately, you are going in the wrong direction.
Like behavior, our emotions are not only responses to triggers and context, but can themselves be triggers for other emotions and behavior. Responding to your internal environment is called state-dependent learning. Consider the example of a rat placed in a T-maze, a long alley at the end of which the rat must go right or left. Prior to being placed in the alley, the rat is given an injection of either a stimulating drug or a saline solution that has no effect. For the rat injected with the active drug, food will be placed at the end of the path leading to the left. When the rat is injected with the saline solution, it will find that the food has been placed on the right. The rat quickly learns to go left when injected with the active drug and to go right when injected with the saline solution. Obviously, it is not the drug that makes the rat turn left, since we could reverse the contingencies and put the food on the right when it is given the drug. The rat has learned where food will be, depending on its internal physical state.
In people, an example of state-dependent learning can be seen in a student who drinks a great deal of coffee when studying for a test. This student will do better on the test if he drinks coffee before taking it. The material was learned in a “caffeinated” state, and the individual will best recall that learning in the same state. The implication is that how we are feeling physically and emotionally is not only a response to what is happening to us. Our feelings also play a role in determining how we are likely to respond in a given situation and will serve as a trigger for other feelings, thoughts, and memories.
How does this apply to you? Perhaps you have found that your OCD gets worse when you are exposed to stressors that have nothing to do with OCD (for example, arguments with a spouse, problems at work, getting married, or moving to a new house). This makes perfect sense. During your worst OCD episodes, what were you feeling? Overwhelming stress, perhaps, accompanied by depression? Whatever feelings were present during your worst OCD trials will become triggers for your OCD. From this point of view, the following chain of events would be typical. You are stressed by a non-OCD situation, such as problems at work. These feelings of stress will trigger your body to respond with an increase in OCD feelings, which may be experienced as any or all of the following: heightened anxiety that gets your guard up in case you come into contact with stimuli and situations that you fear; greater anxiety when you’re accidentally exposed to things you fear; increased urges to ritualize, making compulsions harder to resist; or rituals that don’t “feel right” when performed, causing you to repeat them over and over. If your initial stressor was OCD-related, then your anxiety and urges to ritualize would be further exacerbated, because the context more closely matches the original learning situation that caused you to ritualize in the first place.
In viewing emotions as part of the context that will increase or decrease the likelihood of OCD responses, we begin to tie together our picture of OCD as both biological and learned. Our feelings are a mixture of what is happening in both our internal and external environments. We are all aware of how the external world affects us. Internal events affect your mood and your behavior as well. If you are very sick with the flu, are suffering from PMS, had a poor night’s sleep, or have a hangover, your emotional and behavioral responses to your environment are likely to be different. A change in your internal environment changes your experience of the world and your reactions to it. When your OCD neurobiology is turned on, the world and how you perceive it is changed in a way that facilitates OCD learning, and the stage is set for you to learn OCD responses.
How does this mix of biology and learning determine which fears and rituals will characterize your OCD? At this point in time, we can only make guesses. Learning is probably more important than biology, since members of the same family with OCD will often have very different symptoms. For some of you, there may be a traumatic triggering event that makes the focus of your OCD easy to understand. For others, personal history may play a role, but there are so many ways this could take place that we wouldn’t be able to predict your form of OCD from your life history alone. For many of you, the best predictor of the form your OCD will take may simply have to do with what thoughts captured your mind when you were most vulnerable to its emergence. Though we aren’t able to predict the form someone’s OCD will take, we are increasingly able to understand the process of how OCD is learned and acquired, which is the key to structuring an effective treatment program.
At this point, I hope your new understanding of where your OCD feelings, urges, and behaviors come from will help make what you are experiencing less mysterious. Your OCD follows rules—it’s not some uncontrollable beast. You are not crazy. Biology and learning have brought you to this point. But you don’t yet know enough to design your recovery program, because knowing about the factors that gave rise to your OCD is just the beginning of understanding OCD itself. What are obsessions and compulsions? What is the connection between them? This is our focus in the next chapter.
Up to this point, my focus has been on the whys of OCD—helping you make sense of the forces that have given rise to the obsessive-compulsive feelings and urges that drive your behavior. Hopefully you have come to realize that, however extreme, severe, and even disabling your symptoms might be, they are still on the continuum of experiences that everyone in the world has.
Now let’s shift from the whys of OCD to the whats and hows—the core OCD experiences and how they interact with one another. This will provide the building blocks for you to analyze and evaluate your own obsessive-compulsive behavior in preparation for designing your own self-guided treatment program.
What Sufferers Fear
There are two aspects of the OCD experience: your fears and how you respond to them. Let’s first consider the range of OCD fears. Your OCD focuses on a limited number of uncertainties that have become your source (or sources) of anxiety. The frightening and uncomfortable thoughts and feelings arising from these uncertainties are called obsessions. The word obsession is generally used in many different ways. Sometimes it is used to refer to the process of thinking the same thoughts over and over again or endlessly trying to analyze something. It’s also used to describe something we like, love, or are addicted to. In this book, I’m using the word obsession to describe what it is that you fear.
What do sufferers fear? What are their obsessions? A better question is: What can people be uncertain about? The content of obsessions is limited only by human imagination, which is to say their variety is limitless. Your obsessions can focus on the external world (for example, being contaminated by germs or causing hit-and-run accidents) or the internal world (for example, experiencing unwanted violent or blasphemous thoughts).