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Monday, December 10 , 2018, 3:17 am | Fair 49º


Jon Lukas: Distinguishing Obsessive Thoughts, Compulsive Behaviors

The mind of an Obsessive-compulsive often creates destructive worst-case scenarios

People often ask me whether I think they have Obsessive-compulsive disorder after I tell them what kind of therapy I practice. They share with me the obsessive and compulsive behaviors that they engage in. They watch shows about OCD and become convinced their behaviors amount to a disorder. Right away, I ask questions. Do these thoughts cause severe distress in their lives? Do the compulsive behaviors take so long to complete that they interfere with functioning or cause significant distress because they can’t be done “just right”? Do these obsessions seem irrational, but still cause enough distress that the person feels compelled to engage in compulsions to try to rid themselves of these troublesome and often frightening thoughts?

Jon Lukas
Jon Lukas

Most often, the answer is “no.” Many people use the term OCD casually to define very normal, common behaviors or even the occasional obsession. Most important, are these “compulsions” or “obsessions” a source of such time consumption and emotional distress that they affect a person’s quality of life, psychological well being, and general level of functioning?

I want to now take you into the lives of three people to help clarify and identify “normal” obsessive and compulsive personality traits in contrast to Obsessive-compulsive disorder. To protect confidentiality, the client’s age and sex might be different from the actual client. Each client has a unique experience as is often the case with OCD. No two people have the exact same set of obsessions or compulsions. It is time to dispel the myths and enlighten you about the mind of an Obsessive-compulsive.

Trisha is very organized and keeps her home quite clean. Every morning she wakes up and performs her tasks to prepare for the day before she leaves for work. She has an order in which she completes her morning rituals. Trisha starts with a quick breakfast and then wipes down the kitchen, starting with the sink and finishing with the countertops. It takes her about 15 minutes to complete the kitchen cleanup. She then goes to take her morning shower and spends 10 minutes wiping down the bathroom and any mess that is caused from showering, combing, brushing, makeup and other things to make herself look her best. Trisha goes to her bedroom and gets dressed, tidying up her bedroom in a ritualized fashion. She checks the lights, checks the stove, the coffee maker, and finally the door as she locks it. After she walks out the door, Trisha quickly goes back and turns the doorknob once or twice to make sure it’s locked.

Trisha is off to work and any thoughts of “what if” she left something undone at home quickly leave her mind as she puts on her favorite CD in the car. The total time it takes Trisha to get through her morning rituals is about 45 minutes. She does this every day and tells me she actually enjoys “her process” — it makes her feel better knowing that she will come home to a nice clean home after a long day at work. This is the extent of Trisha’s daily ritualized behaviors, and when she comes home from work, she goes walking, makes a nice dinner, calls up some friends for a movie night, and at the end of the evening goes to sleep feeling content and peaceful. She sleeps soundly.

Jacob is a 13-year-old boy with a constant, nagging thought running through his mind. At the end of the summer, Jacob and his family are flying to Hawaii for a family vacation. Jacob can’t stop thinking that he will die in a horrible plane crash. His constant thought is that he only has two more months to live and he obsesses about the plane hitting terrible turbulence, and then dropping out of the sky, nose-diving into the ground. Jacob sees the entire plane ride happening in extremely vivid details but is afraid to tell me the “full” details because it causes him so much anxiety.

For two months leading up to the trip, Jacob engages in very rigid and ritualized behaviors. Every night before he goes to sleep, Jacob has to say a prayer while he interlocks his fingers so tightly that all of the blood leaves his hands and his fingers hurt from the tightness. He has to repeat this prayer at least four times because he must pray an “even” number of times. As he does his fourth prayer, if it doesn’t feel right for him or he thinks that God didn’t hear his prayers correctly, he has to go another four times. Jacob shares with me that he sometimes has had to pray up to 88 times to unlock his fingers and finally go to sleep.

Throughout the day, Jacob counts each step he takes and has to finish on an even number. If he doesn’t, he has to step backward an even number of times and then go forward again and finish on an even number. Sometimes it takes him 15 to 20 minutes just to leave his bedroom because of this compulsive behavior.

When Jacob turns on the TV the first word he hears must be a “good” word. He explains this by saying, “If the word that I first hear has anything to do with death, planes, flying, crashing, turbulence, then I have to turn off the TV and wait eight seconds and then turn on the TV again. I do the same thing when I am turning off the TV.” Jacob shared with me that he got stuck one day with the TV ritual to the point that the TV made a popping sound and stopped working all together. He told his parents he had no idea how the TV broke.

When Jacob lies in bed at night, he obsesses for up to two hours about a violent and painful death on his way to Hawaii with his family. Finally, after so much emotional exhaustion, he drifts to sleep, but the obsessions enter his dreams and they turn to nightmares. He has the plane crash nightmare seven nights a week.

Jacob does not like to spend time with friends and avoids his family as much as possible because he is scared, sad and angry inside. He is most angry that his parents planned this trip without asking him and feels that they are the reason his life will end.

“Why did they have to plan this trip?” he asks me. “Don’t they get it that we are going to die in a plane crash”?”

Jacob keeps reminding me that it’s not fair that he doesn’t get to live past the age of 13. The anger manifests in obstinacy, irritability and the silent treatment toward his family. As the trip draws closer, the rituals intensify and the depression increases. Jacob struggles to eat, has constant diarrhea, stomach pains, and has even shared with me that he wishes he was in a car crash so he could break his leg and not be able to fly to Hawaii. Irrational thinking is a huge component of OCD. Jacob finds comfort in the idea of a car accident but can’t handle the thought of a plane crash. He tells me he has no control over the plane but in a car, at least he is on the ground and can see what’s coming.

Mark is a 21-year-old college junior who is taking a semester off from school. He has come to see me because of a constant obsession that he has contracted HIV and hepatitis C from a tattoo he got in his freshman year. Mark has had health-related anxiety since he was about 11. He has had treatment on and off for several years with minimal success. By the time he came to see me, Mark appeared very underweight, his voice was weak and he appeared very depressed. He told me, “All I think about is AIDS and hepatitis. I spend hours on the Internet reading about these diseases and I am convinced that I have them. I have no appetite, I am losing weight, and my skin and eyes are turning yellow.”

Mark also shares with me the exhausting compulsions he does constantly throughout the day and night. He spends hours in front of the mirror, staring at his eyes to confirm the yellowing of jaundice. He checks his temperature every two to three minutes to see if it is too high and he searches for lesions on his body that would signal full-blown AIDS. Mark has begun to go to support groups for HIV and hepatitis C and attends these groups multiple times a week to be around people who have these illnesses.

Finally, Mark shared with me a compulsion that really broke my heart. Before he left school, he couldn’t stand the sight of that tattoo that had brought him so much emotional turmoil. One night he sat down in his bathtub with a sandpaper block and proceeded to sandpaper his ankle to remove the tattoo. He spent roughly two hours grinding away at his ankle pulling off skin and hair in a bloody mess, until he could no longer find a glimpse of that blue ink embedded in his skin. I asked him about the pain. He replied, “It was incredibly painful and disgusting but in a way it felt good. I removed this diseased tattoo from my body and didn’t care how painful it was. I just focused on getting that ink out of my body.”

Mark ultimately tested negative for both viruses but he was left with an increasingly challenging case of hypochondria, an Obsessive-compulsive spectrum disorder.

These three cases represent, respectively, someone who engages in ritualistic behaviors, a moderate to extreme case of OCD and, finally, a severe, treatment-resistant type of Obsessive-compulsive disorder. In the first case, the client is functioning in work and in her social life, and is not crippled by certain ritualistic behaviors that she engages in, but rather finds that it works for her. In the second case, Jacob is severely distressed by his thoughts and tormented by the compulsive behaviors that he feels he must engage in to get through the day. Finally, with Mark, we have a very extreme case of OCD, in which the compulsions have actually become dangerous to his physical health and have become so irrational that he is no longer functioning psychologically, and finding very little pleasure in life.

In my next column, I will discuss the treatment of Exposure and Response Prevention to battle dysfunctional behaviors and the severe distress that Jacob and Mark are experiencing. I hope that these cases, although extreme, provide you a better understanding of the OCD mind.

Jon Lukas MFT is a psychotherapist specializing in cognitive behavioral therapy. He is in private practice and runs The OCD Treatment Center of Santa Barbara, working with adolescents and adults with anxiety disorders. Click here for more information or call 805.453.2347.

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