Fighting Fear

Confronting phobias and other fears

Obsessive-Compulsive Disorder (OCD): the Need to Do Something

The act of washing is more important than being clean

It seems sometimes that OCD—obsessive-compulsive disorder—is defined by a set of beliefs.  Someone with this condition believes in orderliness, cleanliness, making sure, doing things the right way.  These are good things, things that often seem to describe successful people. Like other emotional disorders, however, OCD seem s to be an exaggeration of an otherwise normal, even advantageous, way of living. What sets apart those who are suffering from an anxiety disorder, of which OCD is one, is another idea, unspoken, but powerful, that lies underneath the surface. It is the idea that danger is lurking everywhere. Phobic individuals engage primarily in a strategy of avoidance. They avoid places where they might feel trapped or circumstances where they feel they might reveal a weakness. Above all, they fear and avoid their own feelings. The panic attack represents a sudden inexplicable rising up of a powerful and frightening feeling. Because the panic attack comes from within, the phobic person cannot run away successfully, but they run away, nevertheless. In its most extreme form, phobic individuals avoid every place. They become housebound; and I have visited some who have not been out of their house in twenty years. But it is not just that they have unrealistic views about themselves and their feelings. It is not just that the feel the world is a dangerous place. It is their reliance on a strategy that defines their condition. Avoidance.  People suffering from OCD are engaged in a different strategy: warding off danger.

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One particular way OCD presents is of someone who is overly concerned about germs. Such a person will not handle a doorknob in a bathroom or tolerate sitting next to someone who is coughing or sneezing. That person may have developed washing rituals that have to be performed in exactly the right way. Over and over. Sometimes these inclinations take on absurd proportions. I remember a woman who threw pieces of her jewelry down the incinerator when they got dirty. And, of course, they were not really dirty. They just seemed to her to be dirty. Touching them made her shudder, like putting her hands down a dirty toilet. Of course, germs are everywhere, and these precautions against germs and getting sick are unnecessary and imply that germs are much more dangerous than they really are.

But, examined closely, the behavior of such a patient is not consistent with the overarching aim of warding off illness. Consider a young woman who washed her hands over and over again. She said she was trying to avoid germs, but her washing facilitated infections on her hands. There are protective oils on the skin that repeated washings remove. In her case her hands first became red and raw, then some time later with further washing they developed cracks in the skin; and, still later, she developed fungal infections between her fingers. Yet she could not stop washing!

Despite what she said about germs, what was important to her was the act of washing itself. Other such persons make no pretense of washing off germs, they say they have a feeling of contamination, of being dirty, that they try to expunge by washing.  It is as if the act of warding off danger has taken on a life of its own.

This way of behaving is not entirely unfamiliar to ordinary people. They are comforted by taking precautions in the face of a threatening situation; and sometimes they continue taking precautions long after the danger has evaporated.

It is for this reason that patients suffering from OCD do not respond to reasoned discussions about the relative dangers, or lack of danger, of germs. The act of warding off danger, in this case, washing, alleviates momentarily the individual’s shuddery sense of dirtiness and danger; and that is what drives them to perform these warding off actions over and over. Unfortunately, the constant focus on a particular danger makes it seem real. Washing repeatedly makes the urge to wash again stronger.

Just as the treatment of a phobic patient involves exposing that person to the frightening situation over and over again, the treatment of a patient with OCD involves preventing them from undertaking their ritual behaviors. The woman described above who washed her hands to the point where they became infected was hospitalized on a psychiatric ward and in a room that had no faucet. She was prevented, sometimes forcibly, from washing her hands. At the end of two weeks she no longer felt the compulsive need to wash her hands.  Unfortunately, there came a time when she had to return home again. Surrounded by those stimuli she associated with the need to wash her hands, she began washing her hands again.  © Fredric Neuman 2012 Follow Dr. Neuman/s blog at fredricneumanmd.com/blog

Fredric Neuman, M.D. is the Director of the Anxiety and Phobia Center at White Plains Hospital.

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