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When I was in the Army stationed in Germany, I went on vacation with my family and came almost to the French border before I realized that I had forgotten our passports. The trip back and forth took an extra four hours. It would have been better if I had checked first to see if we had everything we needed. That kind of mistake is an unusual occurrence for most people, as it was, certainly, for me. Usually, the more important it is to have a particular document, the more someone is inclined to check. Someone about to go on an airplane trip may check her purse two or three times to make sure she has her tickets. If someone is carrying $10,000 in an envelope in his jacket pocket, he is likely to check every once in a while to make sure it is still there, even though he remembers putting it there. Still, you read every once in a while about someone who leaves a Stradivarius in a taxi.
Patients with OCD are likely to treat every action as if there is a lot at stake. Therefore, they check everything, They check the front door, some of them, over and over again, sometimes literally for hours, to make sure it is locked. Why? If asked, they say to make sure it is locked. If pressed further, they may speak about robbery, although I remember one woman who felt that if the door was unlocked, someone might sneak in and leave something undesirable. They tremendously exaggerate the risk of having an unlocked door. They start off with the idea that the world is a threatening place. Even so, however, why isn’t checking the front door just once enough to reassure them?
Similarly, OCD sufferers may check to see if the stove is turned off, sometimes checking over and over again. They may check to make sure the toaster is not only turned off, but just to be really safe, unplugged. In fact, it is part of their illness to check, over and over again. And, it seems, the more they check, the less certain they are of what they are checking. I remember another woman who stood in front of her television set, turning it on and off repeatedly for hours in order to hear the click when it was turned off. Why does she care if the set was left on inadvertently on occasion?
Like the patient with OCD who washes over and over again, it is the repetitive act itself that seems to matter. It is more important to ward off danger, than to be safe.
One might think the compulsive person feels some relief in engaging in these checking behaviors, and does it over and over again for that reason. But they do not report any such feeling. What they experience is a kind of agonizing doubt about not having closed off some danger. Imagine, that you are running at night down a foggy street, trying to escape from men with weapons who are running after you. Every time you look back in the fog, you see that they are not there, but you know they are close behind. And, as you run, you look back repeatedly. Can it be said that you feel a sense of relief each time you look back? Perhaps, but the principal feeling you have is of fear. Suppose you did not see the attacking men, but heard their footfalls in the fog? Suppose whenever you paused for breath, you heard something in the darkness that sounded like a footfall? Or heavy breathing? Or muttered imprecations? The mere fact of feeling threatened and checking reinforces the idea that there is something out there that may attack and overwhelm you any minute. So it is with the compulsive person. The more checking he/she does, the more real the danger seems.
One would think that if it were possible to convince the compulsive person that there is no real threat—let us say, from a toaster that was turned off—that the person would stop checking. But it works the other way around: if you can get him/her to stop checking, that person will stop worrying.
Someone who can be persuaded to stop checking the front door will no longer wish to do so after a relatively short period of time, perhaps as little as a week. Checking the door less and less frequently as time goes on will not work. The person has to confront the anxious feeling and the chance, however remote, that someone will break in. Checking every once in a while maintains the fiction of an intruder. But walking away from an unchecked door causes a very bad feeling, which is too much for some people to tolerate. So, treatment is difficult. Medication may or may not help, but its effect is not dramatic.
One example of a successful treatment: A tormented woman came to our health anxiety clinic reporting that she had just given birth and was very concerned with the possibility of the baby dying from crib death. She checked every few minutes all night long to make sure the baby was still alive. She worried constantly. Of course, there are precautions that can be taken to prevent crib death, and we told her of them. Then she was instructed not to check on her baby (which would have done no good, anyway) unless the baby was crying. Within a few days, she was no longer thinking about the possibility of crib death.
Some people with OCD are among the most tormented people I have known. If the choice was between living the way they do and losing my passport every few years, or few weeks, I would prefer to suffer the consequences of losing my passport—or having an intruder rob something from my house. I would rather have my house burn to the ground by leaving the stove on than have my life ruined by worrying endlessly about that possibility.
(c) Fredric Neuman 2012.
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