Most people use the word obsession loosely. I have a patient who travels with the Rangers hockey team to see all their away games. She is often described by her friends as being obsessed with the Rangers. Another patient (actually, a handful of patients) are preoccupied by thoughts of their previous boyfriends/girlfriends, calling them up, driving to their houses to see if their cars are there, wondering how to handle the next chance encounter with that person. They describe themselves as obsessed with these ex-boy/girl friends. These are not true obsessions. These are behaviors that the individual recognizes as an expression of their feelings and thoughts. Although they recognize that their behavior may seem exaggerated to others, they understand that it grows out of real desires and concerns that they have. Obsessions are intrusive thoughts that are troublesome and “ego-dystonic,” which mean that they seem to come from outside of themselves. They are not expressive of the person’s real intent. They are not simply a preoccupation, as someone might feel about politics, or religion, or the chance of a nuclear accident; they are rather a symptom, an upsetting thought that they wish they did not have.
Patients suffering from obsessive-compulsive disorder (OCD) have a variety of obsessions, most of which suggest to them a danger which requires them to behave in certain ways to mitigate that danger. Some of these obsessions have to do with germs, fires from household appliances, intruders, ill health, or the possibility of bad things happening to members of their families. Phobic patients, on the other hand, can be said to be obsessed, speaking loosely, about being trapped, or losing control of themselves, while driving, or of having a panic attack on an airplane or in other such situations where they think they could lose conceivably lose control of themselves. Since they really believe in these risks, these preoccupations are not true obsessions.
OCD and the various phobic conditions are all said to be anxiety disorders; illnesses that seemed to be defined primarily by an underlying fearfulness that pervades thoughts and influences behavior. But OCD and the various phobic conditions, including panic disorder, can be distinguished from each other in a number of ways: the particular thoughts that the effected person has and the different strategies used to cope with those thoughts and fears. (Among other differences, phobics rely on avoidance, whereas patients with OCD tend to “ward off” danger, a subtle, but real distinction.)
Nevertheless, there are two real obsessions that many phobics have. They grow out of the concern they have of losing control of themselves:
- Some phobics express a fear of open windows or terraces, especially high up. They feel they may inadvertently fall, or, indeed, jump, from a height, killing themselves.
- Similarly, many phobic patients feel uncomfortable standing near the edge of a subway platform when the train is coming into the station. They are afraid of falling or jumping into its path.
Treatment: The treatment of these two obsessions illustrates the technique of exposure therapy of all the anxiety disorders.
When I was in the army I was told to treat expeditiously a recruit who could not go above the second floor. (His father also could not go above the second floor. You did not have to be a psychiatrist to see how this problem developed.) I did not have to expend much effort convincing the young man that he ought to cooperate in treatment. The C.O. told him he would be court-martialed if he did not. The C.O. threatened me at the same time. Both of us found enough time to practice every day, usually for at least one or two hours.
We started by sitting on the steps between the floors of the hospital, while other people went by. Slowly, after the soldier felt more or less comfortable, we moved up a step, and then another step. Pretty quickly we were sitting on a chair in front of a third floor window, then closer and closer, then looking out the open window. Then, onto the fourth floor and the fifth floor. There came a time when he could lean out of the windows of the top floor of the hospital. He had come to believe he was not in danger of falling or jumping out. (I tell this man’s story in more detail in a novel, “Maneuvers.”) A similar process is undertaken in people who are afraid of terraces: sitting in a chair away from the railing, sitting closer and closer, each time waiting for the level of the anxiety to drop somewhat, then standing up at the edge of the terrace and looking over. This may take the better part of a couple of weeks.
Specifically, in order to get better:
- The patient has to be willing to acknowledge openly that he has a problem. There is a public aspect of getting treatment. Usually, people nearby, and certainly friends and family members, become aware of the patient’s phobias. Any embarrassment has to be overcome in the course of treatment.
- Treatment progresses slowly, step by step—in the case of the soldier described above, literally step by step.
- Time, sometimes a lot of time, has to be spent practicing in the phobic situation.
- Often a Phobia Aide, or some other kind of helper, is critical to encouraging the patient to keep practicing.
A similar process takes place getting used to subway platforms. I had one patient who was a very successful lawyer, who spent over a month inching closer to the edge of the platform every day before he felt completely comfortable standing there as everyone else was doing.
The treatment of most cases of OCD is more difficult since the anxious feelings that characterize that condition last longer than the panicky feelings of a typical agoraphobic. (c) Fredric Neuman 2012 Follow Dr. Neuman's blog at fredricneumanmd.com/blog