DIAGNOSING OCD: MENTAL COMPULSIONS
Author: admin
When I was in medical school I suffered the obsession of a phlebotomy needle suddenly plunging into my skin. It was a startling image that shook me to my bones, like fingernails raking across a blackboard. To lessen its effect I developed the habit of immediately bringing to mind a certain protective image: my skin being covered by a soothing, impenetrable cream.That was a mental compulsion, an attempt to escape an obsession by employing a special, counteractive idea. With mental compulsions, as with behavioral compulsions, something is done repeatedly, mechanically, for no purpose other than to lessen the discomfort of an obsession. As one person may repeatedly check the stove, another may habitually conjure up a corrective fantasy.Ten years ago, mental compulsions were not even known to most mental health professionals. The last edition of the official manual of American Psychiatry, the DSM-II1-R, published in 1987, defined compulsions as “intentional behaviors that are performed in response to an obsession.” It is now recognized, however, that compulsions occurring in the form of thoughts are extremely common, probably even more common than behavioral compulsions. How far our knowledge of OCD has come in just a decade!
Counter-imageperhaps the most prevalent type of mental compulsion is the type I developed in med school, the counter-image. In my OCD group, a student described her counter-images in this way:I get pictures ill my mind of knives being stabbed into my grandmother These thoughts cause me so much anxiety that I have to rethink them whenever they occur. I have to get a good image of my grandmother in my mind, one where she doesn’t have the knife sticking in her. So I see the knife going in, and then I have to pull it out. But as soon as 1 pull the knife out, it’s there again. So this goes on and on. I think a bad thought, then I have to think a good one.
Repeating of Prayersanother common type of mental compulsion is the rote repetition of a prayer. The words no longer have real meaning, they have been reduced to ritualistic incantations performed exclusively to drive away an obsession. A Catholic woman in her fifties described her ritual:I say to myself “Holy Mary mother of God have grace on us sinners” over and over. It’s because an awful thought keeps coming into my mind. A thought to stab Jesus. God knows why it happens. The prayer used to work to make it go away; but now 1 say it over and over, for hours, and the terrible thought keeps on coming back anyway.
Countingthis compulsion includes numbering objects as well as repetitively counting to a certain number. The key is that the compulsion is in the process of counting itself. A thirty-five-year-old man, totally disabled by OCD, needed to count anything in sight. In my waiting room, he counted the tiles in the ceiling. In my office, he counted the books on the bookshelf. He said he just had “an urge to do it.”
Ruminationsalthough there is little written about this type of compulsion, it seems to be fairly common, especially in students. A rumination has been defined as “a train of thought, unproductive and prolonged, on a particular topic or theme.” Sometimes, ruminations clearly represent mental compulsions. An engineering student described his unwanted musings:I constantly over-think things. I’ll be out with my girlfriend, and suddenly I say to myself, “Oh no, here come the thoughts!” I know then that I’m going to get carried away with thinking things over. The thought comes that I’m not real. I’ll have to answer endless questions regarding whether my girlfriend and I are actually here or not. The metaphysical analysis goes on and on and on. I get an isolated, alone feeling. Then I may start questioning why I’m thinking these crazy thoughts in the first place. My whole evening will be ruined.
Mental compulsions, like behavioral compulsions, in the long run only worsen obsessions. A particularly devastating outcome is when the obsession itself starts to be triggered by the very images used to counteract it. A gentle, civic-minded man described how this happened to him:
I’d kill myself before I’d harm a kid. I have kids myself. I’m a Scout leader, for God’s sake. Yet I will be walking along and I’ll see a little boy across the street, and then the thought will come into my mind to run over and strangle him. Nothing will get rid of the awful idea. I used to play a trick to try to get rid it. When the terrible idea would hit, I’d immediately imagine myself teaching the child how to play baseball. This worked for a while; but now things are even worse, because now whenever I see a baseball game on TV, it brings the terrible thoughts right into my mind.
The compulsions mentioned above—washing, checking, reassurance, hoarding, repeating, ordering, and various mental rituals—do not exhaust all possibilities, but they are the types most commonly seen. All of them share one feature: They are defensive, done solely to lessen the torment of obsessions. Yet, from the extreme checking rituals developed by Howard Hughes, to my own more modest protective fantasies, compulsions in the long run only guarantee that the self-tormenting thought that caused them will return again and again.
the diagnosis of obsessive-compulsive disorder presented no major difficulties in the cases of Raymond, Sherry, Jeff, and Melissa. All four had typical obsessions and common compulsions. Usually OCD is like that, very easy to diagnose. Anyone who has obsessions and compulsions that are interfering in their lives has obsessive-compulsive disorder, unless proven otherwise. Occasionally, however, there are times when it is not completely clear whether a person suffers from OCD or from another somewhat similar psychiatric disorder, such as hypochondriasis or body dysmorphic disorder, or from a related neurological disorder, such as Tourette’s syndrome. Phobias can also overlap with OCD. These more complicated situations will be discussed in chapters 9 and 10.To put the whole process of psychiatric diagnosis in broader context, it has been observed that medicine has three levels of diagnostic sophistication. The first stands on the recognition of specific symptoms (“pneumonia is a cough with a fever”). The second level founds diagnosis on measurable biochemical changes in the body (“pneumonia is congestion in the lungs”). The third, the highest level of diagnostic refinement, fixes diagnosis firmly on the ultimate cause of a disorder (“pneumonia is a bacterial infection of the lungs”). Psychiatry, for the most part, is still in the first stage, whereas the other branches of medicine have advanced to levels two and three.Later in the book it will become clear that psychiatry, in the case of OCD, is on the threshold of moving up one or two levels in diagnostic sophistication. For now, though, OCD continues to be diagnosed completely on the basis of the recognition of its symptoms, obsessions and compulsions.*14/338/2*
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