Tamar E., Chansky, Ph.D.,
Director, the Children's Center for OCD and Anxiety
ISBN 0-8129-3117-3
Read: 2004 August 1 – September 2
Reviewed: 2004 October 9
The summer of 2004, like the winter of 2001, was difficult. I drove from California to Pennsylvania (stopping by Texas to look in on my mother on the way) to bring Viannah home from her first year at college.
(That story is told at http://cbduncan.110mb.com/Family/Travel/Spring2004.html .)
She was fresh off a messy breakup with her first serious boyfriend, plus, her best friend and roommate didn't think she would be returning the following year. But, going back to these problems were three months and three thousand miles away. She and her stuff ($200 via UPS and every nook and cranny in a Mazda 626 besides the front seats) were coming home and she had leads and plans for possible summer jobs and what to do with her "spare" time.
A month and three busted jobs later she was no longer even willing to drive a car (except when a passenger was sitting there talking, as I had done on the coast-to-coast trip), much less go to a job or spend several hours there; she was too anxious. We sent her back to her psychologist whom she had been seeing since the initial crises in winter 2001 who in turn started trying to get her to a psychiatrist who could prescribe appropriate medicine. This was all delayed by the inadequacy of our Health Maintenance Organization. After an all-nighter in the Emergency Room and a couple of days on the Psychiatric Unit in mid July we were scared.
The diagnoses was OCD, Obsessive Compulsive Disorder, and one of the first things patients and family members do is to obtain background information on the condition through resources such as this book. In addition to a description of the condition, its causes and symptoms, the book contains guidelines for dealing with various facets of an OCD situation in various scenarios and detailed descriptions of clinical cases. I started reading it as soon as Viannah was finished and finished it myself on the plane trip back from returning her to Lancaster for her sophomore year. It was necessary for me to accompany her to make sure she was connected with the right people to keep the condition monitored and controlled. Her roommate did not, in fact, return.
Before continuing, I must say that I fully agree with a quote with which the book ends:
Connie Foster, OCD advocate and educator wrote in a 1996 Obsessive Compulsive Foundation Newsletter, "I truly believe that what is needed in the mental-health field today is nothing short of a full-scale revolution. The sad truth is that even on the very threshold of the twenty-first century, the world is still rampant with stigmas, myths, and misconceptions regarding OCD and like illnesses . . . illnesses that are caused by physiological--not psychological--conditions.
Stone knives and bear skins indeed!
The basic fact is that this is a chemical imbalance in the brain, specifically a lack of "Seretonin Re-uptake Inhibitors" (SRIs). As such it can have hereditary origins. When synapses fire a chemical is released then re-absorbed into the neuron. If it is taken back too quickly, an effective open circuit (referred to throughout the literature abstractly as a short circuit) causes certain thought processes to malfunction. Therefore, somehow inhibiting the re-uptake is one treatment.
There are two types of effective treatment, Cognitive Behavioral Therapy (CBT) discussed below, and medication with SRIs such as Paxil. As with all medication, there are associated costs and side effects that make usage problematic but not impossible. Sometimes both therapies are used, sometimes only one. Either or both are seen to be effective. The medication brings about improvement by changing brain chemistry. CBT also results in brain chemistry changes as the patient learns to recognize the symptoms, deal with them cognitively, and does not get stuck in destructive patterns of various magnitudes.
The movie, A Beautiful Mind came to mind throughout.
Viannah's case is mild (but serious) compared to much of what is described in the book and, being the hypochondriac that I am, I recognize some of these symptoms from my own youth and some of the blind struggles I have made to learn to live with them.
The primary sociological problem in dealing with this, or any mental illness or condition for that matter, is (see quote above) that the symptoms are hard to distinguish from other normal behaviors. For example, OCD is common in children and adolescents. The main presenting symptom is to engage in repeated, obsessive rituals around common, necessary activities, like washing hands hundreds of times or having to button a shirt in a certain way and having to take it off and start over again if it doesn't go right. To a parent, this sort of thing is difficult to separate from normal child behaviors such as stalling or defiance but the instinctive response, to shout, "Quit that and get dressed before we're late!" while appropriate normally, is inappropriate here. It is therefore tricky to get past well-intentioned but uninformed helpers who advise that they should just "snap out of it" or "get mad get glad". You know, the way we won World War Two, not by being sissies but by getting on with the tough job at hand! Well, it is a tough job to combat and overcome but still live with OCD, but shouting and snapping aren't the ways to face it.
The symptom experience by the patient might be described as vivid horror. When a normal person, for instance, passes a dumpster with rotting food in it, they will be repulsed and wrinkle their nose and move away more quickly. This is a normal response. With OCD, such a response gets stuck in the forefront of the mind, due to the chemical imbalance in the brain. No matter what the patient does, it stays there for 15 or 20 minutes rather than the 15 or 20 seconds that anyone else would experience. While the ordinary person moves on and possibly forgets about it in a few minutes, the OCD person cannot move on. One response (and the reasons why this is common are not clear) is to develop some ritual that it is believed will keep this from happening. For instance, the patient might feel that to keep their family safe from an accident they must count any stairs they walk on accurately. If something causes them to lose count they have failed in the quest for safety so they go to the beginning and try again. Of course, this has no effect on either the reality of safety or the mental perception that there is a danger so the false coping mechanism grows until the patient can't get past going up and down stairs repeatedly. Good hygiene is one thing but when child washes her hands repeatedly until they are bleeding because she's afraid of germs or contaminating someone else, it is time for intervention.
Cognitive Behavioral Therapy is different from the more common "talk about it" or "talk therapies" in psychology and psychiatry in that it is training to face the fears which one gets stuck on with OCD and to counter them. Typically it means being exposed to the very thing that triggers the ritual response, sitting with the pain, and not doing the ritual response until it goes away. For example, one patient described in the book was afraid of swearing impulsively in public. Working with the therapist, they first wrote swear words on paper, then spoke them out loud for fifteen minutes (until it got boring) without ever doing the ritual that the patient would do to avoid the behavior. When everybody lived through this and the urgings calmed down after some time, the patient felt ready to go out in the world facing this on her own, not swearing and not worrying about impulsive swearing. Through CBT, the patient learns to recognize consciously an OCD thought versus a true, real fear and to respond by dismissing (sometimes angrily, as I would) the thought or facing the real fear appropriately and without repetition of unrelated behaviors. As they become better at the recognition and response, brain chemistry is seen to change (in PET scans on patients, for example) and the patient is capable of dealing with life.
Parents and/or family members participate by understanding the condition and its symptoms, helping with recognition and non-compulsive response, and of course, getting help. The book, like many books of its type, warns not to try to deal with things like this on your own. Read the book for information but get professional help.
It is hard to consider symptoms and treatments for something like this without remembering story after story in the Bible where people were demon possessed and had various symptoms, some of which were like this. Decades or years ago, a condition like this might be treated as a spiritual problem. This is confusing when the obsession itself is to pray continuously for someone's safety, or against acts of terrorism in the world. Diagnoses and treatments within the psychiatric profession have also been incorrect for at least a century (maybe forever) and have often made things worse. One concept that the book hammers at the reader is that a condition such as this, which is caused by physiological processes, is no different from, for instance, diabetes. The patient has to do some things to cope with the condition and to present themselves as normal in society but it is not just something that can be wished or browbeat away.
The fact is that everyone deals with some problems in their bodies, minds and spirits. Some of them are the same, some of them are shared, but we all have a "sack of rocks to carry" as dad used to say.
Jesus healed people, whatever condition he found them in, whether the issue was a physical deformity, spiritual starvation, or demon possession. This fact hasn't prevented society from going ahead and understanding conditions to the greatest extent possible and developing treatments that control or eliminate them, absent Jesus physical presence in the world or universal application of his healing power. Jesus would have healed a diabetic of diabetes and its symptoms. Today, lacking faith or something I guess, we prescribe insulin and diet. The same needs to be true of mental illness, while the field itself continues to learn to do effective research, diagnoses, and treatment. My view is that mental health in this respect is about a hundred years behind physical health. We know some things and are making progress in good directions, but there is still much that we do not know. I would not want to be a heart bypass patient or to have chronic periodontal disease in 1904, yet, here we are in 2004 as all people have always been, living where and when they are and dealing with it as best they can. Separating OCD from other compulsions, from rebellion, and from psychosis, and treating it appropriately is one of those steps in the right direction.