Finding the ‘D’ in the ‘OCD’

It’s not about the content, it’s about the process.

This is something my CBT therapist discusses with me a lot.  He’s pleased that recently I’ve been attending OCD support groups and Bryony Gordon’s excellent Mental Health Mates meet-ups; things I’d have previously shied away from.  We’ve discussed the therapeutic benefits, amongst which is finding the similarities with others who overtly, at least, seem to experience something very different to me.  Realising that the similarities lie in the process of how the illness works, not the content of thoughts and scenarios experienced, is a very valuable thing indeed.   For the more that you realise that the content of intrusive thoughts does not matter, the closer to recovery you come.

Let’s strip OCD down to the basics.  Meet the stars of today’s two made up examples: Buffy and Davros (what?!  That’s their names, ok?).  Buffy loves going jogging, but has been terrorised by this intrusive thought: that when she runs along the street and encounters a little girl playing on her scooter, she’s going to violently shove that little girl out of the way, into the road, under the path of a speeding van.  She is horrified by this image, appalled that she has thought it, and terrified about why she has thought it.  Is there something bad in her?  Is she actually going to do that?  She can’t get rid of the image, and  she stops going running, or even walking in the street.

Davros doesn’t understand Buffy’s problem at all, and wishes that was all he had to worry about.  His anxiety has gotten out of control since he nearly left the house with the kitchen tap running.  He turned it off, but then turned it on and off again to be sure.  He finished getting ready to go out, but then checked the tap again, turning it on and off again twice more.  Getting to the front door, he thought, what if he left the bathroom tap on as well?  So he went back, turned that on and off again three times to be sure of that too.  Feeling better he finally left, but now he keeps thinking about the incident.  Before he knows it, he is struggling to ever leave the house or any room without turning taps, light switches, all sorts, on and off three times; and his anxiety about it and how weird it is, is making him feel sick.  Buffy hears about this and thinks it’s stupid.  Why worry about that?  It’s not like he’s being terrorised by images of pushing little girls in the road all day long, which might mean she has evil impulses!

The scenarios differ in content, but the process of Buffy and Davros’ problems are the same.  There is a thought that invades their minds (‘push girl in front of van’, and ‘left tap running’).  This thought glares the spotlight of each ones attention, gets trapped in their minds, like a song you can’t stop replaying in your head.

To try to neutralise this obsessive thought, both carry out a reactive behaviour.  Even though she loves running, Buffy stops going.  When this doesn’t work she even stops walking in busy streets.  Davros checks all the taps.  He checks excessively by turning them on and off three times each.  When this doesn’t work, he starts checking all manner of things, turning them off multiple more times.  This is a compulsive behaviour.

Ok, but last time I talked about mental images that upset me, and about abstract misery regarding the concept of humour.  They were obsessive thoughts, sure, but where was the compulsive element?  These type of OCD experiences are sometimes referred to under the umbrella term ‘pure O’, meaning pure obsession.  It is a term that I dislike for a couple of reasons.  Firstly it sounds to me like the title of a porn video!  Secondly, it is misleading, as there is a very strong compulsive element in terms of my reactions to the obsessive thoughts.  For a start, I do carry out overt behaviours, such as avoidance.  Also, the behaviours don’t have to be overt – they can be internal, mental.  In my case I try to transform the images to make them more acceptable or manageable.  Or I try to justify reassuring arguments that I construct to deal with the obsessive abstract terrors; try to ‘solve’ or ‘clean’ the thoughts.  Inn Buffy’s case she tries to stop the image, or questions the reason for it.

However, the real compulsive element in all cases, is not just found in the action carried out to manage the situation, but also the initial reaction to the thought.  This is a very important point in understanding and fighting the illness.  Because this negative reaction involves an interpretation of the original thought.  Buffy thinks ‘that’s horrible – but why did I think it; what if I actually do it;I must not do that; does it mean there is something bad in me; what if I can never walk in a street again?’.  Davros thinks ’how do I know I turned off the tap if I forgot before; why am I still worried about it; I must not let this happen; why did it feel better after three times; what if I can never just do things first time again’.  These are thoughts-about-thoughts – meta-cognitions.  They tell you that you need to do something about the thought.  Now.  NOW!!  They tell you the thought is dangerous, frightening, disgusting – do something about it, neutralise it, NOW, and don’t stop until it is gone.

And how do you make the thought gone?  Do you try to ignore it?  No, no, no.  Ok, you need to keep acting out sets of behaviours or counter thoughts until you find the right one to stop it, right?  Do you arse! (if you are reading outside the UK, this translates as ‘most certainly not’).  Look at Buffy and Davros’ examples.  The more they do, the worse it gets.  Oh, ok, shit.  So what do you do to stop them?

Well – you don’t.

What?!  But… surely…. What?!

What I mean, is that you don’t try to stop them.  And also, you can’t stop them.  But don’t worry, you don’t need to stop them.

You see, the thoughts themselves are not the problem.  They are just thoughts.  No matter how weird or unpleasant.  Everyone has thousands of thoughts passing through their minds every minute, and some of them are, well, weird and unpleasant.  Having the thoughts is not the disordered component in OCD.  How could it be, when the thoughts themselves can be about anything at all?  What is disordered is the reaction to the thoughts.  The severity of that compulsive reaction, that alarmed interpretation, keeps the thought in the spotlight of attention.  The meta-cognition which demands corrective behaviour, a mental solving of a problem, that doesn’t actually exist, maintains the obsessive problem in a vicious cycle.

This is the reason that, in cognitive-neuropsychology terminology, OCD is such a total, utter, bastard.  But while it is a long, long way from easy, once you fully get to grips with where the disorder truly lies – in the process, not the content – then you can start working towards dealing with it effectively.

How OCD first invaded my mind, and other stories

As I explained last time, the experience of OCD is massively varied.  Not only does it vary from person to person, but within one person’s experience it changes too.  This is an important point to emphasise – as next time I’ll discuss how it is not the content of the thoughts that is important, but the process.  Today, to provide that discussion with some context and to demonstrate OCDs variable nature, I’m going to take you on a tour of the earliest years of my illness.  Believe me – this is deeply uncomfortable.

14 -16 years old: Contamination

It began with a problem at school.  Bullying?  Girls?  Long division?  No.  Acid.

I don’t mean acid as in LSD or late 80s dance music (‘this is aciiieed!’).  I mean hydrochloric, sulfuric… whatever acid as used in chemistry class.  Although I believe that acid tends to announce is presence on skin quite proudly, I felt deeply uncomfortable after science class.  What if the chemicals were on my hands?  On my clothes?  On my school bag?  Within no time at all, just going to school resulted in a feeling of entering a contaminated environment.  And I mean feeling: I experienced a highly sensitive physical discomfort, like walking in to lukewarm, dirty, water.  My home life and school life were wrenched apart – I had to keep them separate.  Anything associated with school took on this irradiated quality, humming with a stale warm glow, like the halo around people who had eaten porridge in the old Ready Break adverts (showing your age Baz – tell them to look it up on YouTube).  When I got home I would remove my uniform, store it, my school bag and books in an isolated location which could not be touched, then go straight into the bathroom to thoroughly wash.  While my school work went to shit (I didn’t do any homework) and social life was affected, I managed the situation up quite well, I thought.  When I went into the sixth form, which was safely separate to the rest of the school, the problem faded away.  It was not until years later, that I told anyone about all this, or associated it at all with what was to come.

16-22 years old: mental imagery

Gradually over these years OCD properly took hold, and took the form of bizarre mental images that intruded upon my minds eye like a waking nightmare.  Polluting and infecting all other mental imagery, they’d twist and distort my imagination.  This is still the most common form of the illness I experience to this day, when I have relapses.

The problem would come and go, be more manageable sometimes or worse others, and last varying lengths of time.  The frequency, duration and severity gradually increased over a few years, until by the age of 21 it was near constant and having a severely distressing impact.  I responded to the images with compulsive feelings of disgust, repulsion and severe upset.  Their presence was feared and delivered an extreme sense of discomfort and wrongness, accompanied by apparent physical sensations: similar to the irradiated contamination I described above, and a warm sickly sensation in my head like a lumpy ooze bubbling under my skull, or rock jammed in my brain.

I was also stricken by a guilt – a responsibility, a need to seek reassurance from myself that I could fix this this.  Try to restructure the mental images, arrange them all as if solving a puzzle to get back to normal.  To have a ‘clear’ or ‘clean’ head again.  I tried to avoid physical or topical stimuli that may trigger the images.  My reaction to encountering such stimuli was as if to an electric shock, or an alarming, explosive sound.  They commanded my attention, demanded reassurance and resolution.

The form that the images themselves took changed every couple of years after they started.  First it was cigarette butts.  I’d be reading a book, picturing a scene – and there was a mound of cigarette butts.  Thinking of nothing in particular – there was a rotting cigarette butt floating in my head.  That changed as the problem intensified, both in frequency and severity.  The first change came when I’d poked my hand down the side of the armchair to retrieve a dropped pen, and recoiled in disgust at feeling food crumbs that had escaped and gathered there over time.  Now thoughts and images invaded my head with a force I’d not experienced before – ‘imagine that mess mixed with cigarette butts; imagine all little things in the world dropped and mixing with that mess; imagine that mess is the rubbish everywhere, all around us choking the world; imagine all chairs, all homes, all safe places you snuggle into… you are snuggling into that disgusting mess!’  Comfort, safety – they felt stripped away.  I felt exposed to a terrifying mass, surrounding me, closing in.

In turn this too changed.  For a long time the images were of a specific food stuff – a gooey, horrible dessert, which, I’m sorry, I’d rather not describe.  But really it doesn’t matter.  As each image changed, what used to upset me no longer did.  I could often deliberately think of previous images and they didn’t bother me, or if they did, the thought passed out of my head.  But the distress remained, and worsened.


22 years old: Conceptual crisis

In 1993 I was in an utter mess.  To this day I have a difficult, anxious, OCD relationship with the number 93.  Some weeks I couldn’t operate at all, and was bedridden, wishing I could just not think at all.  The images had gone after one day the foodstuff image took the place of something else as a punchline in a joke.  My response was devastatingly strange.  My compulsive, defensive instinct was to try to stop the image being associated with the joke, so as not to ‘contaminate’ it.  But then this other thought smashed everything away.  What was funny about the joke anyway?  How does it work?  How does any joke work?  What is humour?  Why is humour?  How is humour?  I scrabbled mentally to explain, and with every explanation opened up a trap door – what did I mean by this?  What did I mean by that?  What is enjoyment?  What is beauty?  Why do you like things?  Explain and justify these things!!

Within a week, all the unpleasant, upsetting mental images had gone.  But they were replaced by this non stop, howling, abstract storm in my head, which carried with it all the feelings of physical discomfort and exposed wrongness that used to accompany the images, and which I knew could not go until I lived up to my responsibility, and solved these unsolvable abstract riddles.  Consciousness was exhausting.  All I wanted was this crap out of head, or just to be dead.

And then help at last

The diagnosis of Obsessive Compulsive Disorder and subsequent psychiatric help late that year saved me (see earlier posts),  and until a little over a year ago, management of my illness has been pretty successful.

But see how varied it can be: an irrational fear of the contamination by chemicals.  Upsetting, stubborn mental imagery.  A compelling need to justify my own thoughts at the cost of despair.  All parts of the same illness, and none of them as funny as arranging my pens by colour.  What is it about these thoughts that makes them so disordered?

Well, the answer is – nothing.  They are, no matter how weird, just thoughts.  It isn’t the content of these thoughts that is the problem in OCD.  It is the mental interpretation of them.  It is in this, and the response, that we find the disorder.  As I shall discuss next time.