"I really care about my wife," my new patient Ed told me, "but I just can't get this idea out of my head that I don't actually love her." Ed was a fifty-one year old successful businessman and entrepreneur. Over the last two years he had been increasingly troubled by repetitive thoughts about his wife not being "the right one" for him, that he would never be happy with her, and that unless he left her, he would forever feel trapped in this unhappy relationship. He would stare continually at other women as a way of double-checking, to see if he found them more attractive than his wife. As he looked, he wondered, "Do I have to leave her because she isn't attractive enough for me, or because these other women look more attractive?" This staring had gotten him into difficulties on several occasions. He and his wife had two children and their marriage had always been a generally happy one. He felt very isolated with these thoughts, and had never shared them with his wife.
Another patient, Maria, was having a somewhat different experience. The thirty-two year old school teacher, related, "I can't stop thinking about my fiancée's last girl friend. I keep asking him over and over if she was mean to him, and also about why they really broke up. I have this idea that I don't have the whole story. I can't stand not knowing." Maria had been relentlessly hounding her boyfriend to discuss these topics day and night. She had no hesitation about calling him at 3 a.m. to question him yet one more time. This had led to an escalating level of arguments, and a refusal on his part to discuss the subject with her any further. They were on the verge of breaking up when she decided to go for help. She felt distressed that she could not prevent herself from constantly bringing up these nagging questions, even though she realized what the consequences were.
Finally, there was Henry, a twenty-two year old graduate student. Things had gone a bit further in his case, and in a not particularly good way. Henry's girlfriend, a fellow student, had broken up with him two months previously following an eight-month relationship. At the time, she explained that she just didn't think he was her type, even though she thought he was "a nice guy." Unfortunately, this was not enough for Henry. As in the case of Maria, he believed that there was more to the story than his girlfriend had told him. He wondered if perhaps she had broken up with him over a simple misunderstanding, which if corrected, would fix everything. He began calling her on the phone several times per day to ask the same questions, and when she began to screen her phone calls, he started to show up at her classes and hound her with the same questions. He also asked her friends some of these questions. Unfortunately for him, she complained to campus security about this, and he soon found himself in the dean's office to explain his behavior. Only the threat of expulsion from his school forced him to stop, and he resolved to quit before it was too late. His good intentions didn't last more than about two weeks. He then began to wait for her outside her house. This resulted in her obtaining a legal order of protection from a judge, and a threat of arrest if he called her on the phone, or came within one hundred yards of her or her home. The word "stalker" was mentioned. "This just isn't me," he told me emphatically. "I really want to stop, but these doubts just eat away at me. It's like they just won't leave me alone. I have to have answers."
These people were not simply wrestling with relationship problems. What they were dealing with was another form of problem altogether. All three were subsequently diagnosed with OCD, known in former times as "the doubting disease." This is not simply ordinary doubt. It is doubt raised to the level of a serious disturbance. An obsessive thought can be very insidious and persistent. It is like a severe and maddening itch that cannot be scratched. Why OCD picks on particular topics remains a mystery. It may be something previously important to the sufferer, or not. At times, it does seem to have an uncanny way of interfering with whatever the sufferer cares about the most. When OCD intrudes into relationships, the effects can be severe. Often, the sufferer doesn't realize that OCD is really the underlying problem they are just too close to what is happening. The partner on the receiving end is equally mystified, and cannot comprehend what has happened to a person that they thought they knew. Problems such as these can build up gradually over years, or may begin suddenly. Sometimes, in looking back over past relationships, a sufferer can begin to see a pattern of smaller occurrences, though perhaps not as severe.
Each of these three individuals had eventually found their way to treatment. Ed insisted at the first visit that his wife not find out. Maria actually brought her boyfriend to her second session so that he could learn about what she was dealing with, and that her urge to question him wasn't her fault. Henry, like Ed, came alone, but hoped to find out enough about the disorder to be able to eventually write his ex-girlfriend a letter and send some OCD pamphlets so she would understand that he was not a "crazy" or hostile person.
Treatment options for all three consisted of a type of behavioral therapy known as Exposure and Response Prevention (E&RP) together with medication in the form of SSRI-type antidepressants. Ed opted for behavioral therapy alone, while Henry and Maria resorted to both. Obsessions are intrusive, repetitive, doubtful thoughts that suggest that harm may come to the sufferer or others in some way. Compulsions are any mental or physical activity performed for the purpose of relieving the anxiety caused by obsessions. In E&RP, sufferers are gradually exposed to those things that bring on their fearful obsessive thoughts, so that they may gradually build up a tolerance to them, and not feel the need to question, check, or perform other compulsions in order to relieve the anxiety. Those who practice this diligently find themselves getting better over time, rather than worsening, as they might have at first predicted. Although all three believed that the answer to their doubts had to be out there somewhere, it was explained that this was really an internally generated problem that had to be confronted rather than avoided. Their attempts to escape their obsessions by getting more information had only led to more doubt and thus, further difficulties. They were all forced to accept that they had gone as far with their compulsive checking and questioning activities as they could safely go, and it was clear that they would never resolve their doubts in these ways. Their solutions had ironically become their problems.
Now, their problems had to become their solutions. That is, the things they had been avoiding would now be used to help them. Please note that the following descriptions of their therapies are only simplified summaries. There is actually a lot more to behavioral therapy than can be described in this article.
Ed listened to tapes and did writing assignments about how he would remain "trapped" and miserable in a loveless marriage. He also watched videos and read books on similar themes. He was assigned to look at pictures of attractive women and, discreetly, attractive women he saw in public places, while telling himself how much happier he would be with them instead.
Maria also listened to tapes and did writing assignments. Her exposure centered on the theme that there were a great many things she would never know about her boyfriend's past. that she would never really understand him, and he would never tell her about any of these things. She was assigned to look at pictures of her boyfriend's former girlfriend, posted on her walls with question marks drawn all around them. She was also forbidden to question her boyfriend about any of her pet subjects. Fortunately, her boyfriend was willing to cooperate with her therapy, and whenever she slipped and asked him a question (no one gets well perfectly), he was directed to say to her "Sorry, you know I'm not allowed to tell you." If she told him "You're not helping me, he was also directed to say "I am helping you. I'm helping you to recover.
Henry, of course, was assigned to stay as far away from his ex as possible, and was forbidden to call her or her friends. His audiotapes and writing assignments exposed him to his obsessive thought that he would never really know why his ex broke up with him, that he would live out the rest of his life without that information, would never get back together with her, and that it would no doubt harm his future relationships. He read books and watched movies about breakups. He was directed to post signs around his apartment that said such things as "You'll never really know," or "She's hiding the truth from you."
In these particular cases, things turned out well. All three experienced anxiety at first, but over time they eventually lost interest in their particular subjects. They discovered after repeated exposure that they could not feel bored and anxious at the same time. At the infrequent times when their obsessive thoughts did occur, they now provoked little or no reaction. Maria and Henry both felt the medication had given them an edge, as it had reduced the frequency and intensity of their thoughts. All eventually came to see that their fears could not simply be avoided or neutralized, and that there was no true escape other than facing them.
Although these three individuals were fortunate enough to get help, there are, no doubt, many others out there with similar stories who do not even understand what they are up against, or that others suffer in similar ways. They may believe that they only have some kind of relationship problem, and are not aware that help is available. Some have lost important relationships, and may even have had tangles with a justice system that simply didn't understand them. If your story is similar, don't wait until there are serious consequences. Get help as soon as possible.
If you would like to read more of what Dr. Penzel has to say about OCD, take a look at his OCD self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000). You can learn more about it at www.ocdbook.com