Fred Penzel Ph.D.

Watch Your Step: People Who Compulsively Observe Themselves

The other day, a 27 year-old named Aaron came to see me in a very anxious state.  He was an IT software engineer.  He related that he was fearful of going out in public and being seen by other people.  He added that his previous therapist diagnosed his problem as social anxiety, but had been unable to help him after 8 months of treatment, even with recommended cognitive/behavioral therapy approaches for that disorder.  He described how when he was out in the street, he could not stop thinking about the way his legs moved when he walked, which ironically caused him to walk in an awkward way.  His thoughts questioned whether he was walking normally, suggested that he wasn’t, and that he looked weird.  He further feared that people would notice this and think there was something wrong with him, and end up judging him badly. The thoughts focused on such things as which foot to put forward first, how rapidly to move them, and even wondered how he even knew how to walk at all.  The thoughts were doubtful, repetitive, and intrusive, and were becoming worse, as they sometimes even occurred when he was home alone.  His anxiety was also becoming increasingly unmanageable, which was no surprise. Things were now so bad, that he avoided going out in public as much as possible and even had difficulty  walking around the office at his job, only walking the halls after first checking that no one else was around.  After talking to him further and obtaining more information about his life and his symptoms, I concluded that the diagnosis was actually Obsessive-Compulsive Disorder (OCD), and given this, it was no wonder that he hadn’t been able to improve in therapy designed to treat social anxiety.

A number of years ago, I previously wrote an article about people with fears of staring inappropriately at, and excessively noticing other people (“Here’s Looking At You, Kid” – Summer Issue, 2010).  After seeing this person, it occurred to me that I had never really discussed people who focus on and pay too much attention to themselves.  I have come to refer to this behavior as ‘compulsive over-focusing.’  Symptoms of this problem tend to involve studying the way different parts of one’s body work or may not work correctly.  People may typically focus on such things as:

  • the way they walk

  • how often, or the way they do involuntary acts (breathing, blinking, swallowing, etc.)

  • the pitch of their voice, how rapidly they speak, how they laugh, etc.

  • how their mouths move when they talk

  • the way their head turns or how their limbs move

  • whether or not their facial expressions are appropriate

  • the way they gesture

  • whether or not they are making eye contact at any given time

  • if they are correctly processing and understanding what others are saying to them

This list is by no means complete, and only seems limited by a person’s imagination.  It is by no means a minor problem.  Aaron had developed severe difficulties at his job, getting around in public, and in social situations to the point where he was isolating himself and had become nearly housebound. He feared losing his job.  What differentiated the problem from Social Anxiety Disorder was the presence of relentless negative and doubtful intrusive thoughts about his body, and his attempts to eliminate or avoid the doubtful thoughts by compulsively studying and analyzing himself and the way his legs worked so that he could perfectly control them.  His thinking was that if he could be in total control of his movements at all times, he would be able to rid himself of the doubt the thoughts caused, and therefore his anxiety.

Of course, attempts to eliminate the thoughts and doubts, such as Aaron was doing can never work.  This is because: 

  • it is futile to simply tell yourself to not think about something because you first must think about whatever it is you are not supposed to think about. 

  • OCD can be very relentless in the way it can constantly bombard you with thoughts.  This is not something that you can directly control.  They cannot simply be shut off.

  • the doubtful nature of OCD makes it impossible to really hold onto whatever reassurance you think you can get from checking yourself, because as soon as you think you have achieved certainty, it vanishes

  • you cannot totally focus on a single aspect of your own behavior at all times, meaning that no matter how careful you are, you will still not be completely certain of what your body is doing

Needless to say, Aaron was not very happy to discover he had been treated for the wrong problem.  I explained to him that he would never be able to succeed in his attempts to achieve perfect control due to the above reasons.  I explained that in order to succeed, he would need to:

  • Surrender his need for certainty and control over what his legs were doing

  • Increase his ability to accept and tolerate his negative and doubtful thoughts by letting them be there, and by not trying to deliberately eliminate or cancel them in any way

  • Do away with any kind of reassurance

  • Allow himself to go places and do things that would cause him to feel the anxiety, but to not try to escape it, to further increase his tolerance for it

I like to explain to my patients that there really is no escape from anxiety or any other Inner experience, and that the only way to overcome a fear is to face it.  I further explained that this would not be easy and would take time to do successfully.  In addition, I could not promise to eliminate the thoughts, but told him we could teach him to no longer do compulsions and to be able to handle whatever anxiety or doubt OCD threw at him.

We began a program of homework for Aaron designed to accomplish the above goals.  Some of his assignments included:

  • Agreeing with any thoughts about his legs moving awkwardly

  • Agreeing with any thoughts of others viewing him critically

  • Not avoiding walking when and where others could see him

  • Deliberately taking walks in increasingly crowded public places

  • Listening to recordings about how badly he was walking, while on some of his public walks, and of all the bad consequences that would result from it

  • Watching videos of other people walking strangely and agreeing that he looked just like them

  • Watching videos of himself walking with a voice-over saying how strange he looked

  • Writing repetitive daily sentences 25 times, that said such things as “Other people can see how weird I walk.”

  • Conducting experiments where he would walk oddly in public and then observe other people’s reactions to it

These were very challenging for Aaron to do at first.  He stated that “I don’t know if I am up to doing this.”  He really had to push himself to carry many of them out.  He felt very anxious at the beginning, but he began to observe that the more he did the assignments, the less anxious he felt, and the less he felt controlled by his intrusive thoughts.  Doing the experiments had a very big effect on him.  He was shocked that when he walked strangely on purpose, no one even seemed to notice or to make remarks to him.  “I can’t believe nobody cares,” he said.  Part of the way through the treatment, he decided to give medication a try to “See if I can cut down on the noise in my head.”  He tried an SSRI-type antidepressant which did reduce the thoughts themselves and made it easier for him to face his feared situations.  Improvement did not happen immediately, but as the weeks went by, he found himself thinking less about his walking and even forgetting to think about it at times.  It seemed to take more work to bring on his anxiety, and what there was, he was able to push through.  This is not to say that everything went flawlessly.  Some weeks were harder than others, and he would occasionally forget himself and caught himself trying to control his steps.  At this point, however, he was able to catch himself more quickly and get back to following his treatment guidelines.  A few times, he thought he might even quit, but then he realized that if he did, it would guarantee that things wouldn’t get any better.  “I guess you never promised me that it would be easy,” he told me.  “Sometimes when I’m feeling down, I remind myself that even though treatment could be hard, having OCD every day was a lot harder.”

Eventually, as happens when people persistently stick to their treatment, we got to the point where it appeared that we were running out of assignments.  Most of the things we were doing no longer made him anxious.  It was becoming increasingly difficult to bring up the old feelings of strong anxiety.  He was able to say ‘I may still not like the thoughts, but I can stand them.  They’re more annoying now than anything else.”  We moved on to talk about maintenance, since getting well was only half of the job.  The other half, of course was staying that way.  He learned that to keep what he had gained, he would need to be vigilant, and to still agree with thoughts when they did occur, and to be sure to resist doing any compulsions.  If he did slip, he would have to act immediately to challenge himself until the thoughts and the anxiety subsided.  At the end, he told me half-jokingly, “Now I can tell my symptoms to take a walk.”

He felt as if he had gotten his life back, and could resume working on his career and reestablishing a social life.  This, too, was challenging, but in a different way.  I told him, “Now you’re free to have the same problems as everyone else.”  He agreed.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

Langley Collyer: The Mystery Hoarder Of Harlem

On March 21st, 1947, at 8:53 a.m., the New York City police department received a phone call from a man giving the name of Charles Smith, notifying them that he believed a man was dead inside a decaying building on Fifth Avenue in Harlem.  Officers arrived on the scene by 10 a.m. and cordoned off the house in order to hold back the crowd that had gathered.  The police removed an iron grill-covered basement door from its hinges, only to find the entrance completely sealed off by a solid mass of debris.  Thus was thrust before the public one of the best-known and most mysterious compulsive hoarding cases of all time.

Compulsive hoarding is a form of Obsessive-Compulsive Disorder (OCD), a neurobiological condition, most likely genetically based. OCD comes in a wide variety of forms, of which hoarding is only one.  Compulsive hoarders may collect only certain types of things, or they may indiscriminately save everything.  We are not talking here about collecting things that are valuable or important such as art, coins, or stamps.  Hoarders generally tend to save things that are of little or no value, or if the things they save do have real value, they tend to save them in ridiculously larger quantities than would ever be necessary.  One of the main obsessive thoughts that causes sufferers to do this is their worry that if they throw a particular item away, it will be lost forever, and they may one day be in need of it in order to be able to use it, to be able to remember it, or something connected with it.  They seem to have difficulty discriminating between what is or will be useful, and what is not.  Some hoarders can freely admit that the things they are saving are currently broken or damaged and unusable.  They will stubbornly insist, however, that they will someday repair or refurbish the items and either make use of them or give them away.

Another reason for hoarding resembles the type of thinking seen in hyper-responsible obsessions.  It is the idea that each thing they save and/or repair might be useful to others (rather than themselves), and that the hoarder would be responsible (and therefore blameful and guilty) for another person not having this vital item should the need arise.  They may also rationalize that what they are doing is actually “recycling,” and are performing a community service by conserving resources.  Throwing away something that could possibly be reused is seen as being highly irresponsible.  In actuality, there really is no need for what they have saved, there is no one to give the items to, and the only result is that the hoarder is burdened with a house full of junk.

Some of the things most commonly saved include newspapers, magazines, lists, pens, pencils, empty boxes, pamphlets, old greeting cards, junk mail, old appliances, outdated books and even assorted labels, string, rubber bands, plastic containers, bottles, and bottle caps.  In the most extreme cases, people have been known to save such things as empty matchbooks, used tissues, old cigarette butts, bird feathers, old cars, discarded paper cups, used aluminum foil, paper towels, lint, and hairs.  Some of these sufferers will even rummage through other people’s trash, and bring home obvious junk that to them, seems quite useful or repairable.  Compulsive savers can accumulate large amounts of things, creating storage problems and fire or health hazards.  Their houses can take on the appearance of having been ransacked, with floors waist-deep in trash and debris, rooms filled wall-to-wall with overflowing paper bags and cardboard boxes.  Many sufferers can only make their way around their homes by creating aisles around and through the trash.  Problems with municipal authorities are not uncommon, and hoarders are sometimes evicted or charged with violation zoning or public health laws.  Ironically, the majority of people who save things compulsively rarely use or look at these things.  Their security comes from merely having the things around "just in case" and in not having to make what seem like difficult decisions about what to discard.

Let us now return to our story.  Its main figures are two brothers, Homer Lusk Collyer (b. Nov. 6th, 1881), and Langley Collyer (b. October 3rd, 1885).  The Collyers were part of one of New York’s oldest families, a branch of the well-known Livingstons.  Their ancestors had come over to America on the ship “Speedwell” in 1664, about a week after the Mayflower.  The family had been members of the congregation of Trinity Church since 1697. Their father, Dr. Herman L. Collyer was a successful and renowned gynecologist, and his father, William Collyer, was said to have been one of the leading shipbuilders in America.  In 1909, Dr. Collyer moved his family from Murray Hill to a fine upper middle class home in Harlem.  It was a three-story brownstone located at 2078 Fifth Avenue (at 128th Street).  Beyond his fame as a physician, the doctor was known to be a bit eccentric, paddling a small canoe to work each day at City Hospital on Blackwell’s Island in the East River.  He would subsequently paddle home at the end of his day, and then carry the boat on his head back to his house.

Dr. Collyer’s two sons seemed destined for successful lives of their own.  Both attended Columbia University, where Homer earned a law degree, and his younger brother graduated with a degree in mechanical engineering and chemistry.  Homer went on to practice admiralty law, but Langley, so far as is known, never held employment, and spent his time playing the piano.  He is reputed to have won prizes as a concert pianist, but this cannot be verified.  Perhaps Langley’s inability to establish a career was an early sign of personal difficulties he may already have been experiencing.

It was probably a warning of things to come when in 1917, the brothers had their telephone disconnected, after being billed for long distance calls they claimed to have never made.  This may have been the beginning of what would become a growing isolation from the outside world. Six years later, in 1923, Dr. Collyer died.  Several years prior to his death, for reasons unknown, he had moved from his Fifth Avenue home to one at 153 West 77th Street.  His sons remained at the family home with their mother.  It is possible that a family breakup may have occurred.  Life seems to have taken an abnormal turn for the two brothers in the year preceding the death of their mother in 1929.  It appears that their gas was shut off in 1928, and they also seemed to have given up the convenience of running water and steam heat, and began using kerosene to light their home and to cook with.  Water was obtained from a public fountain four blocks from their home.  This was all clearly out of step for people of their education and social status.

Despite all this, nothing appeared out of the ordinary to those in the outside world.  The brothers were said to be courteous, cultured, and shy.  The only sign that something might be amiss was that no one was ever permitted to enter their house.  Around 1928, Homer worked for another attorney, John R. McMullen, who later became the family legal advisor.  Homer next worked for City Title Insurance doing research in the New York City Hall of Records.  He was described, at the time, as being courtly, and dressing in 19th century attire, presenting a rather Victorian appearance.  He was said to resemble a gentleman of the 1880’s.

In 1932, Homer purchased a building across the street at 2077 Fifth Avenue for $8,000.  He planned to divide it into apartments and to rent them.  This plan was never realized, as he suffered a stroke in 1933, becoming blind as the result of hemorrhages in both of his eyes.  With one exception, he was reportedly never seen outside of his home again.  Langley then gave up his music to take on the job of nursing his brother back to health.  No physician was ever consulted.  Langley apparently believed that the cure for his brother’s blindness was for him to eat 100 oranges a week, and to keep his eyes closed at all times, in order to rest them.  The brothers possessed a large library of medical books, and it would seem that Langley felt he had the information and knowledge necessary to treat his brother.

At some point in the 1930’s, the West 77th Street home where their father had lived was sold, and the new owner, a Mrs. Peter Meyer, discovered an intact Model T Ford in the basement.  It is not clear how it got there.  Mrs. Meyer is said to have paid a workman $150 to disassemble the car and put the pieces in the street.  This somehow came to Langley’s attention, and for reasons known only to him, he carried the car piece-by-piece back to the basement of his Fifth Avenue home.  It would appear that along with the loss of their other utilities, the brothers had no electricity, as Langley apparently tried to connect a generator to the car’s engine in order to provide power, but was unsuccessful.

The brothers eventually came to the attention of the general public when they were mentioned in an article written by Helen Worden, a reporter for the World-Telegram.  A real estate agent named Maurice Gruber was attempting to buy some farmland in Queens that belonged to the brothers.  Their refusal to respond to his letters or to answer the door when he tried to see them in person resulted in Gruber keeping a vigil at their home.  In her article, Worden referred to Langley Collyer as “the mystery man of Harlem,” and included in it, a whole range of sensational rumors that had been circulating about the brothers and their home.  It was said to contain all sorts of rich furnishings, a vast library of books, and huge amounts of money that Langley would not trust to banks.

Worden, herself, kept a watch on the Collyer’s home, and finally caught up with her elusive quarry one night, as he was leaving the house to go on what was one of his regular after dark shopping trips.  She questioned Langley about a boat (his father’s) and the Model T Ford said to be in their basement.  Langley confirmed these stories.  Rather than clearing up the mystery, Ms. Worden’s article seemed to have only increased the speculation and rumors about the brothers, and during the 1930’s other articles were written about the brothers in the New York papers.  The brothers were depicted as wealthy hermits, living in a storehouse of money and valuables.  People visited the house, banging on the doors or attempting to see them, while neighborhood children committed various acts of vandalism that included breaking windows.  As windows were smashed, Langley systematically boarded them up instead of replacing them.

Throughout this time, and most likely the result of a case of compulsive hoarding, Langley was hard at work filling the once attractive home with huge amounts of newspapers, cardboard boxes, barrels, metal cans, tree branches, scrap metal, and other assorted trash.  In the case of the newspapers, it is said that he believed that his brother Homer would someday regain his vision, and would then want to catch up on the news he had missed.  He was known to prowl the streets at night, gathering items from curbside trash piles and bringing them home.  No one knows how many years he had been actively engaged in this collecting.  His foraging resulted in all three floors of the house being filled with literally tons of things he had collected.  Perhaps it was his knowledge of engineering that enabled him to arrange the boxes and packing cases in interlocking arrangements that concealed a maze of tunnels that only he knew.  Langley was said to harbor fears of being burglarized, and there had, in fact, been several attempted break-ins over the years by those perhaps lured by the tales of stockpiled riches.  The home became a sort of fortress for the brothers, with booby-traps constructed of great piles of debris rigged with the aid of trip wires to fall on unsuspecting intruders.  This, of course, only served to increase the brothers’ growing isolation.  If their goal was to keep the world out, they were succeeding.

Although the brothers were by no means poor, Langley is also said to have regularly rummaged through garbage cans seeking food.  He went begging at butcher shops for scraps, and was known to have walked as far as Williamsburg, in Brooklyn to purchase stale bread at the lowest possible cost.  The Collyers again appeared in the newspapers in April 1939, when, armed with a court order, a city marshal together with representatives of the Consolidated Edison Company entered the brother’s two Fifth Avenue buildings and removed the gas meters, which had been in a state of disuse since 1928.  A crowd said to be as large as 1,000 people gathered outside their home to see what was happening.

Homer’s last appearance outside the house is said to have occurred a number of months later on January 1st, 1940.  Sgt. John Collins, a city policeman from the 123rd Street station who was familiar with the Collyers, spotted the two brothers carrying a large tree limb from across the street into their basement.  Langley guided the branched end, while Homer held up the other end.

Although the brothers did everything they could to avoid public scrutiny, it had its own way of intruding into their solitude.  Ironically, it was their reluctance to encounter the outside world that continually brought the world to their doorstep.  It appears that not paying taxes and other bills was a symptom of their reclusiveness, and it caused them no end of trouble.  The most highly publicized example occurred in August of 1942, when the Bowery Savings Bank foreclosed on a mortgage that amounted to $6,700 plus interest (no interest had been paid since 1940).  After going to state Supreme Court, the bank obtained permission to evict the brothers from their home.  The very same day, however, the Collyer’s attorney, John R. McMullen, met with bank officials with an offer by his clients to repurchase the property.  As the house was seen to be in very poor condition, it appeared that the Bowery Savings was not all that eager to repossess it.  Mr. McMullen had never actually been allowed in the brothers’ house, so instead, Langley, who almost never appeared in daylight, had walked all the way to his attorney’s office on Park Row to discuss the matter. Mr. F. Donald Richart, vice president in charge of real estate for the bank, consented to give the brothers “a generous amount of time” so that they could work out the details of the repurchase.  

There were growing rumors on the street, around this time, that Homer had died and that his body was still in the house.  Sgt. Collins of the 123rd Street station (mentioned earlier), took it upon himself to look into the matter.  He encountered Langley, and somehow got his permission, despite some reluctance, to enter the house through the basement door.  In a surreal journey through a labyrinth of tunnels in the trash and homemade booby-traps that lasted a half hour, Langley led the officer to the bedroom where Homer was to be found.  What happened next is told in Sgt. Collins own words. “I switched on my flashlight, and there was Homer sitting up like a mummy.   He was on a cot, a burlap bag beneath him and an old overcoat on the foot of the cot, and he spoke directly to the officer.  “I am Homer Collyer, a lawyer.  I want your shield number.  I am not dead.  I am blind and paralyzed.”  Langley subsequently made a complaint to the police department about the incident, but no action was ever apparently taken on the matter.

In the matter of the Bowery Savings Bank, it seems that no repurchase offer was ever worked out, so in October, Supreme Court Justice Bernard Botein signed an order permitting the City Sheriff to evict the brothers from their brownstone.  This same judge’s decision, which had been issued in August, was now about to be carried out. The bank, still trying to not have to resort to force, repeatedly mailed eviction notices to the brothers, who never responded.

The Bowery Savings Bank was not to be put off indefinitely.  As the new owner of the building, they were required by the city to make repairs to the property according to the city’s building and sanitary codes.  At the end of September, they dispatched a crew of workmen to the house to begin carrying out the repairs that had been ordered by the Department of Health.  A number of police officers and patrol cars were sent to the scene to manage the inevitable crowd that had gathered, as it always did whenever any activity took place at the Collyer home.  As the workmen went about repairing a falling stone cornice, replacing missing window panes, and removing piles junk from the rear of the property, Langley Collyer called out to them from an upper story  window, demanding to know by what right they were trespassing on his property.  The contractor was then forced to stop work and obtain a copy of the city order, in order that the repairs might continue.

On November 19th, following the brothers’ repeated refusal to respond to various notices, the bank requested that the city sheriff carry out the eviction order and enter the house by force, if necessary and remove the brothers. In short order, at 10 o’clock, there showed up at the Collyer’s door two deputy sheriffs, Herman A. Murray and Gillespie Anderson, police captain Christian Zimmer of the 128th Street Police Station, Dr. Marshall Rose, sheriff’s physician, John Redfield of the Bowery Savings Bank, and Joseph and Herman Cohen, a father and son, respectively, who were both locksmiths.  Mr. McMullen, the Collyer’s attorney, met them there.  The group took turns pounding on the door for over an hour, but the only answers were echoes.  A crowd collected on the sidewalk, hoping to get a glimpse of what was going on at the “haunted house,” as it had come to be known in the neighborhood.

The locksmiths then tried for another hour, in vain, to force the lock on the large wooden front doors, but were unsuccessful because of all the rust and corrosion.  Going to the rear of the house, they were able to remove an iron grille-covered door leading to the basement with the help of the two deputies.  Here, they found themselves stymied again, as they found their way barred by a mass of wire netting, behind which was a solid mass of crates, barrels, and large tin canisters from floor to ceiling.  Seeking another entrance, they next moved on to another rear door, and tore away its rotted boards, only to find a further wall of garbage cans, trunks, crates, and pieces of rusted iron.  Breaking in yet another rotted door next to this one, they were met with a similar obstruction.

Covered with dust, and feeling frustrated, the team returned to the front of the building to form a new plan of action, and decided to now make their way into the building via a window.   One of the locksmiths, Joseph Cohen, swung up from the top of the front stoop and made his way to the ledge of one of the building’s high north windows, where he forced open the shutters.  He then broke a windowpane with a hammer, and climbed in through the now empty frame.  His son Herman stood outside the window on the ledge and peered in at his father, who by this time was half-choked with dust.  As with the other parts of the house encountered thus far, the room was filled to overflowing with various and sundry items – heaps of old sheet music, gilded picture frames, Christmas ornaments, broken plaster cherubs, piles of books, garden baskets, etc.  Joseph Cohen finally managed to work his way downstairs to the front entrance where he and deputy Murray were able to open a path near the door.  Clouds of choking dust enveloped them, making the going difficult, and breathing an effort.  They eventually opened a parlor door and made it into a hallway where they encountered further barricades.  Suddenly, they were greeted by a weary voice from out of the gloom, asking, “What is the meaning of this?”  Deputy Murray replied, “I have an eviction notice.”  Langley then asked him, “Is Mr. McMullen here?”  McMullen, who had by now worked his way to the barricade called out to his client, “They will put you out, Mr. Collyer, unless your keep the agreement.”  Langley replied, “Do what you think best.”  Following his attorney’s advice, Langley then borrowed a pen from the deputy, and signed a check for the full amount, thus ending the invasion.

But the Collyer’s troubles were not yet over. They came in for some further unwanted attention in February 1943, but this time from the Internal Revenue Service.  The IRS was now pursuing Homer for what it claimed was $1900 in income tax arrears plus interest that had accumulated over the previous twelve years.  Homer was notified that unless this sum was promptly paid, the house he owned at 2077 Fifth Avenue would be sold at auction on February 3rd.  This was the building across the street he had purchased with the intent to divide into rentable apartments.  The ever-patient Mr. McMullen hoped his client would come through at the last minute, as had happened previously, although the attorney had been unsuccessful in his attempts to contact the brothers.  On the day of the auction, the IRS representatives waited for over an hour beyond the scheduled auction time, and finally, the property was put up for bid.  When no bids were offered, and with Mr. McMullen present, the government took possession, although it was not eager to do so due to the poor condition of the property.  It was so rundown, that it hardly seemed worth the effort. Beyond the building being of little worth, there were also the problems of the cost of the auction itself, not to mention the $3,000 in back taxes on the property owed to the City of New York that had been unpaid since 1938.  According to the rules, the government would have to hold onto the property to allow Homer the chance to pay what he owed and get his property back.  He never paid, and it does not appear that the government ever went any further in the matter of taking possession of the building, as will be seen.

Over three years later, the Collyers once again found themselves in the news.  On July 23, 1946, two police officers, Daniel Pesek and John Killoran, while on radio car patrol, heard noises coming from 2077 Fifth Avenue.  Upon further investigation, the officers discovered two men stealing plumbing and electrical fixtures from the building.  The two patrolmen tussled with the vandals, capturing one of them, a homeless man named George Smith, aged 25.  Officer Killoran hurt his leg when he fell through a hole in the floor.  The officers then attempted to contact Langley in order to get him to swear out a complaint against the thief, but speaking to them through his locked door, he refused to do so.  Despite his lack of cooperation, Langley was named as the complainant, and notified that if he did not appear in court, the city would issue him a subpoena.  He still refused to cooperate, but after officer Pesek tried several times to serve him with the subpoena, he relented. It seems that time and again, only the threat of legal action could pry loose the reclusive Langley from the decrepit building he and his brother called home.  On July 27th, dressed in turn-of-the-century garments, he appeared in the city’s Felony Court as complainant against Smith.  What was particularly unclear about all this was that technically, the Collyers no longer owned 2077 Fifth Avenue.  Langley clearly did not accept all this, and prior to signing the complaint, he stated, “My invalid brother, Homer Lusk Collyer, and I still own that house and we have the keys to it.”  He added, “The government seized the property on the contention we did not pay income taxes, but we are going to sue and get that property back, because the government can’t demand income taxes from us when we had no income.”  The brothers had, in fact, never surrendered the keys to the building.  He went on to relate that this was the third incident in which he had had to go to court to swear out a complaint against criminal intruders at his home.

The last time either of the Collyer’s was seen alive, was the result of yet another tax problem with New York City.  It seems that the brothers owned two land parcels in Queens County, which they had inherited from their father.  The city had wanted this land for new streets and other purposes, and Langley, together with Mr. McMullen, had had a meeting about this with the city’s Corporation Counsel the previous October.  After Langley refused two summonses to testify before Supreme Court Justice Charles C. Lockwood, the land was condemned by the city, and the brothers were awarded $7500, which was substantially less than its appraised value.  Unfortunately, they would see none of this award, in any case, as the city claimed the brothers owed it $27,000 in back taxes.  Interestingly, a news article about this in the New York Times mentions that the brother’s only regular means of contact with the outside world was a crystal radio set.

Which brings us back to the beginning of our story on the morning of March 21st, 1947, with the police receiving the phone call from the mysterious Mr. Charles Smith.  The police had received a number of such calls over the years, but as usual, they were obliged to respond.  An officer was dispatched to the scene, but was unable to open the front door.  He then put out a call to Police Emergency Squad 6, which arrived on the scene at 10:00 a.m.  They began by cordoning off the Collyer’s house in order to hold back the crowd of curious onlookers, which grew as large as 600 people.  The officers began their search by using crowbars and axes to try to force an entrance into the house.  They broke their way through an iron grille-covered door to the basement in the front of the house, but as had happened in the past, they immediately found themselves confronted by the usual floor-to-ceiling wall of crates, newspaper, furniture, and odd pieces of junk. 

For their second attempt to gain entry, the officers obtained ladders from the Fire Department and tried the windows on the upper floors. Unfortunately, many of the shutters on the windows couldn’t be opened, and it wasn’t until 12:10 p.m. that a patrolman William Barker was able to make his way through a second story window.  Patrolman Barker was not seen for several minutes, and on his return to the window, called to his fellow officers, “There’s a DOA here.”  In response, Detective John Loughery made his way up the ladder in order to view the body, as other officers began to batter in the wooden front doors with axes.  They were again faced with another massive obstruction of neatly tied bundles of newspaper, as well as cardboard boxes filled with assorted contents.  Although they tried to tear down the wall of debris, they were forced to admit defeat.  Meanwhile, Detective Loughery related what he had seen – the emaciated body of a white-haired man dressed in a tattered gray bathrobe, sitting upright, and tentatively identified as Homer Collyer.  The medical examiner, Arthur C. Allen, arrived at 3:45 p.m., and declared that the individual had been dead for approximately ten hours.

The next order of business was to locate Langley, who was nowhere to be found on the premises. It was reasoned that if he were within the house, he would have made an appearance by this time, as he usually did. Police were perplexed about how Langley was able to enter and leave the building, but neighbors stated that he regularly entered and left on his daily shopping trips via the front basement’s iron-bound door.  After their own struggle to enter, the officers refused to believe that this was possible.  According to the New York Times, the entranceway past the basement door contained “… an old stove, several umbrellas, numerous packages of newspapers, a gas mask canister, an old stove pipe, and a broken scooter.”  There were also numerous rats seen darting around and through the piled trash.  An inspection of the rest of the premises through various windows and around the second floor where they had entered revealed that the entire house was packed with debris of various kinds.  It appeared that the building was riddled with a maze of tunnels through which Langley had moved, pulling bales of newspaper in behind him, to prevent intruders from entering.  The police also found tin cans and piles of heavy debris wired together to form booby traps, in which the cans would sound an alarm, and a mass of junk would fall on the unsuspecting invader.

Homer Collyer’s body was taken away in a body bag to the police van that would transport it to the morgue.  An autopsy was to be conducted to determine the cause of death, although foul play was not suspected.  The crowd, milling around on the sidewalk hoping to see what was going on inside, and trading stories about their unusual neighbors, and the fabled wealth that was rumored to be hidden in the house. Some believed the numerous cardboard boxes that filled the house were stuffed with cash. As they searched further, police found newspapers lying around that dated from as far back as 1915.  Strewn everywhere were such things as hats, boxes of Christmas cards, a folding chair, a broken sled, and automobile seat, part of a piano frame, etc.  The police were careful to put everything back in place, including the materials they had removed to be able to enter the building.  They then boarded up the house at 5 p.m., at which time, Attorney McMullen arrived on the scene.  He took charge of all papers, notes, and letters discovered there by the police, and stated to the press that he was sure his elderly client would soon be in touch with him.  He also quoted Langley as having said that they were entitled to live their own lives.

The next day’s papers puzzled over the missing Langley.  No one had any idea of where he might be found, with the exception of Mr. McMullen, who told reporters, “Your guess is as good as mine, but I think he is in the house, myself.”  Detectives from the 123rd Street station thought that he might still be out on one of his shopping trips to Brooklyn.  These were sometimes known to last as long as twenty-four hours, because he made the trip on foot.  Deputy Inspector Christopher Salsieder announced that if Langley did not show up by 1 p.m. on March 24th, a missing person’s alarm would be issued.  In the meantime, it was decided to not perform an autopsy, as the cause of death was believed to be the result of “atherosclerotic heart disease,” which, it was said, could be determined by external examination.  Later reports seem to indicate, though, that an autopsy was finally performed.

Of course, the usual publicity-seekers were quick to come out of the woodwork.  William Rodriguo, a sometime Democratic politician from Harlem, came forward, claiming to be the “Charles Smith” who had phoned the police, touching off this latest incident.  He stated that he had used a false name due to not wanting to get involved, but had later changed his mind.  He added a further touch of mystery to the story, telling police that he had been told of the Collyers’ deaths by an unknown man he had met in front of their house the morning of his phone call.

The next day, on the 23rd, the crowd outside the decaying brownstone had grown to several thousand people.  Langley had still not appeared, and the curious were hoping for a glimpse of him, or failing that, his remains. One man showed up with a shovel and began digging in the building’s front yard, but was removed by the police.  A stream of autos from as far away as New Jersey and Connecticut crawled by the building in a regular procession. The daily papers thirsted to know about the contents of the house, rumored for years to contain numerous grand pianos, a Model T, and a boat.  Inspector Joseph Goldstein of the Tenth Division speculated that a thorough search of the entire house would occupy a police emergency squad for three weeks.  They were to begin work later that day, following an inspection by the Department of Housing and Buildings and the Board of Health.  The strategy would be for police officers to begin with a search of the top floor, dumping the contents into the backyard.  It was decided that the items removed would not be taken away until the Public Administrator or an heir of the Collyers gave approval.  A relative of the brothers, William Collyer of Yonkers, turned up at the house that day, relating to reporters that his mother and sister had visited the brothers in 1928, and noted that the house, at that time, contained no furniture, but was already filled with quite a bit of debris.

The clearing of the building began the next day on the 24th.  This first stage of the operation, the clearing of the top floor, began that afternoon, headed by Inspector Goldstein.  After Mr. McMullen declared Langley missing at 1:15 p.m., and after officials from the two city departments declared the building safe to enter, the officers of Emergency Squad 6 began their task by sending over a ladder from an adjoining rooftop.  After climbing across, they broke open several skylights and a roof trapdoor, through which they entered the building.  Once inside, they smashed windows in order to get some badly-needed ventilation.  A large crowd, whose numbers now ran as high as 2,000 watched the spectacle from the street, windows, fire escapes, and rooftops, cheering each time a sizeable object was thrown into the yard below.  Among these items were a gas chandelier, the folding top of a horse-drawn carriage, a rusted bicycle, a child’s chair, an automobile radiator, dressmaking dummies, a sawhorse, a rusted bedspring, a kerosene stove, a doll carriage, a checkerboard, and numerous bundles of newspapers.  A team of sixteen men inspected each object as it was thrown out, looking for valuables and important papers to be saved.  They found enough ledgers, correspondence, and legal documents to fill eight crates which were taken to the West 123rd Street station to be looked over by someone from the Public Administrator’s office. 

At 3 p.m., Inspector Goldstein called off the search for Langley for that day, and sent his men to check out the basement.  They found the walls lined with ceiling-to-floor bookcases containing over 2,000 dust-covered volumes, among them numerous books on the law and engineering.  Reporters and a family member were allowed to have a look around, and among the newspapers and cardboard boxes there were as many as five pianos.  With much effort, the officers cleared a path to a stairway, but were unable to open up the stairway itself.  While clearing this area, they stumbled on a generator, which may have been used to produce electricity.  Some of the debris removed was piled in the front areaway, and included a kiddy car, three women’s hats, a box of curtain rings, a green toy bus, some lead pipes, and a Metropolitan Opera program from 1914.  At 4 p.m., the Emergency Squad forced their way into the first floor.  Aided by searchlights powered by a portable generator, they made out a mahogany mantelpiece containing a large cracked mirror resting against a wall, an old RCA radio in a corner, and a large pile of furniture covered with dust standing in the middle of the floor.  The windows were covered with a filthy green drapery.  At this point, the search was ended for the day, with the police boarding up the windows, and piling the collected debris in a section of the yard surrounded by a tall iron fence.  Langley had still not been found, but the police were determined to return and finish their search.

The following morning at 10 a.m., the officers resumed their search.  It was now March 26th, with still no sign of the missing brother.  The day was particularly windy, blowing some of the old newspapers down the street, where they were snatched up by the ever-present crowd as souvenirs.  The overwhelming mass of debris the police removed from the house consisted largely of old newspapers, cardboard boxes, magazines, and pieces of wood.  Among the other assorted things uncovered that day included a nursery refrigerator, a beaded lampshade, a box of toy tops, and a toy airplane.  In the basement, they found the chassis of the fabled Model T Ford, thus confirming one rumor.  Important documents and papers continued to turn up, and these were removed to the 123rd Street station.  Any useless material that could be combustible was carted away in two truckloads by the Department of Sanitation, to be burned in its incinerators.  The first load weighed 6,424 pounds, and the second a bit less.  One rumor that was put to rest was the existence of a secret basement tunnel connecting the brother’s two buildings.  In addition to discovering a further maze of tunnels, several new booby-traps were found, consisting of things such as cans, or large tree limbs (as large as twenty inches in diameter), set to drop on unwary intruders.  The police were becoming increasingly convinced that Langley was not to be found alive on the premises, but they were determined to continue their search of the entire house.  Inspector Goldstein stated that the work would continue, “… until we are sure Langley Collyer is not in there, dead or alive.”  One theory was that his body might yet be found stuck in one of the booby-trapped tunnels. Assistant Chief Inspector Frank Fristensky, Jr. told the press that it would take them several more days before they had a clear picture of what the interior of the building contained.  Attorney McMullen had already become concerned about the brother’s tangled finances and their numerous bank accounts.  He estimated their worth to be in the six-figure range, not including the real estate they owned.

Work continued on the 26th, much as it had the day before.  The Emergency Squad began work at 10:00 a.m., halting briefly at noon when some confusion arose over whether proper legal authorization for their work had been obtained.  At 2:30 efforts to clear the top floor resumed, with the searchers tossing large amounts of material from the windows.  Relatives watching the operation from the street complained to the police that they were being less than careful in discarding things, and risked discarding items of value, as well as important papers.  This resulted in the officers being somewhat less energetic in clearing things out.  One particular item that attracted attention was the discovery of a .22 caliber pistol and holster, along with ammunition of various types.  This was turned over to the Police Ballistics Bureau.  A report submitted to the Public Administrator of New York County by Deputy Chief Inspector Conrad Rothengast stated that it was believed that Langley Collyer was dead based upon the facts that the brother had never been away from his home for more than twenty-four hours, and that the death of Homer would certainly have been cause for him to have at least contacted his attorney or his relatives.

The next day, the New York Times reported that the Surrogate, a Mr. James A. Delahanty, was unable to appoint Francis J. Mulligan, the Public Administrator as temporary administrator of the Collyer brother’s estate.  While everyone in the case agreed that Langley Collyer was most likely dead, Mr. Delahanty felt that definite proof was required for such a move to be made.  Various affidavits from such people as John R. McMullen and William Rodriguo were due to be submitted to Mr. Delahanty.  As of the 27th, police searchers still had been unable to turn up any trace of the missing Langley, although they did turn up a cigar box containing three more revolvers, a sixteen-gauge shotgun, a .22 caliber rifle, a .30 caliber rifle, a two-foot long bayonet, and a three-foot long cavalry saber.  Near the spot where Homer’s body had been discovered, they found another old cigar box containing thirty-four bank books from various savings banks.  Eleven of them had been canceled, and they showed savings totaling $3,007 dollars.

By March 28th, the police were having their hands full following up on numerous tips they were receiving, concerning the whereabouts of the missing Langley.  Officers were dispatched to the Borough Hall-Jay Street Station in Brooklyn after a conductor reportedly saw him board the subway there.  They also searched a group of boarded-up summer hotels and bungalows in Asbury Park, New Jersey; a place where the brothers had spent time between 1901 and 1907, and where it was thought Langley might be hiding.  In the meantime, Surrogate Delahanty finally appointed Francis J. Mulligan as temporary administrator of Langley’s estate, in addition to being made administrator of Homer’s.  Following these appointments, police halted their intensive search for Langley in the Fifth Avenue home, and decided, instead, to begin shipping the contents to an unused school building at 67 Rivington Street on the 31st, where they would be inspected for valuables and important papers.  Items of obvious value were to go to this location, while things that were obviously trash would be removed by the Department of Sanitation. 

On the following day, Mr. Mulligan, as administrator, visited the city morgue to claim the body of Homer.  Funeral arrangements were set for April 1st, to be held at Cypress Hills Cemetery in Queens, where the family owned a plot.  Police were still hard at work tracking down various leads.  Their latest took them to New Jersey.  A waitress in Tuckerton reported to police that she had served food to a customer who appeared to fit Langley Collyer’s description, which by then, had been widely distributed.  She added that the man had subsequently boarded a bus headed for Atlantic City.  Police in that city then proceeded to make a sweep of hotels and rooming houses.

Police recommenced their search on the 31st as planned, beginning at 8:30 in the morning.  It appeared that they would be able to clear about one room per day, and there were an estimated twelve rooms in the building.  The workforce at the house now consisted of two detectives and five laborers hired by Mr. Mulligan.  Their work concentrated on the front basement room, which was found to hold 3,000 books, numerous telephone directories, a Steinway piano, a horse’s jawbone, a Model T Ford’s engine block, numerous campaign buttons, and large amounts of newspaper, as usual, tied up neatly in bundles.

Homer Collyer’s funeral was held on April 1st, but of the fifty-three people who were present, only two actually knew him.  Both were neighbors.  Seventeen cousins of the Collyers were also in attendance.  John R. McMullen also attended, hoping that perhaps that Langley would appear at last.  Said Mr. McMullen to the press, “I had hopes until the last minute that Langley would be here if he were alive.”  When questioned if he believed Langley was still alive, he replied, “One guess is as good as another.”  The police search for the missing brother continued.  They sent out 500 pictures of him to every New York City police precinct, and also to the police in eleven states.  Efforts to clear the house were now in the second day.  The detectives and laborers continued their methodical work.  By the end of that day, nineteen tons of trash and objects had been removed.  The bulk of this came from the first floor hallway.  It was decided by the Public Administrator that Langley’s estate would pay for the use of a school building where valuable items from the home were being stored.  The Department of Housing and Buildings, meanwhile, ruled that the house would eventually have to be repaired or demolished.

On the 3rd, it was thought that the mystery of Langley’s whereabouts had been solved when a body resembling his description was discovered floating in the East Bronx in Pugsley’s Creek, but the excitement ended abruptly when the body was identified as an elderly man who had recently disappeared from a houseboat.

By the 7th of April, workers had removed approximately 103 tons of rubbish from the home, with twenty-two tons having been removed on that day alone.  Among the more interesting items found at that point were five violins that were to be sent for appraisal.  It was estimated by the supervising detectives that it would take another week to ten days to clear out the structure.  Down at the Missing Persons Bureau, Detective Charles Meyers offered the theory that “Everything points to Langley being dead in the building.”  He added that the results of an autopsy on Homer indicated that there had been no food or liquid in the invalid’s stomach. Detective Meyers concluded that, “Homer died for lack of care.” It simply did not add up that Langley would have allowed his brother to die unattended, or simply not show up at his funeral.

It would ultimately turn out that Detective Meyers was correct, as on April the 8th, Langley’s body was finally discovered, pinned by one of his own booby-traps in that same room on the second floor where Homer’s body was previously found.  The work of clearing the house that day had proceeded as usual, with workers from the Public Administrator’s office and police working their way through the second floor.  By 3:30 that afternoon, about seventeen tons of material had been removed and loaded onto Department of Sanitation trucks. Shortly afterwards, a detective, Joseph Whitmore emerged from the building and asked reporters waiting on the scene to follow him. He led them to a corner drugstore. Placing a call to his headquarters, he reported, “We’ve got him.”  He went on to explain that he, and detective John Loughery, had located Langley’s body.  Loughery added, “We were scraping around in the rubbish when we saw a foot sticking out.”

Within an hour, as word spread of the discovery of the body, a crowd of around 500 locals who had gathered to watch the day’s work at the house, swelled to over 2,000.  Police higher-ups, including Commissioner Arthur W. Wallander, soon arrived on the scene.  The commissioner commended detectives Whitmore and Loughery for their work in the investigation.

Thomas A. Gonzales, the medical examiner, spent a half hour examining the corpse.  He estimated that Langley had been dead at least two weeks, and possibly as long as four, and that the cause of death was either starvation or suffocation. Langley’s body lay on its right side, inside one of the two-foot-wide tunnels that was part of the maze he had created, his head turned toward the area where his brother’s cot had been, only eight feet away.  The room, itself, was filled with piles of newspapers, books, old furniture and tin cans.  The materials that had apparently trapped Langley were a suitcase, three metal bread boxes, and bundles of newspapers.  One particularly unpleasant detail was that the numerous rats that infested the house had gnawed at his partially decomposed body. Jacob Iglitzen, who also happened to be the druggist from whose store the phone call had been placed, subsequently identified the body.  He stated that he was able to recognize Langley’s face, although it was somewhat decomposed.  He also identified Langley’s clothes.  Overall, the evidence appeared to indicate that Langley had been killed by falling debris, and that his invalid brother, Homer, died from dehydration and malnutrition.  Attorney McMullen, told the press that he planned to confer the next day with Joseph A. Cox, an attorney for the city’s Public Administrator, concerning the handling of the brother’s assets, which were now estimated to be in the range of $100,000 distributed among various bank accounts and real estate holdings.  This finally laid to rest the popular notion that the brothers were multimillionaires.

The next day, on April 10th, the medical examiner concluded that Langley Collyer had been smothered by the debris, which had collapsed upon him, and had been dead for at least a month before his brother, Homer. A funeral was held the next day on the 11th at Cypress Hills Cemetery in Brooklyn.  The Reverend Dr. Charles T. Bridgeman, the assistant pastor of Trinity Church presided.  There were forty persons in attendance, including many cousins.

The saga of Langley Collyer was not quite finished, however.  A month later, the Commissioner of Housing and Buildings, Robert F. Wagner, Jr., announced that the house at 2078 Fifth Avenue still contained substantial filth and garbage, and that it remained “a distinct menace to health.”  He requested that the public administrator in charge of the brother’s estate, Francis J. Mulligan, clear out the building, in order that the property could be surveyed.  Findings would then be sent to the state Supreme Court so that the city could receive permission to demolish the building.  On June 30th, Supreme Court Justice J. Edward Lumbard signed the order for demolition.  An inspector from the Department of Housing and Buildings had noted that the “roof beams were water soaked, rotted, and defective,” and that all the floors throughout the entire building are sagging and defective.”  The city would next seek bids on the demolition of the building, and sometime after, the Collyer mansion was no more.  As a final chapter, the lot at the corner of 128th Street was publicly auctioned on March 1, 1951.

Unfortunately, Langley Collyer lived in an era when problems such as compulsive hoarding were regarded as eccentricities; something to be laughed at or ridiculed.  Assuming that even had he been able to come to grips with the fact that he had a serious problem, there is little that would have been done for it at that point in history.  Back in the first half of the 20th century, problems such as OCD were treated with psychoanalytic-type talk therapies, which produced little in the way of results.  Even today, we still read reports of individuals whose trash-filled properties have been condemned, or who were forced by law to clean up dwellings, which have been declared public nuisances or even health risks.  Municipal governments and the media still seem to not understand what is going on in these situations, and that these are individuals in serious need of help.

Sufferers of O-C disorders can be found to have varying degrees of insight.  They may differ in their ability to recognize that they have a disorder, or that their behaviors are not those of the average person.  It would appear that Langley Collyer, if he in fact had OCD, might have been one of those with a lower level of insight into his problem.  It may well be that he believed his hoarding behaviors served a valuable purpose of saving money; an ironic notion, considering that the brothers were relatively well off for the era they lived in.  It would also seem that in terms of reclusiveness, Langley and his brother became caught in an insidious loop.  That is, as their behavior moved further and further away from the norm, and people’s reactions to them became more critical and judgmental, they pulled in their boundaries and cut themselves off even more.  This, in turn, would most likely have served to make them seem even more abnormal to outsiders, resulting in even more harsh treatment by the outside world.

Nowadays, compulsive hoarding is regarded as treatable via behavioral therapy and medication.  Sufferers can learn to clean up their dwellings, and to keep them that way.  In behavioral treatments for OCD, individuals are encouraged to gradually confront situations that cause them to feel anxious, while at the same time, resisting the performance of the compulsions they ordinarily use to relieve their anxiety.  This approach is known as Exposure and Response Prevention.  In the case of hoarding, we are talking about gradually sorting out and discarding things that have been accumulated.  This may be done under the direct supervision of a therapist working on the scene, or by giving the individual weekly or daily homework assignments. 

Before the actual work of therapy begins the therapist makes a thorough behavioral analysis in order to determine what is being saved, how it is being saved, and where it is being saved.  This may involve either a home visit by the therapist to directly observe the scene, or the patient may bring in photographs showing views of all areas of the home.  Clutter and trash may be dealt with either by location or category, and in either case, is approached by first working on things that are easiest, and then working towards those that are more difficult.  For instance, the therapist may pick a particular room, closet, or area for the individual to begin clearing out, and then, over time, assign tasks designed to accomplish this.  Alternatively, as some people tend to save only certain types of things, therapy may start by earmarking these particular items for removal, wherever they may be found.  One example would be people who save excessive quantities of newspapers, magazines, etc. having to bundle and put out a certain amount of them each week.  Or in the case of those who have accumulated large amounts of clothing (old or new), having to throw out or donate a set number of articles between therapy sessions.  In addition to this activity, the therapist will work with the individual to establish a set of rules for what can and cannot be saved, and in the case of saved items, how to store or arrange them in a neat and organized fashion.  Some therapists will set up a rule governing how long an item may be kept without being used, before it is considered in need of disposal.  With my own patients, I have always used what I refer to as my “Three Year Rule.”  Under this rule, any item that has not been used in any way during the previous three years must be discarded.  There can be exceptions, of course, as in the case of family heirlooms, antiques, valuable collections, family photos, or useful tools, etc. Where people’s lives and dwellings have been disorganized for long periods of time, these rules are necessary to establish some kind of order, and to prevent the person from falling into chaos again.  In all cases, the ultimate goal is to get the sufferer to take personal responsibility for the state of their dwelling, and to accept that they really do have a problem.

Some people seem to think that the ultimate solution should be to descend upon a sufferer’s home, and forcefully clean the place out.  While this might remedy the immediate problem, nothing else really changes, and within a period of time, the dwelling will fill up with things again in the same way as before.  In addition, the anger and anxiety on the part of the sufferer that would result from such a remedy would probably only push them away from seeking help in the future.

The story of Langley and his unfortunate brother remains as a cautionary tale – an example of just how serious hoarding can become when left untreated.  With appropriate therapies, however, such extremes of behavior can be prevented from engulfing the lives of otherwise intelligent and potentially productive human beings.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

How To Manage Your Parents When You Have OCD: A Guide for Teens.

Having OCD definitely sucks! As if there isn't enough to deal with in life. Getting well is hard work too. All this would be enough on your plate, if it weren't for further problems that can come up when some people's families get involved in their OCD too. Sure, they mean well, and they think they are helping, but a lot of times they don't do the right thing because they just don't really understand what it's like. How could anybody understand something like OCD if they don't actually have it? Don't get me wrong; not everyone's family ends up adding to the problem, but it happens often enough that I decided to write this as a brief guide to help you if you have to deal with it. Families, as well as OCD sufferers, need to be educated. Here are some ideas I hope will help you to do this. When you are upset with the way your family is reacting to your OCD, the worst things you can do are to get angry at them, or else pull into your shell and not talk to anyone about it. Either way, nothing will get solved. Perhaps you can show your family this article. Here is a list of some of the way they can get it wrong and some understandings about them. Some of them may sound familiar to you. I call this list:

Common Mistakes Parents and Other Family Members Can Make

  1. Their idea of helping you with compulsions is to say, "Why don't you just stop."

    A lot of people think that the behaviors they see in OCD are just bad habits, and that with a little bit of willpower, you could simply choose to not do them any more. They may tell you to "Just stop," or ask, "Why don't you try thinking good thoughts instead?" They don't seem to understand that this is a problem of brain chemistry, and not any kind of weakness on your part. It may even be genetic. While you can learn to stop doing compulsions, it takes a lot of effort over a period of time, usually with expert help. You on't just throw OCD away like a pair of old sneakers. It needs to be made clear to family that this type of suggestion is unhelpful, and can only lead to making you feel worse, since you can't just stop these things cold the way everyone thinks you should be able to do. It also makes you feel more alone with the problem, since it is clear that they don't understand what you are going through. A good answer to give when they tell you to "Just stop," is "Don't you think I want to? Who would do this if they had a choice?"

  2. They assume that everything you do is a compulsion, and keep labeling your behavior this way every time they think you've done one.

    Unfortunately, when you've had OCD for a while, everyone tends to assume that every different looking behavior you are doing is a compulsion. Families can get overenthusiastic at times. They get too eager about wanting to see you get better, so they think that if they keep drawing your attention to what you are doing, you will stop. As if you don't know when you are doing compulsions. Right. Also, this becomes like nagging after a while, and sort of ties in with the "Just don't do it" advice. They need to be told that the only one who needs to recognize that you are doing compulsions is you, since you are the only one who can really do anything about them. If you had to depend upon others to tell you when you were doing these things, you would never learn to deal with them yourself. Also, no one likes to have their problems constantly pointed out to them. This is doubly true when other people keep getting it wrong.

  3. When you're in treatment, they watch you like a hawk, waiting for you to do a compulsion, and accusing you of not really trying.

    As I just mentioned, families can get carried away, thinking that your recovery is really their responsibility, and not yours. They think they have to be in charge of your therapy, when you are really the only one who can be in charge of it, if it is going to work. This can come across so negatively on their part that it can almost make you feel that they are always waiting for you to screw up and fail. I think a little praise for the things you are getting right would go a lot further, but I sometimes tell families that if they can't say anything positive, don't say anything at all. With my own patients, I tell family members that my patient's homework is their own business, and everyone else has to keep totally out of it. The family's main homework assignment is to leave the person to do what they have to do. It is important to say something like, "The only one who really needs to be able to tell if I am doing a compulsion is me, since I'm the only one who can do anything about it." It has to be the patient's total responsibility. The goal is to learn to manage yourself and your disorder. Even if someone else could constantly monitor you, what would happen when they weren't around?

  4. If you are in treatment, they assume you are not going to do your therapy homework, and keep nagging you to do it. If they don't think you are progressing fast enough, they may even threaten to stop your treatment because you aren't working hard enough, and it is costing them a lot of money.

    This is pretty typical of parents who aren't very trusting, and who automatically assume that you are always looking for the easy way out. They can be suspicious, quick to blame, and tend to set unrealistically high standards without taking your abilities into account. They also tend to be kind of controlling. I think that parents of this type need to realize that threats and nagging are no way to motivate someone. Getting recovered is hard work, even when someone is motivated. I have actually seen some people sabotage their own treatment, just to teach their families to leave them alone. I have also seen some people get so discouraged at all the criticism that they just feel like giving up. I have always believed that people will rise or fall to whatever level of expectations you have for them. If you expect a person to do well, it is more likely that they will. If you expect nothing, then that is what you will probably get.

  5. If you accomplish anything, instead of encouraging you, they're quick to point out all the other things you still can't do yet.

    I like to think of those who do this as the "glass-is-half-empty people." They seem to mostly concentrate on the negative, and ignore the positive. They tend to be perfectionists, as well as pessimists. Either you are getting it all right, or else you are totally failing. In OCD, there can sometimes be a tendency to think in all-or-nothing, black-and-white ways as a part of the disorder. I don't think that sufferers need encouragement from their families to be even more like this. They also don't seem to realize that overcoming OCD is a difficult chore, and it isn't always easy to keep your morale up. It can really get you down, and this kind of negative focus is likely to make you feel like giving up because you can come to believe you will never succeed. No one likes to have their faults constantly pointed out to them, and it serves no good purpose to only emphasize what still remains to be done.

  6. If you are in therapy, and show some improvement, they ask you how long it's going to take until you are totally recovered, or complain that it is taking too long.

    There can be several reasons for this kind of behavior in parents. One is that they just don't know a lot about what therapy for OCD involves, and are unrealistic about how long it should take to recover. They see a little improvement, and they suddenly expect that you will instantly change everything. They want you to get well yesterday. The person treating you can help educate them about this. Another possibility is that they are perfectionists, and think that everyone should overcome their problems instantly, no matter how serious, or how long the professional say it should take. They just want what they want. The reality is, that everyone in treatment gets well only at his or her own pace, and not at someone else's. It doesn't matter what anyone else wants. You really can't compare any two people who are working on their recovery. 

  7. If you slip up and do a compulsion, they tell you that you're not trying, and that you'll never get better.

    Parents in this category don't seem to be aware that one of the main things about therapy for OCD or any serious problem is that it doesn't always go in a straight line. There can be many potholes and detours on the road to recovery. No one ever learns a new set of skills without making mistakes, or taking a step backward now and then. No one is perfect, neither in therapy nor in anything that human beings commonly do. In fact, there are many people who have learned more about getting well from some of their mistakes and slip-ups than from the things they got right. I can honestly say that in over twenty years of doing therapy, I have never actually met anyone who recovered from OCD without getting it wrong now and then. You can ask family members, "If you went out to learn a new skill such as playing tennis, would you expect to play a championship game your first week on the tennis courts?" Doing behavioral therapy means learning a whole new set of skills, and really is 't any different. You can also share this example with family members who expect you to get well instantly.

  8. They blame the family's troubles on you, and tell you how much easier their lives would be if it weren't for your OCD.

    Sometimes, when a person's OCD is bad enough, it affects the lives of everyone in a family. Your symptoms may have forced family members to do compulsions with you, answer your questions, and do everyday things that you could normally do if you didn't have OCD. They may have also been forced to cancel things they would have liked to do, give up their free time, not been able to go places, or say certain things. This can cause anger and resentment to build up on their part. Family life can get pretty tense. What they may really be angry at is your OCD, but unfortunately, they may be mistakenly angry with you. They may even feel, at times, like you are trying to make their lives difficult on purpose. None of this is true, and they are mistaken, of course, but then, the people who live with you are only human. What they should really be telling themselves is, "We really dislike your OCD and wish you didn't have it." Unfortunately, what may get communicated is "We don't like you because you have OCD." They need to not learn to confuse you, the sufferer, with the disorder. It should really be everyone against the OCD, and not against each other.

  9. They keep constantly reminding you about all the bad times or scenes your OCD has caused in the past.

    I think that the only place a person can really live in, is the present. The past is gone and out of reach, and the future is always unknown. Bringing up old hurts or bad scenes can only make everyone miserable and won't change anything at all. You can tell them, "I really feel bad about the past too. I wasn't well and was only doing the best I could in a bad situation. Maybe we could all have done better. Why don't we all try to let go of things we can't change, and try to make things better for ourselves now." My advice is, "Don't let your past cripple your present. Let it go."

  10. They have become involved in your compulsions and help you to do them, or they do things for you that your symptoms keep you from doing for yourself.

    Getting your family members involved in helping you to do compulsions, to get answers to your questions, or avoid doing or touching things that make you anxious may seem like solutions to your obsessive fears when you first start. Unfortunately, after a while, these things become a whole new set of problems. You start depending on everyone so much that you can become unable to get through a day on your own. Your family starts to feel trapped, because if they don't cooperate, you might find yourself getting very upset and angry with them. You may feel resentful, because no on likes to constantly be dependent upon others. This can lead to fights, insults, shouting matches, etc. This is clearly not a good thing, because being dependent this way also keeps you locked into your illness. For you to get well, your family will need to learn to stop doing these things and to allow you to learn to face your fears on your own. In most cases, it will take a trained therapist to help them to gradually do this. Family members are taught that rather than solving the problem, they have become part of it, and that you will never recover as long as they are involved with your disorder in this way. You, yourself, may not be really eager to give up this help, but there really is no other way.

  11. When they get annoyed at you, they threaten you with things that your OCD makes you anxious about (e.g. - that they will contaminate things, mess things up, throw things out, etc.)

As I mentioned earlier, when OCD enters a family's life, anger and resentment can sometimes be part of the picture. Unfortunately, some families handle this less well than others. One of the ways in which this can go really bad is when family members use a sufferer's fears against them as a way of punishing them for annoying them with their symptoms or for other resentments. They may threaten to contaminate things you use, mess up things you have arranged, throw out things you have hoarded, etc. They may even go so far as to actually do some of these things. Family members need to understand that this is simply cruel, abusive, and something for which there is no excuse. You need to remind them how much this hurts, and how it is like kicking you when you are down, and punishing you for something that you didn't ask for. As difficult as your OCD may be for everyone you live with, it simply isn't your fault. You are not to be blamed.

Overall, you can tell your parents and other family members you're doing the best you can. If they have discussed OCD with a trained therapist, remind them of what they've learned, or have them look at sites like this one. This way, they will have a better idea of what to do, and what not to do, and also see that you (and they) are not alone.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

How Much Is Too Much? Ethical Exposure And OCD.

Following a panel discussion at the 2009 national meeting in Minneapolis, entitled “The Ethics  Of Exposure: When And Why to do E&RP, And Is There Such A Thing As Too Far?” it seemed to me that this was a topic that merited some follow-up in the newsletter as a matter of importance to OCD consumers.  Although I kept a record of what was said, I neglected to note who said what, so I will simply credit the panel members, Drs. McGrath, Mansueto, Grayson, Zasio, Gorbis, Pollard, Hale, and Reimann with having contributed some of the points I will be mentioning here.  This isn’t a transcript of what was said, but will instead, simply discuss the issue in a more organized way, together with some thoughts of my own.

The whole topic of how behavior therapy for OCD should best be conducted is an important one.  Behavioral therapy (BT) for OCD first began with the publication of Victor Meyer’s 1966 study, which was a single case report in the journal, Behavior Research and Therapy.  Since then, the field has greatly expanded with many different professionals weighing in with their studies and views on how therapy should best be conducted.  Behavioral therapists do not all work from the same ‘cookbook.’  They each put their personal stamp on a set of accepted principles.  What we have now is a whole range of individual approaches to BT, varying from the conservative to the more radical.

The concept behind what we do in therapy for OCD is that sufferers can learn to overcome their fears by gradually facing those fears, and challenging their theories about what will happen if they do.  There is no way someone can overcome anxiety without facing it in one way or another.  The question here is how they can best do this – i.e., how far to go in facing fears, and how rapidly it should be done.  This is not a matter to be taken lightly, as it can spell the difference between success and failure for each patient.

For example, a new patient related to me how he had dropped out of his previous treatment after the first exposure session.  He had been taken out into the community for the first day of what was to be a three week course of intensive treatment.  The therapist was a fairly new one, and she asked him to touch several things in a public place.  He recounted, “The things she asked me to touch were right at the top of my list of fears, even though this was our first treatment session.  I did what she said, even though I was totally freaked out.  I wanted to say something, but since she was my therapist, I didn’t think I should be telling her how to do her job.  I decided to not go back the next day.  It took me several days afterwards before I could calm down.”  While it could be said that this was simply a mistake on the part of a novice therapist, it also points up a more important issue.  Therapists relative to patients are in a position of authority.  They have power and influence in the therapist/patient relationship.  Patients are paying the therapist, willingly putting themselves in their hands, and hoping to get approval and positive feedback about their progress.  This authority, like all authority, can be misused, no matter how well-intentioned.  While it is true that patients have some shared responsibility for their own treatment, and should ideally give the therapist feedback, some may not have the confidence or assertiveness to question or challenge what they are being asked to do.  This is because they may be in a state of depression, be distracted by their thoughts, be in an anxious state, or feel weak and poorly about themselves.  It is also the responsibility of the therapist to be able to read the patient, and to create a treatment plan that is practical and realistic for that particular person, and tailored to their specific needs.  Therapists can push patients too far in different ways for a variety of reasons.  Inexperience is the most obvious one, and possibly the most common.  Other reasons might include a kind of zeal and perfectionism about treatment where they have to go in with all guns blazing.  Some may even take a strange kind of pride in being more radical and creative than other therapists.  They may even brag to colleagues about how far they have gone with patients.  Others may simply be insensitive to patient distress or have poor clinical judgment.     

What is being advocated here is for therapists to take a reasonable and humane approach.  It all begins with good training and supervision of therapists in training.  Beyond this, there are several other points that should be made here.  The importance of the proper assessment of patients cannot be stressed enough.  Only by making a careful behavioral analysis of each patient’s symptoms can we know exactly what we are treating, the circumstances, the function of each symptom, and the severity of each symptom, both individually, and relative to all other symptoms.  One of the reasons we do this is to be able to create a rank ordering of symptoms from the lowest level to the highest.  Therapy tasks are then drawn from such a list.  The goal in treatment is to gradually build feelings of success and effectiveness as patients work their way up the list, and see that they can gain control over their disorder.  Guiding patients to then work on their tasks is the next step, and it is a really crucial one.  There is a fine line between encouraging someone who is merely overcautious, and pushing someone who simply isn’t ready to do something.  This should be done with finesse rather than brute force or coercion.  It could be seen as the difference between attacking the problem with a scalpel, versus a sledgehammer.  It also calls for creativity and even humor at times.  By this, I don’t mean being creative in going further than any other therapist.  It is creativity in finding exposures that are the most efficient and intelligent, and that cause the patient to face no more anxiety than is really necessary.  It is creativity in pacing the patient’s overall therapy, from the first exposure to the last.  It is why we don’t begin to teach people to swim by throwing them into the deep end of the pool.  Therapists need to really focus on the difference between graduated exposure, rather than sudden total immersion, although a kind of gradual and total immersion is the ultimate and long-term goal.  There are times when negotiation with patients is called for, as a way of gradually approaching therapeutic goals.  Patients, after all, need to be partners in their own treatment, and should always be regarded as such.  If something cannot be done in one step, perhaps it can be divided into two or more.  Therapists should be asking themselves, “What are all my options?  How can I do the most with the least?”  If it appears, at first, that a fairly high level exposure or one that the patient is reluctant to do is called for, the therapist needs to consider, “Is there some other way?  Is there another way I can get the patient recovered without this?”  If there genuinely is no other way, this must be clearly explained to the patient.  This does not mean that therapists must be timid or hesitant when it comes to treatment.  There are clearly times when boldness and decisiveness are called for, but these must be guided by logic and judgment.

Some particular areas of OCD treatment that need to be handled with care would include:

  • Religious scrupulosity

  • Thoughts of harming others (morbid obsessions)

  • Obsessions about suicide

  • Compulsive perfectionism (when directed by the patient at their own treatment) 

When treating religious scrupulosity, we walk a fine line between giving effective assignments and infringing on people’s deeply held beliefs.  It can sometimes help to get advice on this from religious authorities.  In the case of treatment assignments for murderous or violent thoughts, we must beware of how much risk we are asking patients to take with themselves or others.  Suicidal obsessions must be carefully assessed so the therapist can determine that they are merely obsessions and not symptoms of a concurrent major depression.  Certain patients need to be protected from themselves.  They may have doubtful obsessions telling them that if they do not do therapy perfectly, they may never recover.  This can sometimes lead them to go to extremes of their own in doing assignments, sometimes going way beyond what was intended by the therapist.  This needs to be recognized in patients, and they usually need to have their assignments clearly spelled out for them, with limits clearly defined.  They may even have to be exposed to the obsessive thought that they are doing therapy imperfectly and will therefore not recover.

Let me conclude by saying that beyond our main principle of doing patients no harm, there are several other principles that therapists might want to consider including as part of their approach to treatment.  These would include:

  • Never ask a patient to do anything that might humiliate them.

  • Do not ask patients to do anything that would violate the true principles of their religious beliefs.  Do not hesitate to get advice from religious authorities on these matters.

  • Do not use a more extreme approach if a less extreme one is available.  If possible, try to divide up tougher assignments into manageable bites

  • Before asking patients to do something, be sure to first determine if the patient is ready or willing to do it.

  • Give patients choices and encourage them to be partners in their own treatment, rather than simply dictating to them.  They are more likely to carry out assignments that they have had a hand in choosing.

  • Don’t do assignments along with patients if doing so would compromise the therapist/patient relationship.

  • Overall, be humane and treat patients the way you, yourself, would want to be treated.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

How Do I Know I’m Not Really Gay? An Update.

O­­­ver the years, I have written quite a number of articles about different forms of OCD.  Because the variations are endless, there always seemed to be a great hunger for information on the part of sufferers trying to understand what was happening to them, specifically.  Interestingly enough, the article that has always generated the most e-mails and phone calls was one titled, “How Do I Know I’m Not Really Gay?”  The OCF published this in their newsletter in 1995.  Back when I wrote this article, it was my belief that although no one had ever written about it, this form of the disorder was far more prevalent than most people realized.  The twelve years since then have convinced me even further that this is so. 

Fortunately for sufferers, the general awareness of this type of OCD has increased over the years, and there is less of a sense of isolation than formerly.  There are now several internet chat groups and bulletin boards that can be readily accessed, and a quick web search will turn up articles on the subject, where none existed in the past.  Within my own practice, there is rarely a time these days when I am treating fewer than six or more people for this form of the disorder.  I think it would be reasonable to say that after all this time an update might be in order. 

OCD, as we know, is largely about experiencing severe and unrelenting doubt. It can cause you to doubt even the most basic things about yourself – even your sexual orientation.  A 1998 study published in the Journal of Sex Research found that among a group of 171 college students, 84% reported the occurrence of sexual intrusive thoughts (Byers et al, 1998).  In order to have doubts about one’s sexual identity, a sufferer need not ever have had a homo- or heterosexual experience, or any type of sexual experience at all. I have observed this symptom in young children, adolescents, and adults as well. Interestingly, Swedo et al., 1989 found that approximately 4% of children with OCD experience obsessions concerned with forbidden, aggressive, or perverse sexual thoughts. 

 Although doubts about one’s own sexual identity might seem pretty straightforward as a symptom, there are actually a number of variations.  The most obvious form is where a sufferer experiences the thought that they might be of a different sexual orientation than they formerly believed.  If the sufferer is heterosexual, then the thought may be that they are homosexual.  If, on the other hand, they happen to be homosexual, they may obsess about the possibility that they might really be straight.  Going a step beyond this, some sufferers have obsessions that tell them that they may have acted, or will act on their thoughts.  A variation on doubt about sexual identity would be where the obsessive thought has fastened onto the idea that the person simply will never be able to figure out what their sexual orientation actually is.  Patients will sometimes relate their belief that, “I could deal with whatever my sexuality turns out to be, but my mind just won’t let me settle on anything.” Some people’s doubts are further complicated by having such experiences as hearing other people talking or looking in their direction and thinking that these people must be analyzing their behavior or appearance and talking about them – discussing how they must be gay (or straight).

For those with thoughts of being homosexual, part of the distress must surely be social in origin. Let's face it: gay people have always been an oppressed minority within our culture, and to suddenly think of being in this position and to be stigmatized in this way can be frightening. People don't generally obsess about things they find positive or pleasurable. OCD has an insidious way of finding whatever thoughts will bother a person the most.  I have sometimes wondered if those who experience the most distress from such thoughts as these do so because they were raised with more strongly homophobic or anti-gay attitudes to begin with, or if it is simply because questioning one's sexual identity can be such a basic doubt. I suppose this remains a question for research to answer. The older psychoanalytic therapies often make people with this problem feel much worse by saying that the thoughts represent true inner desires. This has never proven to be so.

Doubting something so basic about yourself can obviously be quite a torturous business.  When I first see people for this problem, they are typically engaged in any number of compulsive activities, which may occupy many hours of each day.   These can include:

  • Looking at attractive men or women, or pictures of them, or reading sexually oriented literature or pornography (hetero- or homosexual) to see if they are sexually exciting

  • Imagining themselves in sexual situations and then observing their own reaction to them

  • Masturbating or having sex repeatedly just for the purpose of checking their own reaction to it.  (This may also include visiting prostitutes in more extreme cases)

  • Observing themselves for evidence of "looking", talking, walking, dressing, or gesturing like someone who is either gay or straight.

  • Compulsively reviewing and analyzing past interactions with other men or women to see if they have acted like a gay or straight person

  • Checking the reactions or conversations of others to determine whether or not they might have noticed them acting inappropriately, or if these people were giving the sufferer strange looks

  • Reading articles on the internet about how an individual can tell if they are gay or straight to see which group they might be most similar to

  • Reading stories by people who “came-out” to see if they can find any resemblance to their own experiences

  • Repeatedly questioning others or seeking reassurance about their sexuality

Compulsive questioning can frequently take place, and usually involves others who may be close to the sufferer. The questions are never-ending and repetitive. Some of the more typical questions sufferers are likely to ask can include those in the following two groupings:

For those who obsess about not knowing what their identity is:

  • How do I know whether I prefer women or men? 

  • Maybe I really don’t know what I am. 

  • Maybe I’ll never know what I am.

  • How does anyone tell what sex they really are?

  • How will I ever be able to tell for certain? 

  • What will happen if I make the wrong choice and get trapped in a lifestyle that really isn’t for me?

For those who obsess that they are of the opposite sexual orientation:

  • “Do you think I could be gay (or straight)?”

  • “How can I tell if I'm really gay (or straight)?”

  • “At what point in their lives do people know what their orientation is?”

  • “Can you suddenly turn into a homosexual (or heterosexual) even if you have never felt or acted that way?”

  • “Did I just act sexually toward you?”

  • “Do I look (or act) gay (or straight) to you?”

  • Did I just touch you?”

  • If I get sexual sensations when viewing sexual material of an opposite orientation does it mean I am gay (or straight)?”

In terms of the last question above, one of the most difficult situations for this group of sufferers is when they experience a sexual reaction to something they feel would be inappropriate.  A typical example would be a heterosexual man who experiences an erection while looking at gay erotica.  It is important to note that it is extremely common for people to resort to all sorts of fantasy material concerning unusual or forbidden sexual behaviors that they would never actually engage in, but that they do find stimulating. Under the right circumstances, many things can cause sexual arousal in a person.   The fact of the matter is that people react sexually to sexual things.  I am not just talking about people with OCD here, but about people in general.  I cannot count the number of times that patients have related to me that they have experienced sexual feelings and feelings of stimulation when encountering things they felt were taboo or forbidden.  This, of course, then leads them to think that their thoughts must reflect a true inner desire, and are a sign that they really are of a different sexual orientation.  This reaction is strengthened by the incorrect belief that homosexual cues never stimulate heterosexuals.  One further complicating factor in all this is that some obsessive thinkers mistake feelings of anxiety for feelings of sexual arousal.  The two are actually physiologically similar in some ways.

Things become even more complicated by a number of cognitive (thinking) errors seen in OCD.  It is these errors, which lead O-C sufferers to react anxiously to their thoughts, and then to have to perform compulsions to relieve that anxiety.  Cognitively oriented OCD theorists believe that obsessions have their origin in the normal unwanted intrusive thoughts seen in the general population.  What separate these everyday intrusions from obsessions seen in OCD are the meanings or appraisals that the OCD sufferers attach to the thoughts.  As I like to explain to my patients, their problem is not the thoughts themselves, but instead it is what they make of the thoughts, as well as their attempts to relieve their anxiety via compulsions and avoidance.

Some typical cognitive errors made by O-C sufferers include:

  • I must always have certainty and control in life (intolerance of uncertainty)

  • I must be in control of all my thoughts and emotions at all times

  • If I lose control of my thoughts, I must do something to regain that control

  • Thinking the thought means it is important and it is important because I think about it

  • It is abnormal to have intrusive thoughts, and if I do have them, it means I’m crazy, weird, etc.

  • Having an intrusive thought and doing what it suggests are the same, morally

  • Thinking about doing harm, and not preventing it is just as bad as committing harm (also known as Thought-Action Fusion)

  • Having intrusive thoughts means I am likely to act on them

  • I cannot take the risk that my thoughts will come true  

The effect of the questioning behavior on friends and family can be rather negative, drawing a lot of angry responses or ridicule after the thousandth time. One young man I know questioned his girlfriend so often that she eventually broke up with him and this added to his worries since he now wondered if she did so because he wasn't a "real man."

The compulsive activities sufferers perform in response to their ideas, of course, do nothing to settle the issue.  Often, the more checking and questioning that is done, the more doubtful the sufferer becomes.  Even if they feel better for a few minutes as a result of a compulsion, the doubt quickly returns.  I like to tell my patients that it is as if that information-gathering portion of their brain is coated with Teflon©.  The answers just don’t stick.

In addition to performing compulsions, one other way in which sufferers cope with the fears caused by the obsessions is through avoidance, and by this I mean directly avoiding everyday situations that get the thoughts going. This can involve:

  • Avoiding standing close to, touching, or brushing against members of the same sex (or opposite sex if the sufferer is gay)

  • Not reading or looking at videos, news reports, books, or articles having anything to do with gay people or other sexual subjects

  • Never saying the words "gay," "homosexual," (or “straight”) or any other related term

  • Trying to not look or act effeminately (if a man) or in a masculine way (if a woman) (or vice versa if the sufferer is gay)

  • Not dressing in ways that would make one look effeminate (if a man) or masculine (if a woman) (again, vice versa if the sufferer is gay)

  • Not talking about sexual identity issues or subjects with others

  • Avoiding associating with anyone who may be gay or who seems to lean in that direction (if the sufferer is heterosexual)

Needless to say, it is crucial for all OCD sufferers to understand that there is no avoiding what they fear.  Facing what you fear is a way of getting closer to the truth. 

The purpose of compulsions is, of course, to undo, cancel out, or neutralize the anxiety caused by obsessions. They may actually work in the short run, but their benefits are only temporary.  O-C sufferers cannot process the information they provide, and it just doesn’t stick.  It is sort of like having only half of the Velcro.   Also, it is important to understand that compulsions are paradoxical – that is, they bring about the opposite of what they are intended to accomplish.  That is, to help the sufferer to be free of anxiety and obsessive thoughts.

 I like to tell my patients that:

“Compulsions start out as a solution to the problem of having obsessions, but soon become the problem itself.”

 What compulsions do accomplish is to cause the sufferer to become behaviorally addicted to performing them.  Even the little bit of relief they get is enough to get this dependency going.  Compulsions only lead to more compulsions, and avoidance only leads to more avoidance.  This is really only natural for people to do.  It is instinctive to try to escape or avoid that which makes you anxious.  Unfortunately, this is of no help in OCD.

 Another problem that arises from performing compulsions is that those who keep checking their own reactions to members of the opposite or same sex will inevitably create a paradox for themselves. They become so nervous about what they may see in themselves that they don't feel very excited, and then think that this must mean they have the wrong preference. When they are around members of their own sex, they also become anxious, which leads to further stress and, of course, more doubts about themselves.  The flip side of this is when they look at things having to do with sex of an opposite orientation and then feel aroused in some way, which they then conclude to mean that they liked it, which means that they are gay (or straight).  This is the mistake I referred to earlier when I stated that people react sexually to sexual things. 

People always like to ask if there are any new developments in OCD treatments.  Aside from a few new medications since the last article, treatment remains essentially the same.  The formula of cognitive/behavioral therapy plus medication (in many cases) is still the way to go.  The particular form of behavioral therapy shown to be the most effective is known as Exposure and Response Prevention (E&RP).

E&RP encourages participants to expose themselves to their obsessions (or to situations that will bring on the obsessions), while they prevent themselves from using compulsions to get rid of the resulting anxiety.  The fearful thoughts or situations are approached in gradually increased amounts over a period of from several weeks to several months.  This results in an effect upon the individual that we call "habituation."  That is, when you remain in the presence of what you fear over long periods of time, you will soon see that no harm of any kind results.  As you do so in slowly increasing amounts, you develop a tolerance to the presence of the fear, and its effect is greatly lessened.  By continually avoiding feared situations and never really encountering them, you keep yourself sensitized.  By facing them, you learn that the avoidance itself is the "real" threat that keeps you trapped.  It puts you in the role of a scientist conducting experiments that test your own fearful predictions, to see what really happens when you don't avoid what you fear.  The result is that as you slowly build up your tolerance for whatever is fear provoking; it begins to take larger and larger doses of frightening thoughts or situations to bring on the same amount of anxiety.  When you have finally managed to tolerate the most difficult parts of your OCD, they can no longer cause you to react with fear.  Basically, you can tell yourself, “Okay, so I can think about this, but I don’t have to do anything about it.”  By agreeing to face some short-term anxiety, you can thus achieve long-term relief.  It is important to note that the goal of E&RP is not the elimination of obsessive thoughts, but to learn to tolerate and accept all thoughts with little or no distress. I like to tell my patients that the goal is to learn to coexist with their thoughts.  This reduced distress may, in turn, as a byproduct, reduce the frequency of the obsessions.  Complete elimination of intrusive thoughts may not be a realistic goal, given the commonality of intrusive thoughts in humans in general.

Using this technique, you work with a therapist to expose yourself to gradually increasing levels of anxiety-provoking situations and thoughts. You learn to tolerate the fearful situations without resorting to questioning, checking, or avoiding. By allowing the anxiety to subside on its own, you slowly build up your tolerance to it, and it begins to take more and more to make you anxious. Eventually, as you work your way up the list to facing your worst fears, there will be little about the subject that can set you off. You may still get the thoughts here and there, but you will no longer feel that you must react to them, and you will be able to let them pass.

There are many techniques for confronting sexual and other obsessions that we have developed over the years.  Some of these techniques include:

  • Listening to 2-3 minute audio recordings about the feared subject

  • Leaving cell phone voice-mail messages for yourself about the feared subject

  • Writing 2 page compositions about a particular obsession (and then taping them in your own voice)

  • Writing feared sentences repetitively

  • Hanging signs in your room or house with feared statements

  • Wearing T-shirts with feared slogans

  • Visiting locations that will stimulate thoughts

  • Being around people who will stimulate thoughts

  • Agreeing with all feared thoughts, and telling yourself they are true and represent your real desires

  • Reading books on the subject of your thoughts

  • Visiting websites that relate to your thoughts

These are some typical Exposure therapy homework assignments I have assigned to people over the years:

  • Reading books by or about gay persons, or gay romance novels.

  • Watching videos on gay themes or about gay characters.

  • Visiting gay meetings, shops, browsing in gay bookstores, or visiting areas of town that are more predominantly gay.

  • Wearing a T-shirt at home with the word ‘gay’ on it.

  • Wearing clothes in fit, color, or style that could possibly look effeminate for a man, or masculine for a woman.

  • Looking at pictures of good-looking people of your own sex and rating them on attractiveness.

  • Reading magazines such as Playboy if you are a woman or Playgirl if you are a man.

  • Reading coming-out stories on specialized websites.

  • Standing close to members of your own sex.

  • Doing a series of writing assignments of a couple of pages each that suggest more and more that you actually are gay or wish to be. 

Some typical Response Prevention exercises might include:

  • Not checking your reactions to attractive members of your own sex.

  • Not imagining yourself in sexual situations with same-sex individuals to check on your own reactions.

  • Not behaving sexually with members of the opposite sex just to check your own reactions.

  • Resisting reviewing previous situations where you were with members of the same or opposite sex or where things were ambiguous to see if you did anything questionable.

  • Avoiding observing yourself to see if you behaved in a way you imagine a homosexual or member of the opposite sex would. 

Some typical Exposure homework for those with doubts about their own sexual identity might include:

  • Reading about people who are sexually confused

  • Reading about people who are transgendered

  • Looking at pictures of people who are transgendered or are transvestites

  • Telling yourself and listening to tapes telling you that you will never really know what you are  

Some corresponding Response Prevention exercises to go along with the above would be:

  • Not checking your reactions when viewing members of either sex

  • Not acting sexually to simply test your reactions

  • Avoiding reviewing thoughts or situations you have uncertainty about

Many of the above therapy tasks can sound scary and intimidating.  Obviously, you don’t do these things all at once.  Behavioral change is gradual change.  Recovering from OCD is certainly not an easy task.  We rarely use the word ‘easy’ at our clinic.  It takes persistence and determination, but it can be done.  People do it all the time, especially with proper help and advice.  My own advice to those of you reading this would be to get yourself out of the compulsion trap and get yourself into treatment with qualified people.  

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

How Do I Know I'm Not Really Gay?: OCD And Sexual Identity Obsessions

In the last century, Obsessive-Compulsive Disorder (OCD) was known as "The Doubting Disease." This is an entirely accurate description, as someone who suffers from it can have doubts about some of their most basic human experiences. These doubts can range from being uncertain of whether or not you have just moved a part of your body to wondering whether or not you are the parent of your own child.

All these different and unpleasant doubts are disturbing in a variety of ways. One of the most fundamental is a type in which an obsessive individual begins to have doubts about his or her own sexual identity. This is not the same as the ordinary doubts people sometimes have about themselves and eventually answer in their own minds. With obsessions, questions are constantly repeated in a sufferer's mind, and they refuse to quit. There are never any answers that stick. Those with obsessions recognize that these doubtful thoughts are not their own, and try to resist them. "Could I be gay?" is a common question they ask themselves, or the reverse, as in the title above. The frequency and intensity of these thoughts can worsen under stress or during idle moments, and have a habit of happening at the worst possible times.

As obsessive thoughts go, this type is probably a lot more common than most people realize. Sufferers find them extremely difficult to reveal or discuss, due to the obvious embarrassment they feel. They live in isolation and shame as a result. This is true of most sexual obsessions.

Please Note: Let me say here that I am not referring to those who actually are gay. I am talking about someone having an obsessive thought that happens to be about being gay. I lean toward the theory that sexual identity is imprinted before birth and that a person is really not given any choice in the matter, one way or the other. Homosexuality would seem to be a naturally occurring variation among humans and, as such, it is neither good nor bad. I'm sure there are some who would differ with me on this point. When we talk about treating these thoughts, we are only referring to working with those who truly are heterosexual and who only obsess about being gay.

In order to have such a thought, a sufferer need not ever have had a homosexual experience, or even any sexual experience at all. I have observed this symptom in both children as well as in adults. It may begin in adolescence or crop up later in adulthood. As with other obsessions, the thought has a repetitious and nagging quality.

Part of the distress connected with these thoughts must surely be social in origin. Let's face it: gay people have always been an oppressed minority within our culture, and to suddenly think of being in this position and to be stigmatized in this way can be frightening. People don't generally obsess about positive subjects. I have sometimes wondered if those who experience the most distress from such thoughts as these do so because they were raised with more strongly homophobic or anti-gay attitudes to begin with, or if it is simply because questioning one's own sexuality can be such a basic doubt. I suppose this remains a question for research to answer. Older psychoanalytic therapies often make people with this problem feel much worse by saying that the thoughts represent true inner desires. This has never proven to be so.

Obsessions eventually lead to mental or physical compulsions. This is because compulsions relieve the anxiety caused by obsessions, at least for a little while, though they make things worse in the long run. Because compulsions are rewarding in this way, they tend to be repeated. In the case of homosexual obsessions, the most common compulsions people use to escape their fears are double-checking (especially mental self-checking), compulsive questioning, and avoidance.

Checking can include:

  • Looking at attractive men or women, to see if you are sexually attracted to them.         

  • Observing yourself while behaving heterosexually to see if you are really "enjoying" it.

  • Testing your mental and physical reactions with gay or straight porn.

  • Observing yourself to see if you "look", talk, walk, or gesture like someone who is gay.

  • Compulsively reviewing and analyzing situations you were in with other men or women to see if you acted like a gay person or acted sexually toward someone of the same sex.

  • Checking the reactions of others toward you to determine whether or not you were acting appropriately, or if  they were looking at you strangely.

  • Taking so-called tests online that supposedly test a person’s sexual orientation

Obviously, those who keep checking their own reactions to members of the opposite sex will create a paradox for themselves. They become so nervous about what they may see in themselves that they don't feel very excited, and then think that this must mean they are gay. When they are around members of their own sex, they also become anxious, which leads to further stress and, of course, more doubts about themselves.

Compulsive questioning usually involves others who may be close to the sufferer. The questions are never-ending and repetitive. Some typical ones are these:

  • Do you think I could be gay?

  • How can I tell if I'm really gay?

  • When do people know that they're gay?

  • Can you suddenly turn into a homosexual?

  • Did I just act sexually toward you? (Asked of a member of the same sex.)

  • Do I look gay to you?

  • Am I acting like a gay person?

  • Did I just touch you?

Obviously, no amount of this type of checking or questioning is ever enough to satisfy a sufferer for more than just a short time. As mentioned before, there may be some short-term relief from the anxiety, so this behavior tends to be repeated, and it becomes habit. Even occasional relief from the doubt is enough to keep it all going. Unfortunately, sufferers do not always realize that they have difficulty in processing and holding onto this information. In reality, a sufferer could gather enough information and answers to fill a library, and it still wouldn't satisfy the doubts for very long.

The effect of the questioning behavior on friends and family can be rather negative, drawing a lot of angry responses or ridicule after the thousandth time. One young man I know questioned his girlfriend so often that she eventually broke up with him, and this added to his worries since he now wondered if she did so because he wasn't a "real man."

One other way in which sufferers cope with the fears caused by the obsessions is through directly avoiding everyday situations that get the thoughts going. This can involve:

  • Avoiding standing close to members of the same sex.

  • Not reading or looking at videos, news reports, books, or articles having anything to do with gay people or subjects.

  • Not saying the words "gay," "homosexual," or any other related term.

  • Trying to not look or act effeminately (if a man) or in a masculine way (if a woman).

  • Not dressing in ways that would make one look effeminate (if a man) or masculine (if a woman).

  • Not talking about gay issues or subjects with others.

As with other types of OCD, there is no magical or instant "cure" for these thoughts. OCD, as we know, is chronic ebbing and flowing, but never totally disappearing. The news is not all bad, however. You can find recovery as others have via medication and behavior therapy. If the thoughts tend to be mild to moderate, it may even be possible to treat them behaviorally with the proven OCD treatment (Exposure and Response Prevention) alone while avoiding the standard OCD medications. More serious cases usually require medication, however. It can be of great help, and is an important tool in helping people to do therapy.

Exposure and Response Prevention (E&RP) is carried out in stages, and is based on a listing you and your therapist make in which you rank fearful situations in terms of how much they would bother you. They are usually rated from 0 to 100. Using this technique, you work with a therapist to expose yourself to gradually increasing levels of anxiety-provoking situations and thoughts. You learn to tolerate the fearful situations without resorting to questioning, checking, or avoiding. By allowing the anxiety to subside on its own, you slowly build up your tolerance to it, and it begins to take more and more to make you anxious. Eventually, as you work your way up the list to facing your worst fears, there will be little about the subject that can set you off. You may still get the thoughts here and there, but you will no longer feel that you must react to them, and you will be able to let them pass.

Some typical Exposure therapy homework assignments I have assigned to people are highlighted below (please note that these are in no special order):

  • Reading books by or about gay persons.

  • Watching videos, movies, or TV shows with gay themes or about gay characters.

  • Visiting gay websites and podcasts of gay interest.

  • Visiting gay meetings, browsing in gay bookstores, or visiting areas of town that are more predominantly gay.

  • Wearing a T-shirt (at home or just alone in your room) that says "I am gay" on it.

  • Wearing clothes in fit, color, or style that could possibly look effeminate for a man, or masculine for a woman.

  • Looking at pictures of good-looking people of your own sex and rating them on attractiveness. 

  • Reading mainstream gay magazines such as Out or Curve.

  • Reading magazines such as Playboy if you are a woman or Playgirl if you are a man.

  • Standing close to members of your own sex.

  • Making casual physical contact with members of your own sex (touching someone's  arm, hand, or  shoulder).

  • Hugging a same sex friend.

  • Doing a series of writing assignments of a couple of pages each that suggest more and more that you actually are gay or wish to be.

  • Making a series of two-minute audio recordings that, based on the writings, gradually  suggest more and more that you are gay, and listening to them several times a day  (changing them when they no longer bother you).

  • Listening to gay rock or music by gay singers or groups.

  • Writing graduated sentences 25x per day that are challenging and raise anxiety.

  • Reading a gay romance novel.

  Some typical Response Prevention exercises might include:

  • Not checking your reactions to attractive members of your own sex.

  • Not imagining yourself in sexual situations with same-sex members to check on how you might feel about it.

  • Not behaving sexually with members of the opposite sex just to check your own reactions.

  • Resisting reviewing previous situations where you were with members of the same or opposite sex or where things were ambiguous to see if you did anything questionable.

  • Avoiding observing yourself to see if you behaved in a way you imagine a homosexual or member of the opposite sex would.

  • Resisting reassuring yourself that you are not gay, and also do not seek reassurance from others.

  • Not questioning, arguing with, or analyzing your thoughts.  Simply agree with them.

  • Not avoiding being around members of your own sex.

  • Not avoiding taking part in conversations that are about gay people or gay subjects.

Although all of the above techniques are helpful, the audio recordings, in particular, are one of the most powerful. They help you to directly confront and build a tolerance for the thoughts. Overcoming obsessive thoughts takes persistence, but it can be done. Old reports that they are harder to treat than compulsions simply aren't true.

If you decide to go for help, be certain your therapist is qualified and experienced. Be sure to ask if he or she has treated such problems before and if he or she has specialized behavioral training. If the therapist starts talking about your symptoms as if they perhaps represent some kind of true inner desire that you are suppressing, you are not getting the right approach.  Be a wise consumer.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

How Clean is "Clean?" : Compulsive Perfectionism In The Home

Recently, a couple came to see me at my practice. They were both in their early 40’s, professionals, nicety dressed. The husband began our session by saying: "Doctor, have you ever seen anyone scrub a ceiling, or polish a towel bar? I can't live like this any more. She's driving me and the children crazy with her cleaning. There are rules for everything. She controls all our lives. I don't feel free to live in my own house any more. It's like living in a museum." He went on to relate how every day of the week his wife had a compulsive and meticulous cleaning routine that lasted about six hours, beginning on weekdays with her return from work and ending about midnight. Sometimes it even ended later. On weekends, it would also take up almost half of each day. It was always done in the same order. He also complained that he and the children were forced to remove their shoes and coats in the garage before they could enter the house, and then were supposed to go directly into the laundry room, where they would change their clothes for a new, clean set laid out for them. This was so they would not bring dirt or dust in from outside. Only then could they move about the rest of the house.

They were not allowed to eat in the kitchen because it would dirty the floor with crumbs. Instead. they had to eat on snack trays in one corner of their family room, and the floor had to be vacuumed immediately afterwards. If the children (ages 6 and 10) wanted to eat or drink anything at any other time. they had to ask their mother and she would get it for them. No one else was allowed to use the refrigerator. No one else was allowed to do laundry or load the dishwasher. Although their home had three full bathrooms, they were all made to share just one. The doors to the other two remained closed to everyone. No one was allowed to go to bed without first showering. The living room was off-limits because lint or dirt might get on the carpet or the furniture, or the couch cushions might get disarranged. The children were only allowed to have their friends in the family room, and could not go with them to other parts of the house. They were not particularly encouraged to invite them over anyway. If anyone violated any of these rules, an angry reaction would erupt. "It's strange," said the husband, "but outside our house, there are no rules, and she's really relaxed when we go to other places. She doesn't even care if the car needs a wash."

A need for symmetry was also part of the problem. In the clothes closets, all the hangers had to be the same distance apart. All boxes, cans, and containers in the pantry and refrigerator had to be lined up in size order with the labels facing forward. The same applied to the medicine cabinet. Every new thing that came into the house such as toys, clothes, groceries, etc., had to be washed, wiped, or cleaned in some way, and then put in its new and special place. She had someone come in to clean her home every week, but she would follow the cleaning person and clean everything again herself.

When the wife finally spoke, it was to explain: "I don't know why I do it, exactly. It's not that I'm afraid of germs or contamination. I just don't feel right unless everything is perfectly clean and in order. It makes me angry and anxious if things get messed up, and I can't concentrate on anything else until it's fixed. I feel like my house is the one thing I have control over." She did admit, however, that she was gradually becoming more exhausted, was upset that her husband and children were growing increasingly angry with her, and believed that life was passing her by as she spent all her time cleaning. She said: "I began doing this about 15 years ago when my husband and I moved into our first home. It began very gradually in small ways, and just seems to have increased over the years. I guess it became a lot more noticeable in the last five years. It seems to have a life of its own. I'd like to stop, but I've been doing this for so many years, that I just can't imagine myself acting differently. I don't know how I would stand the anxiety it would cause me."

This represents a very accurate picture of what life is like for someone suffering from this type of compulsive perfectionism. In this case, the focus of the symptoms was this sufferer's home. While we live in a society that values cleanliness and neatness, there is a line that is crossed when the individual moves into a dysfunctional zone. At one point, my new patient asked, "Is having a clean house really so bad?" "It is," I answered, "when the price includes ruining your marriage and your relationship with your children, as well as having it take over your entire existence." I pointed out to her the paradox she had created: By trying to control everything within her home, she was losing control of her life.

Her husband had gradually become more exasperated with her as time went by. He found himself unwillingly participating in all sorts of compulsive behaviors, and had come to feel that she was somehow doing this to him on purpose to make his life miserable. He had already considered divorcing her, but decided to give behavioral treatment a try as a last resort. It took some time to convince him that this was most likely a genetic problem to begin with, and that his wife had had no choice about having her disorder. She was not to be blamed, and his getting angry with her would just add to her stress, only causing her to have more symptoms.

In the course of therapy, I explained to her that she would need to help retrain herself to clean normally, and to gradually give up the excessive control of her home and family. She might not like some of the things she would have to do, but she would have to accept that there could be no other way to correct the situation. She would also need to accept that she had lost the struggle to make her home "perfect" and, at the same time realize she could have a decent life. She would have to accept the short-term discomfort of letting go in order to achieve a long-term recovery. She asked me if medication would be necessary, and I explained that I would recommend it only if she felt her anxiety was so high that she could not follow treatment. if she did need it, it would not mean that she was too weak or "crazy," just that the problem had been allowed to grow to a level where something extra was needed. I further explained that because OCD was partly a biological disorder, medication was a helpful tool that could reduce her obsessions about perfection, alleviate her cleaning compulsions, and improve her mood; by itself could not change her beliefs about perfection or eliminate all the behaviors that had now become habitual.

Behavioral therapy was explained to her, specifically the type known as "Exposure and Response Prevention." The basic principle is to confront the obsessive thoughts while resisting the use of compulsions to relieve the anxiety in order to buildup a tolerance for the discomfort. We would create a list of everything she was controlling in her home, and then rate, from one to 100, how nervous she would feel if each particular item was disarranged or unclean and left that way. She would have to gradually work her way through this list, starting with items rated at about 20 to 30. By staying with the anxiety and not cleaning or straightening up to relieve it, she would gradually build up her tolerance to these unpleasant thoughts and feelings, and would not feel as pressed to act on them. She would, in a way be conducting "experiments" to see if anything awful would happen if things weren't so neat or perfect. One of her beliefs was that if others saw she was being messy, they would think she was a slob who could not control her life, and they would reject her. She also believed that she would come to think badly of herself and then give up all cleaning in a sort of "all-or-nothing" way. I suggested that we would test these beliefs to see if they were true, but that she might have to prepare to be proven wrong.

We proceeded with the therapy process. Each week, she would clean fewer things or do them less perfectly At the same time, she let her children and husband live more freely in their home. Other techniques we employed included the following: listening daily to a series of audio tapes that gradually exposed her to the thought that she was rapidly becoming a filthy slob whom no one could respect; wearing a T-shirt around the house with the word "SLOB" in bold letters on it; and posting signs around the house with such slogans as, "This place is a dump," or "A slob lives here." Later on, we began to bring in cognitive therapy to teach her to challenge her beliefs about the value of trying to be perfect. Most importantly, we examined the illogical idea that she could be rated in her entirety as a human being based upon how neat and clean her home was. After a while, she was instructed to begin inviting friends and family to her home, and was told to not clean after they left. She was shocked when people still commented about how nice her home was, rather than condemning her. She correctly began to question her own ability to judge just how clean "clean" was.

After about six months of weekly sessions, her home had begun to look a lot more like everyone else's. She, of course, had her lapses where she would forget herself and start cleaning things, but as time went on, she seemed to gradually catch herself a bit more quickly each time. It also took more and more disorder to get her anxiety going. I would constantly remind her that she would never "perfect" her symptoms. That is, she would never be able to make her home perfect and live a life like everyone else. Through persistence and determination, she began to accept this, and her world gradually returned to normal.

This particular story has a happy ending. Not all do. In this case, my patient realized in time that it was becoming too risky to continue as she had been, and that she stood to lose much of what was important to her. Also, at the point where she had gone for help, her husband was still in a supportive frame of mind, and had not given up on her or their marriage. She was also able to get through the process without medication; something that not everyone is able to do.

We finally moved on to maintenance, where she was given a set of guidelines and schedules for housekeeping which, if she stuck to them, would enable her to stay out of trouble. I ran into her recently and she excitedly told me how she had allowed her younger child to have a birthday party for friends in the house. "You should have seen all the crumbs!" she laughed. Some of the children had even spilled their drinks, but she "'as able to matter-of-factly clean up the mess a few hours later. Her son was worried about what she would say, but she told him that it was all right and that it was more important to have fun.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

“Here’s Looking At You, Kid”: People Who Notice Things Too Much

Over the years, I have written a number of articles about some of the lesser-known forms of OCD, which often fall under the radar.  Although they are not as well known as some other forms of the disorder, they do affect numbers of people, and I think it is helpful for them to read about them, in order to see that they are not alone, and to help them to get some direction in finding treatment.  My other hope is that clinician’s learning to treat OCD will also become more aware that these problems really are OCD, or at least OCD related, and diagnose and treat them appropriately.  The following case is representative of a number of cases I have treated over the years, and is not all that unique.

When Marie, a 35 year-old accountant first came to my office, she was in a pretty bad way. She looked every part a depressed and very anxious person. “It’s getting harder and harder to get myself to go to work,” she told me.  “I’ll use any excuse to stay home, and my boss is beginning to notice.  I feel as if I’m losing my mind.  Maybe I’m psychotic.”  I asked her what the difficulty was, and she then went on to relate her problem to me, prefacing her remarks with the statement, “I know you’ll probably think I’m crazy or some kind of sicko.” She said that she had been to a psychiatrist for a consultation, and that he had sent her to me, suspecting that this might, in some way, be related to OCD, although he wasn’t entirely certain.

“I’ve always had this weird problem, but lately it’s beginning to get worse.”  What’s getting worse?” I asked.  “It’s really embarrassing to say this, but I have this thing about staring at people,” she replied.  “Why is that so bad?” I questioned.  “As human beings, it’s quite normal for us to find other human beings interesting.  Some people consider people-watching an art, and may spend hours at it.”  “Well, it isn’t just that I stare at them,” she replied.  “It’s the way I do it.  I stare at women and men, and I don’t just look in their direction.  I feel as if I have to stare at them sexually in very specific ways.  What I mean is, that with women, I stare at their chests, and with men, I stare at their crotches.  I feel as if I can’t stop myself, as if my eyes are just drawn to these places.  Sometimes I think I’m doing it without even being aware of it.  When I stare at the women, I wonder if I am really gay, or some kind of a pervert.  Also, all this staring makes it hard to listen or talk to people at work, and it’s really beginning to affect my concentration.  Sometimes I stare at the floor instead of looking at them.  I think people are noticing that I do this, and are probably thinking that there’s something wrong with me.”  As if this were not enough, Marie added that she also suffered from strong doubts about whether or not she was staring at someone at a particular time.  In an attempt to eliminate this doubt, she would then stare at the person on purpose to check the way it felt so she could determine if she had been staring.

Marie went on to explain that about three years previously, she became aware that she was noticing other people’s bodies, and that this had gradually progressed to pointedly staring at them.  She was convinced that this behavior had already cost her a good job, where she believed that one of her coworkers had become aware of her staring and had complained to a supervisor.  Obviously, Marie felt the most relieved when she was home alone, with no one to look at.  In addition to avoiding going to work, she was becoming increasingly avoidant of going out for social occasions as well.  Even going out in public on errands was starting to seem a bit challenging.  All of this added up to a great deal of anxiety on her part, not to mention feeling depressed about a behavior she couldn’t seem to control.

As we know, OCD can occur in a great variety of forms, and it occurred to me that this was another variant, as I explained to Marie.  I had observed over the years that there is another related form of the disorder where people are seen to take excessive notice of particular objects, sounds, or people (or parts of people) in their environment, and cannot seem to stop looking at or listening to them.  These were not your typical cases, but met the criteria for OCD nonetheless.  In one case, a patient couldn’t stop noticing how people’s mouths moved when they spoke, and was continually looking at other people when they spoke.  Another patient would tend to notice how close people were to him, or in what position they stood relative to him.  He would also try to determine if they were smiling, and would stare at their faces.  In a third instance, a patient who worked in an open office situation couldn’t stop listening to the sounds the copy machine made, to the point where he couldn’t get his work done. He had the same problem at home with his refrigerator.  In all cases, sufferers felt ‘crazy’ and ‘abnormal’ for noticing things or looking at others excessively, and felt anxious about the fact that they couldn’t seem to control themselves.  Those whose target was other people in public places also feared criticism and negative judgments from these others in case their behavior became noticeable (which it actually sometimes did).

In the case of OCD, it is not unusual for some people to become overly preoccupied with what are actually normal, everyday things, and to start noticing them to excess.  What happens next is that they begin obsessing about these things, and almost have to look at or listen to them repeatedly so that they can double-check whether they actually are noticing them excessively or not.  They ask themselves, “Did I just stare at that person?”  Then, so as to not be in doubt, they do stare at the person to be able to compare it to what it felt like before, so they can tell whether they actually did stare or not. This may then lead to more doubt, and to getting caught in a seemingly endless loop.  If this sounds confusing, imagine what it must be like for someone going through this all day long.

I suspect that many such people may not receive proper diagnoses of treatments as a result of their symptoms not fitting the usual stereotypes associated with OCD.  Never mind their getting a misdiagnosis; many clinicians just don’t know what to make of these behaviors at all, and can’t even come up with a diagnosis. My patient, Marie, was, herself, surprised to find out that this is what her problem turned out to be.  Like many others, she held the clichéd view of OCD sufferers as people who washed their hands excessively, or who had to arrange everything perfectly.  At least her psychiatrist had a partial clue.  Obviously, you cannot get a good treatment without a proper diagnosis.  Treatment for these problems has to be more than simply giving someone a tranquilizer or antidepressant and sending them on their way.

With that said, it should also be clarified there are some forms of this behavior that may lean more toward the impulsive end of the spectrum; forms that are performed in response to a sudden urge and that are done without purpose and are tic-like.  There are also some that have elements of both compulsions and tics.  A colleague, Dr. Charles Mansueto, has referred to the forms that seem to have both compulsive and impulsive characteristics as Tourettic OCD (the subject of an article in a past newsletter).  This is where sudden, impulsive acts that are more tic-like are performed in very particular (and sometimes ritualistic) ways to relieve the anxiety caused by obsessive, repetitive, doubtful thoughts.  Tics can be sensory in nature, and can cause a lot of discomfort if not performed immediately.  It strikes me that at least some of those people who suddenly find themselves having to stare, or listen to particular things may fall into this category.  On factor that may reinforce this view is the possible antisocial and potentially sexual nature of some people’s staring.  It is not unusual for some of those who tic, to feel that they have to sometime perform tics that involve socially unacceptable things, or things they know would somehow embarrass them.  They do not consciously want to do these things, but feel as if their symptoms are directing them to impulsively act in these ways.  All this can make diagnosis a challenge, due to this gray area that exists between tics and compulsions.  The distinction between the two is not always clear cut. 

In Marie’s case, it was not too difficult to make a diagnosis.  She denied the presence of urges or sudden impulses to stare or to feel that she had to do something on purpose that would embarrass her.  Her symptoms seemed to be driven, instead, by doubt and feelings of anxiety.  What we came to learn was that she wasn’t sure that she was really staring inappropriately, would get very anxious about the uncertainty, and used staring to compulsively relieve her anxiety. 

In any case, once a diagnosis has been made, there are fewer problems in choosing the appropriate treatment.  Treatment can go in at least two different directions.  One would be the familiar Exposure and Response Prevention (E&RP), where sufferers are directed to gradually face their fears and uncertainties in situations that are more and more challenging, while at the same time, resisting urges to compulsively avoid or neutralize their fears.  This then leads them to develop a tolerance for what they fear, and for the fears to gradually diminish.  Along with this, there is a decreased need to then do compulsions.  I like to tell patients, “The anxiety is not the problem – the compulsions are the problem.”  When they stop doing compulsions, this causes them to stay in the presence of what they fear, which then leads to even more tolerance.  If they cling to the idea that the anxiety is the problem, they will be more likely to keep resorting to doing to compulsions to eliminate it.  This, as we know, never works.  E&RP has a well-documented track record in terms of its effectiveness in treating the symptoms of OCD.  Interestingly enough, it has also been used successfully to treat tics in some cases as well. In the case of tics, it helps sufferers to build up a tolerance to the discomfort they feel when a tic is not performed.   It also aids them in accepting the idea that they can observe and experience their impulses without having to always act on them. Should another approach be needed, the time-tested approach of using the technique known as Habit Reversal Training (HRT) can also be used.  This is where the patient is trained to self-monitor when, where, why and how they perform their tics.  Once they have begun obtaining this information on a regular basis, they are then trained to relax, breathe, and center themselves.  Together with these techniques, they are also taught to use a muscular response that it incompatible with the tic and that is performed instead of the tic.

In Marie’s case, we opted for E&RP, as her symptoms appeared to be in the OCD category.  I had her gradually work up to deliberately staring at her coworkers in increasingly challenging ways, and not avoiding them as she had been doing.  I obviously instructed her to not be so conspicuous about it that it would cause her to be discovered doing her assignments.  The key was to do it discreetly, but to still do it.  Actually, before working at this level, she started by staring at pictures of men and women in her home, and then moved on to staring at people on TV or in videos.  Later, she graduated to deliberately staring at strangers in public places, and eventually, as mentioned earlier, at coworkers, though this time, in a more discreet manner.  As she did all this directed staring, she also had to heighten her exposure by telling herself that she was abnormal, perverted, and might be caught and have to suffer the consequences at any time.  She was also instructed to look up information on the internet about voyeurism (one of her fears was that she was a voyeur), and about the social and legal problems of people caught engaging in these types of activities.  She also listened to a graduated series of audio recordings (several times per day), which exposed her to the thought that she was some kind of pervert, a possible sex offender, and a thoroughly crazy person.  I made the recording for her, at first, and later, she learned to write and record her own scripts.  Another assignment was to view sex offender registries online. Over a period of several months, she gradually became habituated to the thoughts and feelings associate with her staring.  Her tolerance for the uncertainty about her own behavior greatly increased. Even if she did stare occasionally, she was able to stay with any anxious or doubtful feelings and get on with whatever she was doing.

It should be added that along with her therapy, she took an SSRI-type antidepressant that seemed to lower the level of her intrusive thoughts and her anxiety, as well as lifting her mood somewhat.  The combination of therapy plus medication can frequently work better than either one alone.  Had her symptoms been more tic-like, it is probable that she would have also been prescribed one of the medications commonly used to treat tic disorders.

As can be seen, OCD is a disorder of a thousand faces, only limited by the ability to imagine.  A good treatment can only be the result of a good diagnosis.  There are clearly many forms of the disorder that lie beyond the popular notions of what it is supposed to be.  A good hunch on the part of a psychiatrist led to a good outcome, but things could have just as easily not turned out well.  It makes a good case for educating professionals and the public, alike, so that no one is denied effective treatment simply for lack of information.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look  at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016). 

Getting Rubbed The Wrong Way: Other People And Magical Contamination

Magical thinking and superstition play a significant role in OCD.  Magic connects things that do not really connect, but lets you think you can control things that in reality, you can never control.  Having intrusive, unpleasant thoughts would make anyone feel that their own thinking was out of control.  The reason that OCD sufferers are so strongly drawn to magic seems to be due to three reasons.  First, in OCD, doubt and anxiety are so great, sufferers will go to almost any length to achieve ‘perfect’ certainty that they can prevent the negative things their thoughts tell them will happen to themselves or others.  Second, human beings appear to have a natural tendency to think superstitiously.  Third, when no real-world solutions are possible, magic can seem like the only option. This is a bad combination for OCD sufferers.

OCD sufferers may use magical thinking to protect themselves, but it ultimately works against them, and can lead to even more frightening and seemingly real obsessive thoughts. The types of magic that can be incorporated into obsessive thoughts come in many forms.  One type that has not been written about very much has to do with a sufferer’s fears of somehow taking on or absorbing the negative characteristics of other people with whom they have some type of contact.  This is actually a variation on obsessive contamination fears, rather than a unique type of OCD. 

In better known (almost a cliche) type of contamination fears, sufferers fear to come in contact with such non-magical things as bacteria or viruses, and things excreted or secreted by other human beings (or animals), and include blood, mucus, urine, feces, sweat, semen, etc.  They may also fear such things as toxic chemicals, spoiled food, radiation, broken glass particles, etc.  Despite the fact that these are things that can be seen, smelled, or touched, sufferers can still have powerful doubts about whether or not they have actually come into contact with them.

Those with magical contamination thoughts involving other people may fear being touched by, being near, or touching things belonging to or touched by, or that may have touched someone (either a stranger or someone familiar), or hearing or touching the name of, or seeing or touching a picture of anyone:

  • an unpleasant character (aggressive, mean, insulting, strange acting, bad manners, etc.)

  • suffering from a physical or mental illness

  • having a developmental disability (such as autism, etc.)

  • who is visibly who is physically unattractive (overweight, having acne, shabbily or strangely dressed or unkempt, having an unpleasant odor, poor personal hygiene, etc.)

  • who has disabled (blind, deaf, in a wheelchair, on crutches, etc.)

  • who is somehow contaminated in a way that the sufferer cannot explain (When asked, they may say, “I don’t know, they just seem contaminated.”)

  • who died of an illness or disability     

Recently, a 13 year-old boy named Ethan was brought to see me for what appeared to be a problem with school refusal.  Learning problems seemed unlikely, as he had always been a good student.  It also didn’t seem to be a social problem, as he was popular and had many friends.  At first, he simply wouldn’t go to school, and became upset and had temper outbursts each morning. When asked why, he said he didn’t want to talk about it.  Ethan’s parents thought that it might be due to bullying.  Eventually, he would not go near the school, and later, wouldn’t even go to the side of the town where the school was located.  The school provided home tutoring, but also threatened to charge his parents with educational neglect for not making him go to school.  They saw it as a discipline problem.  However, it appeared this might be a more serious problem than simply being bullied.  His parents took him to a therapist who didn’t get very far with Ethan, and diagnosed him as suffering from Oppositional Defiant Disorder.  At this point, a friend of the family, whose daughter I had once treated for OCD, suggested that Ethan had a similar problem, and referred them to me.

At his first visit, I could see that he was really edgy.  Bringing up the subject of bullying, brought a quick denial.  I switched to discussing his favorite subjects in school, as well as his after-school soccer playing and his team’s excellent record.  I asked him if he missed these things.  He sadly agreed         

I sympathized, and told him that since he missed these things so much, I was puzzled at his non-attendance.  He replied that it was embarrassing and that I wouldn’t get it.  I asked him to try, and that if I didn’t get it, I wouldn’t bother him any further.  I asked that if I did get it, would he give me a chance to help him.  He accepted the deal.

Ethan related, “There are two boys in my school who are mean.  It’s not like they’re bullying me, but they push kids, cut in lines, and I think their clothes don’t look very clean.  One of them picks his nose, and I heard that their grades are bad.  I never hung out with them or went near them.  One day, one of them brushed against me in the hall, and then the other one bumped into me in the cafeteria.  I worried that something from them rubbed off on me, and that it would make me mean and get bad grades.  When I got home, I showered and changed my clothes because I thought it would help.  When I went back to school the next day, I tried to not go near them.”  I asked Ethan, “So you were worried about becoming like them?”  “Yeah,” he replied, “Like I would turn into being the way they were.”  “Like you were contaminated?”  “That’s it.” Ethan answered.  “I know it sounds stupid,” he added.  

I looked at him and said, “Did you start worrying about how to avoid touching things they touched, like desks, chairs, books, or doorknobs?”  Ethan stared at me in surprise.  “How did you know that?” he asked.  Still looking at him, I added, “And that’s why you don’t want to go to school anymore?  Was it because there were too many things to avoid, and you would feel totally contaminated if you went there.”  “That’s right,” he shrugged.”  I didn’t tell anybody because they would think I was crazy.”  “Would you like me to explain it to them?” I asked.  I think they’ll listen to me.”  “Okay,” Ethan replied uncertainly.  “If you think it can help.”

I asked, “Would you be willing to work with me, if I could help you to get rid of these worries and get you back to school and sports?  It will take work, but I think you can do it.”  “Yes,” Ethan stated with sudden enthusiasm.  “I would like that.”

I informed Ethan’s family and school about the situation, and got everyone on the same page.  The school eased off, and his parents brought him for weekly treatment sessions.  Because Ethan’s thoughts were so believable to him, and because his anxiety was so high, I also referred him to a child psychiatrist I work with, who started him on an SSRI-type antidepressant.

We started Ethan’s behavioral therapy by making a complete listing of all his magical anxiety-provoking thoughts, all the things he was avoiding, and all the physical and mental actions he was taking to avoid or neutralize his anxiety.  Next, we made a hierarchy, which is a rating scale of all the people, places, things, and activities that could trigger Ethan’s fears.  Having this would allow us to be able to tackle his fears starting with the lowest level ones, and gradually work toward the highest.  I explained to him that if he stayed with what he feared long enough, he would learn the truth, and wouldn’t be fearful anymore.  I told him it would be like visiting a Halloween haunted house a hundred times.  “Do you think that by the hundredth time it could still scare you,” I asked?  Ethan agreed it wouldn’t.

We began by looking at pictures of the feared boys, and writing down and looking at their names many times each day.  We also posted their pictures and names in his room.  Along with this, we moved on to drawing on a map, the limits of how close to the area of the school he could go.  Each week, we set as targets, places he would visit and remain in for a while, that were closer to the feared zone.  He would also bring home objects or things to eat from these locations, which included stores, movie theatres, diners, etc.  Next he had to drive closer to the school each day in a car with the windows closed.  He was later able to get out of a car across the street from the school when it was closed.  He also listened to recordings telling him how he would be contaminated and become like the two feared boys.

A breakthrough came when Ethan entered the building on a day when it was closed.  It wasn’t easy for him, but he was brave.  He gave me a tour of the building, to see his classrooms.  He seemed relieved to finally be back there.  Soon afterward, we visited the building at the end of a school day, and next walked around during a school day (without going to class), sitting through a few subjects where the feared boys wouldn’t be seen, and then finally, attending a full day of class.  During this time, he was instructed to bring home some small things and touch them to many things there. The last phase was walking and inhaling near the feared boys, touching things they touched, and finally brushing against them in the hallways.

This work took about nine months.  It can sometimes take longer, but Ethan was really motivated.  Magical thinking doesn’t respond to logic but facing what you fear will significantly reduce both doubt and anxiety.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look  at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016). 

Call Me Irresponsible: OCD and Hyper-responsibility

The other day, a patient of mine, a woman in her thirties arrived several minutes late for her appointment all out of breath.  The lateness, she announced, was due to her having misplaced a very important list, which she was still unable to locate.  When I inquired as to what was on this list, she informed me that it amounted to about twenty pages of notes she had made about every possible situation she had been in, over the last fifteen years in which she might have been negligent and caused harm to another person.  These notes, she believed contained vital information about her every word and movement on each of these various days.  At least everything she could recall.  These situations included possible traffic accidents, insults to others, property damage, the creation of hazards for others, and what might have been some sexual acting out.  At various times, she would recall one of these situations, experience strong doubts about what she had or hadn’t done, would repetitively worry that she had really done something wrong, and then become convulsed with anxiety. These were what we would call, obsessions.  They might change from day-to-day, in terms of the particular incident, but were all alike in terms of their basic theme.

Typically, when O-C sufferers experience these types of thoughts, they react by performing compulsions.  In my patient’s case, this amounted to rereading the particular page of her list hundreds of times in an attempt to review all the events of the day on which the supposed event happened.  In this way, she believed she could reassure herself that the worst had not happened, and that she would therefore not have to feel guilty.  My patient had worked out this scenario that if she had actually harmed someone, she would feel a crushing sense of guilt she could not then live with, and might then either “go insane,” or would have to kill herself.  Because she had lost her list earlier in the day, she had spent many hours alternately ransacking her house and car, and trying to mentally reconstruct everything she had written on her list.  This, then, is a glimpse through the window of what is known as hyperresponsibility (HR).

I suppose that if you had to identify one of the chief hallmarks of OCD, it would be doubt. This is no ordinary doubt, however.  This is a no-holds-barred, debilitating, paralyzing doubt.  When it occurs, the need to resolve it and find relief can grow to outweigh every other priority in a person’s life.  OC sufferers can become doubtful about almost anything the human mind can conceive of.  Exactly why certain individuals with OCD can become doubtful about having harmed others in some way remains a mystery. Although many OCD sufferers worry about bad things happening to them, there are many who only fear for others, and care little about what happens to themselves.  This is particularly true of HR.

In cases of HR, we see sufferers taking on responsibility for others health, safety, and well being that are all out of proportion.  They are not just partially responsible for what occurs in their dealings with others.  They are totally responsible.  In addition, their sense of what they are capable of doing to others is also exaggerated.  For instance if an average person physically bumped into someone on the street, they might be concerned for that instant that they might hurt the other person, but then seeing that everything was okay, would then go on their way without giving it another thought.  A HR sufferer would immediately assume that they had caused serious injuries or would obsessively worry for hours or days afterward that the other person had sustained internal injuries and was most likely hospitalized or dead.  Subsequently, they might even read the papers or watch the news to see if anything had been reported.  Whey driving, some HR sufferers have problems with what has come to be known as “Hit-and-Run-OCD.”  Every bump in the road may be a body their wheels have driven over.  Every pedestrian or jogger at the side of the road becomes someone they may have struck with their car.   Even blurs or a shadow seen out of the corner of their eye becomes a potential victim.  Driving back and forth over the same route to hunt for bodies, or getting out to check the car for dents or bloodstains can become a routine part of every trip.

Food preparation has always been a problem area within HR-type symptoms.  The fear is that the sufferer will act negligently and serve spoiled, contaminated, or poisoned food to guests or family members.  There may be thoughts that such things as household cleaners, bits of broken glass, insecticide, drain cleaner, etc. will somehow get into the food they are cooking, so all food must be prepared in an absolutely meticulous way to rule out all possible accidents. Fears of botulism or salmonella may lead to repeated hand washing, smelling or meticulous examining of the food.  Many end up not being able to prepare food at all, as the process has simply become too difficult..

Conversations with others can be potential mine fields.  Every offhanded remark may later be reviewed to see if something offensive or insulting was said.  Repeated questions or phone calling may follow these conversations, in order to find out exactly what was said, or how the other person regarded it.  When someone with HR also suffers from contamination phobias, their main concern is with sickening or killing others rather than themselves.  Those with HR may also find themselves in a constant state of high vigilance, continually scanning the environment for possible hazards to others.  If they spot a streetlight out, or see a damaged traffic sign, they will be the ones to report it.  If someone’s car looks like it has a tire low on air, they will feel compelled to leave a note under the car’s windshield wiper.   They may be seen picking up pieces of broken glass in the street, or bringing outdated packages of food to show the supermarket manager.  They may ever re-stack the canned goods on the supermarket’s shelves so they will not fall on anyone and injure them.  It is almost as if they have been appointed as the world’s guardian and protector.  It can become a full-time job.

One of the more unpleasant forms of HR is when obsessions turn to sexual themes.  A commonly occurring one is seen among adult sufferers who worry excessively about having carelessly behaved in inappropriate sexual ways toward children.  I have met numerous individuals who feared that they had made sexually suggestive remarks that could corrupt children, or even worse, that they have touched children sexually or exposed their bodies to them in some way.  Even touching a child on the shoulder, or getting an innocent hug may seem, to them, to be filled with sexual meaning.

Treatment for this type of OCD would, of course, involve the use of Cognitive/Behavioral Therapy (CBT), and the approach would be twofold.  One the behavioral level, Exposure and Response Prevention would be utilized.  In this type of treatment, following a careful study of all the sufferer’s obsessive thoughts and compulsive avoidances, fearful situations are gradually confronted, starting with the lowest level ones, and working up to the highest.  The goal is to build a tolerance to the anxiety and the anxiety-producing thoughts and situations.  By staying with the anxiety, the sufferer comes to learn the truth of the matter – that the anxiety eventually subsides, and that the dreaded event never happens.  Thus, working in a step-by-step way, the sufferer can eventually be able experience the thoughts or situations and not feel that they must react in any way.  Ultimately, they can achieve the ability to accept the thoughts, even though they are extremely dislikable.

One the cognitive level, sufferers are taught to challenge their beliefs about just how responsible they are for the safety and well-being of others, and in their dealings with others, what proportion of the responsibility is really theirs.  The role of guilt is also examined, and a better understanding of what it is and what role it has to play with regard to people dealing rationally with real errors and mistakes.  Further, the assumption is also challenged that any given individual can be perfect and never do anything wrong or harm anyone else in any way.  In my own work, this type of therapy is brought in after the sufferer has done more behavioral work and begun to get a grip on their anxiety.

Medications, too, may have a role to play in treatment.  If the sufferer is highly anxious and agitated, or severely depressed, medication can make it possible for them to approach therapy to begin with.  Additionally, if obsessions are so strong and believable that an individual feels truly unable to approach behavioral assignments, medication may also have to be included in the treatment package.  Medication should not be considered a complete treatment on its own.  It should, instead, be regarded as a tool to enable a person to successfully participate in therapy.  Medication alone cannot teach you new skills you need to confront the things that make you anxious or in how to think about living in a world where you must take risks (or what look like risks) each day in order to live freely.  Finally, medication cannot teach you to accept your disorder so that you can begin the process of change.

With proper treatment, sufferers can recover and live lives as normal and average as anyone else’s.  It takes hard work and determination, but recovery is there if you want it.

The other day, a patient of mine, a woman in her thirties arrived several minutes late for her appointment all out of breath.  The lateness, she announced, was due to her having misplaced a very important list, which she was still unable to locate.  When I inquired as to what was on this list, she informed me that it amounted to about twenty pages of notes she had made about every possible situation she had been in, over the last fifteen years in which she might have been negligent and caused harm to another person.  These notes, she believed contained vital information about her every word and movement on each of these various days.  At least everything she could recall.  These situations included possible traffic accidents, insults to others, property damage, the creation of hazards for others, and what might have been some sexual acting out.  At various times, she would recall one of these situations, experience strong doubts about what she had or hadn’t done, would repetitively worry that she had really done something wrong, and then become convulsed with anxiety. These were what we would call, obsessions.  They might change from day-to-day, in terms of the particular incident, but were all alike in terms of their basic theme.

Typically, when OC sufferers experience these types of thoughts, they react by performing compulsions.  In my patient’s case, this amounted to rereading the particular page of her list hundreds of times in an attempt to review all the events of the day on which the supposed event happened.  In this way, she believed she could reassure herself that the worst had not happened, and that she would therefore not have to feel guilty.  My patient had worked out this scenario that if she had actually harmed someone, she would feel a crushing sense of guilt she could not then live with, and might then either “go insane,” or would have to kill herself.  Because she had lost her list earlier in the day, she had spent many hours alternately ransacking her house and car, and trying to mentally reconstruct everything she had written on her list.  This, then, is a glimpse through the window of what is known as hyperresponsibility (HR).

I suppose that if you had to identify one of the chief hallmarks of OCD, it would be doubt. This is no ordinary doubt, however.  This is a no-holds-barred, debilitating, paralyzing doubt.  When it occurs, the need to resolve it and find relief can grow to outweigh every other priority in a person’s life.  OC sufferers can become doubtful about almost anything the human mind can conceive of.  Exactly why certain individuals with OCD can become doubtful about having harmed others in some way remains a mystery. Although many OCD sufferers worry about bad things happening to them, there are many who only fear for others, and care little about what happens to themselves.  This is particularly true of HR.

In cases of HR, we see sufferers taking on responsibility for others health, safety, and well being that are all out of proportion.  They are not just partially responsible for what occurs in their dealings with others.  They are totally responsible.  In addition, their sense of what they are capable of doing to others is also exaggerated.  For instance if an average person physically bumped into someone on the street, they might be concerned for that instant that they might hurt the other person, but then seeing that everything was okay, would then go on their way without giving it another thought.  A HR sufferer would immediately assume that they had caused serious injuries or would obsessively worry for hours or days afterward that the other person had sustained internal injuries and was most likely hospitalized or dead.  Subsequently, they might even read the papers or watch the news to see if anything had been reported.  Whey driving, some HR sufferers have problems with what has come to be known as “Hit-and-Run-OCD.”  Every bump in the road may be a body their wheels have driven over.  Every pedestrian or jogger at the side of the road becomes someone they may have struck with their car.   Even blurs or a shadow seen out of the corner of their eye becomes a potential victim.  Driving back and forth over the same route to hunt for bodies, or getting out to check the car for dents or bloodstains can become a routine part of every trip.

Food preparation has always been a problem area within HR-type symptoms.  The fear is that the sufferer will act negligently and serve spoiled, contaminated, or poisoned food to guests or family members.  There may be thoughts that such things as household cleaners, bits of broken glass, insecticide, drain cleaner, etc. will somehow get into the food they are cooking, so all food must be prepared in an absolutely meticulous way to rule out all possible accidents. Fears of botulism or salmonella may lead to repeated hand washing, smelling or meticulous examining of the food.  Many end up not being able to prepare food at all, as the process has simply become too difficult.

Conversations with others can be potential mine fields.  Every offhanded remark may later be reviewed to see if something offensive or insulting was said.  Repeated questions or phone calling may follow these conversations, in order to find out exactly what was said, or how the other person regarded it.  When someone with HR also suffers from contamination phobias, their main concern is with sickening or killing others rather than themselves.  Those with HR may also find themselves in a constant state of high vigilance, continually scanning the environment for possible hazards to others.  If they spot a streetlight out, or see a damaged traffic sign, they will be the ones to report it.  If someone’s car looks like it has a tire low on air, they will feel compelled to leave a note under the car’s windshield wiper.   They may be seen picking up pieces of broken glass in the street, or bringing outdated packages of food to show the supermarket manager.  They may ever restack the canned goods on the supermarket’s shelves so they will not fall on anyone and injure them.  It is almost as if they have been appointed as the world’s guardian and protector.  It can become a full-time job.

One of the more unpleasant forms of HR is when obsessions turn to sexual themes.  A commonly occurring one is seen among adult sufferers who worry excessively about having carelessly behaved in inappropriate sexual ways toward children.  I have met numerous individuals who feared that they had made sexually suggestive remarks that could corrupt children, or even worse, that they have touched children sexually or exposed their bodies to them in some way.  Even touching a child on the shoulder, or getting an innocent hug may seem, to them, to be filled with sexual meaning.

Treatment for this type of OCD would, of course, involve the use of Cognitive/Behavioral Therapy (CBT), and the approach would be twofold.  One the behavioral level, Exposure and Response Prevention would be utilized.  In this type of treatment, following a careful study of all the sufferer’s obsessive thoughts and compulsive avoidances, fearful situations are gradually confronted, starting with the lowest level ones, and working up to the highest.  The goal is to build a tolerance to the anxiety and the anxiety-producing thoughts and situations.  By staying with the anxiety, the sufferer comes to learn the truth of the matter – that the anxiety eventually subsides, and that the dreaded event never happens.  Thus, working in a step-by-step way, the sufferer can eventually be able experience the thoughts or situations and not feel that they must react in any way.  Ultimately, they can achieve the ability to accept the thoughts, even though they are extremely dislikable.

One the cognitive level, sufferers are taught to challenge their beliefs about just how responsible they are for the safety and well-being of others, and in their dealings with others, what proportion of the responsibility is really theirs.  The role of guilt is also examined, and a better understanding of what it is and what role it has to play with regard to people dealing rationally with real errors and mistakes.  Further, the assumption is also challenged that any given individual can be perfect and never do anything wrong or harm anyone else in any way.  In my own work, this type of therapy is brought in after the sufferer has done more behavioral work and begun to get a grip on their anxiety.

Medications, too, may have a role to play in treatment.  If the sufferer is highly anxious and agitated, or severely depressed, medication can make it possible for them to approach therapy to begin with.  Additionally, if obsessions are so strong and believable that an individual feels truly unable to approach behavioral assignments, medication may also have to be included in the treatment package.  Medication should not be considered a complete treatment on its own.  It should, instead, be regarded as a tool to enable a person to successfully participate in therapy.  Medication alone cannot teach you new skills you need to confront the things that make you anxious or in how to think about living in a world where you must take risks (or what look like risks) each day in order to live freely.  Finally, medication cannot teach you to accept your disorder so that you can begin the process of change.

With proper treatment, sufferers can recover and live lives as normal and average as anyone else’s.  It takes hard work and determination, but recovery is there if you want it.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look  at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).

“But I Love My Kids …”: Parents Who Think About Harming Their Children

Make no mistake about it, obsessions, whatever the category, are nasty in content, and very difficult to live with.  If I were asked about which ones I think are among the most punishing to sufferers, I would have to say that my own selection as a therapist would be morbid thoughts, and of the many subtypes of morbid obsessive thoughts, wanting to harm your own children would probably get my vote. In actuality, all forms of OCD are unpleasant and torturous for sufferers, so perhaps this may be my own prejudice showing, being that I am a parent myself. 

Any normal parent feels a strong protectiveness toward his or her offspring.  When they are very young, we feel concern for every aspect of their lives.  Even after they have become adults, we worry about their well-being and happiness.  Is it any wonder, then, that when a parent suddenly begins to have thoughts about injuring, sexually molesting, or murdering their beloved child (or children) this would strike fear in the deepest recesses of their instincts?

Some of the most anxious and depressed people I ever see in my practice fall within this group.  I am not thinking here about parents who obsess about causing their children harm via forgetfulness or carelessness.  I am not even referring to those who think of doing harm to other people’s children.  These, too, are all very difficult thoughts to have to endure.  I am strictly speaking about those who experience ideas that they are going to actively stab, strangle, drown, suffocate, beat, sexually fondle, or rape their own children.  I would also include here those who think they may have intentionally molested or injured their own child (or children) in the past.

I would ask all those neurotypicals (those of you with normally functioning brain structures and chemistry) who may be reading this to imagine, for a moment, what it is like to experience such unpleasant things being broadcast from within your own mind on a steady basis, and not being able to change the channel.  I would further ask you to imagine questioning yourself continually why you are having these thoughts, and what their occurrence might mean in terms of your own motives and intentions.  One of the most frequent questions I get asked by patients is, “Why would I think such things if I haven’t done them, or didn’t want to do them?” 

Within this subcategory of morbid obsessions, there are further subcategories,  that would commonly include thoughts such as I will list for you below.  Please note that I divide these thoughts by younger and older children.  Also note that these categories are by no means exhaustive and there can be overlap between them.

Thoughts More Exclusively About Infants and Toddlers

  • Drowning, suffocating, choking, or smothering them

  • Shaking them violently or striking them

  • Dropping them out a window, off a balcony, a bridge, or other high place, or dropping them on their heads

  • Stabbing them

  • Poisoning them

  • Sexually molesting or raping them

Thoughts More Exclusively About Older Children And Adolescents

  • Stabbing, punching, or striking them with objects

  • Poisoning them

  • Sexually fondling them

  • Raping them

  • Suffocating them in their sleep or choking them

Within this group of sufferers, there are also three broad categories:

  • Those whose thoughts take the form of severe doubts about the present or past

  • Those who experience sudden impulses to carry out these acts

  • Those who have both of the above

Those in the first category worry that having these thoughts indicates they are crazy and dangerous and will be likely to act on their thoughts (or, “Why else would I be thinking them?”).  Their thoughts generally take the form of “How do I really know I won’t harm my children?”  OCD could be summed up in two words: pathological doubt.  It is doubt that just won’t quit, and cannot be put off with simple answers.  A complicating factor is that sufferers tend to mistakenly believe that the obsessive thoughts are their own real thoughts, and therefore must be important and paid attention to, rather than actually being irrelevant and the product of bad brain chemistry.  This leads to the idea that thinking is the step before actually doing, and that these thoughts must be heeded and dealt with, simply because they are occurring within their own minds.  They tend to respond to them with compulsions.

Simply put, compulsions relieve the anxiety produced by obsession, if only for a short time.  There is a compulsion for almost every obsession. The main compulsive strategies that morbid thinkers tend to use to cope with their thoughts include:

  • Avoiding being around their children, or at least being alone with them

  • Checking their reactions when around their children, to see how they really feel

  • Arguing with their thoughts, to try to prove to themselves that they would never do these things

  • Analyzing their thoughts, to see if they really do agree with them

Another variation on this would be those who keep questioning themselves as to whether they might have already done some of these things, either very recently, or in the past.  An example would be a sufferer who has older children, but looks back in time wondering whether or not they may have inappropriately touched them in sexual ways or molested them when holding, hugging, dressing, playing with, or bathing them.  They will continually reanalyze these events, relive them, and try to fill in the missing details or clarify hazy memories.  This activity can literally occupy hours of their lives.  In some cases, they may question those close to them, either directly, or in subtle ways, hoping to utilize other people’s memories in order to fill in the blanks.

Those in the second category experience what I like to call ‘impulsions’, or mental calls to action that, for example, might sound like “Go ahead – stab them!” They might also get physical dysperceptions.  By this I mean experiencing sensations that they:

  • moved their hand in an almost imperceptible way, as if to strike their child, or to fondle them in an improper way

  • thrust their pelvis toward their child in a sexual way or leaned or brushed against sexual areas of their child’s body, or held them in their lap while moving in a sexual way

  • somehow pushed or shoved their child because they wanted to make them fall or injure themselves

  • somehow exposed a private area of their body to their child

These are not just thoughts, but physical sensations in their bodies that seem very real and almost (but not quite) certain.  There has always been a question as to whether or not symptoms of this type may fall into a gray area between OCD and the tics seen in Tourette’s Disorder.  This has yet to be determined.

New mothers make up another distinctive subgroup where thoughts of harming one’s child are frequently seen.  Post-partum OCD is a well-known phenomenon, which may have links to post-partum depression.  It can result in the sudden appearance of OCD where no symptoms were previously seen, or else may involve the worsening of mild OCD, or OCD that was previously under control.  I have encountered a number of cases of women with or without prior histories of OCD, who within a short time after giving birth began to think of ways in which they might be able to harm their newborns.  In one particular case, a patient of mine, a new mother, shared these thoughts with an obstetrics nurse, and was then denied contact with her baby by hospital administrators, who feared an act of violence might occur.  Only an intervention on my part with the hospital’s department of psychiatry set the situation right, after I convinced them that my patient, a known OCD sufferer, was being obsessional, and was absolutely not capable of such behavior.

One potentially difficult situation for parents who suffer from morbid thoughts is feeling anger, as in their minds, this could surely lead to acting their thoughts out.  We all lose our tempers with our children now and then.  None of us are saints, and it is a rather normal occurrence – except when you then move on to experiencing thoughts about how you might now want to kill your child.  In such cases, ordinary parental anger over everyday occurrences quickly turns to fear.  Parents with this form of OCD tend to work extra hard to never lose their temper, or to squelch their rising emotions.  This leads to constant fears of emotion, and a great deal of overcontrol when around their children. 

So, having reviewed the various forms of this insidious form of OCD, then question remains, “What to do about it?”  I think that in tackling OCD, it is crucial to have an understanding of what it is you need to do.  The first thing to understand is that OCD is chronic; that is, you cannot be cured, but you can recover and live a normal life like everyone else. It won’t simply go away, but with work, you can get it under control and keep it under control.   Secondly, when it comes to controlling OCD, I think the single most important thing to understand this: “The problem is not the anxiety – the problem is the compulsions.”  If you think that the problem is the anxiety, then you will most likely keep doing compulsions as a way of relieving it.  This is, of course, wrong, as the compulsions only keep things going, and convince sufferers that the thoughts really are important and should be acted upon.  In actuality, when you stop doing the compulsions, the anxiety eventually subsides, when nothing bad occurs.  It is also important to realize and accept that you cannot block the thoughts out, switch to a different set of thoughts, argue with them, or reason them away.  You need to see that when it comes to escaping the thoughts, you have lost this particular battle, and that it is one you will never win.  Once you understand this, you can then get down to the business of confronting and overcoming your frightening thoughts.

This is obviously a bit of an oversimplification. Learning to not do compulsions has to be done gradually, takes time, and along with it, you have to learn to stay in the presence of what you fear – not run away or avoid.  In this way, you build up tolerance to what you fear, and at the same time, discover the truth of the situation.  That is, you learn to test your theories of what may happen to you or others if you don’t avoid things, or perform compulsions.  As I mentioned earlier, nothing ever happens. It is really a lot like being a scientist.

All this is best done within a program of behavioral therapy – that is, Exposure and Response Prevention.  Within such a program, patients learn to gradually expose themselves to what they fear, be it thoughts or situations, and at the same time, resist performing the compulsions they usually do to relieve their anxiety.  In this way, as I have said, they learn the truth.  As part of my own approach to treatment, we first make a listing (called a hierarchy) of all possible situations and thoughts relating to the problem, which can cause any noticeable anxiety, and assign number values to them from 0 to 100.  From this list, patients are given weekly homework assignments to help them do these things, and which they, themselves, are responsible for carrying out between visits.  Some typical assignments might include the following (and I list these in no particular order of difficulty, as this can be different for each sufferer):

  • Agreeing with thoughts of harming the child (or children) in question, instead of analyzing or studying them

  • Resisting the reviewing of past events in detail to determine if they actually did something harmful or unacceptable

  • Not questioning others, directly or indirectly to determine if they might have done something wrong in the past, or will do something in the future

  • Writing, taping, and then listening repetitively to compositions about how they really want to do (or really did) the unacceptable things they are thinking about

  • Holding their young child near a window, balcony or other high point

  • Becoming more physical in playing with their child (if they are avoiding this), and creating more opportunities to hold, hug, massage, cuddle, etc.

  • Reading news articles or books about parents who have injured, killed, or molested their children

  • Being around their child while holding sharp, or pointed objects, or other weapon-like things

  • Visiting websites concerned with child molesters and murderers

A sufferer might look at such a list and say, “You are asking me to do these scary things as if you think they’re easy!”  My answer is that I would never tell anyone that these assignments are easy, but then, having unrelenting OCD isn’t easy either.  No one usually argues that point.  When correctly educated, the overwhelming majority of patients are able to successfully carry out these assignments.  Some have suggested that having people carry out such therapy work is cruel or mean in some way, but thirty-five years of research contradicts this.  It is a complete misrepresentation of behavioral therapy.  If the therapy ultimately relieves people of their suffering in the quickest and most efficient way, and enables them to function as parents again, I would label it as kind.  Besides, as I tell my patients, “You know what I would really do if I wanted to be mean?  I’d leave you the way you are.”

When most sufferers come to see me for the first time, they are, of course, seeking reassurance that they aren’t crazy, and won’t act on their violent thoughts.  I explain to them that they aren’t (OCD sufferers do not act on their thoughts, in fact, quite the opposite), and they won’t, but I also make it clear to them that I do not give ongoing reassurance about these things, as this will only make them worse.  I also try to disconnect family and friends from any involvement in responding to compulsive pleas for reassurance or help in avoiding as well.  This is often a crucial factor in treating these types of symptoms.

One typical fear that patients sometimes express goes something like this:  “Maybe I really don’t have OCD, and my anxiety about doing something awful to my children is the only thing keeping me from acting on it.  If I get rid of my anxiety, will I then do it, because nothing will be holding me back?”  I will initially reassure them that this is never seen to happen in those with OCD.  If they can’t stop worrying about it, we then treat it as just another obsession.

Over the following weeks, patients systematically work their way through their hierarchy, carrying out the homework assignments at their own pace, and in order of difficulty.  While everyone would like an exact figure as to how long this takes to finish, it may vary from person to person.  I tell them that on the average, it can take from about six to twelve months, barring complicating factors, such as depression, serious life problems, or other types of disorders. 

Medications can also be of help. They should be viewed as a tool to help you to get through therapy, and not as a magical complete treatment by themselves.  What they can do is lower the level of obsessions, anxiety, and depressed mood.  What they cannot do, is teach you how to face what you fear, or how to develop the tools necessary to resist compulsions or avoidance.  That is where the behavioral therapy comes in.

With current technology, OCD can be successfully treated, and the vast majority of sufferers can recover.  This can only happen, however, if you get yourself out there and get help.  Too many individuals still suffer in silence, or put themselves in the hands of practitioners who lack the expertise to treat them.  My advice is to not wait, and start working to find the way to recovery today.

Beyond Belief: When Your Parents Don’t Believe You Have OCD

I get a lot of e-mails from OCD sufferers in a lot of different places.  Some are positive and encouraging, some are seeking information about diagnosis and treatment, and some are even negative, defeated and sad.  Usually, in the latter case, it is because the writer lives in one of the places where proper treatment isn’t yet available.  There is also one other type of e-mail I get from time-to-time that falls into the sad category.  To illustrate it, I’ll let one writer speak for himself:

“Dear Dr. Penzel,

I don’t know if you can help me, but I have a really serious problem and I don’t know how to handle it.  I think I have OCD.  I was in health class in school and we were doing a lesson on mental health.  When the teacher started describing the signs of OCD, I realized that it sounded just like me.  When I got home, I went on the internet and looked it up, and again, it sounded just like me.  I have two different kinds of thoughts that just won’t go away.  One kind tells me that I want to harm people, like stabbing them with a pencil in class, or pushing them down the stairs.  I don’t just get them in school – I also get them at home and they can be about my family or my dog.  I also get thoughts that I could be gay.  Both of these thoughts really scared me and I feel like I’m not sure about myself any more.  Some of the things I read online told me that these thoughts really aren’t things I want to do, and that you can get help.  When I read them, it can help for a little while, but it doesn’t last.  I told my teacher that I think I have OCD, and he told me that I should talk to my parents so that I could get help for this.  This is where the biggest problem comes in.  I told my mom and dad about what was happening, and they acted like I was making all of it up.  My dad said, “I don’t believe in things like that.  It’s just your imagination, and if you’re trying to get attention, it’s not a very good way to do it.”  My mom was nicer, but she said that when people hear about different symptoms in classes like the one I’m taking, they start imagining that they have them, too.  They said that because I had friends and was doing well in sports (I play basketball), and my grades were okay, there couldn’t be anything wrong.  They didn’t want to go on talking about it, and said it would go away after a while when I got busy with other things.  I just couldn’t make them understand, and now I’m afraid I won’t be able to get any help for this.  I feel really hopeless and don’t know what to do.  I want to beat this thing but I won’t be able to get help on my own.  What should I do?”

While I don’t believe that this happens in every home, I have a hunch that situations like this happen a lot more than we would like.  Someone once said, “The only thing worse than having OCD, is having OCD alone.”  I think that e-mails like this prove it.  It takes work to recover from this disorder, but it shouldn’t also be such hard work to get help from those close to you.  Sometimes it can become even a bit more complicated, with one parent believing that their son or daughter has OCD, and the other one stubbornly refusing to see it, resulting in family disputes and much bad feeling.  No one wants to think that their child has a problem, much less a psychological one.  It’s one thing if a child has had serious problems from an early age, but it is quite different if a child has always appeared to function well.  In the former case, parents have many years to come to terms with it, get advice, and to seek help.  Not so, in the latter case.  Some parents find it so unthinkable, that they resort to denial, figuring that if they act like they don’t see it, it doesn’t exist.  As we know, this doesn’t turn out to be a very good strategy.  It can set a teen against their parents, or it can set one parent against another, making one into a hero and the other a villain.  I have also met some parents who are flatly opposed to the concept of mental illness, altogether.  They see it as some kind of myth.  It may be that modern science hasn’t caught up with them yet.  I have been told by parents on a few occasions that “You guys just like to make people believe they have problems so you can get them to come for treatments,” or “She’s just making this up, and if we just use some more discipline and don’t put up with it, she’ll stop doing these things.”

No one who understands OCD would dispute that such a thing exists, and fortunately, these problems don’t occur in every case.  When they do, the question is, what options do you have?  There are several things that might help and that I have suggested to people such as our e-mail writer:

Talk to the people in school, especially your health teacher and also the school psychologist.  Both will have heard of OCD and can be good people to get on your side.  Perhaps they can help set up a meeting with your parents to discuss the problem and possibly help them to understand what it is all about, and what you need.

If you have a relative with OCD (you can often see OCD run in families) they can sometimes be a good ally.  This is especially true if they are someone your parents will listen to.  It’s always a plus if they got help, themselves, and are now doing better.  Perhaps they can persuade your parents to take you for help.

Maybe you have a friend who also happens to have OCD and has been for successful treatment.  One out of forty people has OCD, so the odds are good that you may know someone.  You might see if their parents would be willing to talk to your parents and share what they have learned about the disorder and about how to get therapy for it.  It will also be a big help if your parents already know these people.

Read up on the disorder, and educate yourself about it.  You can start with articles on the website of the International OCD Foundation (www.ocfoundation.org), and also check your local library for books on the subject.  There are many good books these days, and the more you know, the better you will be able to speak up for yourself.  Whatever you do, always make sure you are getting your information from reliable sources.

Don’t get angry at your parents or fight with them about this.  This is the worst possible thing you can do.  When people are angry, they listen to you a lot less and become more stubborn about sticking to their ideas.  To get their help and support, you need to win them over.  Remember that they do care about you, but just don’t ‘get it’ yet.  It’s something they clearly don’t understand or have much information about.  One helpful approach would be to get some good articles and books on the subject (again, check with the IOCDF to find which ones are recommended) and ask them if they will at least read them before deciding anything further.  There may also be some good personal videos or documentaries about OCD on YouTube they can watch.  Just be sure that the videos aren’t too extreme and give good, clear information.  Watch them yourself, first, just to make sure.

If you belong to a church, synagogue, or mosque, and have a good relationship with the person in charge there, you might be able to talk to them and get them to speak to your parents.  Parents will often listen to people in authority that they respect and who are seen as honest, caring, and helpful.

The main thing is to not get discouraged, and to not give up.  If you keep on looking for a way to get through to them, you will be more likely to find a solution than if you just get frustrated and quit.  Again, as we already said, don’t do it in an angry way, or in a nagging way that might only get them annoyed at you.  You want to win them over, and you want them to see that you are serious, and are really having difficulties that require special help.

If you do manage to convince them, the next step is finding the right kind of help that will get you well the most quickly and effectively.  OCD is not something that just any psychologist or social worker simply knows how to treat.  It takes someone with special training.  If you have done your research, you will have found out that what is known as Cognitive/Behavioral Therapy (CBT) is the way to go.  A special type of behavioral therapy known as Exposure & Response Prevention is what you want.  It will help you to gradually learn to face and overcome your fearful thoughts, as well as teach you better ways to beat your anxiety without having to do compulsions.  The IOCDF website can give you further reliable information about this.  Medication is sometimes also used, to help you do better with your therapy.  Understand that it is not something that is automatically used with everyone, and is something that is only used when someone is seen to be struggling with their therapy.  Even then, it is a matter to be carefully discussed with your therapist and physician.

I did give this young person some of the above advice, but I never heard back from them.  I’m hoping they showed their parents my answer, and that they chose to get help.  After all, everyone deserves a fair chance to get well.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016). 

Skin-Picking and Nail-Biting - Related Disorders

Although this newsletter has always been limited to discussing matters related to trichotillomania, I would like to introduce a slightly different but related topic. It may come as no surprise that there are other types of problem behaviors quite similar to trich in a number of ways. I am referring specifically to compulsive skin picking and nail biting (also known as onychophagia).

Advice for Significant Others (Dealing with a TTM sufferer)

A frequent problem among those who pull their hair (as well as other obsessive-compulsive type disorders), is one involving the attitudes and behaviors of the significant others in their lives, i.e., husbands, wives, boyfriends, or girlfriends. You significant others can be of great help and support to the recovery process, or you can create many types of obstacles.

Coming to Terms With Your Child's Hair Pulling

Speaking to you as both a clinical psychologist and a parent of a child with special needs, I now realize how easy it is to sit back and give other people advice on how to be objective about their child's problems. However, since I have spent the last two years learning to accept my own little boy's difficulties, I believe I may have a few insights to share with you, about what you should learn to accept in order to get a handle on these things.

Childhood Trichotillomania (Dealing with the reluctant child's pulling)

Case 1: "Mrs. R___," I began, "Your daughter Marcie (nine years old) just isn't making the progress in her therapy that we had hoped she would. She hasn't been doing her homework, and it just seems that her heart isn't in it. I think she's just going through the motions, and is only coming here because she doesn't want you to get upset with her. 

Fight for Your Rights: Getting Insurance to Pay for Your BFRB Treatment

Over the years, I have written a number of articles about the treatment and acceptance of Body-focused Repetitive Behaviors (trich, skin picking, or nail biting), or BFRBs as they are known. These are all very practical issues, to be sure, however, another practical issue I would like to inform you about has to do with getting your insurance company to cover the cost of treatment.

A Stimulus Regulation Model of Trichotillomania (Why people pull)

Recently, I looked back over the article I wrote on CBT for TTM a decade ago (The Cognitive-Behavioral Treatment of Trichotillomania) in the Spring 1992 issue of In Touch. As I looked it over, I couldn't help notice how much my understanding of the disorder has changed since then. I realize now how much more complicated it has turned out to be, and at the same time how much more we need to learn.