Say for example that a female client with a responsibility obsession about harming/killing her husband displays classic responsibility compulsions. She seeks reassurance that he is safe and that she would never do anything to harm him. She calls his mobile phone repeatedly, she insists on sleeping separately with the door locked so that she can’t hurt him in his/her sleep and finally, she regularly confesses her imagined crimes as and when they occur to her. OK, no surprises here, we would be expecting this type of OCD symptomology. However, recently, she imagined that she could also harm her husband by infecting him with a contagious condition she recovered from years ago.
So now, she her compulsions change and she starts exhibiting contamination compulsions centered around cleaning and her own personal hygiene. Yet she isn’t worried about becoming contaminated herself, she is more worried about harming her husband. So she has responsibility obsessions that manifest with both responsibility and contamination compulsions, forming a cross matrix of responsibility category obsessions linked to various categories of compulsions.
The nature of OCD obsessions rarely remains consistent over time and often morphs into new fears and hence new compulsions. In our example, let’s say that, a year or so later, our client’s obsession changes again to her worrying about harming her husband by being unfaithful. Now she begins to analyse their relationship, mentally ruminates about whether she genuinely loves her husband and researches examples of infidelity in the media. To all intents and purposes, this could appear very much like relationship OCD (a sub-type we are coming across more frequently) but it is actually still based upon responsibility obsessions.
Phew, I hope you get the point about the complicated matrix of obsessions and compulsions. It’s not easy!
So now let’s add a couple of environmental factors into the mix to complicate matters further (since life is invariably like that!) and to throw many a therapist or doctor off the true scent. Let’s imagine that our client is a pregnant woman who five years ago contracted malaria under traumatic circumstances. What’s more, her husband, uncharacteristically, had a brief affair with a co-worker a year ago. Given her symptoms, suddenly you have a hormonally sensitive expectant mother with post-trauma related to a previous chronic illness constantly living with the danger of an unfaithful husband who is soon to become the father of her child, the latter issue being reinforced by her female friends who see the analysis and evaluation of relationships as a valuable pastime.
Except, in this case, this is not what you have. You actually have a woman with OCD who happens to have these life experiences and this environment. Hence environmental issues can cloud diagnoses and delay people realising they need to present for treatment.
Not surprisingly, culture, society and even technology hamper our ability to detect OCD. I have recently treated a young client whose major OCD obsession stems directly from the burgeoning media celebrity focus. She is obsessed with an incident where someone she used to admire said that a famous celebrity, featured almost constantly in the media, was much more attractive than her. The discomfort she remembers from this experience has led to her avoiding images of the celebrity, which in today’s culture, encompasses pretty much everywhere. She carries out rituals if she sees certain words, phrases, images and dates and can’t look in the mirror. She hasn’t washed her face for 5 years and if she touches her face, the touch must be symmetrical on each side. For years, her family assumed she was having an understandable adverse reaction to the over-exposure of this public figure in the press. And by the way, parents, relatives, partners and friends can be an important part of the diagnostic criteria. How much they are involved in OCD is a clear determinant of its existence.
Most of the OCD-aware general public consider OCD to be a matter of contamination and/or checking. The truth is that responsibility obsessions are as common as contamination obsessions but gain less media coverage due to the sensitivity of the obsessional content (harming/killing/abusing people) and the fact that it is often less physically compulsive or visual, i.e., doesn’t make great TV. The media particularly shys away from reporting on the common OCD fear about harming children or pedophilia which is ironic, since the media’s fascination with the subject is a key driver in an OCD sufferer’s fear that they will become something that the public most despise (personally, I’d feel safer leaving my children with an OCD person with these fears than a person without. It is so unlikely to be true). Similarly most people would never attribute some of the more obscure obsessions and compulsions with OCD; for example, an 11 year olds fear that his brother will “steal” his intelligence, a husband who is convinced that his newborn baby has been fathered by his own father, a woman who fears that she might sexually abuse her beloved cats and a man who fears that walking and sitting down will damage his vital organs.
Then there is a larger category of what I call the “social OCD’ers”. Those people I meet socially who quiz me, “I go crazy if my desk isn’t organized, do I have OCD?”, “I can’t help but align my cutlery to face the same direction, do I have OCD?”. I don’t really need to know further details since my first question to them would be, “How much is it affecting your life?”. 99.9% of the time they aren’t greatly hampered by their OCD traits. So the answer is “Probably!”, but they aren’t in need of my help. The more people I meet, the more traits I hear about, the more I believe that the 2.5-4% global prevalence rate is largely accurate. It is this smaller but still significant number whose lives are considerably impaired.
So, if you now feel even further away from knowing if you have OCD, next week I will outline the criteria we, at the OCDCentre, consider to be determining factors……..