Obsessive-Compulsive Disorder
a number of time-consuming tasks. Even though the wedding was in a city only 2 hours away, and they planned to return the next day, Margaret had written out a long list of household jobs that had to be completed before she would be comfortable leaving home. Some of these tasks, such as vacuuming the entire downstairs part of the house and laundering all the bed sheets and bath towels they had used that day, seemed unimportant to Bill. Margaret fell behind in her preparations to leave because of interruptions and her desire to complete all the tasks according to her preferences. She admitted, “I knew it was getting late but I couldn’t leave until I was ready. There are things I simply have to do before I leave town overnight. It wasn’t my fault there was a terrible traffic jam on the way out of town.” Turning very defensive, she added, “The next time we have to leave town, I just won’t go.”
The Diagnostic Interview
Dr. Jordan asked questions about Margaret’s motivation to perform these house-hold cleaning rituals to make sure these behaviors were not simply a dutiful response on Margaret’s part to some culturally prescribed rituals regarding food preparation or cleanliness. Satisfied that they were not, Dr. Jordan asked how much time these activities required and what Margaret was thinking before, during, and after performing the rituals. Dr. Jordan also asked Margaret whether she had ever had any unusual thoughts, such as beliefs that she has special powers or is subject to external inf luences that control her behavior, and whether Mar-garet had heard voices or had visions other people claimed not to see.
As the interview progressed, it became clearer that one of Margaret’s primary symptoms was intense anxiety about germs and contamination. The anxiety led to a number of avoidance rituals, chief among which was washing her hands.
Margaret’s handwashing was “ritualistic” in the sense that a carefully prescribed series of procedures must be followed before it was “safe” to return to what she was doing previously. Furthermore, Margaret disliked being interrupted by the telephone or by a request from one of her children while in the midst of one of these rituals.
Although Margaret was clearly upset about the focus on handwashing and the way she organized the family’s out-of-town trips, and so was reluctant to give further details about her symptoms, Bill was not. From him, Dr. Jordan learned that Margaret’s handwashing ritual was virtually mandatory after almost any activity where she touched something—her car, a doorknob, the vacuum cleaner, and, of course, any food or laundry item; the ritual itself involved copi-ous amounts of disinfectant soap, vigorcopi-ous rubbing, and careful drying of her hands and arms using many disposable paper towels. Although each handwash-ing episode might take only one or two minutes, the frequency of episodes was such that Margaret typically spent more than an hour a day in front of the sink washing her hands.
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Dr. Jordan also discovered that numbers were quite important to Margaret.
If she touched something that she felt was particularly dirty, she might need to wash her hands with a circular motion a certain number of times. The dirtier the object, the more times she “needed” to complete the circular washing motion.
Bill recounts one particular time when Margaret picked up what she thought was a discarded paper towel. When she picked it up and discovered that it was a used tissue, she felt compelled to wash her hands and would not stop until she had counted 50 circular washing motions.
Other Rituals and Worries
Another very time-consuming part of every day was taken up by Margaret’s laundering of clothes, towels, and other household items, which followed a care-ful and rigid protocol. First, all items needed to be thoroughly shaken outdoors behind the house, to rid them of crumbs, lint, hair, and other germ-carrying elements. All items were then presoaked in a tub with strong, bleach-containing detergent dissolved in hot or warm water, and only after soaking for an hour or more were small groups of similar items put in a full-cycle wash and rinse.
Each family member’s clothing or linen was washed separately from those of other family members. If an item fell on the f loor or brushed against the door or the toilet, it had to be put through the entire procedure again, beginning with vigorous shaking outdoors. After they were washed, all laundry items must be machine-dried, since Margaret believed that hanging items outdoors on a clothesline would expose them to airborne contaminants that would require that they be laundered all over again. In following these procedures, it could take Margaret an entire morning to do two small loads of laundry.
Bill described several other difficulties that suggest Margaret suffered from excessive anxiety. During the day while their children were at school, she often worried for no reason about their safety. When Bill left town on busi-ness, Margaret worried that he might have an accident or even be killed. At times, it seemed to Bill that Margaret was a hypochondriac. For example, there were occasions where Margaret acted as though ordinary complaints like temporary abdominal pains were potentially serious problems like a heart attack or cancer. Finally, when she was driving, Margaret was sometimes seized with a concern that she has carelessly hurt someone—a pedestrian or bicyclist—or has run over something that may have damaged the underside of her car. When parking her car, she feels it must be perfectly aligned within the space and as close to the curb as possible. This usually required her to take extra time repeatedly backing in and out of the space. After she exited the car Margaret could not walk away without further examination of her car’s condition and her parking job. Sometimes Margaret’s tight parking resulted in minor problems like scraping tires on the curb, which caused Margaret to become very upset.
The Initial Diagnosis
Dr. Jordan diagnosed Margaret as having obsessive-compulsive disorder (OCD).
Several criteria must be satisfied to diagnose OCD using the DSM-5. The first is the presence of obsessions (unwelcome ideas that intrude into consciousness and are recognized by the individual as inappropriate) or compulsions (ritual behaviors that Margaret feels driven to perform in order to neutralize the obsessions), or both. For Margaret, the obsessions most often concern germs and contamination or harm that could befall loved ones. Her compulsions revolve around cleaning and counting rituals that she performs in an effort to prevent harm to herself or others. By performing the rituals (and usually, performing each a certain number of times), Margaret feels that she can “fend off” the harm that would befall her or a loved one if the ritual were not performed or performed incorrectly.
To qualify for a primary diagnosis of OCD, the obsessions or compulsions must be recurrent, disruptive, and a source of distress to the individual. For example, they may be time-consuming to the point of taking up to an hour a day or longer. Other requirements are that the individual has at some point recognized that the thoughts and rituals are excessive, and that the disturbances are not attributable to the effects of a substance (medication or abusable drug) or to a general medical condition. In diagnosing OCD, the clinician also indicates whether there is poor insight or not. At the time of her interview with Dr. Jor-dan, Margaret recognized that her obsessive-compulsive thoughts and behaviors were inappropriate and self-defeating, and Dr. Jordan concluded that she did not have poor insight or any delusional beliefs.
During a second intake interview Dr. Jordan conducted with Margaret alone, Margaret complains of fatigue, irritability, difficulty in concentrating, and occa-sional feelings of worthlessness. As a routine part of the intake procedures, Dr. Jordan asked questions designed to evaluate other disorders that may occur along with OCD, such as depression, panic disorder, and substance abuse. She asked Margaret to have her family physician conduct a physical exam to help evaluate the possibility that Margaret’s symptoms are related to a general medi-cal condition (e.g., thyroid dysfunction) or to a medication she might be taking.
A CRITICAL THINKING AND QUESTIONING PAUSE
At one time or another, nearly all of us have had persistent, intrusive thoughts (such as being unable to get an annoying musical tune out of our minds), or perhaps engaged in excessive checking of locks or keys or important papers. What makes Margaret’s symptoms different enough to warrant a psychiatric diagnosis? Try to delineate at least three reasons from the information already provided about the nature of Margaret’s symptoms.
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It is important to note that while Margaret’s intrusive thoughts bear some relationship to reality (that is, germs can contaminate clothing, and accidents can befall family members), they entailed scenarios that were so improbable that the amount of time and energy Margaret devoted to worrying about them was excessive. Neither Margaret nor anyone else in her family has ever acquired an infection from having unclean hands or from inadequate laundering on her part.
Furthermore, Margaret does not drive carelessly and has never even come close to hitting a pedestrian. Thus, although the concerns Margaret had were not delusional in the sense of completely departing from reality, they were clearly excessive and inappropriate.
Also significant is that her rituals did not bring Margaret any pleasure, but only temporary relief from her obsessions and the anxiety that they triggered.
At times in her adult life she has recognized the excessively time-consuming nature of her rituals, but in the past whenever she resisted performing them, her anxiety level rose significantly. This anxiety would continue to rise to the point that Margaret felt absolutely compelled to engage in the rituals. Nothing would relieve the anxiety until the rituals were performed. When Margaret would finally give in and undertake one of her counting rituals or busy herself with cleaning, the relief from anxiety would quickly follow. The more intense the anxiety, of course, the more times each ritual would need to be performed.
With obsessions, it is important to note that the content is not only inap-propriate in the view of others, but is also recognized as such by the OCD sufferer herself. In other words, Margaret was very bothered by these thoughts and the necessity of “undoing” them through her various rituals, wished they did not exist, and tried to resist them. It was also clear in Margaret’s mind that she herself was the source of the thoughts and impulses, making this experience different than that of a person with schizophrenia who may be convinced that external voices are implanting thoughts or demanding the compulsive responses.
Margaret’s reality testing was intact, her speech was coherent, and she did not experience hallucinations or delusions.
Other Possible Diagnoses?
Although she showed indications of mild depression (e.g., fatigue, irritability, obsessive worrying, difficulty concentrating, occasional sleep disturbances, and feelings of worthlessness), Margaret’s symptoms were not severe enough for a diagnosis of major depression. In addition, these symptoms often persisted only brief ly (i.e., for a few minutes at a time) rather than continuously for 2 weeks or more (as required by the DSM-5 for a diagnosis of major depression). Margaret’s symptoms were not persistent enough (that is, present more days than not for at least 2 years) to diagnose dysthymia. Similarly, her intermittent hypochondria (excessive worrying over minor health complaints) seems secondary to the anxi-ety associated with her obsessions and compulsions.
What about another anxiety disorder other than OCD? For example, was Margaret’s clearly irrational fear and avoidance of unseen germs sufficient for a diagnosis of a specific phobia? By themselves, her carefully scripted avoid-ance behaviors resembled phobic responses, but in Margaret’s case, her phobic avoidance was clearly a secondary reaction to strong, disruptive obsessions and compulsions rather than a distinct phobia.
Finally, there is also an obsessive-compulsive personality disorder that includes rigid, stereotypic behavior patterns, such as elaborate cleaning routines. However, most of the time, individuals with this condition are not so overtly anxious as Margaret and do not see their rigid preferences and rituals as “alien” or repugnant.
For these individuals, their compulsiveness is better understood as a pervasive lifestyle pattern emphasizing orderliness, inflexibility, control, and placing work responsibilities above pleasure.
One other point is worth noting: There may be a public perception, fed to some extent by media inf luences, that gambling, sexual activities, and drug use can be “compulsive” in nature. Excesses in these areas are not the same as OCD, since in the former conditions, the individual is driven towards performing the behaviors for their pleasurable consequences and experiences anticipatory excite-ment beforehand (instead of, as in OCD, discomfort and resistance to performing the response). Also, when it comes to gambling, sex, or substance abuse, any anxiety present is most likely related to the real risks that may be involved (los-ing the money gambled, feel(los-ing guilty about a sexual indiscretion, and so on).
Margaret’s History
As part of some history-taking during the second intake session, Dr. Jordan learned that Margaret’s parents did not get along while she was growing up, and eventually they divorced. Margaret was anxious during her parents’ many argu-ments in her presence, and later, as their marriage fell apart, Margaret worried about being abandoned by one or both parents. To cope with these distractions and worries, she developed counting rituals. These began normally enough, as when she concentrated hard on counting the seconds between a f lash of light-ning and the subsequent clap of thunder during storms.
As the fighting of her parents intensified, so did Margaret’s fears that she would be abandoned. The more her anxiety level rose, the more intensely she relied on her rituals. For example, if her parents were having a loud argument, Margaret might intensely count the f lowers in the wallpaper pattern, trying to block out the sound of her parents’ argument with the loudness of her own counting. If she lost count or missed a f lower as she scanned the wall and counted from right to left, she would become increasingly anxious and feel compelled to begin the counting ritual over.
When her parents finished arguing, Margaret would feel “dirty” and “ashamed.”
She somehow felt that the arguments were her fault and this compelled her to scrub
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herself to “wash away” the shame. Similar to the counting rituals, her compulsion to clean was intensified by the level of hostility displayed by her parents when arguing. If the argument consisted primarily of her father yelling, for example, Margaret felt less need for cleansing than if both parents were yelling at each other.
Still, however, Margaret’s anxiety and resulting compulsive rituals were evident primarily when her parents were fighting. In most other situations and around most other people, Margaret was relatively anxiety free.
At the time she met Bill, Margaret’s most serious symptoms had not yet devel-oped. In fact, Bill appreciated some of Margaret’s fussiness about keeping things clean and orderly, since it meant there was less need for him to attend to those matters. Margaret’s most disruptive symptoms became evident to Bill when she was in her late 20s. Their first child, Steven, had serious respiratory problems as an infant and was hospitalized several times. His breathing problems alarmed Margaret greatly, and each time Steven returned home from the hospital, Mar-garet sat in his room for the first two or three nights listening to him breathe and worrying about him. On one of these occasions, as she was thinking how fragile and vulnerable Steven was, Margaret was seized by the thought that it would be easy to suffocate him with a pillow in only a minute or two. She was horrified by herself, seeing little or no difference between having the thought she could suf-focate Steven and actually committing such an act. To her dismay, such thoughts about harming Steven persisted long after that. Margaret found that once she had such thoughts, the most effective way to push them out of her mind was to focus intently on cleaning or some similar household chore.
Although Steven’s breathing problems improved as he grew older, Margaret continued to be very worried about him and became rather overprotective. In particular, she was concerned that dirt and other contaminants in the home envi-ronment were responsible for his breathing difficulties and the frequent infections he came down with. Failing to keep his room spotlessly clean would mean that she was the cause of his illness. By the time he entered school, the doctors were opti-mistic that Steven’s susceptibility to ear and respiratory infections would eventually disappear. Margaret had another child by this time and was determined that this child, Brian, would be exposed to the absolute minimum amount of dirt or germs.
She developed very elaborate cleaning rituals to guard against germs and contami-nation, and also became quite anxious if she spotted any bugs such as ants or spiders in the house. To further minimize problems related to germs or dirt, Margaret forbade her children any pets other than goldfish, and insisted that the goldfish bowl be emptied and scrubbed with a strong household cleanser every other day.
These elaborate rituals and precautions did not eliminate Margaret’s worries, and as time passed, the only option she saw was to increase and intensify her compulsive behaviors. Margaret’s anxiety and the resulting compulsive rituals became worse when she was under stress, as when her husband was out of town for several days on business, or when a problem developed in the house such as a broken pipe or appliance.
Until her children were born, Margaret worked outside the home. By the time they were in school and she was in a position to return to work, her obsessions and compulsions had become serious enough to hamper her mental efficiency and productivity. She often had difficulty concentrating, and if interrupted, could not easily return to the task at hand. It was also much easier for Margaret to work by herself (be self-employed), since she could organize the work the way she wanted and would not have to explain if she became distracted or preoc-cupied and had to stop. Yet in her housework and other activities, many projects were only partially finished. Spending the vast majority of her time at home had the added advantage that Margaret could avoid contact with foreign objects (doorknobs at public restrooms, money that strangers hand her, and so on).
During the day, Margaret often had the television on, and she came to be strongly affected by shows that purport to document the threats posed by envi-ronmental toxins, viruses, and other illness-producing germs. From one of these shows, Margaret also learned that in rare instances, an electrical storm can dam-age household appliances. Because storms can begin quickly or happen when no one is home, Margaret insisted that all electrical appliances be unplugged when not in use. Although, in and of itself, this demand is not that unusual, the intense anxiety that accompanied Margaret’s concern about unplugging the appliances is beyond normal.
Margaret needed to be in control of details in her immediate surroundings.
She spent a significant amount of time checking things. She also requested (and eventually might demand) assurances from her family members that they have followed the steps she prescribed, such as washing their hands as soon as they enter the house from outside, regardless of what they have been doing. Before and after meals, and at other regular intervals (e.g., when they left for school or returned from a friend’s house), Margaret scrutinized her children for dirt, stains, or lint on their clothing—and if she found anything, there was consternation and immediately a cleaning operation needed to commence. The boys resented these incidents because they interrupted their activities and sometimes made them late.
Margaret herself had to work very hard to complete all preparations to go out or to receive visitors, with one consequence being that if at all possible, she avoided morning appointments. When her husband or children attempted to hurry Mar-garet along, she found such intrusions distracting enough that they sometimes interrupted her to the point where she becomes frustrated and angry.
Margaret’s relationship with Bill came to lack spontaneity and warmth. She rarely felt relaxed enough and free of worries to the point where she could enjoy herself. She found entertaining guests very taxing because of the many exacting preparations required. She became easily upset if the guests were close friends or family members who commented innocently on her compulsive antics while they were there. In recent years, entertaining became very infrequent. Even her children were unable to have friends over to spend the night. In response to complaints from her family about this, Margaret said that she would like to move