CLINICAL OBSESSIONS: A CLOSER LOOK
One major source of confusion must be cleared up right away: The term obsession means a totally different thing to mental health professionals than it does to the general public. In magazines and on television, “obsession” has come to mean just about anything people want it to–as long as it has to do with thinking and carries a negative connotation. Most often, the word is used either for what is more accurately termed a preoccupation, like a coach’s “obsession” with winning; or for an addiction, as in a gambler’s “obsession” with horse racing. But these common uses of the word obsession have nothing to do with what we are talking about here. Clinical obsessions are much different.
Let’s review again the excellent definition provided in 1877 by the German psychiatrist Karl Westphal: “Obsessions are thoughts which come to the foreground of consciousness in spite of and contrary to the will of the patient, and which he is unable to suppress although he recognizes them as abnormal and not characteristic of himself”. A similar, precise definition is found in the official manual of American psychiatry: Obsessions are “recurrent and persistent thoughts that are experienced as intrusive and inappropriate and that cause marked anxiety or distress.”
These definitions highlight the four main qualities of clinical obsessions. Intrusive, recurrent, unwanted and inappropriate. Occasionally, not all of these characteristics are present, especially in children, chronic OCD sufferers, and OCDers with other psychiatric disorders in addition to OCD. In the great majority of cases, owever, all four are clearly recognizable. It is worth looking at each characteristic in some detail in order to become clear on just what an obsession is and what it is not.
- AN OBSESSION IS AN INTRUSIVE THOUGHT
- AN OBSESSION IS RECURRENT
- AN OBSESSION IS UNWANTED
- AN OBSESSION IS INAPPROPRIATE
Intrusive describes the way a thought may pop into the mind, interrupting the normal flow. A person will be thinking along, one idea leading to another, when all of a sudden–what’s this!–a new thought butts in unexpectedly, involuntarily. Intrusive thoughts are normal. Indeed, thoughts that show up suddenly and unannounced are often intensely creative. The French mathematician Henri Poincare, perhaps the greatest scientist of his day, once described how he solved a particularly difficult problem just as he boarded a bus: “At the moment when I put my foot on the step, the idea came to me, without anything in my former thoughts seeming to have paved the way for it.”
This quality of intrusiveness, however, is acutely prominent in obsessions. I once treated a psychology graduate student who described her obsessions in this way: “I can’t stand to ride the bus any more, because awful sexual thoughts keep jumping into my mind–violent fantasies about men who sit next to me. I don’t want to have the thoughts, but they keep popping into my imagination, coming from out of nowhere. I can’t control them.”
It keeps coming back again and again. This can continue all day long. Sometimes an obsession repeats itself as a kind of undercurrent. One patient noted that his mind operated on two different levels at once. He could successfully teach a class, while at the same time be continually tormented by unwanted sexual images. Another patient in my OCD group in this way: “I’ve been having weird obsessions off and on for years. Sometimes I get strangulation visions and images of gory things happening to my body. I will imagine a belt going around my neck, or I will see a knife being thrust into my back, or I’ll see my ribs being cut open. These thoughts keep coming into my mind, over and over, sometimes all day long. Nothing stops them. Sometimes they really interfere with my work, which is bad, because I’m supposed to be getting my PhD thesis done. This morning, thoughts were running through my head nonstop.”
A couple of key differentiations are important to note. First of all, an obsession is not a sensation. The buzz of a refrigerator late at night can feel like an obsession: persistent, recurrent, and bothersome. But a sensory experience comes from outside your mind, while an obsession is a thought within it. An obsession, furthermore, is not a phobia. Phobias are very similar to obsessions, both being recurrent, irrational fears. The difference is this: a phobia is a fear of a particular situation, such as riding on an elevator, entering a shopping mall, or speaking in public; and avoidance keeps a phobia at bay. A person with a public-speaking phobia will be fine so long as he or she is away from the lecturn. With an obsession, in contrast, the focus is on a certain thought, such as knifing your daughter, crashing your car, or spreading germs. Avoidance doesn’t work with thoughts.
It is a gate crasher, an intruder in the night. The person afflicted with an obsession struggles mightily to resist it. This resistance can take up prodigious amounts of time and energy. One patient noted: “I try to stop thinking these thoughts but I can’t…It’s like I’m involved in a battle with Satan, like he’s forcing them into my mind.” Another, sharing the OCD sufferer’s most typical refrain, said: “I fight them with all my might, but I can’t stop them.” I saw a young mother who was having thoughts about harming her baby. Could there be any obsessions that are more unwanted? Hospitalized for exhaustion, thinking she had “gone crazy” and might actually harm her child, she told me:
I was doing great until I got home from the hospital with my baby. All of a sudden, while I was feeding her, the thought came into my mind that I could choke her to death. I saw myself killing my baby. God bless her. I haven’t been free of that thought since. I don’t want my husband to leave me alone, because I’m afraid of what I might do. I don’t let myself go sleep, because I might let my guard down. I try to stop these thoughts every second of the day with all my strength, but they don’t let up.
The terrible irony is that, indeed, the more strongly you resist an obsession, the more strongly it comes back. The mind does not work like a computer screen, where an unwanted thought is simply deleted. Rather, as a student patient of mine once observed, an obsession is like Freddie, the character in the “Nightmare on Elm Street” movies. Every time people thought they were finally rid of Freddie, he came baaaaack even stronger.
The strong resistance engendered by obsessions is probably their most defining characteristic. When I was in training at the University of Iowa, my chief of psychiatry emphasized this point: “Look for how much the patient resists the thought–how much he or she fights it,” Winokur used to say. “That will tell you whether you’re dealing with an obsession or something else.”
Again, to distinguish: An obsession is not a depressive preoccupation. A 62 year old man with intrusive, recurrent, and severely troubling thoughts was referred to me for “treatment-resistant OCD.” The usual anti-OCD medications and behavior therapy had been tried. Nothing worked. He presented as a warn out, agitated gentleman who spoke of nothing else but his fears of going into bankruptcy and losing his farm–concerns which were, in reality, totally groundless. He did not, however, resist these thoughts or consider them unwanted. On the contrary, to him these were realistic worries that needed to be dealt with immediately. What tormented him were recurrent, depressive thoughts, not obsessions. He responded well to a standard, antidepressant medication, Imipramine. An obsession is not an addiction. Degree of resistance also serves to differentiate here. Obsessions are always unwanted–and not just 80 or 90 percent unwanted, but 100 percent. No part of a person wants an obsession. With an addiction, the unwanted urge carries a certain thrill. The gambling addict, for instance, gets a kick out of the action. A part of him looks forward to gambling, even while another part of him knows that he shouldn’t do it. With an obsession, there is no enjoyment at all.
Given a chance to sit back and reflect for a minute, the person with OCD just can’t figure out why the tormenting thought would ever have occurred in the first place. There seems to be no earthly reason for it. Mental health professionals use the term ego-dystonic to describe this characteristic. The term means against a person’s very nature, a mismatch to a person’s sense of self. When a person suffers from violent, sexual, or blasphemous obsessions, this sense of mismatch is especially acute. One says: “Why am I thinking this crazy thought? This isn’t me.” The sense of inappropriateness is also keen in common filth and harm obsessions. A new student in our OCD group described her obsessions this way:
I will fully admit right now that my worries are unrealistic and completely stupid. Like before I go to bed, I will keep having the thought that the door isn’t locked. I lock it and unlock it, lock it and unlock it, a dozen times. But the thought still comes back: what if I didn’t lock it right? I will get up and go over and check the door again. It’s so crazy that I’m reduced to tears.
An obsession is not a psychosis. Sometimes the recognition of the ego-dystonic quality of an obsession–realizing that a thought is violating who you are–causes people to think that they are “going crazy.” This is a common reaction to severe obsessions: “I should be locked up!” One patient thought he was “hearing voices.” Even though he recognized that these “voices” came from his own mind, and did not sound like real voices; still, because his tormenting thoughts were so inappropriate and senseless, so unlike himself, he mistook his obsessions for psychotic hallucinations. There was nothing psychotic about them. It was OCD.
OCDers often feel like they’re going crazy because of the experience of a loss of control of their thoughts. Yet obsessions never–repeat, never–lead to a true loss of contact with reality, to a psychosis. People who are psychotic lack the ability to discern what is sensible. OCDers, on the contrary, are intensely aware that their thoughts don’t make sense. OCDers probably have less of a chance of going crazy than anybody else.
The four qualities of intrusiveness, recurrence, unwantedness, and inappropriateness are what set clinical obsessions apart from the preoccupations, temptations, and worries of everyday life. An adolescent male, starry-eyed over a new girlfriend, is not really “obsessed.” He’s merely preoccupied. Likewise, the lady who has to grit her teeth and punch down on the gas pedal to get past the liquor store is not “obsessed with alcohol,” not clinically, at least. She is tempted, perhaps addicted. With ordinary temptations, addictions, and worries, there are ways to fight back–willpower, for instance, or thinking more rationally. But for obsessions there seems to be no defense at all. They are like body snatchers from outer space. A person will do anything to find relief. And that’s where compulsions enter in.