CLINICAL COMPULSIONS: A CLOSER LOOK
The term “compulsion,” like “obsession,” has taken on a broad, which is to say vague, meaning. Popularly, it is used to indicate anything done to excess: compulsively eating Ben and Jerry’s ice cream, for instance, or compulsively planning one’s day. But again, the clinical meaning is much more specific. A clinical compulsion is sometimes defined simply as “a repetitive act that is performed according to rules that must be applied rigidly.” A better definition, however, is one that stresses the close relationship between compulsions and obsessions:
A compulsion is a repetitive act that is clearly excessive and is performed in order to lessen the discomfort of an obsession.
An obsession strikes, anxiety mounts, and repetitive acts provide a way out. Why compulsions are effective in the short run to alleviate anxiety is not completely understood. Here is an interesting possible answer. Animals are known to perform many stereotyped rituals when under stress (monkeys in the zoo strumming the mesh of their cage, or rocking back and forth continuously). Many OCD experts believe that compulsions are related to these, and involve genetically programmed tendencies.
Compulsions can take an infinite number of different forms. Most often they are reasonable responses gone haywire, such as checking a gas stove a hundred times in a row for fear of a leak, or confessing one’s sins over and over to alleviate a sense of guilt. They can also, however, be acts that are completely foreign to reason, like jumping up and down eight times because of the thought that an accident will occur. But all compulsions have this property: although they provide short-term respite from obsessions, in the long run they only make obsessions worse. Obsessions, in turn, make compulsions worse. It’s a vicious cycle.
Compulsions can be divided into two groups: behavioral (observable acts), and mental (thought-rituals). Let’s take a look at the common types of compulsions within each of these groups.
- REQUESTING REASSURANCE
- MENTAL COMPULSIONS
- REPEATING OF PRAYERS
I get to thinking that my hands are unclean in some way. It’s not that they look dirty. And it’s not that I imagine germs on them, either. It’s just that I have this feeling they’re unclean. So I’ll lather them up good, wash them for a couple minutes, and dry them carefully. But pretty soon I’ll touch something and then I’ll get the feeling again. Some evenings after work I wash my hands every five minutes. They’re in bad shape. I have to put medication on them and wear gloves when I sleep.
The most famous description of excessive hand washing is found in Shakespeare’s Macbeth (Act 5, scene 1):
Doctor: Look how she rubs her hands.
Gentlewoman: It is an accustomed action…I have known her to continue in this a quarter of an hour.
Lady Macbeth: Yet here’s a spot…Out, damned spot! Out, I say!…will these hands never be clean?…Here’s the smell of blood still: All the perfumes of Arabia will not sweeten this little hand.
Although this would seem to be a good description of compulsive washing, in the context of Shakespeare’s play it probably does not represent true OCD. Lady Macbeth’s hand washing occurs during sleepwalking, and her ritual is driven not by clinical obsessions, but rather by depressive delusions or preoccupations fueled by her guilt over Duncan’s murder.
These compulsions are also very common. With this type of compulsion, a person must examine a situation over and over to make sure that no harm will come of it. Obsessions such as “Is the gas shut off?” and “Are the doors locked?” drive the checking. A young wife described the torment and disruption that these rituals can cause.
I stand there and turn the light switch off and on, off and on, off and on, off and on. I can’t make myself stop. It’s crazy. What happens is that I have the thought that maybe I didn’t completely turn it all the way off. Maybe the switch is somewhere in between the off and on position and a fire will start because of a short circuit. I know that this does not make sense. Still, I have to keep on switching back and forth until I get it just right. I might stay there for ten or fifteen minutes. One time the light switch started smoking. Now my husband swears at me and yells, ‘Leave the light switch alone or you really will start a fire!’
This type of compulsion tests the patience of family members more than any other. Here, a sufferer becomes obsessed that something terrible has happened, and is compelled to coax a pledge from another person that everything is okay. “I didn’t hit anybody with the car, did I?” “That lump doesn’t mean I have AIDS, does it?” The OCDer asks over and over, unable to stop, knowing the answer she’ll get, but needing to ask again anyway. Reassurance must be endlessly provided. A newlywed explained how her marriage was going on the rocks due to her reassurance compulsions:
I love my husband more than anything. But I get the crazy thought that I might be interested in other men. I’ll be walking in the mall and I’ll notice a handsome guy, and afterward I’ll get to wondering if I looked at him too long, if maybe that means I’m interested in him. I’ll worry all day; I can’t stop myself from thinking that I might have had thoughts of unfaithfulness. Then, because I feel so guilty, I’m driven to tell my husband. I know it makes him feel bad, but I have to. He says that it’s okay, that he knows I’m not interested in anyone else. Then I feel better. But I’ve been doing this every day, and it’s driving him nuts.
Here, the natural tendency to save things is stretched to a pathological degree. A young man whose apartment was more than half filled, floor to ceiling, with magazines and newspapers explained that he was afraid to throw an article away, because he might later remember that there was something critically important in it. Then, if he couldn’t find it, he might get so upset that he would have a nervous breakdown.
This ritual involves the mindless counting of objects and activities. One young woman did everything in fours. She scratched her head, brushed her teeth, and chewed on Lifesavers in fours. She said she could find four in anything. This compulsion was a source of frustration and embarrassment for her, yet she could not stop it. A 35- year-old man, totally disabled by OCD, needed to count everything in sight. In my waiting room, he counted the tiles in the ceiling. In my office, he counted the books on my bookshelf. He said he just had “an urge to do it.”
Here, items must be arranged so that they are “just so.” These rituals differ a bit from all others: They occur frequently in young boys, and their corresponding obsessions are often hard to identify. It has been observed that symmetry compulsions bear some resemblance to another kind of abnormal, repetitive action, the jerky movements referred to as “tics.” It seems therefore possible that symmetry compulsions represent a hybrid symptom between OCD and the related neurological disorder of tics, Tourettes syndrome.
These may actually be the most common form of OCD-related compulsions.
These are attempts to escape an obsession by employing a special, counteractive idea. With mental compulsions, as with behavioral compulsions, something is done repeatedly, mechanically, for no purpose other than to lessen the discomfort of an obsession. As one person may repeatedly check the stove, another may habitually conjure up a corrective fantasy.
Twenty years ago, mental compulsions were not even known to most mental health professionals. The last edition of the official manual of American Psychiatry, the “DSM-III-R,” published in 1987, defined compulsions as “intentional behaviors that are performed in response to an obsession.” It is now recognized, however, that compulsions occurring in the form of thoughts are extremely common, perhaps even more common than behavioral compulsions. How far our knowledge of OCD has advanced!
Perhaps the most prevalent type of mental compulsion is the counter-image. In my OCD group, a student described her counter-images in this way:
I get pictures in my mind of knives being stabbed into my grandmother. These thoughts cause me so much anxiety that I have to rethink them whenever they occur. I have to get a good image of my grandmother in my mind, one where she doesn’t have the knife sticking in her. So, I see the knife going in, and then I have to pull it out. But as soon as I pull the knife out, it’s there again. So this goes on and on. I think a bad thought, then I have to think a good one.
Another common type of mental compulsion is the rote repetition of a prayer. The words no longer have real meaning-they have been reduced to ritualistic incantations performed exclusively to drive away an obsession. A Catholic woman in her fifties described her ritual:
I say ‘Holy Mary mother of God have grace on us sinners’ over and over. It’s because an awful thought keeps coming into my mind. A thought to stab Jesus. God knows why it happens. The prayer used to work to make it go away; but now I say it over and over, for hours, and the terrible thought keeps on coming back anyway.
Although there is little written about this type of compulsion, it seems to be fairly common, especially in students. A rumination has been defined as “a train of thought, unproductive and prolonged, on a particular topic or theme.” Sometimes, ruminations clearly represent mental compulsions. An engineering student described his unwanted musings:
I constantly over-think things. I’ll be out with my girlfriend, and suddenly I say to myself, ‘Oh no, here come the thoughts!’ I know then that I’m going to get carried away with thinking things over. The thought comes that I’m not real. I’ll have to answer endless questions regarding whether my girlfriend and I are actually here or not. The metaphysical analysis goes on and on and on. I get an isolated, alone feeling. Then I may start questioning why I’m thinking these crazy thoughts in the first place. My whole evening will be ruined.
Mental compulsions, like behavioral compulsions, in the long run only worsen obsessions. A particularly devastating outcome is when the obsession itself starts to be triggered by the very images used to counteract it. A gentle, civic-minded man described how this happened to him:
I’d kill myself before I’d harm a kid. I have kids myself. I’m a scout leader, for God’s sake. Yet I will be walking along and I’ll see a little boy across the street, and then the thought will come into my mind to run over and strangle him. Nothing will get rid of the awful idea. I used to play a trick to try to get rid it. When the terrible idea would hit, I’d immediately imagine myself teaching the child how to play baseball. This worked for a while; but now things are even worse, because now whenever I see a baseball game on TV, it brings the terrible thoughts right into my mind.
The compulsions mentioned above—-washing, checking, reassurance, hoarding, symmetry, and various mental rituals-do not exhaust all possibilities; but they are the types most commonly seen. All of them have one thing in common: they are defensive, done solely to lessen the torment of obsessions. Yet in the long run, compulsions only guarantee that the self-tormenting thought that caused them will return again and again.