What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (16 page)

19. I can use well-kept toilets only with hesitation.

TRUE
        
FALSE
    

20. My major problem is repeated checking.

TRUE
        
FALSE
    

21. I am unduly concerned about germs and diseases.

TRUE
        
FALSE
    

22. I tend to check things more than once.

TRUE
        
FALSE
    

23. I stick to a very strict routine when doing ordinary things.

TRUE
        
FALSE
    

24. My hands feel dirty after touching money.

TRUE
        
FALSE
    

25. I usually count when doing a routine task.

TRUE
        
FALSE
    

26. I take quite a long time to complete my washing in the morning.

TRUE
        
FALSE
    

27. I use a great deal of antiseptics.

TRUE
        
FALSE
    

28. I spend a lot of time every day checking things over and over again.

TRUE
        
FALSE
    

29. Hanging and folding my clothes at night takes up a lot of time.

TRUE
        
FALSE
    

30. Even when I do something very carefully, I often feel that it is not quite right.

TRUE
        
FALSE
    

Each TRUE answer counts for 1 point. The most severe total score is 30. There is a Checking Scale (questions 2, 6, 8, 14, 15, 20, 22, 26, and 28) with a maximum of 9, and a Dirt and Contamination Scale (questions 1, 4, 5, 9, 13, 17, 19, 21, 24, 26, and 27) with a maximum of 11. If your total score exceeds 10, you are in the range of clinically diagnosed obsessive-compulsives. If your Dirt and Contamination score is 2 or greater or your Checking score is 4 or greater, you are also within the clinical range. Scores this high mean you should have professional help. Later in this chapter, I will discuss what kind of professional help is best and how much change is likely to ensue.

There are two viable approaches to OCD: the biological and the behavioral. Each has a theory and each has evidence in its favor. Each has also generated a therapy that helps the majority of people with OCD. Neither is wholly satisfactory.

The Biological Viewpoint

Biological psychiatrists claim that OCD is a brain disease.

Their first line of evidence is that OCD, once in a great while, develops right after a brain trauma.

Jacob, eight years old, was playing football in the backyard. He collapsed and went into a coma with a brain hemorrhage. When he came out of brain surgery, which went very well, he was plagued by numbers. He had to touch everything in sevens. He swallowed in sevens and asked seven times for everything.
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Sometimes OCD begins with epilepsy, and after the great sleeping-sickness (a viral brain infection) epidemic of 1916–18 in Europe, there was an apparent rise in the number of OCD patients. There is also some marginal evidence for a genetic factor in OCD. It runs in families: 30 percent of all adolescents with OCD have a parent or sibling with OCD.

The second line of biological evidence comes from brain-scan studies of patients with OCD. Two areas of the brain show higher activity in OCD patients: These two areas are related to filtering out irrelevant information and perseveration of behavior. When patients improve with drugs or behavior therapy, activity in these areas diminishes.
⁶

The third line of evidence concerns the specific content of the OCD jingle channel. What goes on there is not arbitrary. Like the content of phobias, which is mostly objects that were once dangerous to the human species, the content of obsessions and of the compulsive rituals is also narrow and selective. The vast majority of OCD patients are obsessed with germs or with violent accidents, and they wash or they check in response. Why such specific and peculiar themes? Why not obsessions about particular shapes, like triangles, or about socializing only with people of the same height? Why no compulsions about push-ups, or about handclapping, or about crossword puzzles? Why germs and violence; why washing and checking?

During the course of evolution, washing and checking have been very important and adaptive. The grooming and physical security of one’s self and one’s children are constant primate concerns. Perhaps the brain areas that kept our ancestors grooming and checking are the areas gone awry in OCD. Perhaps the recurrent thoughts and the rituals in OCD are deep vestiges of primate habits, run amok.
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This would mean, as it does for phobias, that it would not be easy to get rid of OCD, that we would not be able to talk people out of their obsessions and compulsions. This is true: Neither psychoanalysis nor cognitive therapy appears to work on OCD.

Effective therapy is, indeed, the final line of evidence for the biological theory. Anafranil (clomipramine) is a drug that has been used successfully with thousands of OCD sufferers, in more than a dozen controlled studies. Anafranil is a potent antidepressant drug, a serotonin-reuptake inhibitor. When OCD victims take Anafranil, the obsessions wane and the compulsions can be more easily resisted.

It is not a perfect drug. A large minority of patients (almost half) taking Anafranil do not get better, or they cannot take it because of side effects including drowsiness, constipation, and loss of sexual interest. Those who benefit are rarely cured: Their symptoms are dampened, but the obsessive thoughts are usually lurking and the temptation to ritualize remains. When those who do benefit go off the drug, many—perhaps most—of them relapse completely. But Anafranil is decidedly better than nothing.
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The Behavioral Viewpoint

There is something magnetic about horrible thoughts and images (the popularity of horror films testifies to this). Some of us are better than others at dismissing these thoughts or distracting ourselves from them. When we are depressed or anxious (as most people inclined to OCD are), such thoughts are even more difficult to stop. Indeed, when people are shown films of, for instance, gruesome woodworking accidents, those viewers who are most upset are the ones who have the most trouble discarding the images.
⁹

Behavior therapists argue that people who are not very good at distracting themselves or dismissing thoughts are most prone to OCD. Once a horrible thought starts, if you cannot dismiss it, it makes you upset. The more upset you get, the harder it is to dismiss the thought. You get even more anxious, and a vicious circle is under way. If thought stopping by ordinary means doesn’t work for you, you can perform a ritual, a
compulsion
, that relieves the anxiety. So if you have mounting horrible thoughts about germs, you can wash your hands thoroughly; if you are obsessed with burglars, you can check the locks. This relieves the anxiety temporarily, but when the thought returns, the temptation to perform the ritual will be even stronger because it has been reinforced by anxiety reduction. This theory fits the subjective experience of OCD quite well.

A therapy follows directly: exposure and response prevention. If you expose the patient to the feared situation and then prevent her from engaging in her ritual, she should become very anxious at first. If she continues to refrain, however, and finds out that the expected harm does not befall her—that she does not become infected by germs, that a gas explosion does not occur—the thoughts should wane and the ritual should extinguish. Thousands of OCD patients have been helped by this therapy. Here is a dramatic instance:

Jackie had obsessions about broken glass cutting her vagina. She kept her panties in a separate, locked drawer. She searched minutely for glass around chairs before sitting down. She could not use public toilets, and she would never wear flared skirts. Her most awful thought was of having to wear a tampon
.

She entered behavior therapy and agreed to a response-prevention treatment. With her therapist’s help, she sat down on unfamiliar chairs without checking. She used public toilets. After she was able to do these things with increasing comfort, she sat on the floor while bottles were broken around her. Finally, with her therapist’s encouragement, she was able to use a tampon. Her obsessions and compulsions disappeared and have not returned.
¹⁰

Between half and two-thirds of patients improve markedly after exposure and response prevention, and for most of those who improve, relief is lasting. At the end of therapy, however, the patient is usually not completely normal: The thoughts still lurk. A clear minority, it must be said, fail to improve. OCD patients who are depressed, who have delusions, or who secretly perform their rituals usually will not improve.
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The Right Treatment

OBSESSIVE-COMPULSIVE DISORDER SUMMARY TABLE

People with OCD have worry and depression as the dominant emotions on their jingle channel. People with other emotional problems have a different dominant emotion on their channel. People with object phobias have terror accompanying horrific scenes of encounters with the feared object. People with panic attacks have recurrent images of heart attack, stroke, and death accompanied by incipient panic. People with agoraphobia feel panic and terror as they tune in on scenes of going outside, of getting sick and being helpless with no one coming to their aid.

That we have a jingle channel is a fact we cannot change. It is an aspect of mental life so important that evolution wants to make sure it goes on incessantly. It is too important to be left to any conscious decision of whether or not to tune in. But its content may be changeable, and its volume is surely changeable. Changing the content, or at least adjusting the volume, can relieve some of our emotional problems. Cognitive therapy for panic probably removes heart attacks and dying as content on the jingle channel. Extinction therapy for any phobia and antidepressant drug therapy for agoraphobia turn the volume from loud to soft on the feared encounters. Both Anafranil and response prevention turn the volume from very loud to moderate in OCD. Changing the volume of the channel, while not simple, can now be effectively done with all these problems. My best guess, however, is that after successful treatment for OCD—and probably for phobias, too—the old jingles are still there—quieter and less insistent perhaps, but still lurking.

8

Depression

W
E LIVE
in an age of depression. Compared with when our grandparents were young, depression is now ten times as widespread in the United States, and the rate is climbing. Nowadays, depression first strikes people ten years younger, on average, reaching into late childhood and early adolescence for its youngest victims. It has become the common cold of mental illness.

Every age has a dominant emotion. The first half of this century was the Age of Anxiety, and its emotional tone was captured by Sigmund Freud. Freud lived through the death throes of the Hapsburg Empire and then through the horrors of World War I and its chaotic aftermath. Freud watched a world order that had stood for hundreds of years dissolve and a new one struggle to be born. Times when old values crumble and the future is unpredictable are times fraught with anxiety. Anxiety was the dominant emotion Freud saw in his patients, and it was the dominant theme of contemporary writing, film, and painting. Small wonder that Freud believed that all neuroses and almost all human action stemmed from anxiety. All the other emotions—depression, awe, anger, embarrassment, shame, and guilt—were just footnotes.

Our age, in contrast, is an age of uncontrollability and helplessness. Our values are stable, but the struggle by individuals and groups never before enfranchised to emerge from helplessness and achieve power dominates our politics, our literature, what now passes as the humanities, and what therapists see in the clinic. Depression is the emotion that comes in the wake of helplessness, individual failure, and unrealized attempts to gain power. For our age, depression and sadness are the dominant emotions, and anxiety, while more important than a footnote, has yielded center stage.
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