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Obsessive-compulsive disorder (OCD) involves intrusive, unwanted thoughts that usually imply some sort of action. (A compulsion.)
Some examples: The obsessional person has the thought that stepping on a crack in the sidewalk will cause some bad things to happen to a member of her family. Therefore, she feels compelled to avoid the crack.
The thought of germs contaminating everything requires the affected individual to wash continuously.
The thought that an intruder may enter through an unlocked door requires the obsessional person to check the door over and over.
Obsessions can be persistent and commanding. Hence, the ordinary meaning of an obsession: an overwhelming preoccupation.
But a variant of OCD is a pure obsessional state. These affected persons are troubled by sudden thoughts or images of awful things, often of that person doing something awful. These thoughts do not involve a compulsion to do anything. In fact, the thought of doing any of these things is repugnant and very upsetting. But the unwanted thoughts come repeatedly, nevertheless. They tend to fall into four categories:
- Violent thoughts, usually against someone who is loved or helpless. Examples: stabbing a child in the eye with a scissors. Picking up a knife and stabbing a stranger. Sometimes these images are gruesome beyond ordinary imagination.
A young woman came to see me with the story that she had become very depressed following the recent birth of her daughter. “I’ve been having evil thoughts,” she said, crying. “I’m the most terrible mother.”
“Wait, let me guess. You’ve been thinking of throwing the baby up against the wall or out the window.”
“How did you know?”
These thoughts are common. There was a time when new mothers imagined stabbing their baby with a safety pin, but that particular preoccupation disappeared when Velcro replaced safety pins as a way of fastening diapers. Another young woman was frightened by the phrase, “murder, murder, murder,” which came to her while she was baby-sitting. (footnote: This taunting thought is quite different than the “command hallucinations” sometimes experienced by paranoid schizophrenics. For one thing, the obsessional person understands that the phrase is coming from her and is not a voice coming from somewhere else.)
2.Shameful sexual thoughts, usually homosexual. “Wouldn’t it be awful ,” a man thinks, “if I suddenly kissed him while he was leaning over my desk.” These thoughts are not accompanied by sexual arousal, but by embarrassment and shame. A woman was troubled by a phrase that came to mind unbidden, “Cary Grant’s penis.” There was no meaning to these thoughts, she told me, although it was true that Cary Grant reminded her in some ways of her father. Or at least that was the explanation given to her by a previous therapist, a psychoanalyst.
3.Just plain disgusting thoughts. These are so ridiculous, commonly, that they seem funny to everyone, except the person who is having them. They even seem absurd to people who, themselves, have other obsessional thoughts. For instance, drinking urine out of a puddle with a straw, kissing someone’s pimply ass, and so on.
4.Sacrilegious thoughts. Picturing the Virgin Mary with a penis, or imagining Jesus in a sexual situation.
I do not know why people have these thoughts.
I remember a man who had two contrasting attitudes about a mentor: he admired and loved him; and he feared him. He had an obsessional thought of, literally, kissing the man’s ass. All right, that suggests some clever unconscious translation of his feelings towards his mentor, but does not explain why he expressed those ambivalent feelings through the medium of such detailed, intrusive fantasies.
I know, without question, that these varied obsessional thoughts are not due to an unconscious wish to engage in these behaviors. First of all, there is nothing else in the thoughts or actions, or other expressed feelings, of these people that are consistent with such morbid urges. Such behaviors are literally the last thing they would want to do. These thoughts seem to be chosen precisely because they are so contrary to that person’s wishes. They are the worst things that person can imagine.
I hesitate to generalize from my experience, which probably includes only at most a couple of dozen of these patients, but I notice that many of these affected individuals are especially proper and controlled people. Maybe these thoughts represent some wish to break out of confining ethical standards.
I saw a woman who had had a baby three weeks before. She told me, “This kid never sleeps. Sometimes I feel like bopping him or throwing him up against the wall.” No sense of horror or dismay. She felt comfortable expressing these thoughts, which she understood she would never act upon; and she did not feel embarrassed by them. Unlike the woman mentioned above, I would not expect this particular woman to express herself through obsessional thoughts.
Maybe pure obsessional thoughts are an expression of a “too up-tight” personality. This is the kind of explanation that gives psychiatry a bad name. I mention this thought only because I have had it. Even though I knew some of these people well, I would never have been able to predict that they would have developed this symptom.
Treatment:
Obsessive-compulsive disorder, when mild, is disruptive to ordinary life. When severe, it can have a devastating effect. These pure obsessions have no effect on the way the affected individuals live. They are important only because they frighten and dismay the person having them. They are uncomfortable. They do not lead to greater problems. Treatment, therefore, involves convincing the patient of three things:
- These ideas, in an obsessional person, never lead to action. There are people who do awful things, sometimes unimaginable things; but they are not appalled by the prospect of doing them. So much can be said also about homosexual obsessions. People who are homosexuals and engage in homosexual acts are not horrified by having homosexual thoughts. (Although in certain religious communities they are told that they should be horrified.)
- These ideas do not mean that the people having them are morally flawed. Quite the contrary.
- Talking to someone about these obsessions—like talking about fantasies in general-- tends to lessen their impact.
Usually, patients respond to treatment well. I try to be reassuring, -- I look bored, therefore, not concerned-- and sometime later, when I enquire about these thoughts, I am usually told they have gone away. (c) Fredric Neuman 2012 Follow Dr. Neuman's blog at fredricneumanmd.com/blog
