by Ian Osborn
I did endeavor to relieve by the outward application of aromatic bags made to the region of the stomach, also by the internal use of bitter medicines … but after three months she was taken with a fainting fit and died.
“Grief, fears, cares, and too much thinking” were, according to Dr. Morton, the cause of this disorder, which he named “nervous consumption.” Later the name was changed to anorexia nervosa, meaning “loss of appetite due to nervousness.” This term, however, is not accurate, since there is often, in fact, no loss of appetite. Probably the best designation for this disorder (but few would favor again changing the name) is the German pubertaetsmagersucht, meaning “adolescent pursuit of thinness.”
Morton noted, astutely, that anorexia “flatters and deceives the patient.” It flatters in that a young women who is mildly overweight feels a great sense of accomplishment when she starts to diet. It deceives in that as normal dieting turns into starvation the sufferer begins to think that she looks better as a skeleton than as a healthy human being. In anorexia, the normal sense of body image becomes unhinged. Even as a patient becomes seriously ill, she pushes herself to lose even more weight by such measures as inducing vomiting, abusing laxatives and diuretics, exercising prodigiously, and absolutely refusing to eat.
To me, anorexia nervosa is the most puzzling of all psychiatric disorders. The girls and young women who contract it (it rarely strikes men) seem almost psychotic. Their lack of ability to reason and their extremely distorted body image suggest to me some major biological brain abnormality. Yet no such major brain irregularity has been found so far.
In my psychiatric training at the University of Iowa, I worked on a hospital ward with a program devoted to the treatment of anorexia nervosa. At that time, we used a strict behavior modification program to foster weight gain: A patient was granted privileges such as radio, TV, letters, guests, and passes only as she put on weight. The program always worked for weight gain, but many of our patients relapsed as soon as they were discharged.
The treatment now favored for anorexia nervosa is cognitive therapy: working to help a patient gain an understanding of, and then to actively refute, her distorted attitudes and beliefs, especially self-image. Exposure and response prevention techniques, so helpful for OCD, do not work in this disorder. The SRI medications may be somewhat helpful, but generally the results are not impressive. The psychiatric therapies for anorexia nervosa remain, on the whole, disappointing.
There are obvious overlaps between anorexia nervosa and OCD. The anorexic’s preoccupations with weight loss and body image resemble obsessions, and her rituals of repeated weighing, checking in mirrors, measuring body parts, and hiding food look very much like compulsions. Furthermore, the two disorders often occur together: Up to a third of anorexia nervosa patients also have OCD. As a result, the two disorders have often been assumed to be closely related. In the 1940s, psychiatrists considered changing the name of anorexia nervosa to “obsessive-compulsive neurosis with loss of weight.”
A closer look, however, reveals that there are more differences than similarities. Most conspicuous is the mystifying lack of insight possessed by anorexia nervosa sufferers in regard to their condition. Whereas OCDers fight to put obsessions out of mind, anorexics welcome their distorted ideas. Whereas OCDers consider their obsessions to be unwanted and alien, anorexics look on their preoccupations as one of the most meaningful parts of their innermost selves.
IMPULSIVE STEALING AND SEXUAL ADDICTIONS
Often included in the OC spectrum are a handful of disorders characterized by irresistible urges to engage in behaviors that are unethical, immoral, or self-destructive, such as stealing, setting fires, pathological gambling, and random sexual acts. The people who suffer from irresistible urges differ from others who behave in the same manner in this way: They truly do not want to carry out the acts that get them in trouble.
Terminology is a problem. Sometimes these disorders are referred to as compulsions, as in “a shoplifting compulsion,” but strictly speaking this is an incorrect use of the word. Often, too, these disorders are referred to as addictions. This label is more appropriate, in that these are destructive habits in which a person’s well-being is sacrificed for a short-term excitation. But the best term for these behaviors is the one used in the diagnostic manual of American psychiatry (DSM-IV): impulse control disorders.
Impulsive stealing has been recognized as a psychiatric disorder for many centuries. The most famous French psychiatrist of the 1800s, Jean Esquirol, named it “kleptomania” (stealing insanity) and defined it as a disorder in which “voluntary control is profoundly compromised: the patient is constrained to perform acts which are dictated neither by his reason or his emotions—acts which his conscience disapproves of, but over which he no longer has willful control.”
It is important to note that the great majority of people who steal do not have this disorder. A recent study of 50 apprehended shoplifters found that only 4 percent could be diagnosed as having kleptomania. (The rest were, presumably, simply criminals.) Another recent finding is that up to 30 percent of people with kleptomania have OCD. Stealing would seem to run counter to the overly conscientious nature of OCDers, but this is sometimes not the case.
Alex, a tall, gangly postal clerk with a broad face and a stubby ponytail, came to see me early in 1996 after being arrested for shoplifting. A very outgoing and friendly man, Alex tended to talk endlessly and without pause on any subject, so that I had interrupt him frequently in order to gather a history.
Alex explained that he came to see me because he had a problem he couldn’t solve. It had started about a year and a half before. While on vacation, browsing in a department store, he had had the sudden impulse to steal a souvenir. In “sort of a dreamlike state,” as he put it, he simply hid the item under his arm and walked out. Once safely in his car, he experienced “a wonderful feeling, like a rush, like a kid opening presents on a Christmas morning.”
The next day he awoke feeling very ashamed. The shoplifting had been intoxicating, but the guilt he felt was “a terrible hangover.” Despite strong feelings of remorse, however, shoplifting slowly developed into a regular habit.
“I’ll walk into J.C. Penney,” Alex told me, “and when no one is looking I reach down under the checkout counter and pull out a plastic bag. I walk around putting items in the bag like a kid on a shopping spree. On the way out I even joke with the sales people. Or I’ll go into a convenience store to buy cigarettes, and before I know it I steal a hoagie for lunch.
“It’s out of control,” he added. “Shoplifting has become a way of life. I’ve tried my best to stop, but I can’t. I’m addicted to it.”
When I questioned Alex about his past history, I found that as a young man he had suffered mild to moderate OCD characterized by obsessions to jump off buildings and bridges. I asked him how his present impulses compared to his past obsessions. He replied: “My thoughts to jump off bridges were terribly frightening. The shoplifting thoughts are much different—they give me a high.”
Alex’s last comment points out a major difference between impulsive shoplifting and OCD. Although both involve repetitive behaviors that a person doesn’t want to do, shoplifting and the other impulse control disorders involve a certain thrill, whereas there is no gratification or pleasure involved in OCD.
The crucial differences between impulse disorders and OCD can again be made clear by contrasting two common sexual problems. On the one hand, there are repulsive sexual thoughts that a person fights to get out of mind. One example would be the unwanted homosexual thoughts of Jeff, described in Chapter 1. Another, the ultimate blasphemous thought of a surprising number of OCD women, is that of having sex with Jesus. Such thoughts are typically fended off through compulsions such as repeated prayers. This is OCD.
On the other hand there are impulsive sexual behaviors that cannot be controlled. Not long ago I treated a student who came for help because she had become a “sex addict.” Almost every
night she went to bars and picked up men. She would take them back to her apartment and aggressively initiate sexual relations, getting a thrill out of staying in total control of the situation. One day, however, she realized that she didn’t want to do this any longer. She tried to stop but found she could not. Invariably, she gave in to irresistible urges to pick up men. This is an impulse control disorder.
There is a way in which impulse control disorders and OCD are the exact opposites: One involves giving in to an urge; the other, fighting it off. Consider my own obsession to stab myself with a needle. Fortunately, I did not have the rare impulse control disorder known as impulsive self-mutilation and prick myself. Rather, having an average case of OCD, I conjured up mental compulsions to counter the obsession.
Because of this inverse relationship, it has been suggested that impulse control disorders and OCD may represent over-excitation and under-excitation of the same brain system. This hypothesis has received some support from studies on violent, impulsive criminals, who appear to have decreased brain cell activity in the same general area where OCDers show hyperactivity. Thus, the two disorders could be related in the same way as hypothyroidism and hyperthyroidism are—at opposite ends of a single spectrum of physiologic activity. Against this hypothesis, however, is the puzzling fact that some people have both disorders at the same time. Whether impulse control disorders and OCD belong in the same spectrum is not yet clear. What is very clear, however, is that they are very different problems.
In the treatment of impulse control disorders, habit reversal techniques are sometimes helpful, but exposure and response does not work at all. What was helpful for Alex’s impulsive shoplifting was to make him more aware of the times and circumstances when he was most likely to shoplift and to rehearse ways of overcoming the urge to steal. In addition, practical steps that limited the opportunities for shoplifting were very beneficial, including taking a companion and wearing tight clothes when shopping. Overall, however, the treatment of impulse control disorders is much more difficult than that of OCD.
SRI medications can be quite helpful, but the therapeutic effect often seems to wear off. Occasionally, SRI medications actually make impulse control disorders worse. I myself saw a patient whose impulsive shoplifting started shortly after he was put on Prozac. The anti-anxiety effect of the medication took away his ability to resist the urge to steal. Treatment consisted of getting him off his SRI.
It is well to note that none of the OC spectrum disorders has been studied nearly as extensively as OCD itself. In the 1996 edition of the authoritative text Psychiatric Diagnosis, the authors caution that “only about a dozen” psychiatric problems have yet been studied in sufficient detail to demonstrate that they are valid and reliable medical diagnoses; that is, that they represent homogeneous disorders that can be clearly recognized, and that do not change into anything else. OCD is included on the list, but hypochondriasis, body dysmorphic disorder, trichotillomania, and the impulse control disorders probably contain several independent syndromes within their boundaries, some of which may be related to OCD, some not.
We will be in a better position to judge which disorders are closely related to OCD when advances in research allow psychiatric syndromes to be classified on the basis of pathophysiologic cause rather than symptoms, an evolutionary step that most fields of medicine took long ago. These advances now appear tantalizingly on the horizon.
11
SPIRITUAL DIRECTORS AND
GREEK DOCTORS: A HISTORICAL
PERSPECTIVE ON OCD TREATMENT
When I was in training in the early 1970s, neither behavior therapy nor medications were used as treatment for OCD. The great majority of psychiatrists favored psychoanalysis and other closely related forms of psychotherapy. Behavior therapy, although known to be helpful in the treatment of phobias, seemed too superficial for complex problems such as obsessions and compulsions. And although medications were used to treat the severe anxiety that often accompanies OCD, they were to be avoided if possible since they were thought to interfere with the ability to participate fully in psychotherapy.
Within fifteen years, however, psychoanalysis was out and behavior therapy was in. Medications were no longer considered a hindrance to therapy but rather a first-line treatment. These changes were part of a general about-face in psychiatry away from Freud’s theories. Psychiatrists were thrown into an identity crisis. It seemed our profession had suddenly abandoned a time-honored course and lurched out in totally different directions.
Yet a closer look reveals that, at least in the case of OCD, what actually happened was that psychiatry simply circled back to its origins. An examination of available historical reports shows that from antiquity to relatively recently the two primary treatments for OCD have been behavior therapy and medications.
BEHAVIOR THERAPY
Although behavior therapy was not embraced by the field of medicine until the twentieth century, its essential techniques—exposure and response prevention—were, indeed, widely used in prior centuries. As has been pointed out previously, because OCDers show a strong aversion to seeing physicians, psychiatrists have drastically underestimated the true incidence of OCD. Who have OCDers turned to for help? In Western cultures, people who suffered from obsessions and compulsions have turned primarily to the clergy.
This makes sense considering that OCD, more than any other mental disorder, has seemed to deal directly with spiritual matters. Obsessions, which tend to take as their subject whatever provokes the most fear, very frequently used to take the form of direct, blasphemous thoughts against God. Past accounts suggest, in fact, that obsessions dealing with blasphemy were once the most common type, a conclusion supported by studies showing that even now obsessions with religious content predominate in devoutly religious communities. Compulsions, too, often took the form of muttering prayers, making religious gestures, and repeatedly confessing sins.
Many of the manuals for religious counselors of past centuries contain sections on how to deal with the tormenting thoughts and repetitive behaviors we now recognize as obsessions and compulsions. What is astonishing is the depth of psychological insight shown by some of the spiritual directors. Although they classified obsessions and compulsions as types of religious temptations, they did not recommend treating them by religious means, such as fasts, penances, or prayer. Rather they recommended what can be easily recognized as behavior therapy.
SPIRITUAL DIRECTION IN THE MIDDLE AGES
One of the earliest reports of the treatment of severe obsessions by exposure and response prevention is related by Saint John Climacus (570–649). He tells the story of a religious brother who was overcome by intrusive, blasphemous thoughts:
A certain monk was troubled for twenty years by horrible temptations to blasphemy. He rejected them with abhorrence and vehemence, arming himself against them by fasts, watchings, and great austerities. Yet because he adopted an unsuitable method, his temptations, far from showing any diminution, daily grew more harassing. At length, being quite at a loss to know what to do, he took counsel of a holy monk. Not venturing to tell him by word of mouth the wicked and detestable thoughts that swarmed in his mind, he gave him a paper to read containing them, remaining meanwhile prostrate with his face upon the ground, deeming himself unworthy to raise his eyes.
The wise old monk read the paper, and quietly spoke as follows: “My son, I take upon myself all the sins which these temptations have led you, or may lead you, to commit. All I require of you is that for the future you pay no attention to them whatever.”
At these words the temptations vanished from the mind of the monk, simply because he was made free from the alarm which gave occasion to all his fancies.
This advice seems simple—as behavior therapy always does—but contains a wealth of insight. First of all, the wise old monk recognized that these temptations were not of the normal variety to be fought by spiritual means. Instead, these thoughts were what we now know as obsessions, the key psych
ological truth of which he articulated clearly: It is the alarm, or fear, that attends such thoughts that keeps them coming back. What he recommended was a psychological approach: Learn to ignore these thoughts. As for compulsions, or “watchings,” the wise old monk deemed these “unsuitable methods” for dealing with such thoughts. Good behavior therapy.
Later in the Middle Ages, the anonymous author of the classic Christian text The Cloud of Unknowing suggested similar strategies for dealing with obsessions.
If it happens that certain thoughts or impulses concerning sins … are always inserting themselves in your awareness … I would like to tell you something, according to my experience, about some spiritual tactics by which you can put them away.
[The first is] you are to do all that lies in you to act as though you did not know that they are pressing upon you very hard. Try to look over their shoulders, as it were, as though you were looking for something else.
[Another is] when you feel that you can in no way put down these thoughts, cower down under them like a poor wretch and a coward overcome in battle, and reckon it to be a waste of time for you to strive any longer against them. Feel as though you are hopelessly defeated.
The reader may recognize two of the more popular present-day strategies for dealing with OCD, as discussed in Chapter 6: ignoring obsessions, and imagining the worst and accepting it (the behavior technique of flooding).
In order to prevent giving a grossly inaccurate picture of the treatment of OCD in the Middle Ages and Renaissance, it should be acknowledged that, undoubtedly, most people were not counseled with such insight and understanding. It is clear from both civil and church records that harm and blasphemous obsessions were often taken as signs of demonic possession and that some people with OCD were brought to trial for witchery. In Mystical Bedlam, Michael MacDonald points out that “few of the people who thought they were possessed by the devil suffered from insanity or displayed spectacular symptoms. Most of them complained of anxiety, religious fears, and evil thoughts.”