OCD

Dark Thoughts

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To understand dark thoughts we need to wipe away our existing notions of the words and approach things with a fresh set of eyes. Let’s examine things with an open, inquisitive mind. 

 Mental experiences 

Obsessions exist in the realm of mental experiences. They are subjective. I can’t tell what’s going on in your head - but you can.  Similarly, you can’t tell what is going on in my head. But we can agree that there are types of mental experiences. Here’s something I’d like for you to play with: the user interface of the mind is built to simulate social interaction between two people. For example, I can talk to myself. Talking to myself involves speaking, internally to myself. My self or mind can talk back to me. It can communicate with me verbally (eg “Remember to mail that letter”) .  

In addition to verbal interactions, my mind can communicate to me in other ways - with emotions. So what exactly is an emotion? We can slide down a slippery slope easily on this one. I will take a stab at a generic description for now (for more on this, Paul Ekman and Richard Davidson have a thoughtful book called The Nature of Emotions). Let’s say emotions are subjective, perceptual “states” of being that feel pleasant or unpleasant, with varying intensity. They can be brief or longer lasting, they have a “motivational” quality - in that they propel us to certain actions. They also have a social, communicative quality in that I might feel the urge to share or “let out” something or often others can guess or relate to what I am feeling. 

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Emotions are like colors - there are some primary ones and then there are an incredible assortment of blends.  In OCD, the dominant emotions are anxiety, fear, panic, shame and disgust. Back when I was in academia, I had a conversation with a friend of mine who was trying to do a research study on emotions and the kinds of thinking that arises with specific emotions. One day I ran into him in our office hallway and he looked really frustrated. I asked him what was going on. He told me he was having trouble with his study because it was extremely difficult to devise aa procedure that cleanly and consistently produced a single emotion. “There’s always other stuff going on!” He told me that people might be anxious but also irritated; or a little sad. My take home message from this is that emotional experience can be simple at times, but a considerable amount of times it is complex. Sorry to make things even more complicated, but in OCD, people can feel considerable anxiety, panic, or fear about experiencing anxiety, panic, or fear. These “meta” emotions are emotions about an emotion. “I’m angry that I feel scared” or “I’m ashamed that I feel so panicked”. or “I’m nervous that I might get scared”. So besides verbal interchanges, our mind can communicate with us with emotions, and with emotions about emotions. 

Our mind also communicates with us via intuitions and urges. An intuition can be thought of as emotion-laden sense of “knowing”.  Here are some examples of types of intuitions: “I just know that this is the right thing for me to do”; “I have a feeling that something bad is going to happen”. Closely aligned with intuitions is another type of mental experience: urges. When partnered with emotions, urges are strong propellers of action. “I need to get out of here”. An urge is almost like an unpleasant feeling about being inactive coupled with a “promise” that some goodness will arrive if I engage in a specific action. Let’s look at thirst. I once was hiking on a trial in the Grand Canyon and ran out of water. My mouth was parched and I felt this uneasy dry mouth feeling - I’d also get images of being at the Canyon lodge cafeteria drinking a tall tumbler of water filled with ice. I could visualize it and it looked so gorgeous and I could feel that cold rush that would happen as I tipped the glass and felt the water gloriously run through my body. Do you know that feeling? So urges have this dual action of uneasiness with the present combined with a sense of fulfillment when the desired action is taken. 

 So let’s summarize. We talk to ourselves. We talk to our mind and our mind talks back. Our mind is not a unitary virtual person, but instead a variety of characters. Our mind communicates with us conversationally with words, with images, with emotions, with urges, with intuitions. See where I’m going with this? So far so good. But we haven’t addressed obsessions, compulsions, and all that good stuff. But before I do, first let’s characterize a few more players. 

 The negative propaganda machine

I’d like to propose to you that  our minds have certain pumps; these pumps pour specific kinds of thoughts into our consciousness. I had the good fortune to be listening to an interview with Bill Nighy, a British actor who has been in a number of movies that I really like. This was back when I used to listen to radio. Remember the radio? Anyway, the conversation turned to depression and he described an inner voice he struggled with - he called it the negative propaganda machine. He described how it would fill his mind with dark, critical, horrible statements about himself; about his work, relationships and about his personhood. I could relate to this. What is this thing? This soulless machine pumping negative junk into my mind space. 

Negative Automatic Thoughts

 The negative propaganda machine was a central piece to the pioneers of cognitive-behavior therapy. In the formulation of what would eventually become cognitive therapy, Aaron Beck wrote that a depressed patient he worked with “consistently embraced a negative construction of himself and his life experiences”. These negative constructions included negative judgments of the world, the future and oneself. Today, psychologists 

who specialize in CBT are interested in thoughts or thinking that have specific attributes. Early on in the development of CBT, researchers were interested in negative, automatic thoughts (NATs): automatic spontaneous thoughts about the self, self-efficacy and the future (“you are a loser”; “you will never succeed”, “you are going to become destitute and alone”). These thoughts “pop into” awareness, sometimes out of the blue, but often are triggered by situation you are in or what you are thinking about or doing. They seem to revolve around themes of loss, failure and danger. NATs are common, especially in depressive and anxiety disorders.  NATs show up verbally; to the person experiencing NATs, the NATs seem believable and the person may even agree with them at times (“I really am hopeless”). 

 So far, we’ve speculated that my mind and I communicate with each other. My mind is complex and communicates in a variety of ways (via thoughts, images, urges, intuitions) and there are “pumps” that infuse my consciousness with specific kinds of ideas, images, urges or intuitions. One such pump is the negative propaganda machine that pumps NATs - negative thoughts about myself, my world and my future into my awareness. But in this story, there is another pump and it is even weirder and freakier than the negative propaganda machine. 

The slime machine

 Slime is popular these days. Kids like to make homemade versions of it. But I think it is gross. I don’t like it and if I get some on my hands, I will try to get it off as quickly as possible. Merriam-Webster offers up two curious definitions of slime- a viscous, glutinous or gelatinous substance and a morally repulsive or odious person. One definition is a physical phenomena and the other is a mental or social phenomena. And just like the Nickelodeon channel’s tendency to drop slime on people’s heads, we have a slime pump that drops slimy thoughts into our consciousness. 

 Disturbing, unwanted thoughts. Where do they come from? What do they want? What are they?

 Thoughts like: “What if I left the door unlocked and an intruder is inside?” “What if I drove off the road right now?” “What if I had an impulse and caused a scene?”

 73 - 60 - 45.  These are the percentages of people who report that they have had the above disturbing thoughts frequently (if you have access to it, the research study was reported in a paper by Purdon and Clark in 1993 in Behavior Research & Therapy). 

 But wait there’s more.  In their study they found that 21% of a random sample of young adults reported being disturbed by thoughts like “When I see a sharp knife, I have the thought of slitting my wrist or throat”. 48% reported having unwanted thoughts about running over pedestrians or animals while driving; 19% had frequent unwanted thoughts about exposing themselves in public  and 55% reported unwanted sexual thoughts about a  boss, teacher or other authority figure.  Whoa! What’s going on here? 

 A more recent series of papers reported findings from an international multi-site study on bad slimy thoughts. Psychologists and psychiatrists call these types of thoughts intrusions. It looks like the slime machine pumps in intrusions in almost everyone. 96% of people in Turkey, 97% of people in Hong Kong and 100% of people in Iran who participated reported having these kinds of intrusive, disturbing thoughts in the past three months. Sadly, North Americans, South Americans and Europeans too had percentages ranging from 84% to 100%.  Remember these participants were drawn from the general population, not a mentally unwell subgroup. Radomsky and a large group of coauthors summarized their findings in the Journal of Obsessive-Compulsive and Related Disorders in 2014. 

 Just like the propaganda machine that pumped in scary, depressing, hopelessness generating thoughts about ourselves, our world and our future, it seems like the slime machine pumps in weird, disturbing and shocking thoughts. Although nearly everyone seems to have these thoughts there are occasional. Thankfully the slime machine doesn’t repeatedly dump their minds with sludgy, slimy thoughts. 

 But what if it did?

 

Obsessions

Some people get deluged with disturbing thoughts that they struggle mightily to get rid of.  We can imagine that their slime machine is big and nasty. Let’s call these kinds of thoughts obsessions. 

 In contrast to intrusions, that are experienced by virtually everyone, obsessions are different. Obsessions are more frequent, associated with stronger negative emotions, are considered more meaningful, and come with a much stronger urge to resist. 

 An unresolved puzzle is whether obsessions are intrusions that morphed into obsessions, or whether they are two separate things that have some similarities. We can explore that down the road, but for now, suffice it to say that our minds communicate with us via thoughts, images and impulses. Also, our mind has a few mental machines that squirt thoughts into our awareness. Some are like NATs, some are intrusions, and for some people, there is an obsession machine. 

 David A. Clark (in Cognitive Behavior Therapy for OCD, 2004) writes that obsessions have five attributes. They are: 1) intrusive; that is to say, the thought, image or impulse enters awareness “against one’s will”; 2) unacceptable - they are distressing in varying intensity to the person having the obsession; 3) accompanied by an urge to resist, the person feels a strong urge to resist, suppress, dismiss the obsession from conscious awareness; 4) uncontrollable , a person senses that their ability to control or suppress the obsession is i too brief or ineffective; 5) ego-dystonic meaning the obsession can (but not always) involve ideas that might be threatening to one’s sense of self or violate one’s sense of values or morality.

 There is one last quality to obsessions that make them stand out: the person experiencing them can have trouble distinguishing the obsessional mental experience from tangible reality. A thought feels like reality. If I have a thought that I might be a child molester, I may actually feel like I am a child molester. If I see an image of a spider, I actually feel like I am seeing an actual spider. This blurring of the lines between external reality and subjective experience is extremely disturbing to the experiencer. Some people have described to me that at times, when anxious, they feel like they have a split brain - one part that “sees” that what is going on and realizes it is irrational, and another part that “feels” the obsession is real. The path to getting through and managing OCD can be difficult. But starting with a willingness to learn and understand what obsessions are and how our minds tend to work can help in making the route clearer. 

Here we go round again

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“And now we’re back where we started

Here we go round again

Day after day I get up and I say

I better do it again” 

            Ray Davies/The Kinks

 Compulsions refer to a set of behaviors, within the context of obsessive-compulsive disorder. So, this means I am leaving out a lot of other behaviors that some people call compulsive, involving substance use, shopping, or pornography. I am leaving this out so we can get some clarity and specificity about to talk about. 

 According to the diagnostic manual, the DSM-5, compulsions are: 

Repetitive behaviors that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The behaviors are aimed at preventing or reducing emotional distress, or preventing some dreaded situation. The behaviors are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Whoa, that is a lot of dense content crammed into two sentences. Let’s unpack it all piece by piece. 

 The definition starts with Repetitive behaviors… what exactly does this mean though? I like applying Low’s definition of stereotypy to flesh out what we mean by repetitive behaviors: “a behavior or sequence of behaviors being repeated in excess of their normal functional requirements.”

 Ok, now that we have a grip on repetition, this comes next - that the individual feels driven to perform…so this part is not about the behavior itself, but describes an unpleasant feeling state that precedes the behavior. We can call this an urge that feels like being pulled to action. This urge can be strong, sometimes incredibly strong and difficult to resist. 

 in response to an obsession or according to rules that must be applied rigidly. so this places the behavior in the context what we can call the “OCD cycle” (more on this later). The compulsive act comes after an obsession thought. Thus obsession and compulsion are joined together. But the definition adds an additional phrase reminding us that alternatively a compulsion can occur when I rigidly apply a rule or a set of rules regardless of context. (“all doorknobs are dirty”). 

 Quick recap. Compulsions are repetitive behaviors that go above and beyond what the situation requires. Before the compulsions there is an urge to do the compulsion, and before the urge,there is an obsession. Thus obsession, urge and compulsion form a cycle. Now onto the next part of the definition. The behaviors are aimed at preventing or reducing emotional distress,…now we get to the purposes of the behavior. This first one is emotion focused. The behaviors are aimed at reducing anxiety, disgust, shame, horror when we are triggered. But in addition, I might also start behaving compulsively to prevent even getting triggered

 Besides preventing or reducing emotional distress, compulsions are also aimed at “…preventing some dreaded situation.” There are an infinite variety of dreaded situations including death, illness, burglaries, fires, theft, injury, becoming homeless, getting arrested, or even offending someone. Do I need to go on? You get the idea. Let’s add one more type of dreaded situation: the possibility of being a deviant, pariah, morally corrupted or sick person. 

 I wish the DSM-5 had added a little piece saying “compulsive behaviors can also be aimed at preventing or getting rid of the obsession thought”. Think of your mind as the space where your self or your consciousness lives. We don’t want obsessions that are gross, sick, perverse, scary, or just plain awful to invade and then become “squatters” in our mind space.  So we employ actions to try and get I’d of these thoughts. Thought replacement, praying, chanting can become compulsive strategies to try to remove obsessions from our mind. 

 The compulsive checklist

 Here then is our checklist to see if a behavior is compulsive:

●      Is it very repetitive? 

●      Does the person feel really driven to perform it?

●      Is the behavior part of the OCD cycle, in which it is in response to an obsession? Or part of a set of rules that must be followed rigidly?

●      Is it aimed at reducing distress, a dreaded outcome or removing a bad thought from my mind?

 

The Compulsive Big Six

 The central aim of a compulsion is to do one or more of the following: 1) reduce feeling bad, 2) make a dreaded outcome less likely; 3) remove a bad thought from my mind. OCD specialists have described compulsions in many different ways and broken them down into many different categories. Here’s my stab at it. 

 Rituals

Cleaning

Checking

Reassurance providing

Mental neutralizing

Avoiding

 Rituals are formula-ized actions. Do the action in the same way each time. They are done in a standardized manner, with a set order, with  fixed repetitions and mannerisms. Deviations are not allowed and the whole thing has to be repeated if even small alterations are made. Praying, chanting, lifting weights, maybe even baking can be ritualized but NOT compulsive. What makes a ritualized behavior compulsive? Well, let’s go back to the compulsive checklist above. And just a final note, I can be repetitive but not ritualized. I can do something over and over, like something observable like washing, or something more internal, like worrying. However, it may or may not be done in a ritualized manner with a fixed order, number of repeats, a fixed number of things that I think about, a fixed way I think about it etc. So being ritualized is different from being repetitive.

 

Cleaning compulsions range from showering, hand washing, tooth brushing, using sanitizer to doing laundry. Cleaning compulsions can also involve excessive cleaning of rooms or items around the house (or getting someone else to clean around the house). They are very often ritualized, but not always. Even if the cleaning is not ritualized, there’s not a lot of flexibility and it’s almost always rigid. 

 Checking How do I know that I know something? Knowing is a sense. 2 + 2? I know the answer and I know that I know the answer. 47231 + 3428 = ? I don’t know the answer but I know that can know it (by doing the math) fairly easily. Imagine the opposite. I recognize someone; I know that I know them but I just can’t place them. I don’t know their name or who they are. Then maybe in a few minutes it will come to me. That’s Bob from my old macrame class. What if this sense of knowing was malfunctioning in a few specific areas? Is the door locked? Did I do something wrong a while ago and I can’t remember for sure? Checking (really rechecking and rechecking) can take shape is such a variety of ways - staring, retracing my steps, checking the house alarm, checking the faucets.

 Reassurance is a checking-adjacent behavior. Like checking, reassurance seeking is a confirmation seeking action, but it has a social piece to it, in that it involves lots of repetitive asking (“Did I wash my hands properly?”, “Did I just run someone over? Did I just say something offensive to someone?” Sometimes an answer from another person isn’t even needed, just the action of asking for reassurance fulfills the requirements of the compulsive urge. In contrast to reassurance questions, reassurance can also be an answer I repetitively tell myself basically saying “I’m ok, it’s ok, everything is going to be ok” “I didn’t do that bad thing”, “I’m not a bad person”. 

 Mental Neutralizing is aimed at mental “undoing”.  Freeston and Ladouceur (1997)  describe a neutralizer as an act aimed at removing, preventing or weakening the obsession or the anxiety or distress that accompany it. As an example, I can imagine a good thought after having a bad one, the idea is to undo the bad thought. Chanting, praying, repeating a particular phrase, taking an  obsession word and repurposing it somehow can be a neutralizer as well. 

 Avoidance. The lure of avoiding triggering situations, people, images, and thoughts can be extremely strong. And avoiding is not necessarily bad. In fact it can be very helpful. But when avoiding causes a progressive narrowing or constricting of my life experiences, when I repeatedly turn away from my triggers, it can make me even more sensitive to anxiety. So in fact in my attempt to get away from anxiety, I become more anxiety sensitive. This means I feel it more intensely and in response to an ever expanding list of triggers. 

 Perhaps all of these actions I’ve discussed can be called “actions to escape from feeling bad”. The frequent use of these avoidant strategies produces more and more anxiety. Why would we do something that causes the thing we are trying to get away from? The answer is not so easy, but in OCD, the answer lies at least partially in an understanding of habitual behaviors. 

 Our minds are built to automate. It is a deep, deep aspect of how our minds handle engaging with the world.

 Think about driving. Think about a golf swing, or a tennis serve, or even beating an egg. Think about the 15-20 times you did those things. Remember how awkward and unnatural they were? 

 Think about how you drive now (if you do). You know how to turn the wheel to turn the car, how much pressure your foot needs to slow the car down. All so routine and natural now. I bet you can parallel park like a boss now. But not at first right? So driving has become habitualized. What does that mean? It means that you have integrated a complex chain of fine and gross motor movements, blended seamlessly with “hand-eye” coordination. If you play a lot of golf, even if you don’t like your golf swing right now, compare it to someone just starting out. For better or worse, their swing is not habitualized yet. 

 A complex chain of behaviors that are habitualized are semi-automated. This means that I don’t have to devote much thought to them. Sometimes your coach or piano teacher might even encourage you to “not think so much” because it might be getting in the way.

 Sometimes when you do these habitualized behaviors you might get a little “ah” feeling - like when your forehand in tennis hits the ball right in your racket’s sweet spot; or when you hit a smooth consistent stride while running. It feels right - and the reward is a feeling that it feels right. We don’t get that feeling all the time, but we know it and remember it and hope for it. 

 So far so good. This is the sunny side of the story. But, as you know there are problematic habits. My old guitar teachers used to tell me variations of  “practicing bad form teaches bad form” and “slow down! Playing fast and making mistakes  teaches your fingers to keep making those mistakes.”

 An interesting thing about habits is that they seem to be independent of distant, “objective” rewards and punishments. I fall victim to doing the habit despite my knowing it isn’t “good for me”. Learning theorists speculate this is because habit behaviors are not tightly tied to our sense of goal driven action, but are more stimuli triggered.  

 So, I hope this overview gives you a sense of how complicated and difficult it is to have OCD or chronic anxiety. I hope this write up conveys how hard it is to work on getting better. It’s not easy, but it can be done, step by step.