Diagnosis – watch out for OCD

A recent posting got me thinking about a problem that arises with certain patients who present with panic and often with obsessive-compulsive problems.  Particularly in the current climate there is the danger that certain problems, OCD in particular, can become almost a “get out of jail free” card.  Focus on symptoms becomes itself a means of avoidance of the problem – of resistance. I realize these statements may be insulting to true sufferers; I’m mostly referring here to those who really don’t have a full-blown OCD, but much of what I say happens in those with serious OCD as well.

37-year-old Sarah came in extremely polite, hesitant, earnest, carefully touching things only with gloved hands, and in genuine pain.  At the same time, when I asked about her symptoms in some detail it became clear that OCD was not really her main problem; the “compulsive rituals” were actually rather mild compared with general anxiety, the checking and persistent rumination/worry were likewise only moderate, and were part of a bigger pattern of anxiety and insecurity.  But she’d been diagnosed as having OCD at some point and she came to find it a comfortable box in which to put her symptoms and much of her life, a way of actually dismissing her more unwieldy unhappiness in favor of a safer, easier focus on specific OCD symptoms.  Sarah brought me a book on OCD from which she had been working with her previous therapist and wondered why I wasn’t suggesting similarly structured work.  At the same time, however, she’d terminated her treatment with that therapist because she felt the sessions weren’t going anywhere.  Further, it was clear she already knew all those exercises and could do them herself.  She had done her “exposure and response prevention” treatment, along with many others, was well versed in them, and had benefited moderately from them.

Meanwhile, she was not taking steps to simply move her life along – steps she was capable of making.  She had not worked in several years, was living off savings from a position that ended after nine years when the company was sold, and she had been recently approached by recruiters to apply for jobs in her field.  It turned out that she was avoiding such forward movement using the excuse that she was “a perfectionist”, unable to pursue job interviews until she was sure that she knew every possible aspect of her field about which she might be asked.  But when I asked her in detail about her field and the interview process it became clear that 1) she knew more than enough to begin the interview process, 2) the amount of detail she was demanding of herself was preposterous – no interviewer would expect such mastery of minutia; 3) the “panic” she experienced en route to an interview, or returning a telephone call from a recruiter was not severe.

Again, I am not suggesting that every patient with anxiety, panic, or obsessive-compulsive problems is avoiding things – taking action or facing the real unhappiness – as Sarah was; but over the years I have been impressed by the number of patients who were, despite their stated interest in feeling better and doing more.  Again, you may recognize that we’re talking here about resistance, as illustrated for example in this man.

Sarah was able to move past this resistance.  After only a few sessions she began returning the recruiters calls, relaxed during our sessions, and described feeling much better the rest of the time as she began to acknowledge that she was using her preoccupation with obsessive-compulsive disorder as a distraction from acknowledging and learning to cope with more basic anxieties.  She also realized that some of her profuse sweating was not anxiety but in fact fury.

Not everyone can take these steps.  Isaac came to see me with almost the exact same presentation, acknowledged in our first sessions as we reviewed the specifics of his symptoms that he really did not so clearly fit the diagnosis of OCD as he’d thought, and he both showed and verbally expressed his sense of excitement at leaving this preoccupation – this “crutch” as he himself put it – behind.  Very soon, however, he began missing sessions.  He would call to say he had overslept or simply forgotten our appointment.  He then failed to return the calls he’d requested from me so that we could reschedule.

Be wary in yourself of such retreats from the very treatment you have been seeking.  A feeling of interest and excitement in early sessions can quickly be replaced by groundless objections such as suddenly finding the schedule difficult, mysteriously forgetting session times – despite being an obsessive type person who never makes such mistakes -oversleeping, or fussing about the fee.

More about this kind of resistance that I see so particularly in people who present as suffering with OCD in my next posting (next week if I stay on schedule).  As I said, this entry was triggered by an account I read of a man who saw his obsessive and phobic symptoms (the latter was the cause of the former) emerging and took steps to end the problem without any resistance, stalling, or evasion.  Again, I want to be clear that there are of course people who suffer from more serious addiction, phobias, or OCD and who cannot take the bull by the horns in this way on their own, who need the help of a therapist or of programs like AA designed to support and guide them.

This entry was posted in Uncategorized. Bookmark the permalink.

Comments are closed.