Our vernacular conception of obsessive compulsive disorder is disgustingly divorced from the formal DSM-IV criteria. Lay people have somehow managed to reduce the archetypal OCD sufferer to a hygiene freak whose preoccupation with preventing contamination is a mere embellishment of Western society's increasingly meticulous sanitary movement.
This stereotypical portrayal of OCD diminishes it to a desire for sterility. Nothing could be further from the truth. OCD is not synonymous with germ phobia in any way, shape, or form. Furthermore, this behaviorist approach, which singles out merely one of myriad compulsions that may be presented, illustrates OCD as an overly simplified stimulus-response relationship that is exhibited when the individual encounters a manifestation of the universe that does not resonate with his or her immaculate expectations. This representation of OCD completely ignores the profound internal mental events that define the disorder.
What I find disconcerting is that even the DSM-IV criteria does not, in my opinion, accurately depict what constitutes a case of severe OCD. It is due to this very reason that it took me seven years to figure out just what the fuck was wrong with me, in spite of having consumed a deluge of empirical and anecdotal literature regarding psychopathology, receiving an associate's degree in psychology, seeing four therapists, and possessing the vast wealth of knowledge concerning the symptomatology, behavioral markers, and biological etiology of mental illnesses that are conducive to keen diagnostic skills. However, even the OCD inventories that are generated by mainstream psychological organizations do not even begin to capture the complexity and hallmark features of OCD, especially in its more severe forms. Consequently, the diagnosis evaded me for years.
Hence, I am going to propose a new way of understanding OCD. It involves acknowledging the remarkable amount of commonality between OCD and schizophrenia. "Although OCD and schizophrenia are distinct diagnostic entities, there is considerable overlap between the two disorders in terms of clinical characteristics, brain areas that are affected and pharmacotherapy" (Price, 2005). Indeed, the co-morbidity between schizophrenia and OCD is high. Studies have directly compared their clinical features. In fact, clinicians are frequently hindered by the difficulty in differentiating between the two.
While more enlightened sources devote a considerable amount of time to further addressing the psychotic component of OCD, most general clinicians don't even come close to tapping the surface of what OCD is really about. I firmly believe that if we analyze OCD in conjunction with its close cousin, schizophrenia, we can elucidate an essential understanding of the suffering endured by people with the disorder that would otherwise be impenetrable. My aim is to elicit compassion and support for people whose struggle is compounded by the trivialization and ignorant attitudes that undermine the disorder known as OCD.
Let us proceed with the comparison.
At the heart of the two disorders lies a gargantuan disturbance of thought. In the case of schizophrenia, this disturbance is often marked by the improper sensory perception that is characteristic of hallucinations, including (but not limited to) auditory and visual distortions. However, in the case of OCD, it is not incorrect information about the external world that is being imposed upon the sufferer. Rather, the individual is beleaguered by recurrent and relentless intrusive thoughts that materialize of their own accord, injected by a foreign jurisdiction rather than having been conjured up by one's conscious volition.
These internal mental events arise spontaneously, like pop-up ads, and are completely unresponsive to suppression efforts. Agency is usurped entirely-while you are at it, suspend the idea of agency entirely- as the individual is forced to share a space in his or her head with a volcano that erupts content of a disturbing and bizarre nature. It is as though a presence has been implanted in one's skull, and the intensity with which this presence asserts itself warrants the status of personhood. Think of the movie Inception, when the character played by Leonardo DiCaprio literally plants an idea in his wife's head, and the consequences of its germination are entirely out of her control. These thoughts serve the foundation for beliefs that, though they are false, are tenaciously held and against all resistance to modify them.
In an individual with schizophrenia, these unshakable beliefs are called "delusions." In an individual with OCD, they are called "obsessions." The nomenclature might differ, but both are characterized by a deeply held conviction that does not have a basis in reality.
The crucial distinction between the presentation of delusions in an individual with OCD and an individual with schizophrenia is that the OCD sufferer exhibits a degree of insight into the validity of their beliefs. That is, he or she is aware that their version of reality is twisted and warped. This lucidity adds an additional layer of horror as mutilated mental processes unfold. One reality is not being substituted for another. Rather, one reality is being supplemented by another. The individual's mind is superimposed by a lens that adds an additional element and another shade of meaning to one's existence.
In the grips of stress, this introspective advantage is lost, and the OCD sufferer operates, on an emotional level, as if they are absolutely convinced that their delusions are derived from a credible source. Hence, during these moments, the veil between firm ground and fantasy adopts a transparency that, for all intents and purposes, imbues falsehood with fact. For the time being, the delusions might as well be true.
The presentation of OCD and schizophrenia share a cognitive appraisal of the external world that has no basis in reality, and this appraisal is accompanied by persecutory themes and emotional components such as intense paranoia. Hallucinations are absent from OCD. Hence, the convergence lies in the misinterpretation of other peoples' intentions, as opposed to the insertion of erroneous sensory phenomena. It is almost analogous to intercepting and subsequently damaging the delicate genetic code that comprises DNA before it can be translated into the amino acids that serve as our biological framework. The entire meaning can become demented not by adding anything new, but by altering in some way what is already there. During severe episodes, namely ones exacerbated by stress and the deprivation of basic biological needs such as sleep, the OCD sufferer can experience episodes of paranoia that resemble a marijuana induced high in which the smoker "bugs out" and lapses into psychosis.
The individual with OCD is convinced that everyone is out to get them. For example, the obscure whispering of complete strangers across a room might be interpreted as negative commentary about the individual, tainted with a malice so incessant that it interferes with any and all attempts to supersede it. A crowded dining hall might prompt a magnetism that directs the eyes of everyone in the entire arena towards the individual. Casual glances of acknowledgement as people enter each others' realm of vision are converted into harsh glares and stares laden with daggers. A public space filled with random bouts of laughter is transformed into an orchestrated effort to destroy the individual with taunts.
The emphasis here should be placed on the judgement of others as it pertains to the individual, precisely because it pertains to the individual. This mindset arises not out of narcissism, but due to a deeply rooted self-directed enmity that results in an affinity for incorporating every surrounding stimuli, no matter how irrelevant, into a grand scheme to achieve self-deprecation at every turn.
Next, we will consider the OCD obsessions that are concerned with classic self-loathing. Again, keep in mind that the OCD sufferer is sharing a space in his or her head with a vicious presence that feeds him or her bellicose criticism all day long regarding every detail of their existence, and that the mercilessness with which this presence asserts itself is equivalent to a draconian, drug induced commander. To the OCD sufferer, every aspect of the self becomes a source of vicious scrutiny. One's gait might be perceived as incredibly stupid. The angle at which one moves his or her arm is a monstrosity. The inflection of one's voice mid-sentence makes one deserving of an execution. Like a topographical map, every perceived slight becomes an additional layer of imperfection, until the intellect of the OCD sufferer has constructed an atmosphere pervaded by inadequacy.
Sometimes, obsessions take the form of repetitive and morbid images. These extremely distressing and disturbing images, often involving themes of death, violence, and suicide, are completely unwarranted and erupt without the slightest provocation. While most people entertain dark notions from time to time, in the case of OCD, these obsessions can occur thousands of times a day. Additionally, it should be noted that these thoughts are entirely unwanted. To the OCD sufferer, it feels as though the spatter of a malevolent artery has extravasated into the compartment of the body that harbors their character. They mistakenly conclude that they have gruesome personalities. They take responsibility for their intrusive thoughts, an impossible feat for a human being, and grow terrified when they try to attribute meaning to these unwanted appearances.
It is worth clarifying that these images are not hallucinations. Rather, the OCD sufferer is forced to confront scenario after scenario in which the darkest elements of human existence are considered as a not so distant possibility. The vicious presence mentioned before taps into the primordial depths of one's deepest fears and exploits them.
Most importantly, it must be noted that the overwhelming majority of those afflicted by these thoughts, while terrified that their true desires are being represented, are so deeply disconcerted by these shocking images precisely because their disposition directly opposes that which is being presented to them. Indeed, the overwhelming majority of people with OCD never inflict acts of violence upon others. Quite the contrary, the afflicted individual often retreats into isolation and secrecy, a perpetuating behavior that further plunges him or her into a steepened state of despair.
Again, the emphasis should be placed on the prevalence of these thought processes. OCD is as debilitating as it is due to its exhausting stamina. Dozens of these thoughts are fired per second so that it is impossible for the individual to experience any semblance of respite. During a severe episode, these thoughts can cycle rapidly, as often as every second of every day. Additionally, it is important to note that the language used by this negative presence is ruthless, unforgivable, and asserts itself in no uncertain terms. The constant state of autonomic arousal that ensues in response to this intensity escalates into panic attacks, as the OCD sufferer is plagued by the calamitous effects of extreme anxiety. It is not uncommon for people with OCD to experience numerous panic attacks during any given week.
At this juncture, I would like to make an analogy that compares OCD and schizophrenia. I do this so that people with OCD might inherit some of the solicitousness that is reserved for those who suffer from a purely biological phenomenon. At this point, I think it is safe to assume that most (educated) people will not condescend to telling someone with schizophrenia, "Just don't think about it," or "Try your hardest not to let it bother you," or "You can ignore it if you really make an effort to do so." It would be silly to say any of these things to someone with schizophrenia. Neuroscientists, geneticists, and other relevant researchers have pinpointed a plethora of biological factors and neural circuits that are present in someone who is experiencing schizophrenia. It has been widely accepted in modern psychopathology that schizophrenia is a neurodegenerative disease, much like Alzheimer's.
Schizophrenia is the sole mental illness that has been observed across all cultures and during all points in history. This strongly suggests that schizophrenia is not influenced by social factors. Interestingly, reviewed studies from a diverse array of nationalities yields the insight that OCD also looks remarkably similar across cultures.
At the present time, I will not discuss the implications of an overactive orbital frontal cortex, abnormal brain cells in the basal ganglia, or insufficient levels of serotonin. Just take my word for it that OCD is biological as fuck.
The analogy that I would like to make alludes to the fact that the brain runs on electricity. Schizophrenia involves a total degeneration of the neural circuits that facilitate full blown visual and auditory disturbances. In the case of OCD, it might be useful to imagine a light bulb on a sign at a store that needs to be changed so that it flickers constantly, and every time it flickers on or off, images of death and irrational thoughts pop into the head, every second, all day, every day.
These obsessions, as they are described above, serve as the foundation for the emergence of compulsions, designated as such because they signify a mental mandate to behave a certain way, no matter how greatly this behavior may serve as an affront to the individual's conscious wishes. Compulsions emerge in an attempt to assuage the smothering din emanating from the obsessions, and because their function serves the purpose of dispelling potent fears and sources of disquietude, engaging in them is part of a contractual agreement. There is no backing out.
Compulsions are not habits. They are an army of addictions. Imagine not one alcoholic occurring within the same body, but countless alcoholics. A continent of alcoholics.
Compulsions can take many forms, and in some cases, one individual can exhibit dozens of them. Compulsions can mean having to breathe a certain way, such that the lungs expand the same width every time. Sentences might need to be read such that an equal allocation of time is devoted to every word. Sufferers might need to engage in activities for certain periods of time, if specific numbers have been deemed as "wrong" or "unsafe." For example, studying for a number of hours that does not end in a quarterly denomination can prompt an individual to believe that he or she is a failure in school. A person with OCD might need to check things, such as outlets, alarm clocks, and windows, as often as several dozen times. He or she may feel that surfaces touched with one hand need to be touched with the other while exerting the same amount of pressure delegated by the initial hand. Movements implemented on one side of the body may be met with the demand for exact replications of that same movement on the other side.
In some cases of OCD, self-injury develops in response to the need for symmetry and "balancing things out." Cutting and burning become motor outlets in addition to actions that signify self-loathing due to an inability to meet the incessant demands of one's mind. The very act of speaking can become a breeding ground for nervous breakdowns as the OCD sufferer scrupulously scans every possible vocabulary choice for imperfection and every potential word pairing for error until it becomes impossible to string together coherent sentences. To the OCD sufferer, it is better to remain silent than to utter a sound that can even remotely be construed as stupid.
Deviating from these irresistible rituals produces agonizing results. Violating the compulsory attendance statute devised by one's impossible expectations leads to utter despondency.
The interfering nature of compulsions with everyday activity and the associated anxiety and depression can lead to a total decomposition in functioning and prevent the OCD sufferer from meeting his or her basic needs, such as sleeping and eating.
The obsession-compulsion cycle takes place all day, every day. It does not cede itself to evenings, holidays, or second hands. It is unfolding during every wrinkle of time. Someone who has OCD may be consumed literally every second of their life by obsessions and compulsions. This is why OCD is one of the most incapacitating mental disorders, and is often met with treatment resistance.
So next time you go to make a joke about having OCD, please, refrain. Chances are, you don't actually have OCD, and your facetious remark is only serving to disconnect somebody who actually does.
