June 25, 2009
Obsessed by fears
By Dr Brian Yeo
One of my patients, Patrick, suffers from obsessive compulsive disorder or OCD. His fear of some things seem irrational. He is afraid to touch the handle of the door of my clinic, so he uses a tissue. He does this to open every door.
He shrinks from flushing a toilet, washes his hands incessantly, frequently scrubs the floor at home and spends hours in the bathroom because of his long-ingrained personal cleansing ritual.
Naturally, there is friction with family members, such as when they have to wait for him to finally come out of the bathroom.
At his insistence, they also have to take off their shoes and wipe their feet in special antiseptic solutions before entering the home.
Patrick's compulsive washing is due to his obsessive thoughts of being contaminated. His cleaning ritual worsens in situations where he believes there would be more dirt or infection, such as in toilets.
About 2.5 per cent of any population is said to suffer from OCD but many cases remain untreated. Apart from fear of contamination by something 'dirty", other compulsive acts include checking and counting rituals.
Certain OCD sufferers have compulsive acts because they harbour constant fears or repetitive thoughts about dirt or that something is not in order or not right. This torments them until they find temporary relief - through their ritual acts. Until they seek treatment, they will find it hard to work or interact with family and friends.
Another patient, Derrick, had obsessive thoughts when he was a teenager. He would imagine that he had not done his work properly and would thus constantly check on his schoolwork. His teachers felt frustrated watching him during examinations when he would frequently check and re-check his scripts only to end up tearing up his answer sheets. He could never complete an examination session.
Derrick, now an adult, would also keep checking the lights and power switches before leaving home. He would check if he had locked his car door too. These actions caused him to be late for appointments and prevented him from performing to the best of his abilities at work.
Patients with counting rituals would need to mentally note certain items, say, the cracks on the pavement while they are walking. They need to count to a personal special number before they can feel a sense of satisfaction.
Others have to ritualistically walk a certain number of steps before entering or leaving a room. These counting rituals can cause great embarrassment to themselves when others laugh at them.
I gave Patrick a reassuring smile as I confidently clamped my palm onto the sole of my shoe. He grimaced when my hand touched the 'soiled' sole as he knew he had to, on my instruction, do the same with his palm on the sole of his shoe.
We had earlier drawn up a hierarchy of his fears: Patrick's least feared situation was touching the clinic's door handle and his most feared encounter was flushing the cistern in a public toilet.
Patients, like Patrick, with compulsive cleaning rituals can be treated using the above behavioural change method called response prevention.
It is, however, harder to treat checking and counting rituals with behavioural change methods, as their checking and counting may not be so easily observed and changed.
Even harder to treat this way are patients with no compulsive actions but who have constant obsessive thoughts about disruptive acts of violence and of sexual imagery that interfere with their daily functions. Most patients require medication to reduce the constant bombardment of these thoughts, which are like a broken tape recorder.
Patrick and Derrick, like all patients with obsessive thoughts, fear they will go mad as they cannot control their thoughts.
In fact, many successful people do have some obsessive traits: they are meticulous in checking, in counting or in keeping time to ensure that the tasks they undertake are carried out to their satisfaction.
It is when such thoughts become too overwhelming that it becomes obsessive compulsive disorder. Nevertheless, such patients will never lose touch with reality or go mad despite their fears.
However, asking OCD sufferers to not think too much about their fears is counter-productive, as they are already constantly trying to stop or ignore such thoughts. Instead, professional treatment is needed.
OCD is curable. Patrick has started to eat in coffee shops and to use the toilets there, while Derrick is now able to do his assignments and is more confident about going out without repetitive checking.
Dr Brian Yeo is a consultant psychiatrist in private practice and an adjunct associate professor at the department of psychological medicine at the Yong Loo Lin School of Medicine, National University of Singapore. He is also a certified master substance abuse counsellor and is currently the Singapore Medical Association representative to the Board of Management, Singapore Anti-Narcotics Association.