With Pesach in front of us, what better time to take a closer look at the annual burst of intensity that propels us, in the weeks and days leading up to the yom tov, into a frenzy of cleaning and scrubbing?
That sustained embrace of scrupulous cleaning offers some insight into a fascinating subject that has lately received a great deal of attention in psycho-educational literature. The topic, OCD, obsessive-compulsive disorder, might be better understood by comparing it with that exhausting endeavor from which many of us are still recovering.
OCD is an anxiety disorder that strikes both children and adults. It is a form of “brainlock,” where distressing thoughts pop up in a person’s mind and refused to be banished. The anxiety they generate compel the person to perform certain rituals meticulously, again and again, until they are done “right.”
OCD is often manifested by a preoccupation with arranging things in a very particular way; excessive cleaning or checking things ad infinitum; irrational fear of germs and contamination; asking the same question repeatedly when the answer is known; touching things a certain number of times; counting before executing the simplest action and many other rituals.
How does OCD differ from a normal drive for cleanliness and order in one’s life? To hark back to the Pesach-cleaning scenario, to insist on moving the stove and refrigerator before Pesach to search for elusive crumbs would not qualify as “compulsive,” or “obsessive.” A once a year endeavor, this effort is inspired by an uplifting sense of purpose.
But imagine a housewife who, in a quest for absolute spotlessness to allay OCD anxiety, is driven to similar exhausting measures every single day?
Such is the terrible burden of OCD, whose rituals are usually hated and dreaded by the sufferer due to their utter meaninglessness and consuming nature, yet impossible to set aside.
The disorder is far more disabling than people realize, and consumes untold hours and outputs of energy. Unlike ordinary worries and obligations, OCD obsessions and compulsions do not go away or lesson even when the demanding rituals are faithfully carried out.
In fact, the compulsive actions tend to increasingly dominate a person’s life. They take inordinate amounts of time (a few hours a day, at the minimum), may interfere with a person’s daily schedule and cause significant distress.
Observing a person engaged in the bizarre rituals of OCD behavior would be enough for most people to regard him as unstable. OCD sufferers know this. Fearful of being thus shunned as crazy, people suffering from the condition go to great lengths to hide their symptoms from others.
In children especially, the fear of being ridiculed, or regarded as weird or “mental,” exacts a terrible price in self-esteem and the need to maintain secrecy about their condition.
Because OCD compulsions and obsessions tend to gradually increase and encroach further and further on a person’s life, life for the OCD victim can become unbearable.
The rituals of repeatedly washing off invisible dirt, for example, or counting a certain number of times before entering or leaving a room, or tying one’s shoes six or eight times until they feel “right,’ begins to get more and more involved and consume ever greater amounts of time.
Psychologists explain that trying to suppress the compulsions and obsessive thinking by sheer will power doesn’t work. It produces so much anxiety that the person invariably surrenders to the urge or becomes haunted by other obsessions.
OCD Behavior In Children and Adolescents
Recognizing the symptoms of obsessive-compulsive disorder may be challenging, as the symptoms can easily be misinterpreted as willful disregard, oppositional behavior or emotional immaturity.
Often, a parent or teacher only sees the end result of the symptom such as hours in the bathroom; extended dallying in the bedroom; inability to finish assignments, or tantrums when the child cannot do something his or her way and is overwhelmed with anxiety.
If left untreated, peer relationships, school functioning, and family functioning all may suffer, cautions Dr. Edna Foa, an internationally recognized expert on anxiety disorders and author of Stop Obsessing!
Depression may develop. In some situations, in response to the extreme anxiety, social isolation, and limited activities, a child may develop thoughts of self-harm or not wanting to be alive.
OCD is usually not outgrown. If left untreated, it follows its victims into adulthood, as the following excerpt from a personal memoir illustrates.
The Monster And Me
In her moving memoir, The Monster And Me, Rena Galloway remembers starting to line up her toys when she was five. At eight she was lining up her shoes and slippers several times a day, the books in her school bag and the items in the medicine closet. At nine, after her parents divorced, her compulsions spread to the pantry. She lined up cans of food in alphabetical order, with all the labels facing in one direction.
“What are you doing in the pantry so late?” my mother called to me from her bedroom, making my hand jerk in fear.”
“Just looking for something to take for lunch,” I managed.
“At this hour? But I made your lunch already, you saw me make it.”
“I know. I just wondered if there were any raisins left. I’m in the mood for raisins.”
“Enough of this nonsense! Go straight to bed!”
She thought I was being impudent. I was exhausted and longed to go to sleep, but the monster had me in its grip. I couldn’t allow myself to go to bed until I had completed arranging the pantry shelves. If I didn’t, I’d lie awake for hours, fearful of something bad happening to my family. I waited in bed for a half hour until I was certain she was sleeping and then crept into the pantry and finished arranging the cans. Only then did I finally go to sleep. This happened three or four nights a week over many, many months.
Twenty years later, I was enslaved to “the monster,” devoting 20 hours a week to carrying out a host of bizarre chores in the privacy of my home. I couldn’t hold a job and had watched my marriage crumble.
– From The Monster And Me
OCD At Home
Symptoms of obsessive-compulsive disorder at home are often more intrusive than at school. Life for the child and the family can become very stressful, and all family members including the child may feel powerless to change rigid patterns of behavior.
At home, children with OCD may display a combination of the symptoms listed below:
Repeated obsessive thoughts. Unlike ordinary worries, these obsessions (such as fear of becoming fatally ill) are not generally realistic. Often the child may deny these thoughts or behaviors, or be embarrassed by them.
Repeated actions to prevent a feared consequence (such as repeating certain words, tapping objects or counting to certain numbers to ward off danger to oneself or to a family member).
Consuming obsessions and compulsions. The child or adolescent is continually preoccupied with these fears (for example, he avoids nearly all contact with objects due to fear of contamination, or showers and washes hands for hours each day).
Extreme distress if others interrupt a ritual. Children may kick up extended tantrums if a parent insists that the child discontinue her ritual.
Difficulty explaining unusual behavior. Children with OCD may not be able to explain what their worries are or why they feel compelled to repeat their behaviors.
Attempts to hide obsessions or compulsions. Children and adolescents are often ashamed of their worries or strange habits and will make great efforts to keep their thoughts or rituals a secret.
Concern that they are “crazy” because of their thoughts. Children with OCD may recognize that they think differently than others their age. Consequently, these children often have low self-esteem.
At School
The differences in behaviors seen at home and at school can be significant. At school, students may be successful in suppressing symptoms, while they may be unable to do so at home. Families often seek treatment once symptoms affect school performance.
At school, a child with OCD may exhibit one or more of the following symptoms:
Difficulty concentrating, which may affect his ability to follow directions, complete assignments and pay attention in class. Concentration can be derailed by persistent, repetitive thoughts that come of their own volition. Finishing work in the appropriate time can be difficult, and just starting schoolwork can be difficult, too.
Perfectionism. A child with OCD may have impossibly high standards of perfection; may spend most of his time erasing and starting over. The child may be almost paralyzed by the inability to tolerate in himself results that are less than perfect.
Social isolation or withdrawal from interactions with peers due to bizarre habits.
Low self-esteem manifesting in social and academic activities.
Problem behaviors, such as fights or arguments, resulting from misunderstandings, ridicule or teasing regarding the child’s OCD behavior, or because an OCD child often can not let go of an argument.
What Causes OCD?
OCD was long assumed to be purely psychological, the mind’s reaction to overly-strict parents or an abnormal emphasis on cleanliness. Scientists now believe it is the result of a chemical imbalance in the brain.
“OCD tends to be occur in families, meaning there is a genetic component. However, scientists believe that it takes a stressful event for the condition to activate, and that exposure to various scenes, encounters or stories can aggravate it, said Dr. Susan Swedo, quoted in Science News.
OCD is the mind’s way of trying to impose control in one’s life when events feel out of control, she said.
Research has shown that OCD is triggered by the way the mind handles messages about fear and doubt. This problem probably has to do with the chemicals that carry messages to nerve cells in the brain.
If the flow of these chemicals gets “blocked,” or if there is not enough of them, messages about doubts and worry seem to get “stuck.” This leaves a person with an agitated feeling of things being out of sync or out of control, and creates agitation.
Cognitive Behavioral Treatment – What’s Involved?
CBT is usually recommended for children and adolescents with obsessive-compulsive disorder. In CBT, a young person is helped to identify obsessive thoughts and compulsions and what triggers them.
With younger patients, personifying the obsessions (for example, “Germy” to describe the fear of germs) allows children to “fight back” against the thoughts or behaviors that create barriers between themselves and peers or family activities.
Cognitive behavior therapy focuses on changing behaviors by “exposure” and “response prevention.” “Exposure” works by having the patient, under the therapist’s guidance, confront the obsession without resorting to the ritual that is meant to allay anxiety. The patient refrains as long as possible from surrendering to the compulsive urge, weathering the panic and anxiety the delay causes.
For example, in one of the cases documented by psychologist Dr. Janice Taussig, a ten-year-old girl named Miriam could not fall asleep at night without calling out “Good night, Mommy!” two, four, six or eight times. Sometimes, she would have to add “Sleep well!” an equal number of times. If her mother refused to respond to her, she could not relax and fall asleep. She would toss and turn for hours, eventually working herself up into anxiety attack and breaking down in tears.
Miraim’s therapist helped her to break these compulsions first by getting her to talk and even joke about them. They rehearsed the nighttime calls over and over and talked about what would happen if she kept them down to first four and then two a night, and then just one.
Slowly and steadily, over a number of months, Miriam was able to practice “response prevention,” reducing the calls without feeling unbearable anxiety.
One night she fell asleep without a single extra “Good night, Mommy!”
She still practiced other OCD rituals like opening and closing soda bottles several times before it felt just “right’ she but was making progress in letting go of those as well.
Individual psychotherapy may be useful for young people with OCD, particularly when they have ongoing stressors in their lives that make symptoms worse. Children with obsessive-compulsive disorder often carry a sense of failure, as if the illness was their fault. In many cases, they know that their disturbing thoughts and rituals are generated by their own mind, which can increase their self-blame and shame. Individual psychotherapy can help young people become aware of and address these feelings.
Parent guidance sessions can help parents to manage their child’s illness, identify effective parenting skills, and learn how to function better as a family despite the disorder. Family therapy may be beneficial when issues are affecting the family as a whole.
“OCD is a like a greedy tyrant,” says Dr. Taussig. “The more you surrender to it, the more it takes over your life. But once you expose the obsessions for what they are, you drain them of power.” She has posted a plaque on one of the walls of her office that encapsulates her approach to this daunting anxiety disorder:
Know your enemy
For once he’s known
He’s nothing but a humbug
A tyrant dethroned.
