A Misunderstanding Central to OCD

A Misunderstanding Central to OCD

The big difference between a little and a lot.

Individuals suffering from obsessive-compulsive disorder are unable accurately to assess risk. They think that if something is dangerous—such as radiation or germs—then it is always dangerous, no matter how much of it, or how little of it, they encounter. Therefore, they think the only sensible way of living is to avoid that dangerous substance altogether, or, at least as much as possible. Plainly this conclusion is wrong. Even very dangerous substances may be safe at very low levels, and, for that matter, ordinarily safe substances can be dangerous at high enough levels. For instance, drinking water in very great amounts will cause a loss of sodium from the blood and can cause organic disorders, such as delirium.

Some examples of well-known risks:

Asbestos. Once thought safe, it is now known that asbestos when inhaled can cause mesothelioma, a particularly dangerous cancer. Asbestos serves no good purpose in the body no matter how small the amount. But in the eyes of someone with OCD even vanishingly small amounts of asbestos are dangerous. For example, it is true that asbestos lurks in some unexpected places, such as the brake linings of automobiles. It is reasonable, therefore, for a mechanic who works all day on brakes in a closed and unventilated garage to be concerned about the amount of asbestos circulating in the air. But I saw a patient who was unreasonably afraid of asbestos. She would not drive on highways that had toll booths because everyone has to brake before reaching the toll. In her mind the infinitesimal amount of brake lining that wore away when approaching a toll booth wafted all the way up and down the highway, endangering everyone. She was worried about a danger that would not even have occurred to most people. Eventually she was convinced to drive on highways only when one of the world’s experts on asbestos assured her that doing so was safe.

Germs Bacteria and viruses, and a few other organisms, cause infectious diseases. Anyone reading a newspaper these days will read about bacteria that have grown resistant to all antibiotics. Some germs are very infectious, some less so. Some are communicated by breathing them in, others by being bitten by a mosquito or a tick. But bacteria and viruses are all about. In certain settings, such as a hospital or a cruise ship, they can cause serious epidemics. But they are everywhere. Opening a petri dish in an operating room for just a moment will inevitably grow out colonies of bacteria. Most germs, including those that reside on and inside us are harmless.

Therefore, it makes sense to take precautions against infectious diseases in certain settings, but not in general. Patients with OCD are often desperate to avoid all germs by washing excessively and avoiding sick people. They tremendously exaggerate the risk of catching an illness. Indeed, excessive washing can lead to infections by yeast and other organisms.

Radiation  Radiation from atomic weapons is deadly. In lesser amounts over a period of years it can cause cancer whether the radiation comes from a weapon or from other sources, such as radium. Even though invisible (like asbestos or germs) radiation from several sources can add up over the course of a lifetime to dangerous levels. Therefore, it is reasonable to avoid situations where someone is chronically exposed to radiation, usually in the course of work. Doctors taking X-rays every day stand behind a barrier. But the X-rays from a single chest X-ray or from dental X-rays are trivial. Yet some patients with OCD treat all radiation as if it is deadly. Consider this: radon, which is a radioactive breakdown product of uranium, is present in every basement to a varying degree, usually in very small amounts. Furthermore, other kinds of radiation come from the sun and are at a greater level during airplane flight than at ground level. These differences have no clinical significance, yet there are some obsessional individuals who are frightened if they are too far below ground or too far above it. In addition, because of the notion that the feared substance can spread everywhere, an idea which is part of their illness, they avoid anyone who they think may have been exposed somehow to that substance.

Fire  The risk of fire is only one of a number of other dangers that can trouble those with OCD. These include: fumes, unhealthy foods, insects and others. An example of the fear of fire being excessive was a woman who walked through the streets of a metropolis looking for cigarettes on the ground that were still smoldering so she could stamp out the fire. In her mind, the risk of fire from a cigarette on a street was equivalent to a burning cigarette in a forest.

Since patients with OCD cannot reliably estimate risk, I suggest to them that they rely on the judgement of others, particularly experts. They retort by telling me that experts can be found on every side of an issue. Some people say that the radiation from headphones is dangerous, others say the opposite. This is true to some extent—but only to some extent. Usually, the precautions that other prudent people take should be sufficient to guide those who are inclined to worry excessively. I tell them to settle for being as safe as everyone else. No safer.

In a way, arguing with patients about what constitutes a risk is beside the point. The nature of OCD is such that the avoidance of danger is at the heart of the condition—not the danger itself. Patients will often shift from one specific worry to another. Indeed, sometimes they will respond to worries that they, themselves, know are simple superstitions. A number of such patients will worry about picking the right clothes to wear in the morning, because if they pick the wrong clothes, something bad will happen to a member of their family.

Still, since obsessional patients are specific about their fears, it seems appropriate to help them determine whether or not that particular substance or situation is, truly, dangerous.

Beyond that, I try to convince them that life should not be given over entirely to a quixotic attempt to stay safe. Obvious dangers (that everyone agrees about) should be avoided, but avoiding everything that is potentially dangerous would mean giving up many pleasurable activities and some that are essential. It is perfectly reasonable for someone to ski even if there is a risk of a fall and injury. The enjoyment of skiing outweighs the risk. Driving an automobile is inherently somewhat dangerous. But it is essential.

The purpose of life should not be solely to be safe. Too much of a sacrifice is entailed. And there is a point where a danger is so low as not to justify even thinking about, let alone worrying about. © Fredric Neuman