Obsessive-Compulsive Calvin As Calvin entered my office, his movements seemed oddly ordered. He seemed to be using undue discretion regarding his simple motor movements. His appearance was neat and presentable, almost too presentable. A vertical descent of inspection revealed a harmonic hairstyle without a single dissident, a freshly shaven face, and a creaseless button-down shirt tucked into a pair of spotless khakis which rested lightly upon a shiny pair of Wall Street-like shoes. -What seems to be the problem Calvin? -Well doc, I've been conquered by concupiscence. -Could you please expand on that? -Sure. My entire life is basically an attempt to ward off my indecent longings. Everywhere and at all times I can't stop these thoughts, thoughts about girls, girls clothes, just thoughts of general infidelity. -You're worried about cheating on your girlfriend? -No, we've been broken up for a while, and as a result of the thoughts I think, but I'm more worried about being unfaithful to Jesus. I mean, he did me a great favor by giving me this body and mind, and all I can think about is defiling them. -I see. Can you pinpoint the point at which these obsessions began? Calvin went on to tell me a story from eighth grade. A friend had given him an adult magazine, which was promptly brought home and hidden predictably - under his mattress. After secretly spying the magazine for a couple of weeks, his precautionary measures became lax. Soon thereafter, after a random mattress check, Calvin was receiving an earful from a disgusted mother. Threats of chores and groundings did not startle Calvin; it was the polemics regarding eternal damnation, teeth gnashing, and savioral obligation that really caused some genuine fear and trembling. Coincidentally, stress is correlated with compulsions (Parkinson & Rachman, 1981a, 1981b). From then on, while lustful thoughts caused increasing amounts of stress and guilt, they also became increasingly harder to stop. Solo prayer sessions and bible readings soon arose as a means towards gaining anxiolytic spiritual forgiveness. As blasphemy mounted atop blasphemy, more and more forgiveness was needed. If so much as a Balley's commercial appeared on the television, Calvin would force himself into hours of religious compulsion in order to purge the ill-begotten ideas. Consequently, he was soon dumped by his girlfriend, lost a majority of his friends, and was even fired from his job. Therefore, Calvin's multiaxial diagnosis was: Axis I: Obsessive-Compulsive Disorder, "with poor insight" specifier. Axis II: None Axis III: None Axis IV: Loss of numerous social relationships and job. Axis V: Major impairment in more than one area of functioning, a score of 35 on the Global Assessment of Functioning Scale. The "with poor insight" specifier was given because although Calvin recognized the excessiveness and unreasonableness of his obsessions, he never made the same concession regarding his extreme compulsions. I think it is this specifier that more than anything played a decisive role in the treatment outcome. Also, it should be noted that Calvin fit several of the criteria for paraphilias such as exhibitionism, frotteurism, and voyeurism; but his obsessions most times were more general and better described by OCD. For OCD, the two most effective treatments are exposure and response prevention (Foa, Steketee, Grayson, Turner, & Latimer, 1984) and Cognitive Therapy (Beck, 1976; Salkovskis, 1985). While some studies have shown both to be equally efficacious (Emmelkamp & Beens 1991), others have shown Cognitive Therapy to be superior (Van Oppen et al. 1995). Given these mixed results and my own insight, I decided that an eclectic approach featuring both therapies would be most beneficial. Exposure and response prevention is built upon the commonly accepted notion that compulsions begin in an effort to reduce anxiety caused by the obsessions. So then, obsessions are to be brought up, while keeping the compulsions repressed. Ideally, the patient will realize that nothing negative is going to result from the obsessions, and anxiety and the need for compulsions are gradually reduced. This technique began with a series of small successes. Obsessive thoughts were brought out with the help of Bay Watch and MTV. Calvin was then prevented from either praying or reading his bible. To make sure he didn't secretly pray in his head, we made sure he was watching the television and his eyes remained open at all times. Also, the volume was up unusually high incase he could still somehow avert his attention. Eventually, the scales were increased by utilizing late-night cinnemax coupled with even longer bible-free periods. However, it soon became apparent that the religiosity of the patient would only allow the compulsion repression to go so far. The thing about compulsions is that in severe cases such as this, they become an all-or-nothing commodity. Humanity and goodwill may have required us to let the patient attend church at least on Sundays, but the treatment would be completely undermined. Cognitive Therapy would thus have to become the main weapon in our battle. With Cognitive Therapy, challenging the patient's irrational beliefs becomes the primary tactic. Basically, the patient has a general notion that some horrible event will occur if the obsessive thoughts are not stopped. By proving the irrationality of this belief, anxiety is abated and compulsions are no longer necessary. Sadly, the previously identified problems surfaced again with this therapy. The event motivating Calvin's obsessions was godly wrath and eternal hellfire. Is it really morally permissible to attempt to falsify someone's entire belief system in the name of a cure? Perhaps the cure would be worse than the disease. In the end I decided it best to bypass these moral dilemmas and try an alternative. The only two alternatives left were medications and psychosurgery. Reminded by the nausea I felt after utilizing ECT-induced brain damage to cure my last patient, Samuel, I decided that the less brain damaging medications were my only option. My mood was somewhat uplifted when I was referred to some studies (Riggs & Foa 1993; Zohar et al., 1996) that showed benefits as high as 60% with serotonin reuptake inhibitors. With few side effects, Calvin's compulsions slowly diminished back to culturally accepted levels. Basically, the drugs appear to have reduced Calvin's physiological anxiety, making it no longer necessary to attempt to reduce it with compulsions. The obsessions remain, but the distressful time-consuming aftereffects have been eliminated. Calvin still feels he is a sinful hell-bound debaucher, but at least now he can make lasting social relationships in which to communicate his beliefs. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author Barlow, D.H., & Durand, V.M (1999). Abnormal Psychology. Pacific Grove: Brooks/Cole Publishing Company Foa, E., Steketee, G., Grayson, J., Turner, R., & Latimer, P. (1984). Deliberate exposure and blocking of obsessive-compulsive rituals: Immediate and long-term effects. Behavior Therapy, 15, 450-472 Beck, A.T. (1976). Cognitive Therapy and the Emotional Disorders. New York: International Universities Press Emmelkamp, P.M.G., & Beens, H. (1991). Cognitive therapy with obsessive-compulsive disorder: A comparative evaluation. Behavior Research and Therapy, 29, 293-300 Van Oppen, P., De Haan, E. Van Balkom, A.J.L.M., Spinhoven, P., Hoogduin, K., & Van Dyck, R. (1995). Cognitive therapy and exposure in vivo in the treatment of obsessive-compulsive disorder. Behavior Research and Therapy, 33, 379-390