Welcome back, people! Last week we continued our foray into all things Xanax and talked about dependence and use disorder. The next step in the chain- withdrawal- can be a special kind of beastie, definitely deserving of its own blog, so this week will be all about Xanax withdrawal.
As I mentioned last week, some folks can take their bit of Xanax a couple of times a day as directed for umpteen years, and never develop a tolerance or pathological dependence. Others start out taking it as directed, but develop a tolerance and maybe start to abuse it- take too much too often- and then begin to develop a more pathological dependency. Others may abuse it recreationally on occasion, to netflix and chill, find they really like it, then develop a severe addiction. It may not sound like these people have much in common, but they do. When they stop taking it, they’re all going to go through withdrawal.
They won’t do so alone, though. In 2017, doctors wrote nearly 45 million prescriptions for Xanax, so it’s no surprise that these prescribing practices have contributed to thousands of cases of abuse and dependence. With those numbers, there has been all sorts of research and stats examined on benzos, and I read that in 2018, an estimated 5.4 million people over the age of 12 misused prescription benzodiazepines like Xanax. That’s a lot of people, people.
To many patients that take their Xanax exactly as prescribed, it seems to come as a surprise that they’re facing a withdrawal experience, but Xanax doesn’t discriminate- so anyone taking enough of it for more than a few weeks will develop a physical dependence. Once you have become physiologically dependent on a drug, you will experience withdrawal symptoms when you stop or reduce your dose. Simple as that.
Withdrawal is different for everyone. Depending on the dose and how often you’ve been using it, the withdrawal experience typically ranges from uncomfortable to very unpleasant, but it can also be medically dangerous. The only safe way to quit is to slowly taper down the dose under the direction of a physician, or in an in-patient treatment center setting, depending on the situation. If you’ve been taking high doses of Xanax several times a day, then quitting is going to take a great deal of time, patience, and determination. Please note that quitting cold turkey can cause extremely dangerous withdrawal symptoms. This can include delirium, which is a state characterized by abrupt, temporary cognitive changes that affect behavior; so you can be irrational, agitated, and disoriented- not a good combo. Sudden withdrawal can also cause potentially lethal grand mal (aka tonic-clonic) seizures. These are like electrical storms in the brain, where you lose consciousness and have violent muscular contractions throughout the body. It’s not a risk you want to take, people- so don’t do this on your own! Even if you’ve been taking Xanax illicitly, that doesn’t mean you have to go it alone. Just fess up to a physician and tell them exactly how much you’ve been taking so they can design a taper schedule for you, or help you find a treatment center. There is a lot of help available if you make the effort.
Tapering your dose is the best course of action for managing withdrawal symptoms, but that doesn’t mean it’s a picnic in the shade. While you taper down the dose, you’ll likely experience varying degrees of physical and mental discomfort. You may feel surges of anxiety, agitation, and restlessness, along with some unusual physical sensations, like feeling as though your skin is tingling or you’re crawling out of your skin. But keep in mind that these are all temporary.
Signs and Symptoms
The major signs and symptoms of Xanax withdrawal vary from person to person. Research indicates that roughly 40% of people taking benzodiazepines for more than six months will experience moderate to severe withdrawal symptoms, while the remaining 60% can expect milder symptoms. It’s very common to feel nervous, jumpy, and on edge during your taper. And because Xanax induces a sedative effect, when the dose is reduced, most people will experience a brief increase in their anxiety levels. Depending on the severity of your symptoms, you may experience a level of anxiety that’s actually worse than your pre-treatment level. Support from mental health professionals can be very beneficial during and after withdrawal, as therapy and counseling may help you control and manage the emotional symptoms of benzo withdrawal.
Physical Withdrawal Symptoms
As a central nervous system depressant, Xanax serves to slow down heart rate, blood pressure, and temperature in the body- in addition to minimizing anxiety, stress, and panic. Xanax may also help to reduce the risk of epileptic seizures. Once the brain becomes used to this drug slowing all of these functions down on a regular basis, when it is suddenly removed, these CNS functions generally rebound quickly, and that is the basis for most withdrawal symptoms. Symptoms can start within hours of the last dose, and they can peak in severity within 1 to 4 days. The physical signs of Xanax withdrawal can include: headache, blurred vision, muscle aches, tension in the jaw and/ or teeth pain, tremors, nausea, vomiting, diarrhea, numbness of fingers, tingling in arms and legs, sensitivity to light and sound, alteration in sense of smell, loss of appetite, insomnia, cramps, heart palpitations, hypertension, sweating, fever, delirium, and seizures.
Psychological Withdrawal Symptoms
Xanax, as a benzodiazepine, acts on the reward and motivation regions of the brain, and when a dependency is formed, these parts of the brain will be affected as well. When an individual dependent on Xanax then tries to quit taking the drug, the brain needs some time to return to normal levels of functioning. Captain Obvious says that whenever you stop a benzo, because it acts as an anxiolytic, you’re going to experience a sudden increase in anxiety levels. While there are degrees of everything, the psychological symptoms of Xanax withdrawal can be significant, as the lack of Xanax during withdrawal causes the opposite of a Xanax calm, which is to say something akin to panic. At the very least, that can make you overly sensitive, and less able to deal with any adverse or undesired feelings. Withdrawal can leave people feeling generally out of sorts, irritable, and jumpy, while some individuals have also reported feeling deeply depressed. Unpredictable shifts in mood have been reported as well, such as quickly going from elation to being depressed. Feelings of paranoia can also be associated with Xanax withdrawal.
Nightmares are often reported as a side effect of withdrawal. I included insomnia in physical symptoms, but trouble sleeping can also be a psychological symptom, as it is both mentally and physically taxing. People can be overtaken by anxiety and stress during withdrawal, and that may cause this trouble sleeping at night, which then contributes to feelings of anxiety and agitation, so it’s a cycle that can be tough to break free of. Difficulty concentrating is also reported, and research has found that people can have cognitive problems for weeks after stopping Xanax. Ditto for memory problems. Research shows that long-term Xanax abuse can lead to dementia and memory problems in the short-term, although this is typically restored within a few months of the initial withdrawal. Hallucinations, while rare, are sometimes reported when people suddenly stop using Xanax as well. Suicidal ideation is sometimes reported, as the anxiety, stress, and excessive nervousness that can occur during withdrawal can lead to, or coexist with suicidal thoughts. Finally, though rare, psychosis may occur when a person stops using Xanax cold turkey, rather than being weaned off of it.
Xanax Withdrawal Timeline
Xanax is used so commonly for anxiety and panic disorders because it works quickly, but that also means it stops working quickly and leaves the body quickly. Xanax is considered a short-acting benzodiazepine, with an average half-life of 11 hours. As soon as the drug stops being active in the plasma, usually 6 to 12 hours after the last dose, withdrawal symptoms can start. Withdrawal is generally at its worst on the second day, and improves by the fourth or fifth day, but some symptoms can last significantly longer. If you go cold turkey and don’t taper your dose, your withdrawal symptoms will grow increasingly intense, and there really is no way to predict how bad they may get, or how you’ll be affected.
Unfortunately, five days doesn’t signal the end of withdrawal for some people, as some may experience protracted withdrawal. Estimates suggest that about 10% to 25% of long-term benzodiazepine users experience protracted withdrawal, which is essentially a prolonged withdrawal experience marked by drug cravings and waves of psychological symptoms that come and go. Protracted withdrawal can last for several weeks, months, or even years if not addressed by a mental health professional. In fact, these lasting symptoms may lead to relapse if not addressed with continued treatment, such as regular therapy.
Factors Affecting Withdrawal
Withdrawal is different for each individual, and the withdrawal timeline may be affected by several different factors. The more dependent the body and brain are to Xanax, the longer and more intense withdrawal is likely to be. Regular dose, way of ingestion, combination with other drugs or alcohol, age at first use, genetics, and length of time using or abusing Xanax can all contribute to how quickly a dependence is formed and how strong it may be. High stress levels, family or prior history of addiction, mental health issues, underlying medical complications, and environmental factors can also make a difference in how long withdrawal may last for a particular individual and how many side effects are present.
Coping with Xanax Withdrawal
The best way to avoid a difficult and potentially dangerous withdrawal is to slowly taper down your dose of Xanax, meaning to take progressively smaller doses over the course of up to several weeks. By keeping a small amount of a benzo in the bloodstream, drug cravings and withdrawal may be controlled for a period of time until the drug is weaned out of the system completely. It may sound like designing a taper would be a no-brainer, but it’s definitely not recommended to taper without a physician’s guidance. Why? Because Xanax is a short-acting drug, your body metabolizes it very quickly. Controlling that is challenging because the amount of drug in your system goes up and down with its metabolism. To help you avoid these peaks and valleys, doctors often switch you from Xanax to a longer acting benzo during withdrawal, as it may make the process easier. And believe me, that’s what you want. If the physician goes this switch route, once you’ve stabilized on that med, you’ll slowly taper down from that a little bit at a time, just as you would with Xanax.
Another reason not to play doctor on this one is if you start to have breakthrough withdrawal symptoms when your dose is reduced, your physician can pause or stretch out your taper. It’s up to him or her, through discussion with you, to design the best tapering schedule for your individual needs. Sometimes it’s a fluid and changing beastie.
In addition, adjunct medications like antidepressants, beta-blockers, or other pharmaceuticals/ nutraceuticals may be effective in treating specific symptoms of Xanax withdrawal, and you’ll need a physician to recommend and/ or prescribe those as well.
Alleviating Symptoms of Withdrawal
An individual may notice a change in appetite and weight loss during Xanax withdrawal, so it’s important to make every attempt to eat healthy and balanced meals during this time. It may sound obvious, but a multivitamin including vitamin B6, thiamine, and folic acid is especially helpful, as these are often depleted in addiction and withdrawal. There are some herbal remedies that may be helpful during withdrawal, such as valerian root and chamomile for sleep. Meditation and mindfulness are very useful for managing blood pressure and anxiety during withdrawal, so be sure to check out my March 15 blog for more on mindfulness. Considering the insomnia and fatigue that may occur during withdrawal, it may seem counterintuitive to commit to exercise, but it has been shown to have positive effects on mitigating withdrawal symptoms and decreasing cravings. Exercise stimulates the same pleasure and reward systems in the brain, so it stands to reason that it can also help to lift feelings of depression or anxiety that may accompany physical withdrawal symptoms.
Xanax Withdrawal Safety
Some of the things I’ve mentioned are so important they bear repeating. Xanax should not be stopped suddenly, or cold turkey, and vital signs like blood pressure, heart rate, respiration, and temperature need to be closely monitored during withdrawal. This is because these may all go up rapidly during this time, and this can contribute to seizures that can lead to coma and even death.
People with a history of complicated withdrawal syndromes and people with underlying health issues should work very closely with their physician during withdrawal, as should the elderly and people with cognitive issues, as there can be unique risks involved. If you have acquired your Xanax illicitly, you can still work with a doctor to taper down your dose. Start by visiting a primary care physician or urgent care center and tell them that you are in, or are planning to be in, benzodiazepine withdrawal. If you don’t have insurance, visit a community health center. If you plan to or have become pregnant, you will need to discuss your options with your prescribing physician and OB/GYN about the risks and benefits of continuing versus tapering Xanax or other benzos. Some women continue taking them throughout their pregnancy, while others follow a dose tapering schedule.
The key to achieving the goal of getting off of Xanax is to follow the tapering schedule to the very end. By the end of your taper, you might be cutting pills into halves or quarters. Note that some individuals may be better suited for a harm reduction approach, in which the taper leads to a maintenance dose rather than abstinence. If you’re very concerned about the risks involved in Xanax tapering for any reason, discuss these concerns with your physician, because you may be better suited for inpatient detoxification. While this is more expensive, it is covered by many insurance plans.
No matter how you slice it, quitting Xanax takes time, patience, and determination. If you’ve been using it for longer than a few months, quitting can be hard, and there will be days where you want to give up and give in. But with medical supervision and support, you can be successful, and in the long-term, the health benefits are considerable. Withdrawal isn’t a picnic, but if Xanax is both the alternative to it, and a problem for you, it beats that alternative hands down.
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Obsessive Compulsive Disorder: Signs, Symptoms, and Treatment
Today I want to thoroughly explain obsessive compulsive disorder, because it is a seriously life altering condition that is frequently misunderstood. We have all heard people refer to friends or family as “OCD” in a joking manner. An example may be if you’re at a party at a friend’s house and the second someone puts their drink on the coffee table, the host runs to grab a coaster and quickly puts it under the drink, prompting a partygoer to say, ‘Oh my gawwwd, Pam, you’re so OCD!” This casual and off-handed way that OCD is referred to in everyday conversation may make it seem that the obsessions and/ or compulsions are just something annoying or amusing that a person can just “get over.” But for people with OCD, it’s not just a simple annoyance, it is a complex, frustrating, and anxiety inducing disorder. OCD is fairly common, affecting roughly 3% of the population. The age of onset is typically during the childhood years, and it is equally distributed between males and females. I have many patients with OCD, and unfortunately, I have diagnosed and treated many children with OCD throughout my career. One of the factors I always think about when assessing and diagnosing children with any disease or disorder is how much they may or may not be able to understand the symptoms they’re having. In cases of OCD, it concerns me even more, because it’s clear that these symptoms are very disturbing to children, especially because they don’t know what the heck’s going on. They don’t know why they get fixated on things or what their ritualistic behaviors are about, like why they have to turn their bedroom light off and on exactly 29 times before they can turn it off for good at night. They don’t understand why they get so upset and angry when they cannot perform their compulsive rituals, or why they constantly get stuck in intrusive, obsessive thoughts. Even adults with OCD don’t understand these things, but they are better equipped to recognize that something isn’t right, and better able to communicate the need to seek help. Obviously, children cannot simply drive themselves to a physician’s office, they rely on parents who may mislable the symptoms as a behavioral problem, not even notice the symptoms, or notice them but not realize there is a problem.
At its root, OCD is an anxiety disorder, marked by the presence of obsessions, compulsions, or a combination of the two. Obsessions are essentially intrusive thoughts that come up for no obvious reason and that just don’t go away. Compulsions are behaviors they feel they must perform, otherwise they become very anxious and very distressed; for some, almost to the point where they are paralyzed if they don’t do them. But, people with OCD do not want to do these compulsive things; they know they aren’t right, know they aren’t normal, and that means that they are not psychotic. A psychotic individual would say they do these things because aliens told them to, or for any reason. The point is that psychotic people believe they have a reason. Contrast that to people with OCD; they have no reason, no explanation. It occurs because a switch in their minds malfunctions. It doesn’t shut off, it doesn’t ever tell them that checking the lock once before bed is enough, that when they see that the lock is engaged, it will stay that way until they unlock it the next morning.
There are four criteria to consider in diagnosing OCD: – The presence of obsessions, compulsions, or a combination of the two. – These obsessions and/ or compulsions cause a significant amount of distress, to the point that they get in the way of a normal life. – The obsessions and/ or compulsions are not the result of taking any pharmaceutical or street drugs.- The obsessions and/ or compulsions cannot be explained by the presence of another illness; for example,being obsessed with body image as a result of body dysmorphic disorder, or being obsessed with food as a result of having anorexia nervosa.
So, what is an obsession? An obsession is an intrusive thought that an individual cannot expel from their conscious thinking, a thought that randomly pops into their head and will not leave. Now, understand that everyone, even people without OCD, will sometimes have some sort of obsessive thoughts; it’s entirely normal, so this is a matter of degrees. For example: if a student has a big important exam the next day, they may check their phone alarm or alarm clock 3 or 4 times the night before. This is not indicative of obsessive or compulsive behavior. But, someone with obsessive compulsive disorder will check the alarm so often, over and over, to the point that they get no sleep. A person basically crosses the bridge from normal, cautious behavior to pathologic obsessive and/ or compulsive behavior when these behaviors interfere with, and prevent them from living full lives.
Obsessive subtypes in OCD sort of loosely fall into five categories, but don’t forget that there’s always something new under the sun.
1. Counting/ math/ calculations/ numbers: they exhibit a ritualization involving numerical calculations in the brain. They have to count something- it may be steps, times turning switches off and on, locking and unlocking a deadbolt, etc. Some have to add or subtract numbers of steps involved in completing a certain action, and they must get the same number each time they perform that action. If they take three steps forward, they must take that many backward. While these things don’t make any rational sense, they actually create order for them. You might think, well, they aren’t hurting anyone, so whatever floats their boat. But they are actually hurting themselves. These people count so much and do and redo so many times that they can’t get to work on time, they can’t live their lives normally. It can have a devastatingly negative impact on every aspect of their lives. Sometimes they literally get stuck somewhere, because ‘the numbers don’t work.’ One of my long time OCD patients, Bruce, does pretty well for the most part, he takes his meds, keeps his appointments, and earnestly works on himself. He’s pretty much a model OCD patient, but every once in a while, the train jumps the tracks, and I get an emergency call from him saying he’s stuck somewhere. The last time was just a few weeks ago; he was inside a bank, and had just realized that there were separate entrance and exit doors, so he knew that the number of steps he had taken to get from his car and into the bank were going to be fewer than the number of steps it would take for him to walk out of the bank and back to his car. I explained that yes, Bruce, it would take more steps to walk out of the bank and back to your car, simply because you parked closer to the entrance door when you drove in. I told him that was normal, and it was to be expected. But he was really stuck, incredibly anxious, evidently pacing back and forth in the bank lobby. He said the tellers and bank manager were seriously eyeing him. They were probably thinking that he had some nefarious scheme in mind and that his constant frantic pacing was his way of plucking up the courage to enact his plan. Thankfully, I was able to talk him down off the ledge that day. It wasn’t easy, and it wasn’t quick, but eventually I convinced him that the difference in the number of steps was expected, that it had to be that way, so it was okay, and that he would see that I was right, that it was true, as soon as he left the bank and got in his car. I stayed on the phone as he walked out of that bank, certainly with great trepidation, and I could hear him counting steps just under his breath, until he got in his car. When I heard him exhale loudly and close the car door, I knew we were home free. He thanked me profusely, I said it was cool, no prob, and I went back to my patient. That’s Bruce!
2. Catastrophic Fears: aptly named, these are fears of major proportions, absolute worst case scenarios on steroids, and taken to the n’th degree. These are not like, ‘oh, I forgot my presentation was scheduled today.’ These are more like, ‘did I leave something on? Oh my, I just know I left the stove on. Oh no, the house is going to burn down to the ground! It’s going to burn! And we’ll never afford to rebuild! Oh God, what will I do?!’
Or, it can be a fear that you will harm someone, even someone you love. That you’ll suddenly take a hammer and bash someone’s head in, or that you’ll take an assault rifle and gun them down in their backyard. I’ve had lots of OCD patients of both kinds, the doom and gloom Negative Nancy types, and the head-smashing-hammer-weilders and assault-rifle-gunners. When I think of the latter type, I always think of a patient named Hillary. She was just twenty when she first came to see me, and she came with her mother, whose name was Alain or Alaina or something like that. I do recall that she had a very french accent. When I asked Hillary why she had come to see me, she didn’t answer right away, so eventually, her mother said in her thick accent, ‘she’s worried that she wants to kill me, to slit my throat.’ I have to say, I was taken aback. I looked across my desk at this whisp of a girl, not looking at me, but at her hands, which she knotted and unknotted, like she was washing them. I asked her if that was true, and still not looking at me, she nodded. I asked her mother, “So you brought her in because you’re worried that she’s going to kill you?” She looked at me and replied, “No, doctor. I brought her because she is worried that she’s going to kill me. I am not worried about that, only about her. She talks about it incessantly. She says she doesn’t think she wants to do it, but she’s still afraid she’s going to.” I asked Hillary how often she thought about it, about killing her mother, and she simply said, “All the time.” I will never forget how heavy that room was. You could feel the oppression, for lack of a better word. Matricide, the killing of a mother by her child is pretty uncommon, especially at the hands of a daughter. I could see clear OCD tendencies, but her pathology really hinged on her obsessive, catastrophic fear, which was undoubtedly 100% genuine. Without any rhyme or reason, apropos of nothing, the thought of killing her mother would randomly pop into her head. Imagine that for a moment. Imagine the first time it popped into Hillary’s head at age thirteen. Then imagine it constantly popping into her head, all the time. But, you know you love your mother, right? Right? But yet you think you might kill her. At twelve. How confusing would that be? I knew that we had a long road ahead, but I wanted to help Hillary. With OCD, one of the main treatments is exposure therapy. For example, if someone had to touch the faucet 37 times before they could turn it on, the exposure therapy would be to push them into walking into a bathroom and simply turning on the faucet without touching it beforehand. You expose them to the thing they obsess about, the thing they perform their compulsion on. It’s very difficult at first, but it can be very effective. There really was no way to try exposure therapy for Hillary’s particular obsessive thoughts of catastrophic fear…I couldn’t give her a knife to hold at her mother’s throat as I tell her to resist slitting her throat. Captain Obvious says that might be traumatic. Nonetheless, we met at least every two weeks, and more often when she was in a tough spot, which happened a lot. We tried drug therapies and eventually hit on a combination that seemed to work well, and we did some serious psychotherapy over several years. And ever so very slowly, she improved. She wasn’t OCD free, but it was possible that it would never be totally gone. There were still times when her obsessive thoughts were exacerbated for no obvious reason, but those have been fewer and farther between as she’s gotten older. I attribute a lot of that to her mother. She is a strong woman, and she could have chosen to dismiss Hillary’s fears because she didn’t understand them or believe them. You have to admit, it would feel weird to hear your child speak obsessively about slitting your throat. But Hillary’s mother didn’t turn a blind eye or distance herself, she actually did the opposite: she drew her daughter closer and sought help. There isn’t always that kind of family support, so it was very reassuring to all three of us. The depth of Hillary’s beliefs in her obsessive fears was significant, especially for a girl of her age. She was sure that she was going to kill her mother, whether she wanted to or not. But please know that just because someone in the family has OCD, it does not mean they’re out to get you.
3. Fear and Hypermorality: hypermorality is essentially taking manners and consideration for others to an unnatural degree. The fear these people have is that they said the wrong thing, did the wrong thing, made a mistake or misstatement to a friend or family member, or sent an email or text or made a comment on social media that may have hurt someone else’s feelings or made them upset. They will go over and over a previous interaction in their mind, obsessively searching for anything they may have said that could have possibly slighted someone, because they’re sure they did, they just aren’t certain when. For example, if they say hello, they will immediately begin thinking ‘did I say hello in the right way, in the right tone? Did I walk away too quickly after I said hello? And I only said hello, I didn’t ask how they were, should I have asked how they were?’ This is not an exaggeration. Can you imagine what these people go through, when the simple act of saying hello causes tremendous amounts of anxiety and endless rounds of second guessing everything! That’s how this disorder interferes with people’s lives; it gets in the way of their daily operations, and they simply cannot get anything accomplished because they are so consumed with these obsessions.
4. Religion: some people have religious obsessions, where they believe they must say specific prayers in a certain order for a multiple of times, and that each round must be perfect; if not, they must start again. This can take up hours upon hours on end. These prayer rituals are compulsive, and are required in an attempt to quell the obsessive thoughts about how to love God perfectly, or how to be worthy, how to ask His forgiveness or how to live a righteous life…whatever obsessive beliefs they affix themselves to. Commonly involved in religious obsessions and related compulsive behaviors involve acts of supplication, kneeling or bowing before God or whatever religious idol they obsess about, because they must do so. Some religions incorporate other compulsory activities like fasting, so OCD people may believe they must also do that to show their devotion. When religious activities are taken to a level of obsession, they are likely to be much harsher and far more restricting than the original religion actually proscribes. Ritualistic self-mutilation and pain is encouraged by some radical religions to prove one’s worthiness, and people with extreme religion-oriented OCD obsessions feel a compulsive draw to these behaviors. They can see that they are different, that others do not take their beliefs to the same levels, but they cannot stop. Whenever I think of OCD cases involving religious obsessions and associated radical compulsions, I have one patient that comes to mind. I’ve seen him over a span of probaby ten years…a long time. His name is Benigno, and he is originally from Peru, but he’s lived on Palm Beach for a long time, and he’s done well for himself. He first came to see me (reluctantly) at the request of his family. They were concerned that his religious beliefs and activities had become far too radical in recent years. They reported that he was now totally consumed by his religion, and that they believed it was endangering his life. That’s all the background his family gave me. When he sat down for his first appointment, I started by asking Benigno to tell me about his upbringing. He said he was raised in a traditional Catholic home in Peru, but he always saw his beliefs as very different from his siblings, even though they were raised in the same home. He said that even his family noticed that from the very early age of seven, he took his relationship with God to an unusual level for such a young child. Even at that age, he spoke endlessly about God, he would fast for days, he would kneel on rocks in the backyard as he prayed for 15 hours straight, he would deny himself sleep in favor of praying the rosary until his voice was hoarse. As he grew and advanced in school, rather than playing sports or making friends, he spent time in a radical religious group, with people far older than he was. They clearly saw his unusually zealous behavior and encouraged it, telling him that he must do more to demonstrate his worthiness to God. It was really the only time I can recall hearing that anyone actually encouraged another person’s obsessive thoughts and destructive compulsions. It was disturbing, to say the least. Benigno definitely had OCD, but it was a little atypical in it’s origins. I think that when it started in his childhood, the religious belief system he was raised in may have contributed to its genesis. Perhaps a nun at his school said that he should pray more, or ask God’s forgiveness for something or else risk eternal damnation, who knows. He didn’t like the OCD label, and wasn’t always sure that his obsessive thoughts and compulsive behaviors were preventing him from having a fulfilling life. He always vacillated on that point, but he did concede that his behaviors weren’t normal. Over time, he’s eased up a little on his compulsions, but he’s uncomfortable during those times, because his obsessive thoughts are telling him that he needs to do certain actions to lead a life that pleases God or to be worthy of His love, whatever thought is screaming the loudest in his brain. I just started him on medication recently, because he had refused it until then. I think that will really help him, but we will continue on with psychotherapy. Benigno is a work in progress.
5. Symmetry/ Order: symmetry and ordering obsessions and compulsions are among the most prevalent OCD symptom subtypes. These people are compelled to make everything line up, to make things equal on two sides, and/ or to arrange things into equal groups. Many times, I’ve seen frazzled parents in my office very concerned, because little Johnny must have his toy trucks in a perfect line, grouped by color, and arranged from largest to smallest. They are amazed and more than a little frightened by his precision. If one truck is accidentally moved a fraction of an inch out of place when Fido runs through to bark at the old lady next door as she heads into her garden, little Johnny loses his mind. And even if mommy runs like a cheetah to put it back perfectly in its place a mere millisecond later, it doesn’t assuage his outrage. This is actually a pretty typical presentation in a child of little Johnny’s age. But these obsessive thoughts on order and symmetry will change as he ages. He may need his third grade class to have an exactly equal number of boys and girls, or else he cannot be in that classroom, and he demonstrates that in all sorts of destructive behaviors…screaming, kicking, biting, throwing books, tearing down posters, and generally throwing a monstrous tantrum. Why? Because little Johnny is pissed off. His brain is telling him that everything is wrong in his world right now, because there are four more boys than girls, and that’s unacceptable. So his brain just fizzes, like when you put pop rocks in a pepsi…it overwhelms him. It’s a difficult OCD subtype to manage because it’s so persistent. Little Johnny will need a lot of time in therapy, but ultimately, I think he’ll be okay.
As for compulsions…these can be as numerous and diverse as anything that people’s brains can come up with, which is to say they’re pretty much unlimited. The ones that often spring to mind are like checking to make sure the stove is off, checking to make sure the garage door is shut, checking to make sure the locks are locked, the alarm is on, the gas is off, the fire in the fireplace is dead, the faucet is off, the grill cover is on, the car has gas, the tires have air, the lights are off…and then checking them again. And again. Maybe locking and unlocking and locking the front door, over and over, until they’re satisfied it’s locked, which is almost never. Their brain never says STOP! THE DOOR IS LOCKED. GO TO BED. That box doesn’t get ticked; it does not happen quickly.
They may be obsessed with cleanliness, either of themselves or their possessions: home, car, clothes. So they ritualistically clean them over and over, it must be perfect. I have a fairly new patient named Launa, and she is obsessed with cleanliness, and she ritualistically cleans…very, very thoroughly. She cleans and cleans and cleans again. She will cover the house seven or eight times in a day, or all through the night instead of sleeping, whenever her obsession moves her. And she doesn’t just sweep, wash, and wax her floors. She gets a roll of scotch tape and gets on the floor, placing her head perpendicular to the floor so that she can see the profile of a microscopic bit of sand, or some flotsam, real or imagined, against the flat surface of the floor. Once she has it in her sites, she takes a piece of the scotch tape and sticks it on top of the speck, pulling it off the floor, trapping it on the tape, then putting the bit of tape with the offending speck in her pocket for safe keeping. She does every square inch of her floors that way, on her hands and knees, moving specifically from her back kitchen door, into each of her two guest bedrooms, and finally finishing at the far wall of her bedroom. She goes through a minimum of six rolls of scotch tape at a time, and she will do this every single day. Often, she gets to that far wall of her bedroom and starts over again immediately. Her knees are perpetually black and blue, and her hands are often swollen and painful from overuse, but that’s more tolerable than trying to deny the compulsive behavior that her obsession demands. It’s sad, because this smart, funny, gentle woman has no life, and she knows it, sees it, hates it, but feels powerless to change it. But I am committed to helping her do just that, and I know she’ll get there.
By the time most of my OCD patients get to me, they’re pretty stuck in their compulsions. There’s the engineer that must spend precisely eight minutes in the shower- no more, no less. He sets an alarm in the bathroom for seven minutes and fifty-two seconds, and when it goes off, he has exactly eight seconds to open the door and step out of the shower. If for some reason something delays his exit, like having to pick up a dropped washcloth, he must start another shower. He will do this until he gets it perfect. I would hate to have his water bill. In a similar fashion, he allows himself four minutes to brush and floss his teeth and use mouthwash…which he must do in a certain pattern…swish quickly in left cheek three times, then right cheek three times, then around his front teeth three times, then tilt head back to gargle three seconds, and spit.
There’s the recent suma cum laud college grad that lost her dream job because she was always late. Why? Because she spent anywhere from twenty minutes to an hour each morning when she was to leave her house to go to work, locking and unlocking her front door over and over until she had to leave. But she was never satisfied that it was locked, so she often went home on her lunch hour, spending it standing at her front door, turning the key, unlocking, locking, unlocking, locking…Losing her job was an eye-opener, and that’s what brought her to me.
Another OCD patient, a 13-year-old boy named Andrew, was consumed with a very detailed and very peculiar eating ritual. The food on his plate could not be touching. His mother had to make sure of this. The meat could not touch the rice, which could not touch the broccoli, which could not touch the roll. If a catastrophe happened and any of the food touched, it had to be thrown out and his mother would have to make him a new plate. But that wasn’t all. When his mother set his plate in front of him, she had to arrange it so that the meat was top left, the veg top right, the starch bottom left, and the roll at the bottom right of the plate. Then, before he could begin eating, he had to hold his fork in his left hand and his knife in his right, each positioned tines and blades up just so, and flanking the sides of his plate. Then he would simultaneously raise the utensils and touch them to the table three times, and then put them together above the center of his plate and touch once there, then put them together again below the center of his plate and touch once there. Only then could he eat his food, but just as the food couldn’t touch on the plate, it couldn’t touch in his mouth either. He ate each part separately, always in order. First the meat, then the veg, then the starch, and then the roll. Well, unfortunately, one day Andrew was riding in a friend’s mothers car, and they were in a terrible car accident, and he was paralyzed, so his mother had to do everything for him, including feeding him. His ritualistic compulsions were still so consuming, so powerful, that before he could eat, his mother had to perform his rituals. Every single one of them. And she had to do them over and over and over, until they were perfect…or else he would totally lose it, scream and spit and curse her for being stupid. She told me that in the beginning, she would be sitting at that table for hours and hours, tears streaming down her face, repeating his knife and fork touching rituals, to the point where she would literally be nodding off, only to be snapped awake by his belittling venom. I told him that everyone understood that he couldn’t help it, that he wasn’t in control of his compulsions, but that it was unacceptable to treat his mother the way he did, screaming at her, calling her names, and spitting at her. I told him that she was the only person even willing to try to put up with his behaviors. His father had zero patience for it, and he didn’t dare speak to him with the words he used with his mother. With time, meds, a lot of therapy, and the acceptance of his paralysis, he mellowed out a little and things have improved. But Andrew needs more work, and his mother is completely devoted to helping him. I honestly don’t know how she does it, but for his sake, I’m glad she does.
I had a nine-year-old boy with OCD come into the office. His mother had to wear gloves and a mask to prepare his food, because otherwise she would contaminate it. She had to serve it on a paper plate, and when she set the food in front of him, he would spend 15 minutes scrutinizing it, like he was looking for germs, as though he could see them. He had to eat with disposable plastic utensils and use only paper napkins. Everything was always single use, so as not to take the chance that old food could stay on ceramic plates or steel utensils even after being washed.
Another patient, a 42-year-old man named Gary, was obsessed with perfectly pristine white sneakers. If he got so much as a speck of dirt on them, they were ruined. He would buy a new pair and burn the offending pair.
Another patient, a man originally from Jamaica, had a ritual of tracing a cross on his chest with his finger every time he felt he had said anything contrary to anyone. He dis this so often, to the point that he wore through the skin, literally down to the sternum bone in the middle of his chest.
I had another patient, a physical therapy tech that had an odd compulsion. While driving, if he went over a speed bump, he had to turn the car around to check to make sure he hadn’t run over a person. He knew on some level that it was just a speed bump, that he had even seen the speed bump as he’d driven ober it, but his obsession told him that it might possibly have been a person, so the compulsion was for him to turn around to make sure. Luckily, it hasn’t been a person a single time.
A young woman came in for her first appointment, and she arrived looking totally exhausted. She had dark circles and huge bags under her eyes, her hair was all messy, and she looked like she was waaay out there. I told her that she looked very tired and she agreed. I asked her why, and she said she had been up all night. That begged the question of why once again, and she said that she had recently moved to a new apartment, and she had been trying to hang a picture. To which I raised an eyebrow and said, and?…. She smiled, blushed, and said that she just couldn’t get it level, so it took ‘a while.’ I said, “Are you telling me that you spent all night hanging that one picture?” Embarassed, she quietly answered yes. I suggested wryly that she buy a level at Home Depot. Still embarassed, she said, “I have one. I didn’t trust it.” Despite myself, all I could do is laugh. Then I suggested that she might have OCD. And I swear, with a straight face, she said, “Really? Do you really think so?” Oh boy…seriously?! She was actually surprised…I’m telling you, never a dull moment.
Late one afternoon not long ago, I finished with a patient, the last one of the day, so I said I’d walk out with him, and I went and turned the AC up, shut the lights off, and walked out the door, never breaking stride. As I locked the office door behind us, I saw that he was looking at me, incredulous. Startled, I said “What?” He said, “Oh my God, how did you just do that?!” Totally confused, I was like ‘what?’ and he said, “How can you just close up and walk out of your office like that, that fast? I spend at least an hour a day getting out of my office, checking everything over and over before I can walk out, then at least another 15 minutes locking and unlocking the front door before I can head to the car.” I told him, “Next appointment, you and I are going to discuss that, man.”
And now of course, I have lots of patients freaking out about coronavirus. I have a specific woman who does not ever leave her home, and even though she’s home alone, never exposed to anything or anyone, she cannot touch anything bare handed inside her own home. So, her solution is to wear surgical gloves, 24-7. We had a facetime appointment recently and I commented on the gloves, and she told me she wore them all the time, even to bed, but that the skin on her hands was getting irritated. I talked her into taking the gloves off for a minute so I could see her hands. They were so pruney, reddish purple, and deeply wrinkled all over, like they had been covered in water for a loooong time…which I mentioned to her. But, she said it wasn’t water, it was sweat. I said, “Ewwww!” and she was like, “Yeah, I should probably let them dry off, maybe air them out a little bit.” Ya think?!
All kidding aside, you can imagine how strong these obsessions can be, and how debilitating all the ritualistic checking, rechecking, doing, undoing can be. Many people with OCD have a very strict schedule. They have a routine that they follow religiously, day in and day out, that helps them to be somewhat functional. They get up at the same time everyday, eat the same breakfast, wear the same color shirt, same color tie, same shoes, drive the same route to work, park in the same space, eat the same lunch, drive the same route home, watch the same television shows, eat the same dinner, on and on and on. For these people, every single day of their lives is groundhog day. They have no room in their lives for spontaneity, no opportunities for joy…not without help.
These are anxious people, stressed out to the max. OCD is a distressing illness at best. But it’s not all doom and gloom. Treatment does work for those willing to put in the work, and they can go on to live healthy lives. The commonly accepted treatments involve psychotherapy and exposure response coupled with cognitive behavioral therapy. What does that mean? Basically, the therapist must coach the patient on what to do with the obsessive thoughts. Explain that they must accept that they cannot control the thoughts. That they must not engage with the thoughts, not feed the thoughts, because once they do, the thoughts will get stuck in their head, with no way to get rid of them. So they must let them just float away, do not address them, just let them float away. Let them drift away, and the further they drift, the more they can replace them with healthy thoughts. Explain that if the thoughts do come, it’s okay, but they should respond to the thoughts in a way that does not escalate anxiety, so not focusing on the thoughts, not feeding the thoughts, but redirecting the thoughts to other thoughts that are healthy, this is the best way to deal with them. There are also drug treatments, SSRI medications, selective serotonin reuptake inhibitors, like Prozac and Paxil. Luvox and Zoloft can also be used to treat OCD. Whenever possible, I like to employ a combination of meds, plenty of psychotherapy, and the exposure response coupled with cognitive behavioral therapy. When an OCD patient is willing to work and sticks to the plan, it’s truly life changing. Need proof? Well, maybe ask soccer star David Beckham, comedian Howie Mandel, actor Leonardo DiCaprio, singer Justin Timberlake, or his ex-girlfriend, actress Cameron Diaz. Or maybe actress and entreprenuer Jessica Alba, Shock Jock Howard Stern, or actor Nicolas Cage. They all seem to have done pretty well for themselves, and I’m pretty sure they’d tell you that treatment works.
If you’re interested in more stories of OCD patients, or other psychiatric diagnoses, you can check out my book, Tales from the Couch, on Amazon.com. It’s a great read, entertaining and informative, and a really awesome way to spend a no- fun quarantine, if I do say so myself.
Be well, everyone.Learn More