Call Me Irresponsible: OCD and Hyperresponsibility
Fred Penzel, Ph.D.
The other day, a patient of mine, a woman in her thirties arrived several minutes late for her appointment all out of breath. The lateness, she announced, was due to her having misplaced a very important list, which she was still unable to locate. When I inquired as to what was on this list, she informed me that it amounted to about twenty pages of notes she had made about every possible situation she had been in, over the last fifteen years in which she might have been negligent and caused harm to another person. These notes, she believed contained vital information about her every word and movement on each of these various days. At least everything she could recall. These situations included possible traffic accidents, insults to others, property damage, the creation of hazards for others, and what might have been some sexual acting out. At various times, she would recall one of these situations, experience strong doubts about what she had or hadn’t done, would repetitively worry that she had really done something wrong, and then become convulsed with anxiety. These were what we would call, obsessions. They might change from day-to-day, in terms of the particular incident, but were all alike in terms of their basic theme.
Typically, when OC sufferers experience these types of thoughts, they react by performing compulsions. In my patient’s case, this amounted to rereading the particular page of her list hundreds of times in an attempt to review all the events of the day on which the supposed event happened. In this way, she believed she could reassure herself that the worst had not happened, and that she would therefore not have to feel guilty. My patient had worked out this scenario that if she had actually harmed someone, she would feel a crushing sense of guilt she could not then live with, and might then either “go insane,” or would have to kill herself. Because she had lost her list earlier in the day, she had spent many hours alternately ransacking her house and car, and trying to mentally reconstruct everything she had written on her list. This, then, is a glimpse through the window of what is known as hyperresponsibility (HR).
I suppose that if you had to identify one of the chief hallmarks of OCD, it would be doubt. This is no ordinary doubt, however. This is a no-holds-barred, debilitating, paralyzing doubt. When it occurs, the need to resolve it and find relief can grow to outweigh every other priority in a person’s life. OC sufferers can become doubtful about almost anything the human mind can conceive of. Exactly why certain individuals with OCD can become doubtful about having harmed others in some way remains a mystery. Although many OCD sufferers worry about bad things happening to them, there are many who only fear for others, and care little about what happens to themselves. This is particularly true of HR.
In cases of HR, we see sufferers taking on responsibility for others health, safety, and well being that are all out of proportion. They are not just partially responsible for what occurs in their dealings with others. They are totally responsible. In addition, their sense of what they are capable of doing to others is also exaggerated. For instance if an average person physically bumped into someone on the street, they might be concerned for that instant that they might hurt the other person, but then seeing that everything was okay, would then go on their way without giving it another thought. A HR sufferer would imwp-content/uploadstely assume that they had caused serious injuries or would obsessively worry for hours or days afterward that the other person had sustained internal injuries and was most likely hospitalized or dead. Subsequently, they might even read the papers or watch the news to see if anything had been reported. Whey driving, some HR sufferers have problems with what has come to be known as “Hit-and-Run-OCD.” Every bump in the road may be a body their wheels have driven over. Every pedestrian or jogger at the side of the road becomes someone they may have struck with their car. Even blurs or a shadow seen out of the corner of their eye becomes a potential victim. Driving back and forth over the same route to hunt for bodies, or getting out to check the car for dents or bloodstains can become a routine part of every trip.
Food preparation has always been a problem area within HR-type symptoms. The fear is that the sufferer will act negligently and serve spoiled, contaminated, or poisoned food to guests or family members. There may be thoughts that such things as household cleaners, bits of broken glass, insecticide, drain cleaner, etc. will somehow get into the food they are cooking, so all food must be prepared in an absolutely meticulous way to rule out all possible accidents. Fears of botulism or salmonella may lead to repeated hand washing, smelling or meticulous examining of the food. Many end up not being able to prepare food at all, as the process has simply become too difficult.
Conversations with others can be potential mine fields. Every offhanded remark may later be reviewed to see if something offensive or insulting was said. Repeated questions or phone calling may follow these conversations, in order to find out exactly what was said, or how the other person regarded it. When someone with HR also suffers from contamination phobias, their main concern is with sickening or killing others rather than themselves. Those with HR may also find themselves in a constant state of high vigilance, continually scanning the environment for possible hazards to others. If they spot a streetlight out, or see a damaged traffic sign, they will be the ones to report it. If someone’s car looks like it has a tire low on air, they will feel compelled to leave a note under the car’s windshield wiper. They may be seen picking up pieces of broken glass in the street, or bringing outdated packages of food to show the supermarket manager. They may ever restack the canned goods on the supermarket’s shelves so they will not fall on anyone and injure them. It is almost as if they have been appointed as the world’s guardian and protector. It can become a full-time job.
One of the more unpleasant forms of HR is when obsessions turn to sexual themes. A commonly occurring one is seen among adult sufferers who worry excessively about having carelessly behaved in inappropriate sexual ways toward children. I have met numerous individuals who feared that they had made sexually suggestive remarks that could corrupt children, or even worse, that they have touched children sexually or exposed their bodies to them in some way. Even touching a child on the shoulder, or getting an innocent hug may seem, to them, to be filled with sexual meaning.
Treatment for this type of OCD would, of course, involve the use of Cognitive/Behavioral Therapy (CBT), and the approach would be twofold. One the behavioral level, Exposure and Response Prevention would be utilized. In this type of treatment, following a careful study of all the sufferer’s obsessive thoughts and compulsive avoidances, fearful situations are gradually confronted, starting with the lowest level ones, and working up to the highest. The goal is to build a tolerance to the anxiety and the anxiety-producing thoughts and situations. By staying with the anxiety, the sufferer comes to learn the truth of the matter that the anxiety eventually subsides, and that the dreaded event never happens. Thus, working in a step-by-step way, the sufferer can eventually be able experience the thoughts or situations and not feel that they must react in any way. Ultimately, they can achieve the ability to accept the thoughts, even though they are extremely dislikable.
One the cognitive level, sufferers are taught to challenge their beliefs about just how responsible they are for the safety and well-being of others, and in their dealings with others, what proportion of the responsibility is really theirs. The role of guilt is also examined, and a better understanding of what it is and what role it has to play with regard to people dealing rationally with real errors and mistakes. Further, the assumption is also challenged that any given individual can be perfect and never do anything wrong or harm anyone else in any way. In my own work, this type of therapy is brought in after the sufferer has done more behavioral work and begun to get a grip on their anxiety.
Medications, too, may have a role to play in treatment. If the sufferer is highly anxious and agitated, or severely depressed, medication can make it possible for them to approach therapy to begin with. Additionally, if obsessions are so strong and believable that an individual feels truly unable to approach behavioral assignments, medication may also have to be included in the treatment package. Medication should not be considered a complete treatment on its own. It should, instead, be regarded as a tool to enable a person to successfully participate in therapy. Medication alone cannot teach you new skills you need to confront the things that make you anxious or in how to think about living in a world where you must take risks (or what look like risks) each day in order to live freely. Finally, medication cannot teach you to accept your disorder so that you can begin the process of change.
With proper treatment, sufferers can recover and live lives as normal and average as anyone else’s. It takes hard work and determination, but recovery is there if you want it.
If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, “Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well,” (Oxford University Press, 2000). You can learn more about it at www.ocdbook.com