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The very first psychiatrist I ever saw declared to me that I was the most paranoid child he’d ever treated. I was afraid of everything, and everything was possible, so living in a constant state of fear seemed rational, safe. It was my OCD, its what if? component, screaming at me through a bullhorn at all hours of the day, but neither myself nor my doctors recognized it at the time. My picking and symmetry tendencies seemed Obsessive-Compulsive, but being afraid of everything, being genuinely convinced that everything and everyone is dangerous? That seemed more on the level of psychosis.
I’ll do my best to describe the kinds of thoughts I have, particularly the ones that have persisted to this day. Some of these are attributable originally to traumatic incidents, but the Obsessive-Compulsive arrangement of my brain specifically hooks me onto them far longer and more acutely than PTSD symptoms persist.
I’m terrified of developing colon cancer. I’m certain I’ll immediately kill someone if I drive a car. I’m terrified that every friendship or relationship of mine is based on false pretenses. I’m frequently certain that everyone around me hates me. My stomach lurches whenever my parents pick up their phones; what if they’re being notified that I’m in trouble? My phone buzzes; it’s surely bad news. A car rolls up to my stoop, unannounced? It’s bringing horrible, terrible, no-good, very bad news with it. I’m always, I am convinced, doing something wrong, breaking a rule. If I break a rule, I’m a bad person, and so being constantly afraid of breaking rules will keep me safe. If anyone says something vague, I assume it’s with the worst possible connotation. “You’ll see!” or “we need to talk” are short form horror stories. I strongly consider that strangers on the street will be randomly compelled to hurt me. I strongly consider that people I’m intimate with will be, too. Everyone can be, and probably is, lying. All of these have corresponding compulsions.
OCD is generally characterized as a disorder in which its sufferers have a high degree of self-awareness. In fact, much of the suffering it creates is derived from the helplessness that the knowledge of the compulsion’s absurdity brings. This is mostly true, but in order to glean a precise picture of the disorder one must consider the insight continuum.
It’s often used to delineate OCD and psychosis. If the sufferer knows they’re being irrational it’s OCD, if they don’t it’s psychosis of some sort. In reality, the degree to which the OCD sufferer understands their irrationality is crucial to a diagnosis, but it isn’t a set do or don’t dichotomy, and some Obsessive-Compulsive people can display minimal awareness of their obsessive/compulsive nature. This complicates the diagnosis process, but there are a few ways to hone in on the split.
The DSM-5 (the Bible of psychiatric diagnoses, in sum) allows for distinctions in OCD insight levels: “good or fair insight,” “poor insight,” and “absent/insight delusional.” The former would indicate that the obsessions are seen as just that by those who experience them, and the latter would indicate that the experiencer believes their obsessions to be rational and true.
There’s much room for flexibility and error within these distinctions that makes it difficult to diagnose someone with the latter two. Some symptoms may be observed with good insight while others may be delusionally interpreted by the same patient (I suspect this difficulty is part of why it took so long for OCD to be seen as my primary diagnosis). Children will naturally have less of a grip on reality versus fiction than adults will. Folks may know that they have obsessions but refuse to acknowledge the seriousness of their level of daily disruption. There is also a difference between emotional and intellectual insight; OCD is a physically experienced disorder, so while a perceptive patient may know that their symptoms are obsessional and irrational, that revelation may not translate into emotional commitment, or just what they feel is true.
In my own case, the latter explanation rings true for me, the most. I know that most (some fall under absent delusional, perhaps) of my obsessions are irrational and battle against them consciously every day. However, my OCD brain was left untreated for so long and in such formative years that my obsessions and compulsions are carved into my nervous system. I would know the odds of a text my mother receives being “Olivia is to be punished” are next to none, if I stopped to consider it logically, but my instantaneous physical reaction is such that one would think that was the content of the text. I rationally understand all of the arguments for getting my driver’s license, but my feeling that I’ll immediately run over and kill someone by accident is so entrenched that for now, it’s a fruitless endeavor.
Another factor to consider is if the obsessions are embedded into an overall belief system about oneself, it can be extremely difficult to separate the obsession and the overall perception of the self, something that must be done in treatment. For example, I have a long-standing belief that I am selfish. It is extremely difficult for me to curb my “sorry!” compulsion because I would have to tackle not only the truth of the specific, non-selfish act that I’d committed, but my core belief that I am a selfish person who should apologize for self-interested wrongdoings. What a task!
Now, all of this complicates, for the Obsessive-Compulsive, creating a framework of an objective continuum of truth and reasonability. Am I overreacting, assuming, is it me being paranoid again? I’ve had folks who know about my disorder use my paranoia against me, insist that I was being paranoid about things I was right about. More broadly, it’s difficult to trust my own mind when there isn’t a set system of these are your obsessions, they are always false, activate disbelief in three, two, one! Some of my obsessions and their corresponding compulsions will sometimes be valid. Some I’ll be able to recognize- my hair brushing, picking, and deodorant application, for example- and some will take intentional self examination in order to deconstruct.
That’s the key, ultimately: intentional self examination. It’s the key with many disorders, and the goal of talk therapy. If the inner self is explored with an open mind, empathy and rationality, many daily sufferings can be unlocked from the reasonable mind and from the nervous system. The Obsessive-Compulsive brain may have to work harder to understand what their inner self is made of. Is it real or it it an obsession? Is it a harmful obsession worth ridding myself of? Does this cut back to a core belief about myself. Am I right, anyway?
It is an extremely valuable quality in a person to frequently self-evaluate. The point of any therapy, any educational construct, and perhaps some theological systems, is to help you understand yourself better. Sit back, relax, and ask why? How do I know? What may prevent me from knowing?
If money allows, do this with a therapist. You’d be surprised at how much more clearly a trained mind can dissect a separate, subjective one.