McAndrew's Case

Obsessive Neuorsis with Hostile Thoughts

      In isolation, patients obtain controllability over their unacceptable impulses by deliberately preoccupying themselves with the "hate" component of the "love-hate" conflict: Extreme obsessive, hostile thoughts that lack feelings of anger become dominant. Lewis (1981) noted that Freud was puzzled by the fact that while obsessive patients perceive their forbidden thoughts as "crazy," they remain powerless to stop them from penetrating the conscious. However, while psychoanalysis considers obsessive neurosis irrational, PBT views it as a rational coping mechanism by which patients consciously produce obsessive thoughts that reduce feelings of guilt and the risk of harmful consequences.

    Obsessive neurosis increases controllability over the unacceptable impulse for the following reasons: 1) Given the artificial production of the obsessions and the lack of a suitable emotional base (e.g., anger), these cognitions are less likely to motivate impulsive behavior than the original emotionally charged thoughts; 2) Obsessive thoughts intensify patients' self-awareness that they may cause harm to others. Consequently, patients will take appropriate preventative measures in order to reduce the likelihood of inflicting harm, such as removing potentially harmful objects, or even sharing their anxiety-provoking thoughts with close family members so that they will supervise their behavior; 3) Obsessive thoughts should reduce guilt, since, unlike the emotionally-charged impulse that dominated prior to the neurosis, they are experienced as foreign to the self. This feeling of alienation stems from the absence of corresponding emotions and the patient's unawareness of his conscious involvement in producing the obsessive thoughts.

    The utility of isolation as an effective control tool is demonstrated in the case study of obsessive-compulsive disorder by McAndrew (1989). A 26 year-old woman was greatly frustrated, as she was dissatisfied with her husband and three children and felt distant and alienated from others. The husband was "very strict, aggressive… insensitive to her needs... [and] physically abused her" (p. 317), and her difficult children frustrated her as she lacked adequate disciplinary skills. The patient was in fact in a state of helplessness, feeling "stuck in a bad marriage" (p. 314). Consequently, she not only experienced severe depression, but intense anger directed at her husband and children as well, which was presumably accompanied by a fear of losing control and guilt. In response, the patient chose the coping style of isolation, which enabled her to satisfy both her needs for distraction and controllability. Bizarre aggressive cognitions detached from their appropriate affect heavily dominated her attention. "I’m having terrible thoughts about stabbing my children. (crying). That’s terrible - isn’t it? I’ve been having thoughts of hurting others too... I love my kids. How could I have these horrible thoughts of hurting them?” (McAndrew, 1989, p. 312, 316).

    The high distractive value of the obsessive symptoms was reflected by the patient’s inability "to force them out of her head" (p. 312). She noted that, when she tried to suppress these cognitions, "the thoughts get worse and I get a headache or my heart starts pounding" (p. 312). Nevertheless, the patient reinforced her distractive measures even more by adopting compulsive bizarre behaviors as well. "I have to keep busy all the time . . . check things . . . clean my house very often.  I’m meticulous and very slow doing things" (p. 316). The bizarre and emotionally detached obsessive cognitions (i.e., isolation) enabled the patient to be unaware of her emotionally loaded hostile impulses.

    At the same time, the symptom provided her a measure of control. The obsessive thoughts heightened the patient’s self-awareness of the potential for being dangerous. As a result she was motivated to take appropriate preventative precautions, hence reducing the danger of losing control. As noted by the patient

"I can't look at violence on TV because I feel I could do something... I have to check things and make sure I know everything is all right. I make sure the guns are locked up many times during the day" (pp. 314-316).

 

   The obsessive thoughts also motivated her to express concern and love, which further minimized the possibility of dangerous impulsive behavior. The patient was distressed, explaining, "I love my kids. How could I have these horrible thoughts of hurting them?" (McAndrew, 1989, p. 316). The patient's symptoms were also aimed at increasing the supervision of others. For example, she stated that, "I had my sister and my mother stay with me so I wouldn’t do anything... I must call or be around other people. Someone would intervene if I was about to hurt my kids" (pp. 313-316).

    The absurdity of these thoughts, and the sense that they were alien to the self, enabled the patient to attribute them to sources beyond her control, thereby alleviating guilty feelings that she experienced ("I feel guilty and think I am a bad person" p. 312). The patient raised the possibility that her symptoms might be due to "premenstrual syndrome" (p. 312), craziness (I usually think I’m going crazy", p. 312), or devils ("someone like the devil must be making me have these thoughts", p. 313).

    Moreover, although the concentration on the obsessive thoughts increases one’s level of anxiety, this emotional discomfort is readily reduced by distractive/neutralizing activities (e.g., forming a counter image, ritualized internal dialogue, and reading) which patients perform soon after the concentration act (see Freeston et al., 1997; Rachman, 1976; Salkovskis & Westbrook, 1989). Thus, although obsessive thoughts are emotionally and cognitively disruptive, like other cases of symptom adoption, the overall resulting experience is not as highly disruptive as the original state before adopting the symptom. In the absence of the bizarre coping mechanism, anxiety and depression would be so intense as to be beyond the patient’s tolerance level.

    The principle of availability apparently affected the choice of OCD's coping mechanism of isolation as well. As noted by Rachman and De Silva (1978) unacceptable obsessive thoughts are not unique to neurotic patients but characterize a large majority of normal people. However, while normal people disregard their sporadic unacceptable obsessive thoughts spontaneously triggered by their impulses (see Rachman, 1976, p. 438), patients who have a need to repress and control their anxiety-provoking impulse, concentrate on these available cognitions and exaggerate them to an absurd bizarre level. Yet, although this may be the most common form by which isolation is adopted, clinical evidence indicates that the patient may create obsessive thoughts on the basis of other personal experiences, such as films (e.g., lurid death scenes; see case 1 Salkovskis & Westbrook, 1989) and reading materials (e.g., see case study by Bevan, 1960). Almost simultaneous with the adoption of these thoughts, the patient becomes unaware of his or her self-involvement in the deliberate exaggeration/production and maintenance of these thoughts due to sophisticated self-deceptive processes (see Part II). Consequently, since the unacceptable thoughts lack genuine emotional basis due to their artificial production, and the patient's unawareness of their underlying causes, they appear bizarre, irrational and foreign to the self.