Will BDD become known as Heidi Montag Syndrome?

Perhaps the most public illustration of this growing problem is the case of Heidi Montag.  Until a year ago, I had never heard of Heidi Montag, and I still have no idea why she is famous.  Apparently, she is on a reality TV show called “The Hills”, which Stylite blogger Linda Ripoll describes as an “amazing exploration into self-hatred, body dysmorphic disorder, and addiction to plastic surgery”.  And while I have never seen her show, I would have to live in a cave to avoid hearing about the highly publicized cosmetic procedures she has had in recent months, including one day in which she reportedly had the following ten procedures performed at one time:

Heidi Montag after recent cosmetic surgeries

• brow lift
• botox in her brow
• Revision of previous nose job
• fat injections in cheeks, nasolabial folds and lips
• chin reduction
• liposuction on neck
• ears pinned back
• breast augmentation revision
• liposuction on waist, hips, and thighs
• buttock augmentation.

This orgy of body mutilation led Ripoll to suggest that BDD might become known as Heidi Montag Syndrome, much like OCD has at times been called Howard Hughes Syndrome.  While I am not prepared to diagnose Ms. Montag from afar, one glance at the photo to the right suggests that she has a profoundly distorted idea of what a healthy woman’s body looks like.

Sadly, despite the multiple procedures that have left her with the outsized physical characteristics of a cartoon character, Montag is reportedly still not satisfied with her size DDD breasts, and is said to be considering having her them augmented yet again.  This cycle of cosmetic procedures, followed by dissatisfaction with the outcome of those procedures, followed by yet more procedures to counter the effects of the initial procedures, is a classic symptom of severe BDD, and suggests the possibility that Ms. Montag may yet supplant Michael Jackson as the most (in)famous representative of Body Dsymorphic Disorder.

Jennifer Aniston, Kim Kardashian, Pamela Anderson, et al

Unfortunately, Montag is not the only media personality to seek respite from her distorted body image by going under the knife.  OK Magazine recently did a cover story titled “Boob Jobs, Botox, and Lipo” that reported on the various surgeries done by over 25 celebrities.  And while some of these reported surgeries may have been done for legitimate medical reasons (i.e., repairing damage done from a broken nose that led to restricted breathing), the great majority of these procedures were on stars apparently having purely elective surgeries in an effort to improve their already very nice faces and bodies.

Amongst the celebrities noted in the above-mentioned story was actress Jamie Lee Curtis, who has acknowledged resorting to liposuction and Botox in the past.  Curtis, who perhaps enjoys the wisdom that only comes with age and experience, also appeared in a recent issue of  More magazine, which is specifically aimed at the “mature women” demographic.  In addressing her own experience with the aging process, and that of her equally famous actress mother (the late Janet Leigh), Curtis wrote with great clarity about the growing problem of modern women’s self-loathing:

“Our dissatisfaction with what we look like has reached epidemic proportions.  Just look around you: people don’t look right.  Lips, eyes, hair weaves, implants.  It is a freak show being fed by the business it generates, a modern day surgical industrial complex.”

And there you have it – “the business it generates”.  Cosmetic surgeons make big money by feeding off the body image insecurities of women, and to an increasing extent, men as well.

Recent ads for Ralph Lauren

But let’s not fool ourselves into thinking that the problem with the business of beauty is solely that of unscrupulous physicians willing to exploit the insecure.  All one need do is look at the world of advertising to see how the public is being sold unrealistic, unachievable ideals of beauty.  Ralph Lauren has come under fire in recent months due to the obvious retouching of photos in two ad campaigns that presented models as being grotesquely thin.  And recently, Ann Taylor has been caught doing the same thing.

Meanwhile, cosmetics companies continue to make billions by successfully convincing women that they need to change the way they look.  And the pharmaceutical company Allergan has gone so far as to (very successfully) market Latisse, a drug originally designed for glaucoma, but now sold as a beauty aid because it has a side effect of increasing eyelash length.

Of course, we can’t blame business interests entirely for our attraction to products and services that we think will make us more beautiful.  It may simply be innate in humans to value beauty, and as such, to seek out these products and services.  As Camille Paglia has noted,  “We should not have to apologize for reveling in beauty. Beauty is an eternal human value”.  It may be that we are naturally invested in being beautiful, even if it requires surgery, drugs, or Photoshop.  But the question arises: At what point does our attraction to beauty become pathology?  At what point does our quest for beauty become an addiction?  At what point does our desire for beauty become a disorder?

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Disorder (BDD), and related conditions. He can be contacted director@ocdla.com.

Chances are, if you’re reading this, you’ve found yourself saying the same thing at some point in your adult life.  Nowhere is this more relevant than from the perspective of someone looking back on a childhood with Obsessive Compulsive Disorder (OCD) or an Obsessive Compulsive Spectrum Disorder.  When I meet a new client under 18, there is a powerful sense of traveling through time.  I think, “If only I had someone like me to go back and talk to me when I was someone like this.” How much time might I have saved being able to resist repetitive, unnecessary rituals?  How many more events, relationships, and simple moments of peace might I have been able to enjoy if only I had known what was really happening to me?

When I work with adults, I often find them lamenting the passage of time under the oppressive boot of their condition.  This illuminates the importance of early detection and treatment.  While the onset of OCD and many OC Spectrum Disorders is most likely to hit near adolescence (statistically somewhat earlier for males), it is not uncommon for decades to pass between the initial onset of symptoms and finally finding appropriate, effective treatment.

Diagnosis of OCD and OC Spectrum Disorders

OCD can sometimes be difficult to diagnose in children because ritualized behavior is a healthy part of the learning process.  Diagnosis requires that the treatment provider be able to recognize clinical OCD symptoms, including excessive, repetitive behaviors, extreme perfectionism, expressions of chronic or acute bouts of guilt, and, most importantly, impaired functioning.

OCD and OC Spectrum Disorders share a common dyad of symptoms:  obsessions and compulsions.  This is true whether the diagnosis is OCD, Social Anxiety Disorder (social phobia), Body Dysmorphic Disorder (BDD), Hypochondria (health anxiety), Panic Disorder, Phobias, Trichotillomania (compulsive hair pulling) or Dermatillomania (compulsive skin picking).  Here is a brief breakdown of some of the symptoms parents and educators might observe:

Obsessive Compulsive Disorder (OCD)

• Obsession:  any intrusive thought that represents a threat to identity or health (i.e. contamination, doubt about completing actions, moral perfectionism, “bad” thoughts such as harm coming to parents or pets)
• Compulsion: any ritualized behavior designed to reduce discomfort (i.e. handwashing, reassurance seeking, physically or mentally checking that something has been completed or resolved, thought neutralizing)

Social Anxiety / Social Phobia

• Obsession:  fearful thoughts of being evaluated negatively by others
• Compulsion: repeated school avoidance or skipping classes; avoidance of social situations; chronic negative self-evaluation

Body Dysmorphic Disorder (BDD)

• Obsession: constant distressing thoughts about being ugly
• Compulsion: avoidance of social activities; school avoidance; constant checking of appearance in mirrors; repeated reassurance seeking about appearance

Hypochondria / Health Anxiety

• Obsession: excessive fear of having a serious disease, illness, or medical condition
• Compulsion: repeated checking of body for “symptoms”; repeated asking for reaassurance about health concerns; excessive time spent online researching medical issues

Panic Disorder

• Obsession: intrusive thoughts of having a panic attack; fear of losing control or being overwhelmed and annihilated by anxiety
• Compulsion:  avoidance of situations that the individual fears may trigger a panic attack or situations that in which a quick exit is not easy

Phobias

• Obsession: excessive fear of a specific object, situation, or event
• Compulsion: consistent avoidance of that specific object, situation, or event

Trichotillomania / Dermatillomania

• Obsession: fear that resisting an urge to pull hair or pick skin will result in unmanageable discomfort and/or fears that skin or hair does not look “right”
• Compulsion: giving in to urges to pick or pull, avoiding situations where picking/pulling might be noticed or might be difficult to engage in, camouflaging evidence of pulling/picking behavior

In addition to the primary symptoms of these conditions, children and adolescents with OCD and OC Spectrum Disorders may have great difficulty functioning socially and academically.  If they have OCD, they may spend inordinate amounts of time re-reading or re-writing homework and classroom assignments.  They may also have great difficulty concentrating while being bombarded with unwanted thoughts that cause them to silently suffer.  Likewise, children with Social Anxiety and /or Body Dysmorphic Disorder may have difficulty integrating themselves socially for fear that they will be teased or judged negatively, while kids with Hypochondria may be so consumed with health concerns that they pay little attention to academmic or social activities.  Kids with Panic Disorder may avoid parties because of a fear that they will panic and be humiliated, while those with phobias may avoid field trips or other school activities.  And those with Trichotillomania or Dermatillomania may feel a need to isolate themselves from the observations of others.

Treatment of OCD and Related OC Spectrum Disorders

Numerous research studies have consistently found that Cognitive Behavioral Therapy (CBT) is the most effective treatment for OCD and OC Spectrum Disorders.  The “cognitive” part of CBT helps children and adolescents with OCD and OC Spectrum Disorders develop the ability to acknowledge and modify the distorted thinking that is endemic to these conditions.  This represents a unique challenge for children.  Brain development is literally still in process until around age 24, meaning the raw materials for information processing are still being organized at the age that symptoms of OCD and OC Spectrum Disorders often first appear.  This has implications for treatment, requiring a trained professional to educate clients on the tools of cognitive restructuring in such a way that makes sense to a young sufferer.  Simply put, being able to recognize distortions in the thoughts you have about your thoughts requires a state of awareness that does not come easily for children (or anyone for that matter).  It is a learned technique.

When treating OCD and OC Spectrum Disorders, the “behavioral” component of CBT focuses primarily on a tool called Exposure and Response Prevention (ERP), and in the case of Trichotillomania and Dermatillomania, a technique known as Habit Reversal Training (HRT).  In dealing with any of the conditions noted above, this means learning to accept and tolerate feelings of anxiety, while at the same time resisting a powerful urge to respond.  For children, this is an alien state of being, something that requires mindfulness to accept.  If the compulsion makes them feel better now, it’s a tough sell to voluntarily aim for long-term benefits.  They must believe it will work even while it makes them temporarily feel worse!

Overcoming fear is primarily about returning things to their natural place.  The first day at a new school is terrifying for many kids because the school and the people in it carry a value that is both magical and scary.  But after going to school every day over an extended period of time, while committing to other behaviors like schoolwork and socializing, the “school” eventually returns to its natural place as just a school.  This metaphor applies equally to the unwanted internal experiences seen in OCD and OC Spectrum Disorders, the goal being to return these experiences to their natural state as “just” unwanted thoughts, feelings, sensations, and urges.

In short, we all feel anxiety throughout life, increasing exponentially at the age we start realizing that we must behave a certain way to get the things we want, and that crying doesn’t get us everything anymore.  But the only thing more painful than the relentless unwanted thoughts and needless demoralizing behaviors that come with OCD and OC Spectrum Disorders is the sense of isolation that accompanies them.  In most cases, clinically significant cases require individual treatment with CBT.

Many young people with OCD and related conditions also benefit from structured group therapy as an adjunct to individual treatment.  Tackling an anxiety disorder with a trained treatment provider, while in the company of peers going through the same or similar challenges, often presents the best environment for recovery.  People who have successfully learned to manage OCD and OC Spectrum Disorders often report that discovering they were not alone was one of the strongest catalysts toward change.  So for children, simply being in a room with other young anxiety sufferers can be instrumental in their recovery.  Not only do they get to share their experiences in a non-judgmental format, but they get a unique opportunity to see their internal struggle played out through others.  This is often the first step toward practicing mindfulness, the ability to observe your thoughts and feelings from a more impartial perspective.

Children develop OCD and OC Spectrum Disorders for a combination of reasons.  A history of anxiety disorders in first-degree relatives make a child five times more likely to develop a similar disorder, but genetics are not the only culprit.  The young brain is constantly creating new networks of learned behaviors, so watching how mom and dad cope with stress and fear contributes heavily to the relationship a child has to unwanted thoughts.  Practicing maladaptive coping skills over time can make the ritual the norm and the norm ritualistic.

There is also research indicating a link between negative expressed emotion in a household and early onset of OCD.  If you have a predisposition to developing an anxiety disorder, being raised in an environment that is overly critical or saturated with shame is likely to bring this predisposition to the surface.

This means that treating children necessarily involves educating parents.  Every family session I have begins with parents asking the same question:  “What can I say or do not to make things worse”? Families commonly get trapped accommodating the behaviors associated with their child’s anxiety disorder because denying reassurance or intervening in a ritual can cause their child incredible pain and stress.  However, if children can learn to talk back to their disorder and parents can learn how to partner with them in this challenge, remarkable change can occur.

By and large, many children do not like therapy.  Most of what they know about therapy comes from what they see in movies and television.  They don’t want to be labeled as ill and they don’t want to sit in a room with some old stranger asking about their private thoughts and feelings.  They also don’t like homework!  So treating children using Cognitive Behavioral Therapy requires patience, a sense of humor, and a variety of therapeutic tools aimed at empowering the child to fight back against the disorder and treat themselves.  When treating OCD and OC Spectrum Disorders in children, the right combination of clinical treatment, peer normalization, and family support can create a sturdy platform for healthy adulthood.

Note: the OCD Center of Los Angeles offers a bi-weekly therapy / support group specifically for children and adolescents aged 12-17 suffering with OCD and OC Spectrum Disorders.  For more information contact the center at (310) 335-5443.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  Jon runs the center’s bi-weekly child / adolescent therapy and support group.  He can be contacted jon@ocdla.com.

My wife and I recently became vegetarians.  Well, she started using the word “vegetarian” to describe already never eating meat.  For me it required more of a lifestyle change.  I grew up on a small beef cattle farm, so I was used to the idea that you could grow meat the same way you grow vegetables.  Throughout my life it always felt as if meat was how one defined the difference between a “snack” and a “meal”.  So as part health experiment and part social consciousness attempt, I have given up meat for the time being.

At first I felt like I was denying myself something purely enjoyable.  I’m used to it, I like it, so why don’t I just do it?  Saying, “I want to change” or “I’m not happy with the consequences” doesn’t seem to be much comfort.  However, nearly 4 months into this experiment, I now get what can only be described as a “resistor’s high” – an addictive satisfaction derived from choosing not to eat meat.

The other night I had dinner at someone’s house and literally had to stare down an absolutely gorgeous pork chop fresh off the grill.  It appeared to be taunting me as I ate the otherwise perfectly delicious pasta and veggie sides, but I made a conscious effort to reserve analyzing the situation until after dinner.  As it turns out, it felt great not to have eaten the pork chop because it felt great to have committed to a choice.  I even get a similar buzz from locating and ordering the vegetarian options on restaurant menus.  So what is this phenomenon?

When you do something for a long time without putting much thought into it, you begin to adopt it as part of your worldview.  I live in a world where meat is something to be eaten every day.  So not eating meat every day seems like a different world.  Similarly, people who grow up engaging in body-focused repetitive behaviors like Trichotillomania (compulsive hair pulling) and Dermatillomania (compulsive skin picking) often fail to identify these behaviors as problematic until the consequences are impossible to ignore.  They live in a world where hair gets pulled and skin gets picked.  If you pull and/or pick every day, and it feels good, how do you find the strength to stop only because you know you should?

Trichotillomania (TTM) and Compulsive Skin-Picking (CSP) function as both behavioral addictions and Obsessive-Compulsive Spectrum Disorders.  As an addiction, a behavior is repeated for a reward, but the reward becomes increasingly difficult to obtain and the behavior continues to be repeated to excess.  The good feeling that comes from picking one’s skin or pulling one’s hair is soon followed by a sense of shame and helplessness as the brain prepares itself to motivate for the next fix.

Viewed from the perspective of obsessive-compulsive spectrum disorders, both TTM and CSP sufferers have distorted thoughts about their ability to experience and  resist uncomfortable urges.  The desire to engage in the addictive behavior is made greater by the fear that feeling and resisting the urge will be overwhelming and unmanageable.  Perhaps as a more familiar analogy, a compulsive hand washer may intellectually understand when washing is unnecessary, but feels that the anxiety produced by not washing is too painful to be tolerated.

Treatment for TTM and CSP follows two parallel Cognitive Behavioral Therapy (CBT) protocols to address both the obsessional urge and the behavioral addiction:

• Habit Reversal Training (HRT) uses a straight-forward pragmatic approach of blocking the addictive behavior with non-destructive alternatives.  This could involve anything from making picking too difficult by wearing gloves, to covering mirrors to aid in resisting checking, to occupying the hands with a competing stimulus (such as a stress ball or piece of string).  HRT also involves strategies for helping the individual with TTM or CSP become more aware of the behavior when it might otherwise be performed absent-mindedly.

• Mindfulness-Based Cognitive Behavioral Therapy uses a combination of mindfulness, cognitive restructuring, and behavioral conditioning:

~ Mindfulness – learning to acknowledge that sensations, feelings, and thoughts about pulling and picking are inevitable, normal occurrences that do not intrinsically mean you have to pull or pick;

~ Cognitive Restructuring – identifying the thoughts, feelings, and sensations that precede the behavior and challenging the distorted thoughts that make the behavior more difficult to resist;

~ Behavioral Modification – while treatment for TTM and CSP typically does not involve exposure the way it does in the treatment of Obsessive Compulsive Disorder (OCD) and other OC spectrum disorders, it does involve practicing the ability to tolerate the anxiety that comes from experiencing and resisting an urge.

Finding your personal “resistor’s high” will likely mean employing all of the above techniques simultaneously.  To learn to love the feeling of not picking and pulling, you need to experience it for extended periods.  People tend not to enjoy training for marathons, but they do appear to enjoy completing them.  The early work toward overcoming TTM and CSP involves regular confrontation with discomfort, and faith that your resitor’s high will come in time.

By using HRT to interfere with your ability to pull or pick, mindfulness to accept your urges as they are, and cognitive restructuring to address your  distorted beliefs about your ability to resist those urges, you can then practice absorbing and digesting the urge.  Taking the urge in and letting it wash over you becomes increasingly rewarding when paired with resisting the urge over time.  In the end, the behavioral addiction can be replaced by fascination with one’s own ability to emerge victorious from inner struggles.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions, including Trichotillomania and Compulsive Skin Picking.  He can be contacted jon@ocdla.com.

Squirrels hoard acorns to make sure they don’t starve during the winter.  Armies hoard weapons to ensure they never run out.  And some people with Obsessive Compulsive Disorder (OCD) hoard objects of uncertain value, usually with the belief that the object’s value may be revealed at an important point in the future. A classic example is the OCD sufferer who won’t throw out old newspapers for fear that he may wish to reference an article at a later date.  Some people hoard various items of little or no real value for fear that they may need them some day, or fear that they may not be disposing of these items correctly and could cause unwanted consequences.

Not all people with OCD hoard.  In fact, not all hoarders even have OCD.  However, many people who suffer from OCD appear to engage in a form of mental compulsion I have come to call memory hoarding.

Memory hoarding is a mental compulsion to over-attend to the details of an event, person, or object in an attempt to mentally store it for safekeeping.  This is generally done under the belief that the event, person, or object carries a special significance and will be important to recall exactly as-is at a later date.  The memory serves the same function for the mental hoarder that the old newspaper serves for the physical hoarder.

People with memory hoarding OCD exhibit two major errors in information processing.   The first error is the distorted belief that they will need this memory someday, and that it would be catastrophic if the memory weren’t 100% accurate.  Second, people with memory hoarding also have the distorted belief that memories can be treated the same way as inanimate objects.

The value of a newspaper article can be debated, but the contents of that article will remain constant.  A photograph can capture a certain image, and that image will remain constant as long as the material upon which it’s printed holds up.  But memories do not obey the same properties.

Not only is a memory a complex amalgam of all of your senses (sight, hearing, smell, and so on), but it is also a function of the emotional state and cognitive processes of the person forming the memory, both at the time the memory is being formed, and when it is being recalled.  Therefore the very act of forming or recalling a memory must, by definition, distort it. When you reflect upon an event, you are necessarily filtering the stored data of the initial memory through the present state you are in.  So the belief that a memory can be hoarded makes the memory hoarding compulsion a guaranteed disappointment for the individual with OCD.

In general, the clients we have seen who engage in memory hoarding compulsions are concerned that moments in time will pass without them fully understanding, remembering, and appreciating them.  The uncertainty surrounding whether or not they will be able to adequately reflect upon and evaluate the significance of specific events, people, or objects causes discomfort which they hope to avoid.  Someone without OCD may best understand this concept as akin to that “last look” we all take the moment we leave an apartment from which we just finished moving all the boxes.  You stop, you consider that this is the last time you will be this person in this place, and then you move on to the next chapter in life.

Someone with OCD who is engaging in memory hoarding symptoms is likely to feel trapped in a state of never fully being able to take in the true value of this moment.  The twisted irony of memory hoarding is that the person trying to perfectly remember things frequently misses out on those very things because they are caught up in the mental compulsion trying not to miss anything.  When we don’t allow ourselves to be present in the moment, we are losing a great deal of the value of life in the process.

This irony is consistent throughout the OCD spectrum.  The compulsive hand washer scrubs furiously over and over and yet still spends most of their time feeling dirty, no matter how much they wash.  The washing actually informs the brain that dirt is on the offensive.  The memory hoarder similarly feels a perpetual state of incomplete memory formation, despite all of the time-consuming and emotionally draining work they put into trying to form memories perfectly.

As in other manifestations of OCD, the form may change but the function remains the same.  Here are some forms of memory hoarding we have noticed in our clients:

• Over-attending to, and dwelling on, an event of perceived importance while the event is taking place (i.e. a wedding, a graduation, a birth, etc.)

• Over-attending to the details of a significant moment (an important conversation, a kiss, a bite of food, etc.)

• Over-attending to the details of a location and what it feels like to be in it (a room, the inside of a car, etc.)

• Over-attending to memory triggers of significant life periods (i.e. a movie from your childhood, pictures from an earlier relationship, etc.)

• Trying to perfectly remember the physical details of a lover, friend, or family member.

• Mentally replaying an event multiple times to gain certainty that it was remembered correctly.

Treatment for memory hoarding is obviously not going to look the same as treatment for physical hoarding.  The goal isn’t to remove memories.  Rather, the goal is to be able to accept memories as they are and choose their value willingly, not compulsively.  Thus, the practice of Mindfulness-Based Cognitive Behavioral Therapy should be employed in the order of its name.

• Mindfulness – Fully and willingly accept that you have thoughts which appear on the surface to pose a threat to your ability to fully and perfectly form or recall a memory.  Recognize that these thoughts are not good or bad, but simply exist.  Accept imperfect memories as they are.

• Cognitive (Restructuring) – Identify what distorted ideas you may have about your memories, and what the logical, rational, and evidence-based consequences are of having an imperfect memory of a given event, person, or object.

• Behavioral Therapy (Exposure with Response Prevention) – Intentionally seek out scenarios where you feel the urge to memory hoard, and resist the compulsion by moving through the event without over-attending to any specific detail for a significant amount of time.  Leave an event, person, or object without checking to make sure it has been fully understood, remembered, and appreciated.  Interrupt mental reviewing with more meaningful, attention-demanding activities.

It’s important to understand the meaning of “over-attend” in this context.  One person’s version of savoring the moment in a healthy way could mean getting trapped in an obsessive-compulsive cycle for someone with OCD.  The trick is to draw a distinction between enjoying a moment, and mentally seeking reassurance by asking yourself if you are completely enjoying and remembering a moment for sure.

Part of this phenomenon may have to do with an OCD sufferer’s difficulty accepting the permanence of the passing of time.  Or perhaps memory hoarding is just another form of trying to do the right thing in the right way 100%.  In any case, if the ultimate objective is to value and enjoy experiences in your life, then your best bet is to let those experiences happen without OCD telling you how to enjoy and remember them.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  He can be contacted jon@ocdla.com.

On November 16, 2009, John Edward Lane, a 70-year-old retired Australian television executive boarded a ferry boat in Sydney harbor.  Also on board was Grant Brown, a 31-year-old Tasmanian boxer who had previously held the Australian lightweight title for three years, as well as six Tasmanian boxing titles and four Golden Gloves titles.

According to witnesses, Brown had a contentious argument with his girlfriend on his cell phone during the ferry ride. After the call ended, Brown was reported to be upset and aggressive, angrily kicking the walls of the boat.  At some point, an associate of Mr. Lane asked Brown to settle down, to which Brown responded that he was going to “bash your head in”.  When the 70-year-old Mr. Lane then asked Brown to relax, Brown replied “Step away, I swear I’m going to punch your f ***ing head in”, and then punched Mr. Lane once in the face.  Lane fell to the ground, bleeding profusely, and suffered a fractured skull, spine and eye socket.

Brown was arrested for the assault, and when originally presented to the local court, his attorney claimed Brown was suffering from depression and relationship problems that had factored into his assault on Lane.  He further requested that his client be released without bail because of his “good character” and lack of a prior criminal record, as well as his having shown remorse for the assault on Lane.  The court magistrate wisely refused bail on the grounds that Brown had perpetrated “unprovoked violence for no apparent reason”, and was a danger to the community.

When Brown’s case was later brought before the court on April 9, 2010, his defense attorney claimed that his client had depression and Obsessive Compulsive Disorder (OCD), and that his assault on Lane was a result of his mental illnesses and his having run out of his medication at the time of the crime.

But the magistrate in the case, Judith Fleming, rejected Brown’s request that the case be thrown out of court.  According to The Herald-Sun, Ms. Fleming noted that “distressing phone calls and feeling annoyed with other passengers on public transport were common occurrences that shouldn’t end in violence”.  The paper further reported that the the magistrate found “no indication in the psychological reports submitted to her that Brown’s illnesses caused aggression” and that “if anything, the reports talk about withdrawal” from his medication, rather than the illnesses themselves,   as a possible factor contributing to Brown’s behavior.

Brown ultimately pled guilty, and on June 10 2010, was sentenced to two years in prison, with no possibility of parole for a minimum of 18 months.  In sentencing Brown, the magistrate described the the former boxer’s actions as  “a cowardly and vicious attack on an elderly gentleman on public transport where the victim was utterly blameless”.  Brown is currently out on bail pending appeal.

This is just another in a recent spate of cases in which defendants and their attorneys have attempted to excuse criminal behavior on the grounds of having Obsessive Compulsive Disorder (OCD).  In this case, as in the others presented in earlier entries here, the court was able to clearly see through the rhetoric being presented by defense attorneys.  The magistrate recognized that the defense presented no evidence of a link between aggressive behavior and OCD – because there is no evidence of such a link.  She also noted that being upset after a difficult phone call with a lover is a fairly normative experience that doesn’t excuse subsequent criminality.

Let’s hope that the disposition of the cases presented in our three-part series on “OCD and the Law” is a harbinger of a broad rejection of efforts by defendants and their attorneys to mislead judges and juries with specious arguments about criminal activity being caused by OCD and other mental illnesses.

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. He can be contacted director@ocdla.com.

In March of 2010, the lawyer for Jerry Seidl of suburban Louisville, Kentucky claimed that his 68 year-old client murdered his wife of 47 years as a result of Obsessive Compulsive Disorder (OCD).  The couple had separated in 2008, and his wife Dorene had moved out of the family home.  On August 7th of that year, after filing for divorce, Dorene sought a protective order on the grounds of domestic violence.  In the petition, Dorene claimed that her husband had previously put a gun to her head, and on a separate occasion had told her “I’m just going to kill myself and get it over with. Do you want to go with me”.  Despite this, the request for a protective order against her husband was rejected by a local judge on August 20th.

Less than a week later, on August 25^th, Dorene returned to the family home to collect personal effects and to present her estranged husband with a note explaining what she felt she was due financially.  It was at that time that the defendant drew a gun and shot his wife in the head five times, wounding her fatally.  He then barricaded himself in the home for four hours until peacefully surrendering to the local SWAT team.

In presenting his final argument to the jury, Seidl’s defense attorney Bart Adams claimed:

“Our defense in this case is he had obsessive compulsive personality disorder,” said defense attorney Bart Adams. “People with obsessive compulsive disorder are driven by an unwarranted but unrelenting pressure to control all persons and objects around them. He lost control, there’s no doubt about that. He’s got to pay for what he did. He knows that I know it, everyone in this courtroom knows, but we’re going to prove to you that it was murder under extreme emotional disturbance.”

The primary flaw with the argument presented by Seidl’s lawyer is quite simple – he first claims that Seidl has Obsessive Compulsive Personality Disorder (OCPD) and then, in the very next sentence, says that his client has Obsessive Compulsive Disorder (OCD).  But Obsessive Compulsive Disorder (OCD) is not the same as Obsessive Compulsive Personality Disorder (OCPD).  In fact, despite the similarity of the two terms, the two conditions are actually quite different.  They are essentially the opposite of each other.

An individual with OCD has very specific thoughts which are experienced as unwanted, intrusive, and anxiety provoking.  The clinical term for these types of thoughts is that they are ego-dystonic, which simply means that the thoughts are inconsistent with the individual’s values, beliefs and character.  For example, some individuals with OCD might have unwanted thoughts about homicide, pedophilia, or sexual orientation.  The individual with OCD experiences these thoughts as completely unwanted, highly disturbing, and incredibly disgusting.  They feel horrible that that they are experiencing these unwanted thoughts, and go to great lengths in an effort to get these thoughts out of their mind.  They never act on these thoughts.

Conversely, an individual with OCPD has thoughts which they experience as wanted, normal, and not at all anxiety provoking.  The clinical term for these thoughts is ego-syntonic, which simply means that the thoughts in OCPD are consistent with the individual’s values, beliefs and character.  For example, some individuals with OCPD might have the thought that their clothes should be folded a very specific way or that their yard should always be 100% free of leaves.  The individual with OCPD experiences these thoughts as completely normal and reasonable, and expects others to comply with their desire that certain behaviors be done in a very precise and specific manner.  They do not feel bad about these thoughts, and make no effort to get these thoughts out of their mind.

In presenting his case to the court, Seidl’s attorney called upon a local psychiatrist, Dr. Douglas Ruth, who testified that Seidl suffered from OCD, which Ruth claimed caused Seidl to be “controlling” and to “snap” when his wife asked for a divorce.  Perhaps Dr. Ruth should return to school to get a better understanding of the difference between OCD and OCPD.  There is nothing in reports of the Seidl case to indicate that the defendant had OCD.  And as prosecutor Christie Foster noted, Seidl had never previously been diagnosed with OCD.  In fact, Seidl’s lawyer describes his behavior as being “driven by an unwarranted but unrelenting pressure to control all persons and objects”, which is actually a pretty good description Obsessive Compulsive Personality Disorder.

Of course, this raises the question of whether or not OCPD should be an acceptable defense for murder.  Seidl’s attorney indicated in court that his client deserved some sort of special consideration because he murdered his wife “under extreme emotional disturbance”.  But aren’t all (or at least most) acts of murder committed under extreme emotional disturbance?  Is being in a bad emotional state now an excuse for murder?

Apparently the jury in the Seidl case didn’t think so – after only four hours of deliberation, they returned a guilty verdict, and recommended a 35 year prison term.

Next week – Professional boxer Grant Brown assaulted a 70-year-old retiree, resulting in a fractured skull and permanent brain damage…and then claimed his OCD made him do it.

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. He can be contacted director@ocdla.com.

In March 2009, the Edinburgh Evening News of Scotland reported the case of Iain McKinlay, a father of three who claimed that the huge amount of child pornography that he had amassed on his computers was a result of his suffering from Obsessive Compulsive Disorder (OCD).  McKinlay was caught after he used his personal credit card to access child pornography web sites.  When the local police raided his home in April 2008, they found 3,557 illegal pictures on two separate computers.

McKinlay’s initial explanation for his collection was somewhat reminiscent of the pedophiles seen on NBC’s “To Catch A Predator”, in which nearly all of those caught on camera claim that they were under the impression that the young child they ostensibly came to meet was actually much older (this despite the video and audiotapes proving that they were explicitly looking for young children).  In McKinlay’s case, he claimed that he was conducting internet searches specifically for young women aged 18-21, and that the search engines somehow mistakenly presented him with the illicit photographs of minors.

McKinlay’s lawyer took a different approach, claiming that his client’s child pornography collection was evidence of Obsessive Compulsive Disorder (OCD), and that his collecting and viewing the pictures “helped him escape from the pressures of reality”.  McKinlay’s lawyer went on to claim that his client should not receive jail time because he was not likely to return to viewing and collecting child pornography, despite the fact that he had been previously convicted of other sex crimes.

Unfortunately, many people, including judges and juries, could potentially be swayed by the argument made by McKinlay’s lawyer that this was a case of OCD.  After all, McKinlay’s behavior (collecting and viewing child pornography) seems “obsessive” and “compulsive“.  But in assessing the merits of the defense attorney’s argument, it is important to note three salient issues.

First – there is absolutely no connection between compulsive pornography viewing and OCD.  There are many problematic behaviors that have obsessive and compulsive components, yet are not the same as OCD, including anorexia, bulimia, compulsive overeating, compulsive gambling, compulsive shopping, compulsive shoplifting, drug addiction, alcoholism, sex addiction…and pedophilia.  It is clear from news reports about this case that McKinlay enjoyed looking at pictures of naked children.  After all, he had collected over 3,500 pornographic pictures of children at the time of his arrest.  This suggests pedophilia…not OCD.

Second, people with OCD do not act compulsively in an effort to “escape from the pressures of reality”, as McKinlay’s lawyer claimed in this case.  Those who suffer from OCD act compulsively with the sole intent of reducing or eliminating the overwhelming anxiety that they experience related to very specific unwanted thoughts.  In other words, they perform compulsive behaviors to counteract unwanted thoughts that they find extremely distressing.  I fail to see how McKinlay’s collecting and viewing of child pornography was driven by an effort to reduce or eliminate any specific unwanted thoughts.  On the contrary, his habit quite clearly seems motivated by a desire to satisfy his sexual urges.

Third, it is worth noting that there is a sub-type of OCD in which people have unwanted sexual thoughts, including thoughts about children.  But in cases where individuals with OCD have obsessions about children, they are uniformly disgusted by those thoughts.  In 15 years of treating people with OCD, I have never once seen a client with obsessions about children act on these thoughts.   In fact, those with obsessions about children often go to the opposite extreme, avoiding all contact with children (even their own) because they are so horrified by these unwanted thoughts.  They never seek out pornographic pictures of children.  Never.

Fortunately, the judge in the case was not fooled by the lawyer’s specious argument.  He sentenced McKinlay to nine months in jail, and placed him on the local sex offenders registry for the following ten years.

Next week – Jerry Seidl shot his estranged wife in the head five times…then claimed his OCD made him do it.

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. He can be contacted director@ocdla.com.

“If I hate OCD so much, why do I fight so hard to keep it around? Maybe my OCD is a good thing. Maybe I need my OCD. After all, If I am not my OCD, then who am I?”

This scenario typically (although not always) presents itself several months into therapy, long after the client has gained some autonomy from their OCD through the use of Cognitive Behavioral Therapy.

Cognitive Behavioral Therapy and the OCD Stockholm Syndrome

Effective treatment for OCD focuses primarily on two Cognitive Behavioral Therapy techniques. The primary cognitive technique used in treating OCD is Cognitive Restructuring.  This technique works by teaching you how to recognize the distorted thinking that builds layers of obsessive fear around you.  The primary behavioral technique used in treating OCD is Exposure and Response Prevention (ERP).  This technique works by peeling off the layers of fear and exposing your mind to freedom from compulsions.  Combined, these CBT techniques are the gold standard for the treatment of OCD and related anxiety disorders.

“But what if the layers of fear are peeled off only to reveal nothing inside?  What if I’m an empty shell?”

Ironically, the appearance of this new fear is often actually a sign that CBT is working.  Since the first time you touched that doorknob and resisted washing or sat alone with a defenseless child while imagining the unimaginable, you’ve had your OCD on the run.  Always looking for its next in, the OCD starts grasping at straws.  The final straw, it claims, is that you need your OCD to be who you are.  This is certainly among OCD’s more cynical traps.

While virtually all clients recognize that life without countless, misery-inducing rituals is better, some people with OCD actually start to advocate for keeping some of their compulsions.  The thinking appears to be that some compulsions are worth hanging on to, and it becomes important for the sufferer to defend them.  The therapist becomes the bull in the brain’s delicate china shop, destroying a carefully constructed self-preservation system.  This opens the door for OCD to attack the one weapon essential for successful treatment: a client’s motivation.

One client often struggles with capturing the motivation to do his ERP homework assignments.  Sometimes the ERP assignments are not as terrifying as he had anticipated they would be and this causes a new problem.  Here is what his OCD exclaims:

“See…this is too easy!  You can do it and your so called OCD will be gone before you know it.  Your therapist will send you off as soon as he figures out your OCD is really not that bad, and before you feel ready.  He has lots of other clients who are probably way worse than you and you would be selfish to ask for any more of his time.  And when he kicks you out, you’ll be lost and confused and wonder whether it was all a lie, and you’ll feel terrible for ever having presumed that your problems were any different than anyone else’s problems or that your problems were bad enough for you to seek special treatment when there are so many out there who have it way worse than you.”

The reason we so often lose at playing the OCD game is that it cheats.  We play fair.  We use logic.  But OCD comes to the knife fight with automatic weapons.  It is willing to go so far as to deny its own existence in order to preserve that same existence.

Well, I have good news and bad news.  The bad news is you will have unwanted intrusive thoughts (everybody does), and somewhat unusual strategies for coping with them, for the rest of your life.  The good news is that, if you accept those thoughts, they need not be so problematic.  Unwanted thoughts happen.  What they mean about you is just an ongoing debate between you and your OCD.  But the effect they have on your functioning is the difference between having a disorder and just being you.

Mastering The OCD Stockholm Syndrome

As with any OCD fear, the way to master the OCD Stockholm Syndrome is to habituate to it through ERP.  For some this may mean being vigilantly compliant with therapy and risking suddenly finding yourself without OCD.  It may mean tolerating uncertain thoughts of being a fraud, a fake, or a deceiver of the mental health world.  It may mean feeling like you don’t deserve quality treatment because you don’t really suffer as much as you think one should.

On a cognitive level, mastering the OCD Stockholm Syndrome means engaging in your ERP homework without first capturing that “feeling” which makes you believe you are motivated to do the work.  In other words, change the behavior first, and then wait patiently for your thoughts and feelings to catch up.

The processing error that allows OCD Stockholm Syndrome to take shape involves a distorted belief that, in the future, you will be the same person, but without all the time consuming rituals to rely on.  However, this ignores the fact that without the rituals, you can actually evolve.  The person you become – the person who lives without the constant terror of OCD – relates to that fear differently than the person who suffers under its reign today.

The light at the end of the tunnel remains as long as you stop checking to make sure it is there.  Stay in the present, but always move forward.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  He can be contacted jon@ocdla.com.

As we noted last week and in prior posts, the past few years have seen a significant increase in the number of professional baseball players going on the disabled list due to Social Anxiety.  This trend is remarkable for numerous reasons, the most noteworthy being that the issue of mental health in baseball is being openly discussed at all.  The overall issue of mental health has long been shrouded in secrecy and shame, leading many public figures to go to great lengths in order to ensure that their mental health issues remain private.  So when professional baseball players not only acknowledge their psychological issues, but actively seek help for them, this is a sign of cultural progress.

It is easy to see how professional baseball players, who are under intense public and media scrutiny while performing at the highest levels of their profession, would experience increased stress and anxiety.  Add to that the fact that many baseball players join the professional ranks when they are barely out of high school, and you have a recipe for psychological problems.  But professional baseball players are hardly the only athletes to publicly deal with an anxiety disorder.

• Football player Ricky Williams, currently of the Miami Dolphins, has long struggled with Social Anxiety.  He briefly retired in 2004, reportedly because of his difficulties with Social Anxiety.  He was treated with both psychotherapy and medication, and briefly served as a spokesperson for the Social Anxiety drug Paxil.  However, he has publicly stated that he prefers to medicate his Social Anxiety with marijuana, and as such has failed numerous NFL drug tests during his career.

• Another football great, hall of fame running back Earl Campbell, has been quite public about his struggles with Panic Disorder.  Campbell reportedly developed Panic Disorder in 1988, three years after his football career had ended.  After becoming agoraphobic, Campbell sought professional help and eventually went on to write a memoir of his struggles titled The Earl Campbell Story: A Football Great’s Battle with Panic Disorder.

• John Madden, the recently retired football analyst and former coach of the Oakland Raiders, has reportedly not flown in a plane since 1979.  While working as an analyst for CBS, he always took trains or his personal tour bus to cover games.  His anxiety apparently began in the late 1970’s when he experienced a panic attack while on a flight.  He has reported that his discomfort is not with flying, but with Claustrophobia, and it is unknown if his anxiety occurs in non-flying situations.

• Soccer star David Beckham has been quite public about his difficulties with Obsessive Compulsive Disorder (OCD).  In a 2006 interview with the British television network ITV1, Beckham acknowledged various compulsive behaviors, including lining up items in straight rows, the need to have only pairs of specific items, needing to count certain items such as clothes, and having to arrange items in hotels in a certain way.

• Retired NHL goalie Clint Malarchuk has also been public about his battle with OCD.  He played professionally from 1981-1992, and has since coached, including his current stint as the goaltending coach of the Columbus Blue Jackets.  Malarchuk was reportedly hospitalized for anxiety when he was just 12 years old, and wasn’t diagnosed with OCD until 1991 when he was 29 years old.  He has also reportedly struggled with alcoholism, a not uncommon problem for those who use alcohol and/or drugs to self medicate their anxiety.

These are just a few of the athletes who have struggled with anxiety.  It is important to remember that athletes, even those at the top of their professions, are just people, and are subject to the same mental health issues as everyone else.  There is growing research that many psychological conditions, including OCD and other anxiety disorders, have a strong genetic component.  The current consensus amongst researchers and anxiety treatment specialists is that many individuals with these conditions may have a genetic predisposition that is triggered and/or exacerbated by exposure to psychosocial stressors.

Being a professional athlete doesn’t make one immune to either genetics or real-life stressors, and may in fact provide a significant increase in certain stressors that many of us would find profoundly unsettling.  Obviously, all of us are exposed to real-life stressors on a daily basis, but I for one am glad that my stressors don’t occur on national television or in the pages of the local newspaper.

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. He can be contacted director@ocdla.com.

This past week marked the arrival of the 2010 Major League baseball season.  And as with last year, this season already has three developing stories of athletes dealing with Social Anxiety.

During the 2009 season, infielder Khalil Greene, then of the St. Louis Cardinals, missed 46 games during two stretches on the disabled list due to Social Anxiety.  During the off-season, Greene signed a one-year contract worth $750,000 with the Texas Rangers.  Unfortunately, Greene’s Social Anxiety continues to be a significant issue, and reportedly was the reason for his failure to report to spring training camp in Arizona.  As a result, the Rangers have voided his contract, though they reportedly are leaving the door open for him to return to the team.

Meanwhile, an apparently happier story is unfolding in Detroit, where former all star and rookie of the year Dontrelle Willis is attempting to make a comeback.  After a 2009 season in which he too had a couple of stints on the disabled list due to Social Anxiety, Willis appeared strong in his first start of the season last Thursday.  After struggling in the first inning, during which he walked two batters, he went on to complete six innings in the Tigers 7-3 victory over the Kansas City Royals.

Of course, Kansas City is the baseball home of Zack Greinke, last season’s big Social Anxiety story.  Even casual baseball fans were delighted by his spectacular turnaround in 2009.  After nearly abandoning baseball in 2006 due to his Social Anxiety, Greinke went 16-8 in 2009, with a 2.16 ERA.  He then spent his off-season collecting the 2009 Cy Young award and marrying Emily Kuchar, a former Miss Daytona Beach and Dallas Cowboy cheerleader.  In two starts thus far in 2010, he is 0-1, with a 3.55 ERA.

All of this points to the ongoing issue of how baseball and other professional sports have never taken the issue of mental health very seriously.  It seems that teams (and fans) expect players to have an innate ability to withstand the huge pressures of performing at the professional level.

As we noted here previously (July 2, 2009), huge salaries and 24 hour-a-day sports coverage on cable channels are stressors that athletes in previous generations didn’t have.  Another factor may be that many baseball players (and other athletes) turn pro at a very young age, and as such, don’t have the opportunity to fully develop emotionally before suddenly being faced with the pressures of professional sports.

For more on this topic, I strongly recommend Roy Johnson’s op-ed piece that ran last week on the ESPN website in which he notes that “baseball and other sports must learn to do as good a job of diagnosing and treating “mind” injuries as they do when the body breaks down”.  Let’s hope leagues and owners are listening.

Next week – anxiety disorders in other sports.

•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. He can be contacted director@ocdla.com.