"Do you think I’m normal?" Every evening she asks her husband that question. She is 31, her baby is eight months old, and while telling us this she kept looking down at the floor. Once, standing on the balcony holding her baby, an image flashed through her mind of herself letting go. From that day she stopped going out on the balcony, and then began avoiding holding a knife when her baby was nearby.
She came to the clinic for insomnia and neck and shoulder pain. It took her forty minutes to bring up the balcony.
Intrusive thoughts happen to almost everyone
This point matters most, and it is also the one most often misunderstood.
Intrusive thoughts are sudden, uninvited thoughts, often completely at odds with the values of the person having them. They are universal. Standing somewhere high, you think of jumping; holding a knife, you think of stabbing; at the moment you love your child most, an image of your child in an accident appears.
People who never get caught up in obsessions have exactly the same kinds of thoughts. The professional literature is clear on this: the disorder comes from how a person interprets the thought, while the content of the thought itself does not create the disorder.
One person thinks "my brain just spat out a piece of junk" and goes to make coffee. Another asks "how could I even think that?" and from then on starts keeping watch over themselves. The same thought, and the two people head in very different directions. A thought passing through her head says nothing about what kind of person the mother on the balcony is; she is so frightened of it usually because she is deeply afraid of hurting the child she loves.
Three kinds of beliefs often seen in people caught up in obsessions
Research on obsessions has found three kinds of beliefs that keep recurring in people who get caught up in them.
The first is overestimating the threat and overestimating one’s own responsibility. With the same thought of being poisoned at a restaurant, one person brushes it aside as absurd, while another feels responsible for warning other people. Even when they know full well the thought is absurd, they still feel driven to do something.
The second is equating thought with action: believing that thinking something bad is almost the same as doing it, or that thinking of a disaster makes the disaster more likely to happen. This belief gives rise to a need to control one’s thoughts. But thoughts cannot be controlled, and the harder you try, the more room they take up.
The third is being unable to bear uncertainty. Knowing something is almost certain is not enough; it has to be certain. Checking behaviors exist precisely because they wipe out that feeling of uncertainty, even if only for a while.
The four steps of the loop, and why it feeds itself
Clinical psychology teaching materials describe obsessions as a vicious circle with four steps.
1. An intrusive thought appears and will not go away.
2. Anxiety follows, with a fast heartbeat, raised blood pressure and restlessness. This part happens in the body, not in the imagination.
3. Reassurance behaviors: washing hands, checking, counting, arranging, praying, asking loved ones for reassurance, or avoiding the situation altogether.
4. Temporary relief: the heart rate comes down and the person calms down.
Then back to step 1.
The cruel part lies in step 4, because the reassurance behaviors really do work. Because they work, they get reinforced. Each time checking the door lock eases the anxiety, the brain records that the checking was necessary, and next time it demands checking sooner and for longer.
That is why advice like "stop thinking about it" or "just stop checking" does not help. Being told it is irrational does not make anyone give up a behavior that is working.
Avoidance runs on exactly the same mechanism. Someone afraid of dirt will walk a few kilometers rather than take the bus, and each time they manage to avoid it, the habit of avoiding gets reinforced by one more layer.
What has been seen in the brains of people with obsessive-compulsive disorder
In the brain there is a circuit that runs from the frontal cortex down to the striatum, through the thalamus and back to the frontal cortex. Normally this circuit helps start, sustain and stop an action or a train of thought once it has done its job.
In people with obsessive-compulsive disorder, the sustaining branch of this circuit is more active than the stopping branch. The frontal cortex is overactive; that level rises with the severity of the symptoms and falls after successful treatment.
The anterior cingulate cortex, which monitors errors and conflict, is also overactive and creates a persistent feeling that something is not right, not finished. The amygdala, for its part, reacts strongly to situations that are not actually dangerous.
So the "not finished" feeling that people describe has a real basis; it is not imagined, and it is not a lack of willpower.
The part that belongs to mental health specialists
Reinterpreting thoughts, working with beliefs, and controlled exposure to break the loop are the work of psychotherapy and of doctors specializing in mental health. We do not do this part and do not take it on in their place.
You should see a specialist early if obsessive thoughts and repetitive behaviors take up about an hour a day or more, if they make you late for things, make you avoid your loved ones or have to hide them, or if you have thoughts of harming yourself or others. This condition has effective treatments, and seeing a specialist does not mean admitting you are weak.
The body’s side of anxiety, where we can help
What we can do lies in the second step of the loop, that is, the body’s side of the anxiety.
People who have lived for years in a state of alertness often carry a fairly similar set of signs. They breathe shallowly in the upper chest, with the diaphragm barely taking part; their neck and shoulders are always clenched; they grind their teeth at night; their stomach churns at odd times; and their sleep is never deep enough.
People who are used to hiding their thoughts, like the mother on the balcony, often find it hard to put all of their anxiety into words. So we bring in the stressor itself and then use muscle testing to see how the body responds. The areas assessed include breathing and the diaphragm, the neck, jaw and shoulders, and the abdominal wall. After that we calm things down through reflex points on the forehead and watch how the breathing changes.
For the long-standing insomnia and digestive problems that often come with it, traditional medicine uses herbal decoctions prescribed for each person’s own constitution.
None of this erases obsessive thoughts. It makes the anxiety less intense in the body, so that the person still has enough strength to do the main work with mental health specialists.
If these thoughts come with an urge to harm yourself or someone else, go to the nearest emergency room or call 115 (the emergency number in Vietnam) right away. Do not wait for an appointment.
