Originally posted Oct. 15, 2011
NOTE: If you’re reading this because you’re plagued by obsessive thoughts or anxieties and are frightened about what that means, please know that help is available. The International OCD Foundation is a great place to start.
I was sitting in a booth at the Olive Garden, when I vividly imagined getting my stepfather’s shotgun out of the basement and blowing my head off.
The fact that I just publicly admitted to eating at the Olive Garden should indicate how important I consider what I’m about to tell you.
It was January 29, 2010 at the Olive Garden in Bethel Park, PA that I first started down the path to understanding that I have obsessive-compulsive disorder. I’d actually been rolling along with OCD for many years — decades — before that, but like most people with the disease, I didn’t know it. And in the moment of shock after realizing that I’d just visualized putting a gun into my mouth, OCD certainly wasn’t what I was thinking about.
Four months earlier, my wife Sophie and I had left on a Virgin Atlantic flight out of Washington DC to live our long-time dream of traveling around the world. We had a nine-month, five-continent trip planned, but just four months and two continents in, we were running out of steam. We decided to return to the US, crash with my parents in Pittsburgh for two weeks, recharge our batteries, then finish the trip. In the back of my mind, though, I’d already started feeling like I didn’t have the energy, will, or even the desire for five months on the road through India and southeast Asia. A few days later I was sure of it. That filled me with a vague but comprehensive anxiety that I was letting down not just Sophie, but also all my friends who were following our progress online and, most importantly, myself for wimping out on my dream.
I’m not going to take any more space describing the root of that anxiety or analyzing why I felt it. That’s because I want to talk about OCD, to make you understand what it is and what it does. And even though OCD is an anxiety disorder, the subject of that anxiety is entirely unimportant. That’s the first vital point I need you to understand. I’m giving you the background of that trip for clarity’s sake, but this is not a story about fears of disappointing others, or suicidal thinking, or even fears of suicidal thinking. Those are the MacGuffin, as Hitchcock would say. They get the story going, but they aren’t what the story’s about. They’re the murder in Rear Window. Or if you prefer fruit metaphors, they’re the cantaloupe that carries the listeria bacteria.
The important thing is that I had all this anxiety, and at some point the thought entered my mind, “Man, these problems would all just disappear if I were dead.” It felt wrong to think it. I knew I didn’t want to kill myself. Just the fact that I’d conjured the idea upset me, so I put it aside. But a few hours later, I was in the Olive Garden, imagining suicide by shotgun. That image simply popped into my head, as close to literally as I’ve ever experienced anything “popping into my head.” I was thinking about pasta, or visas, or whether I’d finally started to like Diet Coke, and then suddenly I pictured killing myself. I remember pausing for a minute, thinking about how strange it was — like I’d for a second intercepted someone else’s thought stream. The image felt strange and alien and certainly not good. In fact it felt frightening and bad, and I didn’t want it to come back. But it was gone, so I chalked it up to a brain fart and went on with lunch.
Later that afternoon, the image came back. Then it came back again. And again. It seemed to be arriving from a place outside of myself. My brain kept bringing the image back — obsessively — even though I tried not to think it. Worse, the more it popped in there, the more I started to feel like I was losing control of my reaction to it. I knew very clearly that I didn’t want to shoot myself or commit any kind of self harm, but I was filled with the anxiety that I wouldn’t be able to stop myself from doing it. I worried that if I was left alone I would compulsively go into the basement, get out the gun, and use it right then and there. At one point I even snuck down there, opened the closet, and looked at the gun, just to prove myself that I could do it without shooting myself. It made me nauseous and scared, and I went back upstairs to find Sophie as quickly as I could without making her realizing that anything strange was happening.
My parents were out of town for a couple of days, so Sophie and I were alone in the house. That night in the basement den, a few feet from the shotgun, we laid on the couch together and watched The Mysteries of Pittsburgh on cable. The image still occasionally showed up, but being there with Sophie relaxed me, and I was able to not worry about it. The Mysteries of Pittsburgh is a lousy movie. It’s also a lousy movie which, it turns out, ends with one of the main characters killing himself by jumping off a building. I watched it, silent.
Getting ready for bed a few minutes later, I started seeing myself jumping out of the second floor bathroom window onto the driveway below. I imagined the same thing from the bedroom window. And the shotgun scene kept making itself known. My anxiety began to snowball into real fear, but I still wasn’t so scared that I was willing to say anything. I’d dealt with anxiety my whole life, crippling anxiety so bad that at times I’d been unable to get out of my house in time for work, but I knew that every night when I climbed into bed with Sophie, it would melt away and I’d be able to sleep. That night wasn’t any different.
The next morning, I woke up early and immediately thought about killing myself. The gun. The windows. The feeling was the same — I didn’t want to do it, but I was afraid I wouldn’t be able to help myself. The thoughts came faster and wouldn’t stop. I was scared and worrying that something was deeply wrong with me.I was going insane. I had a brain tumor, psychosis, schizophrenia. Sophie was lying asleep right next to me, and I thought about waking her and telling her what was happening, but I didn’t want to do it. I imagined life playing out in front of me. If I woke her, she would think I was out of my mind. Unquestionably. But she’d still have to get me help, take me to the hospital or a doctor. From that point on, I thought, I would be the Guy Who Wants to Kill Himself. I would be crazy. I would never have a job or a friend again, because I would be the suicidal freak. I couldn’t let that happen.
Then suddenly I saw myself hanging from the ceiling fan with my belt around my neck. I shook Sophie awake, shouting through tears, “Something’s wrong with me! You have to help me.”
Of course what I expected to happen was wrong. Sophie hugged me and said, steadily and calmly, “Tell me what’s wrong.” I explained what had been happening the best I could while being, for the first time in my life, completely and utterly panicked. I howled and gasped, barely able to breathe. I’d experienced minor panic attacks before, but nothing that went past the point of losing control. I’d blown by that now. But even though I was hyperventilating and bawling about killing myself, Sophie didn’t think I was crazy, not for a second. She stayed calm and promised she would help.
It might seem obvious that she or any spouse would react that way. We’d been married for ten years; she knew her husband hadn’t suddenly lost his mind. But I’m pointing it out here because there’s another very important point that I need you to understand. OCD is sometimes called the Doubting Disease, because no one who suffers from OCD believes they have a disease. Until you finally understand that you have OCD, you think your anxieties, obsessions, and compulsions are all normal things that everyone experiences. Or you think that, okay maybe other people aren’t worried about the things you’re anxious about, but that’s because they are wrong. “They just don’t understand that we’ll all burn to death if I don’t check the stove one more time.”
And worst of all, when the disease gets really bad — and OCD will always get worse if it’s left untreated — so bad that you finally think something might be broken in your head, at that point you’re afraid to tell anyone. You’re too ashamed, or you doubt your own sanity. “How can I possibly tell anyone that I can’t stop thinking about killing myself? I’m a maniac!” You feel embarrassment and fear and think that no one will understand or want to help you if they were to find out the truth.
Everyone who has OCD believes those things to some degree, but they are wrong. I’m telling you how Sophie reacted so that you can understand. I’m talking now to a hypothetical OCD sufferer that I’m imagining reading this. If someone loves you, they will not turn their back on you. They will help you. If you feel alone, you can find a doctor who will listen to you and help you and understand that you’re not crazy. With OCD you have to get beyond that doubt, because you will need help to get your disease under control. Getting that help is the hardest step. It took me over thirty years and fear for my own life before I took that step. But that morning in bed telling my wife, “something is wrong with me” was one of the most important things I’ve ever done. I divide my life into two parts: before and after I asked for help.
Okay so of course Sophie helped me. We were in Pittsburgh at the time, a city we’d lived in for several years before moving away 18 months earlier. Sophie’s dealt with clinical depression, and had a psychiatrist in the city who’d helped her tremendously. She asked if she could call him for me. Despite a lifetime of anxiety, I’d never seen any kind of mental health specialist, but I said yes right away. He happened to have a canceled appointment that day and said he’d see me at noon, about four hours later.
Those four hours were long and hard. I remember lying sobbing on the couch, suicidal images appearing uncontrollably in my mind, and grabbing my head yelling, “Why won’t they stop?” But the amazing thing is, in the midst of all that, because of Sophie’s calm and the prospect of seeing a doctor whom we both trusted, I was able to, for a minute here and there, relax and, once, even laugh. It had already begun to sink in that the horrible consequences I’d imagined weren’t necessarily going to happen.
I say it was amazing, but it wasn’t really. I know now that I was actually already taking the first step to overcoming OCD: realizing that there was nothing wrong except what my mind said was wrong. When I had a second of calmness and rationality I was, without trying, just ignoring the part of my mind telling me over and over that I wanted to kill myself. There’s absolutely no reality to irrational anxiety. That’s its secret. And so as soon as you make the irrational anxiety go away, the entire problem just evaporates, because there was no problem. If my hypothetical OCD reader is a hipster, imagine Jennifer Connelly in Labyrinth telling David Bowie’s goblin king, “you have no power over me.” Of course, that’s easier said than done, and I’m getting ahead of myself.
We made it to the doctor, and with Sophie sitting next to me, he listened closely while I explained to him, crying, what had happened. He asked us both of a lot of questions, about my history with depression (none) and anxiety (lots). He was able to conclude pretty quickly that I wasn’t a danger to myself. He told me that what I was going through was so common that he could give me a book about it. After taking proper precautions for my protection on the slim chance that he was wrong, the doctor sent me home with a temporary prescription for Xanax and an appointment to start treatment in three days, after the weekend. He said one sentence that I won’t ever forget and that kept me going through the next three very difficult months. “You and Sophie are going to have a long, happy life together. This is just a bump in the road that you’ll get over.”
He knew that I was experiencing a textbook form of OCD, but it’s one that takes some explaining.
Most people think of OCD sufferers as maybe Jack Nicholson in As Good As It Gets, viciously cycling through the same precise routine every day, washing his hands with multiple bars of soap and frantically avoiding every crack in the sidewalk. Or maybe as Monk, that TV detective who’s so darn lovable because of his adorable severe mental illness. Those are both in fact manifestations of OCD, but they don’t comprise the extent of the disease. And they don’t resemble me nor what my psychiatrist recognized in my symptoms.
To help you understand how my obsessive suicidal images relate to a charming, ethnically indistinct goofball touching every parking meter he passes, I’m now going to give you a brief capsule description of the nature of OCD. It will be overly simplistic and will filter vital facts through my own interpretation, so please don’t use it for any term papers or game-show research.
OCD results from a problem with biochemistry which causes a malfunction in the part of the brain that controls thought processes. Imagine your thoughts as a playlist of MP3s, something like:
- Read the word “cookies.”
- Think about cookies.
- Remember that you’re out of cookies.
- Desire to go to the store immediately to buy cookies.
- Decide not to buy any cookies because of what happened last time with the Double Stuf Oreo Cakesters.
A normal brain grabs the top thought in the playlist, processes it, shuttles it off to any other part of the brain that needs to deal with it, then moves on to the next thought. The brains of someone with OCD doesn’t do that properly. My brain will get caught on a certain thought in the playlist and loop it right back up, front and center in the brain. Those thoughts play on repeat over and over.
When that happens, those sticky thoughts become obsessions. And OCD is an anxiety disorder, which means that the thoughts that become obsessions are ones that cause anxiety. And because people want to act on their anxieties, those obsessions often lead to compulsions. The classic example of this is the OCD hand washer. A person with OCD might become obsessed with the thought “I am dirty.” It plays over and over in his head. He reacts to it by washing his hands, which gives him a temporary sense of relief. But because his brain doesn’t work correctly, the “I am dirty” thought always returns. So he washes his hands again. The hand washing becomes his compulsion — a ritual reaction to his obsession. That obsession-compulsion loop continues, increasing its frequency, until it cycles out of control.
It’s important to note here that every time an obsessive thought returns, it feels just as real as the first time. This can be very hard to understand for someone who’s never dealt with obsession. Even now, with my OCD well under control and knowing everything I know, I will occasionally be frozen with fear at the sudden thought that I am going to get up and kill myself. It feels like the truth every time. My favorite illustration of the perceived reality of obsession comes from Jeffrey Schwartz’s Brain Lock. He describes a patient who was obsessed with the idea that he had razors on his fingertips. He wouldn’t touch his family out of fear that he’d cut them. It seems silly — couldn’t the guy just look at his fingers and see that there weren’t any razors on them? The answer is yes, and he did. But as soon as he’d look away again, his brain would replay the thought “I have razors on my fingertips,” and even though he’d just proven he didn’t, that thought felt like the truth.
You’re probably getting the point that the obsessions of OCD sufferers are complete irrational nonsense. They might start off in some understandable or rational anxiety (“Are my hands dirty?”), but as an anxiety becomes more severe, it becomes more and more irrational. Everyone’s experienced this at least a little bit. You hear there might be some layoffs at your company, and within a few minutes you go from fearing that you might lose your job to being pretty sure that you’ll be living in a PODS crate calculating the cost/benefit analysis of selling each of your organs. A normal person puts their anxiety aside and comes back to rationality, but someone with OCD cycles through it endlessly. On each return trip the anxiety becomes more severe, more irrational, and feels more urgent. This feedback loop eventually leads to anxieties that seem utterly insane to everyone but the person with the obsession. A hand washer might think something like, “If I don’t wash my hands, somewhere a puppy will die.” I at one point was obsessed with the idea that I would walk into the kitchen and chop off my hand with a meat cleaver. It felt completely real to me, as sensible an anxiety as worrying about my dwindling bank account.
I’m hoping at this point you’re beginning to understand what was going on with me when I was clenching my skull, filled with images of killing myself, begging it to stop. I was experiencing a severe obsession. My brain had stuck on the thought “you are going to kill yourself” and was playing it over and over. But the more important, more confusing thing I need you to understand is that the obsession didn’t mean that I was going to kill myself or that I wanted to kill myself. It in fact meant the exact opposite. To loosely put it in terms of the hand-washing metaphor, instead of my brain saying, “I am dirty. I must wash my hands,” it was saying, “I must not wash my hands, or I will become dirty.”
In other words, I became obsessed with thoughts about killing myself not because I wanted to kill myself, but because I was so frightened of killing myself. This type of looping bad thought, an obsession without a compulsion, is an extremely common manifestation of OCD, and it’s what my psychiatrist immediately recognized when I first spoke to him. The example he gave me is of a new mother, holding her baby at home, who suddenly realizes how easily she could toss her child out the window. The thought horrifies her and sickens her. She knows she’d never hurt her baby. But the thought keeps coming back, and frightens her more and more. She starts to avoid holding the baby when no one else is around out of fear that she’ll act on the obsession. Then she becomes afraid to be alone with the baby at all. Eventually her anxiety about the obsession becomes so severe that she refuses to be around her baby, period. In my case, I was filling the roles of both the mother and the baby. I was terrified that I might hurt myself.
The key here is that people suffering from those types of bad thoughts will never act on them. We’re obsessed with the bad thoughts precisely because we don’t want them to happen, so we would never do anything to make them happen. But because of the nature of OCD and how real those thoughts seem, it’s incredibly difficult to convince ourselves that they’re not a reflection of reality. We honestly feel that we’re going to compulsively act on those thoughts, just as much as the guy honestly believed he had razor blades on his fingers. Convincing ourselves of the truth — that the thoughts are just nonsense, our brains churning a piece of crap over and over — is the secret to getting our OCD under control. But that’s very, very hard.
Okay so I’d been diagnosed with OCD. From there it got a lot harder before it got easier. It took me me three months of cognitive behavioral therapy and trial-and-error with multiple medications before I had things well under control.
Actually, that’s a little bit of a lie, the part about it getting harder before it got easier. Because in a very small sense, it immediately got easier. Within minutes of leaving the psychiatrist’s office, I was smiling and laughing. Because I wasn’t crazy. It had never occurred to me that I could have OCD, or anything so common that a doctor could recognize it right away and tell me that I was going to get better. And best of all, he didn’t think I was going to kill myself. I read the first couple of pages of the book he’d given me . It described exactly — exactly — what I experienced and talked about other people who’d gone through the same thing. It gave me an overwhelming sense of relief.
Of course, that didn’t last very long. Rationality was briefly overcoming my irrational anxiety. But just as quickly, my broken brain churned the irrational thoughts right up again, and they felt just as real as the first time. Not only that, but my anxiety was starting to adapt.
My obsession mutated from the simple fear that I was going to kill myself to the fear that the doctor had misdiagnosed me and that I was in fact suicidal and, thus, would kill myself. I didn’t read any more of the book, because I was scared that I’d find something to support that refined anxiety. As time went on, whenever I came close to getting a handle on a particular anxiety, it would evolve into something slightly new that I hadn’t developed a resistance to. Meta-anxiety was common — I’d have anxiety about having anxiety, which in turn somehow meant I was going to kill myself. I’d come up with multiple layers of meta-meta-anxiety so complex that I can’t even explain them to myself anymore.
And while I kept birthing those mutant anxieties, the old ones still stuck around. Plus all sorts of simple variations spun off from that original suicide fear, kind of daughter anxieties. A big one concerned kitchen knives, specifically the fear that I’d stab myself in the stomach with one. Fear that I would go into the bathroom and take a handful of Xanax. While riding in a car, fear that I’d open up the door and let myself flop out onto the highway. I mentioned the meat-cleaver thing yesterday. I think at one point I feared that I’d slit my wrists with the tiny safety razor in my pill cutter. I could go on.
Needless to say, all these things made me afraid to be alone. Sophie and I had of course by now canceled the rest of our around-the-world trip, and neither of us were working. We’d moved into a temporary furnished apartment in Pittsburgh. So we were home together all the time, and it was weeks before I was by myself other than when one of us were in the bathroom. Our landlady thought we were idle aristocrats. But I wasn’t idle at all. I spent all my time endlessly working over obsessions, frozen to the couch, afraid to go anywhere. I thought that if I went into the kitchen, I’d stab myself. And I couldn’t go into the bedroom, because I had to walk through the kitchen to get there.
I could write another four parts of this story just about my mental adventures over those three months, so to avoid that I’m going to focus on my treatment, to help you understand what’s involved. To start with, I’ll mention that research has shown over and over that most OCD patients experience better results with a combination of cognitive behavioral therapy (CBT) and medication than with either treatment alone. Luckily my doctor at the time is one of the (increasingly rare) psychiatrists that handles both.
I’ll get the medication part out of the way quickly, because it involves far fewer fun stories about me acting like a lunatic. A whole class of selective serotonin reuptake inhibitors (SSRI) are approved by the FDA as effective pharmaceutical treatments for OCD. SSRI are well known anti-depressant drugs like Paxil, Luvox, Prozac, etc. Often, as in my case, those are combined with an anti-anxiety benzodiazepine like Xanax or Klonopin. I was quite lucky in that finding my ideal medication cocktail required a minimum of experimentation. SSRI are notorious for behaving differently in every patient, but I only switched SSRI once (from Luvox to Paxil, because I was getting some palpitations from Luvox). I moved from as-needed Xanax to daily Klonopin. And from there it was just a matter of raising and lowering the dosage of each until we found the combination that worked the best. When I say “just,” it still took three months. But that’s a relatively short time. SSRI can take weeks to kick in, and dosage adjustment can’t even start until that happens. Some patients take many months to find the right medications in the right amounts to help them with a minimum of side effects.
The CBT for OCD is way more engaging. It’s surprisingly simple, but exceptionally difficult — sometimes so difficult that patients can’t bring themselves to get through it and end up suffering from their disease much more than they need to. And I’m not suggesting that I’m somehow better or stronger than other OCD sufferers for succeeding with my CBT. If anything, my success lies with the nature of my particular brand of OCD. But I’ve thought a little about why I was able to do some of the hard stuff when other patients fail, and I think it’s because I had three things going for me.
One is that I’m good at finishing work when it’s assigned to me. As a student I always did my homework, and when I have a job, if my boss asks me to do something, I try very hard to do it really well and on time. Partly that’s just because I don’t like letting people down or getting in trouble. So in a way I just saw CBT as homework: “This is your assignment. You have to get it done or Mr. Doctor will be unhappy.”
The second thing I had going for me is actually the opposite of the first. Except in situations like work and school where I voluntarily put myself in the position of being told what to do, I really, really hate being told what to do. I hate being coached. I hate unsolicited advice. I hate being told what to think to the point that I will argue against people making a point I agree with, if I feel like they’re being too bossy. And at some point in my treatment, which I’ll talk about later, I realized that OCD is nothing more than my broken brain trying to tell me what to do. I didn’t like that at all, and so I more or less said, “Fuck you, brain. You aren’t the boss of me. And I’m going to prove it.” I would’ve punched my brain in the nards, but I learned early in my therapy that brains don’t have nards.
Lastly, also hate-related, is that I’ve got a big hate on for not being good at things and an even bigger one for failing. I’m not competitive, but I get very angry and disappointed if I try to do something and don’t do it well. When I was having trouble getting started on the hardest step in the CBT process, my doctor, knowing I like video games, tried to frame it in that context. He said, “Think of it as a video game. Each time you let your anxiety get the upper hand, it gets a point. Eventually your OCD will win.” I thought, “This guy doesn’t know shit about video games.” But the idea stuck with me, and he was right to set it up as a contest. I started to see my OCD as my brain — which was already trying to tell me what to do like some kind of asshole — trying to set me up to flunk. It thought I wasn’t going to be very good at this CBT stuff and would probably fuck it up and lose. That was all I needed. From that point on CBT was a literal challenge, and if I didn’t finish it, I’d fail.
So the first technique the doctor gave me was an easy one intended to help me get enough of a grip on my anxiety to be able to progress through more difficult treatments. It’s a piece of cake and promotes rationality. Whenever I felt anxious, I’d get a notebook and write down a specific description of the fear. Underneath that I’d list any reasons why the fear might be rational. Then I’d list any reasons why the fear might be irrational. Obviously the evidence of irrationality outnumbered the evidence of rationality, sometimes by like 12 to zero. But the benefit of the exercise wasn’t in the numbers. The benefit came from the fact that the simple act of making the lists forced me to think about each anxiety head on. Just doing that pokes holes all through an irrational obsession and brings some calmness and rationality. Then later when the obsession returned and seemed totally and completely plausible, because it inevitably does with OCD, I could go back and read my notes for that fear and realize, “Nothing’s changed. This is the exact same garbage anxiety I had when I wrote this, and it’s just as irrational now as it was then.”
CBT wasn’t easy anymore after that. The next step was to quit the writing and, when I felt an anxiety, to just let myself feel it. I was supposed to acknowledge the anxiety, note that I was experiencing it, and just allow it to hang there while I went on with whatever else I was doing. Anyone who’s ever been anxious (which is everyone) can tell you that anxiety is not pleasant. The moment you start feeling it, you want it to stop. That’s compounded when you think that the very presence of your anxiety is going to compel you to jump in front of a bus. I didn’t enjoy it or understand the point of it. I wanted my anxieties to go away; I didn’t want to make friends with them. But eventually I found out that getting chummy with my anxiety was a baby step to emptying out a drawer and letting it move in with me.
That shacking-up step would be the core of my CBT and is proven to be the most effective behavioral therapy for anxiety disorders (and one that you should definitely not undertake without a doctor guiding you through it). It’s called exposure therapy. In the simplest terms, it’s intentionally exposing yourself to whatever causes you anxiety and making it cause you anxiety until it doesn’t cause you anxiety any more. Like lowering yourself into a freezing pool until the water stops feeling cold. An example of exposure therapy is taking someone who’s afraid of flying, and showing them footage of airplane crashes until they’re not scared anymore. It’s about as much fun as it sounds.
Exposure therapy seems crazy, but it’s effective because it calls irrational anxiety’s bluff. It takes advantage of anxiety’s secret that I told you about earlier — that it only exists in your mind and has no actual bearing on reality. Once you expose yourself to enough of whatever makes you anxious, your brain more or less tires of producing anxiety and just stops. It quits bluffing. And once your brain stops grinding out anxiety, the whole problem disappears, because there never was any problem other than anxiety.
For OCD sufferers with a clear obsession-compulsion chain, designing exposure therapy is pretty easy. You feel compelled to wash your hands? Too bad. You can’t wash your hands. Just sit here and feel the anxiety for five minutes. Then for ten minutes. Then twenty. Etc. etc. over days, weeks, months. But for OCD sufferers with intrusive thoughts, it’s harder to figure out how to set up treatment. If I’m afraid of killing myself, I’m already not killing myself. And actually killing myself would be counter-productive. So my doctor and I started with one of my simpler obsessions, which was causing me some anxiety but not nearly as much as my core obsession. I worked on the fear that I’d stab myself with a kitchen knife.
My first exposure therapy assignment was simply to spend thirty minutes a day using knives. It says something about the nature of OCD and the irrationality of obsessions that it took me a couple of days to find the right behavior to make me anxious. When I used knives as normal in cooking, I didn’t feel any anxiety, because I enjoy cooking, and I was thinking about the recipe and not about my obsession. I was very pleased with myself at how little anxiety I was feeling — look at me go! — until I realized that I was missing the whole point. I needed to face the anxiety, not find a way to avoid it. So I discovered that when I wasn’t cooking, if I just opened the drawer full of knives and stared at them, I’d get anxious. So that’s what I did for the first week. I stood in the kitchen, staring at knives for half an hour every day, feeling like I was going to barf.
You can understand why exposure therapy often knocks people off the treatment wagon. Exposure therapy requires you to position yourself directly in front of what frightens you and let it frighten you as much as it can. For the therapy to work, you have to let it frighten you a lot and for a long time. We all know what fear feels like — real, middle-of-the-night, “there’s an intruder in my house” fear. We don’t want to spend every night thinking there’s an intruder in the house. Imagine if you believed — if your broken brain made you really and truly believe — that if you didn’t wash your hands, your family would die. Then imagine that you had to sit on your hands and not wash them for as long as possible every day. Could you do it?
But the thing is, exposure therapy works. You can actually feel it working, both in the short term and the long term. For the first several of my knife sessions, I would very quickly peak at a high level of anxiety and stay there until I hit my preset time limit and ran out of the kitchen. But pretty quickly I started noticing the level of anxiety I felt during the sessions lessening. The anxiousness would start to wane before the end a session, earlier and earlier each time. Then the plateau of the worst anxiety would get progressively lower. Then both. You finally know you’ve gotten somewhere with exposure therapy when you desperately want a session to end not because you’re anxious, but because it’s so freaking boring. It becomes as dull as staring at a drawer full of knives if you have no fear of (nor interest in) knives.
Once I got a handle on the knife thing and knew I could do exposure therapy, we moved into getting at my core obsession. My exposure therapy became reading factual information about suicide, and then eventually reading accounts of actual suicides. Unlike fondling a knife I feared I might gut myself with, the reading didn’t involve any risk of physical danger, but yet it scared me much, much more. In fact, within seconds of just telling me what my assignment would be, my doctor saw me become physically anxious. At that point I was scared that reading about suicide would mean I’d discover that I was suicidal. Or worse, I thought it might compel me to kill myself.
But I wanted to get better, so I developed a routine of sitting at the computer in the bedroom, gathering up articles on the web and reading about suicide for thirty, then sixty, then ninety minutes a day. At first, the sessions caused me real terror. Mental and physical anxiety. Hyperventilating, sweating, nausea, all of it. I would stare at the clock in the corner of the screen begging for the time to run out much the way an Olympic weightlifter stares at the timer while holding a 500-pound barbell over his head. But just like with the knives, it became less and less frightening, and I progressed up through the subject matter, starting over from almost zero again when I switched to focusing on reading about actual suicides and suicide attempts. But the anxiety faded ever quicker until, after several weeks, the whole thing became a chore. The thought that I might kill myself — or want to kill myself, or want to want to kill myself — didn’t scare me anymore. And that, 12 weeks after I first started treatment, was when I was done.
The last thing I’ll say about exposure therapy is a tip for anyone who might have it prescribed. As scary as it seems at first, it gets easier. And the more you do it, the easier it gets and the faster it gets easier. That doesn’t seem like much of a tip, until you’ve actually done exposure therapy. But trust me — remember it. Say you’re training to become a lifeguard. The coach tells you to swim a lap of the pool underwater. Your first thought might be, “This is going to be hard. I don’t really want to do this.” And at first it’s really really hard, and you can’t do it. But then it quickly becomes easier, and you’re able to swim the lap. Then it rapidly becomes less and less challenging, and you do it regularly until finally you think, “Why the hell is he still making me do this over and over?”
Great. Duh. That’s obvious, and that’s why it’s not what I’m talking about. What I’m talking about comes after that, when the coach tells you to swim two laps underwater. Your initial thought is different, because now you know that you’ll eventually be able to do it. You think, “Ugh, this is going to be a total pain in the ass, but I have to do it, so I might as well get it over with.” That is what happens with exposure therapy. Once you start, it eventually stops being scary and starts being just a pain in the ass that you know you have to get through to get what you want. Exposure therapy by its nature always gets easier. And it works.
I was going to talk about one more aspect of my CBT, the most significant one. But it’s become such an important part of my everyday life that I’m going to save it for tomorrow and the conclusion of this story, when I talk about just that — my everyday life, before and after treatment.
The night of November 20, 1983, my fourth-grade teacher watched the TV movie The Day After, about life in a small town during and after a nuclear war. The next morning in class, for reasons I’ve never understood, he ranted in horrifying detail about what it would be like living through a hydrogen bomb blast and on the scorched earth that followed. I was nine years old. For the next several years — well into adolescence — I was consumed with anxiety about impending nuclear armageddon.
Thoughts of it filled my mind whenever it wasn’t otherwise occupied. Even sometimes when it was. I remember standing out on a baseball field during pee-wee practice and staring at the next hill over, imagining burnt sienna mushroom clouds exploding up from behind them. I once saw a construction crane in the distance and thought it was a missile, raised to the launch position. TV news special reports panicked me — eventually one of them was certain to report that the rockets were in the air, on their way, good night.
I’m not sure my parents even know about this. Like everyone with OCD, I became excellent at hiding my anxiety. I never talked about it to anyone that I remember. Much of the time while I was sitting quietly I was stewing over the likelihood of the world’s blowtorching or wondering how everyone managed to just go around living normally with a giant fissionable gun pointed at their heads. I covered up my anxiety so thoroughly and constantly that eventually it became second nature, and I wasn’t even aware that I was doing it. I was such an expert that my stepmother once told me that she’d “never seen me nervous.”
As I grew up and lived through the years of kindly Gorby and drunky Yeltsin, the threat of atomic destruction diminished, and that particular anxiety faded. In my later teen years and into college, I became a more well-rounded adult with actual friends and even a girlfriend. My life was changing enough to push my obsessions further into the background. But fears of war, natural disaster, and other apocalyptic events never went away completely — not even close — and in my twenties they got worse again. On a road trip with a friend, I made sure we zipped through Los Angeles as quickly as possible, so that we didn’t get nailed by an earthquake. After seeing Saving Private Ryan, I became obsessed first with the idea of having to live through a war, and then with being drafted and sent away to fight one. That obsession traded off with, and was eventually replaced by, one about impending terrorist attacks. That lasted almost as long as my nuclear fetish.
This was years before 9/11. It started somewhere around 1996 or 1997, I think, and I don’t know what triggered it. I was living in New York City at the time, and just like when I was a kid, my idle brain was flooded with the certainty of impending destruction. At times in a busy public place — or a quiet public place, or a busy private place, or any place that met my constantly shifting mental criteria — I’d be overcome with the anxiety that I had to leave, because the place was too easy of a target. Something terrible was about to happen. I asked Sophie to marry me just before Christmas in 1998. The next day we left for different airports to go visit our separate families. I sat on the bus to Newark, waiting for Al Qaeda’s hidden atomic bomb to destroy the city. The only question in my head was whether she and I would both be able to take off in time to escape the blast and see each other again.
Of course, almost no one knew about my obsessions. In fact, I was afraid of people finding out. It wasn’t until after September 11 that I started to open up a little, and then just to Sophie. We were still in New York and both experienced the attacks directly in ways that I’m not going to bother to go into right now. Surprisingly, during the strikes and their immediate aftermath, I didn’t lose my shit as completely as you might expect. The fantasies that up until then had been locked inside my head suddenly turned into reality, but reality is usually way less scary than anything an obsessive-compulsive can imagine. So while while all those terrible things were happening (and after I knew Sophie was safe) I felt like, “Hey, this isn’t nearly as bad as I thought.”
That calmness was gone by the next day, replaced by an obsession of what was coming next. There were days when I couldn’t bring myself to go down into the subway, or to get on the bus, or to leave the apartment, or to do whatever my brain said was unquestionably dangerous activity. As time went on, I developed a kind of checking compulsion around my obsession with the next attack. Whenever I heard something disquieting on the news — or heard a strange noise, or overheard something in a cell phone conversation (every one of which I’d come to assume involved someone calling to tell someone else about something terrible happening somewhere) — I’d start clicking through news on the Internet to see if I could figure out what was going on. I’d get caught in a loop for hours, jumping from one site to another and then back to one I’d checked several times already, in case it’d been updated.
Sophie and I moved out of New York in December of 2001. We’d been wanting to do it for years, to escape from a whirlpool of debt and general stress, so we weren’t just running scared. At least Sophie wasn’t. But the sudden decision to move, the quick choice of Pittsburgh as a destination, and the nearly immediate move were all, for me, a direct result of my obsession. I was scared, and I thought living somewhere other than New York would make us safer.
I concealed those facts just as well as I’d been concealing anxiety my whole life. But when that anxiety got mixed together with a dash of PTSD, eventually it got bad enough that Sophie knew something was wrong with me. And I had in my favor (or disfavor) the fact that at the time it was okay to be scared. Everyone in the country was scared, at least a little. Fuck, if you weren’t scared, you weren’t patriotic. So I eventually was able to bring myself to tell Sophie about my fears and let her know whenever I was feeling particularly anxious. We weren’t really doing the right things to treat it, because neither of us knew what was going on. But our life together was so good that I was able to be happy and trundle on. We even eventually moved back to New York. On rare especially good days I’d have no severe anxiety. On others anxiety would just take hold for a few minutes several times a day. But often it would consume me for hours. Days of anxiety with short breaks of relaxation. Anxiety was a permanent part of my life — one I took for granted as a typical inconvenience, like plaque buildup.
It should be obvious that everything I just described to you was my OCD before I knew that I had OCD. But I want to make clear two very important things about it. The first is how completely my obsessions had taken over my life without my knowing it. They had a hand in almost everything I did, from something as large as the city I lived in to something as small as rushing through a dog walk because I saw a plane overhead and needed to get home to check to see if it had crashed into anything. My career path veered off down the path of least resistance, largely due to decisions I made because of my anxieties. I’m only now, at the age of 37, switching it permanently over to the track that it should’ve been on all along.
The second fact I want to clarify is that I didn’t think anything was wrong with me. I’ve made this point before about people with OCD, but I’m making it again, because it’s critical. I knew everybody had anxiety. I just figured mine was a little worse. Some people ate too much; I worried too much. So what if I thought that that tornado in Kansas was a sign that the Yakuza were probably going to use their weather-control technology to detonate the supervolcano under Yellowstone? I just knew more about those things than other people, and I needed to worry about them because they weren’t. I thought the way my life worked was just the way life is.
I WAS WRONG. I put those three words in underlined, bold, italic all caps because they are the most important truth you need to understand if you suffer from severe, life-affecting anxiety. It is not normal. There is no need for you to be overwhelmed by fear. It is not something that everyone experiences. It is not a necessary part of life. Everyone who suffers from an anxiety disorder thinks they don’t. I told you about OCD being called the Doubting Disease, but doubt and denial come along with all irrational anxiety. And the key to freeing yourself from that anxiety is being aware that it exists.
That brings me to the crucial part of my own cognitive behavioral therapy, and the only aspect of it that I still do regularly. It’s mindful awareness — identifying when my obsessions are just obsessions, when my anxieties are irrational, when whatever’s worrying me is just effluent from my brain. The ability to recognize those things takes such huge gaping bites out of anxiety that I find it tremendously perplexing, and even a little unfair, that I didn’t know about it my whole life.
A couple of days ago I mentioned Jeffrey Schwartz’s Brain Lock. The meat of that book is a self-directed CBT for OCD based around mindful awareness. It’s a bit more complex than that and involves several specific — and sometimes difficult — steps, but Dr. Schwartz describes how simply being mindfully aware that your obsession is nothing but an obsession can not only make it disappear, but also can make you progressively less obsessive.
I worked through Schwartz’s CBT technique in conjunction with my other therapy, and I witnessed it pay off. I was finally able to teach myself the things I’d never been able to learn: I recognized that my anxiety has no bearing on reality, that obsessions are nothing but a self-created internal universe which is the be-all and end-all of itself and which has no reason to exist other than what you imbue it with. Best of all, I learned to identify obsessions, distinguish them from real thoughts, and throw them away.
I’m lucky enough now that on most days I don’t have any obsessive thoughts. When I do, I stop them from spiraling out of control by being mindfully aware of them and ripping off the masks disguising them as reality. I have a lot of techniques to do that, and I’m constantly inventing new ones. A few months ago, I was cleaning up for a housewarming party and trying to hide the mess of AV cables around my TV cabinet. I fiddled with them over and over and couldn’t get them right. I was sure that if the guests saw any visible wiring they’d be horrified and wouldn’t want to be my friend any more. Eventually, Sophie came to check on me because I was yelling, “Oh Jesus Christ, enough already!” I wasn’t frustrated with the cables. I’d suddenly realized I was obsessing, so I was yelling at my brain, berating it for pumping out bullshit. I made myself aware of what was happening, and I stopped worrying about the TV cabinet.
If you follow me on Twitter, sometimes you’ll see me tweeting things like “Bad OCD! Go lie down! Get in your crate!” That’s because I’m having a bad patch of obsession and anxiety, and I need to make myself aware of what’s going on and who’s in charge. Sometimes I’ll just tweet a description of the actual anxiety so that I can get it out of my head, look at it, and recognize it for what it is. That has the side effect of convincing people that they should by no means ever let me buy them lunch, but oh well. Lately when an obsession pops up I find myself laughing at it. Literally laughing out loud and thinking, “Ha! You expect me to believe that?”
Like I said, no one with OCD thinks they have a problem. That’s why mindful awareness is critical. So critical that right now while I’m talking about it is the only point in the many pages of this story that I’m going to ask you to do something for me. If you have a surfeit of anxiety or obsession of any type, just play along with me for a second.
Okay, first, just try to make yourself aware that the anxiety exists. Don’t worry about whether it’s irrational or legitimate or hormonal or anything else. Just be aware that you’re anxious. Simple. Now, make yourself aware that you don’t like being anxious. And face it, you don’t. Even if you feel like you need to be anxious — for yourself or on other people’s behalf — you can’t really say that you like it, can you?
All right, those two steps should’ve been easy. Now you’re aware that you have a lot of anxiety and that you don’t like it. But there’s one more thing to make yourself aware of, and this one might be harder. You might not even believe it, so just treat it like a fact that you read in a textbook: be aware that you can live your life without that anxiety.
If you need proof of that, I’m it. Until I got a hold of my OCD — OCD that I didn’t even know I had for almost thirty years — I didn’t know what life is supposed to be like. Not only didn’t I know it, I didn’t even know that I didn’t know it. Now I do. And my life is so much better, immeasurably so.
Yes, I still feel anxiety sometimes, and I still deal with obsession. OCD, like other mental illnesses, never goes away. It flares up regularly, like arthritis. But whenever it does, I’m aware of it, and I can get it back under control. Sometimes it takes days or weeks for me to gain that awareness, but I’m always able to do it. As a result — and with the help of medication — I live most days without anxiety. A lead blanket that had weighed down my life and blotted out the sun has been yanked away. I still get depressed, nervous, embarrassed, scared, but now it’s for the reasons that everyone does, and everyone should. But my life is so much better now. That’s the second time I’ve said that, and I’m going to say it once more to make sure you get it: my life is so much better now. A couple of times while writing this story I’ve teared up, and it’s happening again right now, because I remember how awful things were before. I can’t believe how bad I let them get. I never knew how wonderfully, purely good life is supposed to be.
So there you go. Three simple things. You’re aware of them now. And now that you’re aware of them, you’re ready to get help. Real life is waiting.