Dr Robert London

When Thoughts Are Obsessive

Clinical Psychiatry News - Volume 32, Issue 8, Page 32 (August 2004)

The patient's obsessive  thought was horrifying: In it, she was being destroyed by a plague of locusts, much like the one that had attacked Egypt in biblical times. The thought had become so vivid over the years that living with it had become almost unbearable.

She was a successful physics professor at a West Coast university. Before earning a Ph.D., she had graduated from a Seven Sisters college. Over the years, she had raised two children and negotiated a divorce.

Finally, she decided that she needed professional help for this recurring, obsessive thought. She began psychotherapy twice weekly, gaining tremendous knowledge about herself. For example, she realized that, as a child, she had been far more organized than most of her counterparts. She also addressed the issues of shame, guilt, rage, and despair. Five years later, despite her valuable self-exploration, she still found little relief from terrifying and obsessive thoughts.

She did not consider medication at first because her clinician had suggested that that approach would mask the root problem.

At a friend's suggestion, though, the patient saw a psychiatrist, who assured her that mediations were safe and prescribed an antidepressant that targeted obsessive thoughts. The obsessive thoughts became less frequent, but their intensity remained. Furthermore, the medication had distressing anticholinergic side effects. She tried selective serotonin reuptake inhibitors (SSRIs) as soon as they were available, but they didn't prove any more successful than the original tricyclic had been.

Finally, the patient tried a “geographic cure.” Years ago, at times, people with adequate funds took cruises and vacations after traumatic events. This patient decided to take a sabbatical and come to New York, but she continued to experience the terrifying obsessive thoughts. At that point, she was referred to me.

As always, I took a thorough history. I then explained the type of treatment I had in mind. The time frame was to be three or four sessions lasting 90 minutes each. I planned to apply three concepts to treat the patient's obsessive thoughts.

First, I explained the P&P (possibility and probability) concept. There was certainly a possibility that the locusts could attack her (this generated some humor), but the probability of this happening was significantly slim. As a physicist, she easily related to that concept. That discussion lasted about 30 minutes.

Next, we discussed Newton's third law of motion: For every action, there is an equal and opposite reaction. When translated into her treatment strategy, this became “for every thought, there is an equal and opposite thought.”

She easily accepted that theory, and it helped to relieve the anxiety of her obsessive thoughts. Taken further, that concept evolved into thinking that for every thought there is a lesser thought—and possibly even no thought.

The no-thought concept helps the patient get long-term relief from the obsessive thought. This second cognitive step led to the concept of thought stopping. Thought stopping is a method in which the patient induces the thought that is so distressful and is then taught how to stop it. (It should be noted that a hierarchy of obsessive and distressful thoughts can be employed for many patients. In this case, however, the hierarchy was not used.) Guided imagery and flooding were used to induce the terrifying thought of the locust attack.

I asked the patient to imagine a large movie screen, onto which I encouraged her to project the scene she had so often envisioned. As she progressed into this stressful imagery, I made a loud noise by hitting my desk with a ruler and simultaneously shouted “Stop!” In that procedure, the image she was thinking or projecting was automatically interrupted, blocked, and stopped. We practiced several times. After six trials, I stopped using the ruler and just shouted “Stop!” It worked. As we proceeded through this technique, the patient began to take over the entire strategy and began to shout “Stop!”

Moving along, we reached a point at which the patient was able to subvocalize the word “stop” and get the same result as if an outside force had interrupted, blocked, and stopped the thought.

Her treatment was completed in three 90-minute visits. She was most pleased that she had control over those thoughts. There was no substitution of symptoms, as traditional thinking might have suggested. The patient did not experience a new problem replacing the newly resolved one. This theory has been developed over 100 years, but it is more anecdotal than scientific.

Her visits were taped and given to her as continual reinforcement of the techniques she had at her disposal. The movie-screen approach to projecting this obsessive thought was incorporated into the longer-term reinforcement she would continue on her own, and she was further instructed that she could change images from the obsessive thought to a pleasant scene to help reduce the anxiety that the thought produced.

When the patient returned to her home, she resumed her thriving and demanding academic career free of that terrifying obsessive thought. She did continue to take the SSRI under the care of the psychiatrist who had first prescribed it. The combination proved effective, not unlike a medication aimed at reducing cholesterol coupled with increasing exercise and improving diet.

These behavioral treatments are hard work. Often, we need to structure the treatment to the patient's thinking, career, and lifestyle, as I did in this case by using the laws of physics for the physics professor. We also can use traditional behavior-modification techniques that have been studied, researched, and proven effective over many decades.

If you have used effective strategies to treat obsessive thoughts, please feel free to write to me at cpnews@elsevier.com. I'll try to pass them along to my readers.

PII: S0270-6644(04)70112-5

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