Sunday, September 13, 2009

Gotta Be This or That

Without even realizing it, we are constantly making choices, from one second to the next. Yet for some, choosing is an agonizing process. Unlike the mandate in the title of the 40’s swing tune – gotta be this or that - some people cannot ever decide between this or that, and they and those around them suffer a good deal as a result.


At worst, such indecisiveness may be a sign of Obsessive Compulsive Disorder (OCD), a mental illness that runs in families. The classic symptoms, such as hoarding, fear of contamination, checking repeatedly, and ordering symmetrically, are considered pathological when the compulsive need to ritualistically perform these actions becomes overwhelming, depressing and disabling.

I’ve seen a number of people for psychotherapy who were never diagnosed with OCD, because their symptoms were not obvious.

For example, there’s the man who repeatedly stays in romantic relationships with women he won’t marry, because he fears he is making a mistake and should be with someone else. He fears the woman he is with will become controlling, demanding, overweight, and that he will lose too much money if she divorces him. He’s also turned down job offers because he felt he didn’t have enough information, only later to realize he had missed tremendous opportunities.

There’s the woman who puts intense pressure on herself to be extremely nice to others, for fear that she will say something cruel and unkind that will hurt them. As a result, she agonizes over any decision involving interpersonal transactions; and obsesses constantly over how she has been offended, or how or if she has offended others.

And there’s the woman who has to exhaustively research any choice about anything – from buying a toaster to moving out of an apartment with an abusive landlord - and as a result, feels unbearably backlogged because of all that she hasn’t been able to get done. When she isn’t utterly exhausted, she’s feverishly busy researching, and obsessing constantly about what and how much she is eating.

The common obsessive-compulsive theme for these people is the fear they have of doing the wrong thing, a fear of making choices which will have both morally and concretely disastrous consequences. They can never fully trust themselves or others, but are nevertheless always unconsciously debating: am I the bad one that cannot be trusted? or are you the bad one that should not be trusted? Is this world safe for me, or am I constantly in danger? No matter how they deliberate, they never get a satisfactory answer.

In therapy, it became clear that each of these people had difficult developmental experiences and certain family problems that seem to have triggered the OCD symptoms. But in each case there was also a history of anxiety disorder in previous family members – a good reason to consider medication.

Today, “SSRI” medications that regulate serotonin levels in the brain are successfully prescribed for OCD, resulting in the relaxing of obsessional rumination. But as with all mental health concerns, talking things out in psychotherapy is also important. For OCD sufferers, medication and psychotherapy can help uncover the underlying psychological structure of the problem, and can aid the development of hope and determination – both of which are needed to gain control of the symptoms.

Choices are often hard to make, but with OCD, choosing becomes a nightmare. If you or someone you know suffers from OCD, the best choice you can make is to consult a licensed mental health practitioner and get you or your loved one some professional help.

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