Step 1. Relabel
Step 2. REATTRIBUTE
Step 3. Refocus
Step 4. Revalue
Step 2: Reattribute answers the questions, “Why don’t these bothersome thoughts, urges, and behaviors go away?” “Why do they keep bothering me?” “What should I attribute them to?”
The answer is that they persist because they are symptoms of obsessive-compulsive disorder (OCD), a condition that has been scientifically demonstrated to be related to a biochemical imbalance in the brain that causes your brain to misfire. There is now strong scientific evidence that in OCD a part of your brain that works much like a gearshift in a car is not working properly. Therefore, your brain gets “stuck in gear.” As a result, it’s hard for you to shift behaviors. Your goal in the Reattribute step is to realize that the sticky thoughts and urges are due to your balky brain. (See Figure 1 on Introduction.)
At UCLA, we use self-directed behavior therapy to enhance the mind’s own power to actually change the chemistry in the brain. That’s what you accomplish when you get around those intrusive thoughts that get stuck in your brain and won’t go away. Our tools are the Four Steps—Relabel, Reattribute, Refocus, Revalue. In time, with persistence, they will enable you to tame that hyperactive unruly orbital cortex. No neurosurgery is needed. You can do it with your mind.
When I talk about self-directed behavior therapy, I mean an active response to OCD symptoms in which you recognize this intruder for what it is and you fight back, using the Four Steps to shift those sticky gears in your brain.
In Step 1: Relabel, you learned the importance of calling an obsession an obsession, a compulsion a compulsion. But Relabeling alone does not make those painful thoughts and urges go away. You wonder, “Why the hell does this thing keep bothering me?” It keeps bothering you because you have a glitch in your brain—the sticky automatic transmission that you learned about in the Introduction.
Now it’s time to bring into play Step 2: Reattribute. You have already identified your problem as OCD. In Reattribute, you learn to place a lot of the blame squarely on your brain: This is my brain sending me a false message. I have a medical condition in which my brain does not adequately filter my thoughts and experiences, and I react inappropriately to things that I know make no sense. But if I change the way I react to the false message, I can make my brain work better, which will improve the bad thoughts and feelings.
“IT’S NOT ME—IT’S MY BRAIN”
Because these thoughts and urges make your life unbearable, you must devise active, positive strategies for working around them. You need to adapt, to keep telling yourself, “It’s not me—it’s just my brain.”
I would never tell a person with Parkinson’s disease, “Stop that tremor! Don’t move until you stop that tremor.” That person cannot wish the shakes away, just as the person with OCD cannot wish away the false messages that the brain is bombarding him or her with. Both have a medical condition to which they must adjust. (It is interesting to note that both Parkinson’s disease and OCD are caused by disturbances in a brain structure called the striatum.) It’s futile and counterproductive for the person with Parkinson’s disease to decide, “Oh, I’m no damn good. I can’t move as fast as everybody else,” and it is equally counterproductive for a person with OCD to give in, to say, “This thing’s too monstrous, too powerful. I can’t fight it, so I’ll do as it tells me.”
Earlier, I introduced the concept of the Impartial Spectator, or mindful awareness. Using the Impartial Spectator, you can distance yourself from your OCD, create a gap or safety zone between your will—your wholly internal spirit—and your unwanted, intrusive urges. Rather than respond to urges in an unthinking, mechanical fashion, you present yourself with alternatives. Early in therapy, it’s good to think of some alternative behaviors to have ready when the pain of OCD seizes you. Any pleasant and constructive activities will do. Hobbies are especially good.
The Reattribute step intensifies the mindful-awareness process. Once you realize this thing is OCD, the next step is to gain a deep understanding of why it’s so bothersome and why it won’t go away. We now know beyond a reasonable doubt that it doesn’t go away because it’s due to a medical condition, a biochemical imbalance in the brain. By Reattributing the pain to this medical condition, you strengthen your certainty that it is not your will, not you, and that it won’t take over your spirit. You are still intact and able to make conscious, considered decisions in response to your pain.
FALSE ALARM!
A woman in my weekly OCD therapy group said it so well: “Behavior therapy breaks the lie of what the anxiety is saying.” In other words, the intensity and pervasiveness of these thoughts or urges is not a personal weakness or a psychological problem. It is simply a false alarm caused by a short circuit in the brain. Thinking of this analogy should help you understand the proper response to these urges: In the middle of the night, a car alarm goes off. It wakes you, and you become agitated and annoyed. But only a fool would lie in bed tossing and turning, trying to will that alarm to cease. It won’t. In all probability, it is responding to a short circuit that has caused a false message. So the sensible person tries to ignore the alarm, think about something else, and go back to sleep. When OCD sends a false message to your brain, you can’t make it go away, but you don’t have to act on it. First, you Relabel it; then you Reattribute it. You tell yourself, “I will not do this. I do not want to do this. It’s not me—it’s just OCD.”
In combating compulsions, we have had success using the fifteen-minute rule: When you are overtaken by the urge to perform a compulsion, you try to wait fifteen minutes. But this is not just passive waiting. It’s a waiting period during which you actively keep telling yourself, “These are not real thoughts. These are faulty messages from my brain.” If, within fifteen minutes, the urge begins to fade—and it frequently does—you begin to see that you have a sense of control over your OCD. You are no longer a passive victim.
It is pointless to sit and ruminate about how dreadful your life is going to be if you act on a fearsome, violent, obsessive thought. You are not going to do it. Why not? Because the real you doesn’t want to do it. Think of heavy smokers who have to quit for their health’s sake: They may never be free from the urge to smoke a cigarette, but they can stop smoking by changing their behavior in response to that urge to smoke. Over time, the urge to smoke fades.
Remember: OCD is not some hidden wish fulfillment. It is simply a broken machine. OCD may mimic the feeling of reality, but reality never mimics the feeling of OCD. This fact leads to a very important principle: If it feels like it might be OCD, it is OCD! If it were reality, it wouldn’t feel like it even might be OCD.
THIS IS WAR
The Relabel and Reattribute steps are often done together because they reinforce one another; that is, mindful awareness (the Impartial Spectator) and a cognitive understanding that this is a blip of misinformation coming from the brain are working together. These techniques are the foundation for building a powerful defense system against this enemy, OCD. You may want to think of it as creating a platform on which to stand to observe the ridiculous nature of OCD and from which to plot your counterattack. No matter how uncomfortable the feelings, when you stand on that platform, you’re in charge. Truth is on your side.
There was a time when Barbara, who obsessed about checking things and locking things (Remember Mr. Coffee?) would come home from work each day so stressed out from her obsessive thoughts—Had she hit someone while driving? Had she put a business contract in the wrong envelope? Had that letter she dropped in the mailbox really gone down?—that she would have to go right to bed. But she wouldn’t let herself go to sleep “because that brought the next day’s OCD on that much sooner. I would lie in bed like a convalescent and just decompress. My life was getting through the day and then recovering from it. And dreading the next day.”
Today, ten years after the onset of OCD and six years after starting self-directed behavior therapy, Barbara is able to say that her few remaining OCD rituals are “just a minor nuisance, like having to floss my teeth every day.”
After four years of suffering, she felt she was losing the fight. Several things had conspired to contribute to her sense of defeat. Once, while out of town for a weekend, she was overcome by the fear that she had failed to lock her apartment door although, of course, she had locked it. So Barbara called her landlady, told her the door was not locked, and asked her to lock it. Naturally, she didn’t say she wasn’t sure she had locked it—“I didn’t want her to think I was bizarre or unstable.” The inevitable happened. The landlady unlocked the door. When Barbara returned home to find the door unlocked, she realized, “I can’t even enlist people unwittingly to help me because I end up sabotaging myself.” For the first time, she felt truly defeated.
About that time, her mnemonic (memory) devices were losing their novelty. At first, Barbara could say, “Okay, I’m locking the door now. I’m wearing a blue shirt. It’s Tuesday.” Then when she got to work, she could tell herself, “Okay. Blue shirt. Tuesday. The door must be locked.” But that technique no longer worked. Her brain had begun to tell her, “Aha! Maybe you also wore a blue shirt on Monday.”
It was at this point that she succumbed one day to hiding the coffee machine and the iron in her book bag and taking them to work. She was mortified. “I had self-esteem problems connected with the OCD and what I was doing professionally [she was a perennial underachiever]. I didn’t also need for it to be found out that I had an iron in my purse.”
Once she learned that she had a biochemical disorder of the brain—and that she could help herself through therapy—she began to improve. Looking back, Barbara says, “Your brain can get into such bad things. You say, ‘Is the stove off? Is the stove off?’ And then you get to the point of saying, ‘Well, what’s off? When I turn the knob up to the off position, how do I know that’s really the off position?’”
When her OCD was at its worst, she couldn’t escape it even on vacation. She’d check other people’s stoves. If she didn’t, her brain was telling her, some terrible catastrophe was going to take place.
By using mindful awareness whenever she checks something, Barbara can now ignore her OCD urges, knowing she has turned off the stove or locked the door. She tells herself, “It is the disease that is making me feel uncertain. And while I feel the stove is not off, I have checked it mindfully and should now walk away.” Her OCD is no longer severely disruptive. It is, rather, “a presence in my life as real and insistent in its own way as a fussing infant.” She knows what to do when her toddler cries. She also knows what to do when her OCD kicks up a fuss.
Incidentally, Barbara became pregnant while in therapy and credits her pregnancy with accelerating her healing process. Stress, we know, exacerbates OCD symptoms. When Barbara became pregnant, her priorities changed. “I no longer cared so much about my job as I cared about remaining stress-free through the pregnancy. I just decided, ‘Well, if a letter goes out riddled with mistakes, who cares?’ I knew I wasn’t going back to that job. And then the OCD symptoms would be greatly lessened.” What’s more, her number of mistakes did not increase.
Anyone who has OCD will tell you that refusing to give in to urges or compulsions is hard to do. Painful is the word I hear most frequently.
Dottie, who performed all manner of bizarre rituals out of an unfounded fear that something terrible was going to happen to her son’s eyes, describes not giving in to doing the behaviors as “like losing an old friend. I always say OCD is like a friendly enemy. It’s something you want to get rid of, but it’s also like a part of you that you don’t want to give up.” It’s easier to take comfort in doing the ritual than to fight off the feeling. And sometimes we can use compulsions to avoid someone or something we don’t want to deal with. But, as we now know, that is a prescription for lifelong pain.
One person with OCD described so well what happens to those who don’t resist: “Bad habits make a groove in your brain.” And those horrible, intrusive thoughts get stuck right in that groove.
IT’S ALL IN YOUR HEAD
The human brain, which weighs about three pounds and is roughly the size of two fists pressed tightly together, is the most complex and fascinating of all our organs, with its network of about ten billion interconnected nerve cells, or neurons.
Our research on people with OCD at UCLA led us to find that, without question, OCD is a neuropsychiatric illness resulting from a malfunction in the circuitry of the brain. But first, let’s take a look inside a human brain and learn a little more about those parts with their mysterious-sounding names, about their functions, and what goes awry to allow OCD to intrude.
This miniglossary should be helpful. (The key structures are illustrated in Figure 2, opposite.)
• STRIATUM: The stratum is composed of two parts, the putamen and the caudate nucleus, which sit next to one another in the core of the brain, deep in the center. The putamen is the automatic transmission for that part of the brain that regulates motor or physical movement, and the caudate nucleus is the automatic transmission and filtering station for the front part of the brain that controls thought.
• ORBITAL CORTEX: The orbital cortex is the underside of the front of the brain, the “hot spot” in OCD. The brain’s “error-detection circuit,” it is located directly over the eye sockets. Here, thought and emotion combine. The orbital cortex can inform you that something is right or wrong, whether it is something to approach or avoid.
• CORTEX: The cortex is the outer surface of the brain. The frontal cortex is where the most advanced thinking and planning take place.
• BASAL GANGLIA: The basal ganglia is essentially the same as the striatum; the terms are almost interchangeable. The caudate nucleus, which enables us to shift gears from one behavior to another, is part of the basal ganglia.
Figure 2. Illustration showing the location of the key structures of the brain that play a part in OCD.
• CINGULATE GYRUS: The cingulate gyrus is at the center of the brain, the deepest part of the cortex. It’s wired into your gut and heart-control centers and is responsible for giving you the feeling that something terrible is going to happen if you don’t act on your compulsions to wash, check, whatever.
• THALAMUS: The thalamus is the central relay station for processing the body’s sensory information.
The book cover shows color photographs of the brain of Benjamin, a patient at UCLA, before and after cognitive-biobehavioral therapy for the treatment of OCD. (This PET scan image is also shown in Figure 3, on Chapter 2.) Benjamin and other subjects in our UCLA study were injected with a tiny amount of a glucoselike solution that was then trapped in their brains for several hours, enabling us to take pictures and to measure metabolic activity in various parts of the brain. Many people feel relaxed during the scan, perhaps because of the humming of the scanner. Before we inject them, we say, “In the next half hour or so, we’re going to be taking pictures of whatever your brain is doing. If you have obsessions now, that’s what we’re here to record, but whatever happens, happens.” It’s basically at rest, no challenge. Later, when we do the follow-up scan after therapy, we tell them that if obsessions or compulsions arise during the scan, they’re to do the Four Steps, just as they’ve been taught. We have found it extremely helpful to show patients these pictures as a graphic way of helping them understand “It’s not me—it’s my brain.” The knowledge of what’s causing their urges motivates them to work to change from pathological to healthful behavior and, in so doing, to actually change their brain chemistry.
These positron emission tomography (PET) scans clearly demonstrate that the orbital cortex, the underside of the front of the brain, is hypermetabolic, or overheated, in people with OCD (see Figure 1 on Introduction). The colors represent different rates of brain glucose metabolism, or energy use, with red as the hottest and blue as the coolest. One thing these PET scan pictures can tell us is that the more automatic a behavior, the less energy the cortex may require to perform it. For now, keep in mind one key finding: The caudate nucleus, deep in the core of the brain, which appears to be the source of the primary problem in those with OCD, “cools down” in response to drug therapy, to drug therapy in combination with behavior therapy, and to behavior therapy alone. This is particularly true on the right side of the brain. We can now say we have scientifically demonstrated that by changing your behavior, you can change your brain. If you change your behavioral responses to OCD’s false messages, you will change the brain circuits that cause OCD, which will lead to an improvement in your symptoms.
During the ten years of research that led to this truly ground-breaking finding, my colleagues and I at UCLA undertook a number of experiments that greatly enhanced our understanding of mind-brain interaction.
Dr. John Mazziotta, who heads the Brain Mapping Division of the UCLA Neuropsychiatric Institute, designed an experiment in which the subjects were required to learn to make simple finger-to-thumb rotational movements of the hand, movements that mimicked those used in handwriting. But, because they’d been instructed to make these movements precisely and in a given order, the subjects actually had to think about doing so. What happened—as expected—was that the part of the cortex that controls hand and finger movements became very metabolically activated. In other words, its energy use increased, and it heated up. Next, the subjects were asked to sign their names repeatedly. Now, you know if you’ve ever signed forty traveler’s checks that you don’t think about it a lot after the fourth or fifth check. What we learned was that when the motor task is extremely familiar, the striatum seems to take over. The cortex expends only marginal energy, but the energy use in the striatum increases noticeably. It’s that smooth, automatic transmission in the striatum at work again.
Think of concert pianists: When they first learn to play, they have to think about moving their fingers, which takes considerable energy in the finger-moving part of the cortex. But once they’ve achieved concert-hall status, they move their fingers automatically. Then, they think about the shades and tones of the music. The cortex doesn’t have to expend much energy thinking about moving fingers; the striatum does that. Thus, the advanced parts of the cortex are freed up to think about the fine points of the music. The experiment with our handwriting subjects gave us insights into this entire process.
When Dr. Mazziotta repeated the signature-signing experiment with a group of subjects with Huntington’s disease, a genetically inherited disease that manifests itself at midlife with the loss of motor control, the results were different. The area of the brain that normally is stimulated by doing an unfamiliar task that requires thinking was stimulated by doing the familiar signature-signing task. Through the degenerative effects of their disease, these subjects’ caudate nucleus and putamen had become mal-functional, and parts of them were dead or dying. The subjects had to use a lot of energy in the cortex to devise strategies to sign their names, since the automatic transmission and filter were broken. They told us it took thought and effort and was hard work. Before the onset of their disease, they could sign their names without giving it a thought. Now, they actually had to control their hands—physically and mentally. They had to use the cortex to take over a function the striatum would normally have been performing. In people with Huntington’s disease, the striatum ultimately disappears, for all intents and purposes, and the abnormal, foreign movements characteristic of their disease, such as writhing and twisting, increase.
Whereas in persons with Huntington’s disease the fact that the automatic transmission and filter are broken causes unwanted movements, in persons with OCD it causes unwanted thoughts and urges, called obsessive thoughts and compulsive urges. Just as the subjects with Huntington’s disease had to apply thought and effort to sign their names because the striatum’s automatic transmission and filtering system were broken, people with OCD have to apply thought and effort when doing behavior therapy to work around the intrusive OCD symptoms. With the automatic screening system of the striatum not working properly, effort must be made to change behaviors while the disturbing thoughts and urges are still there. (You’ll learn more about this process in the next chapter.) But there is one big difference: OCD is largely a fixable problem; at the present time, Huntington’s disease unfortunately is not, although active research is going on, and there is much hope for progress.
This experiment with people with Huntington’s disease taught us much about the brains of people with OCD. We know that when the striatum is working properly, it acts as a filter, “gating” the sensory information sent to it, which is its proper role in the behavioral loop in the brain. In all likelihood, what happens in OCD is that evolutionary old circuits of the cortex, like those for washing and checking, break through the gate, probably because of a problem in the caudate nucleus. When there is no efficient gating, the person can become overwhelmed by these intrusive urges and act on them in inappropriate ways. These actions are called behavioral perseverations, a fancy name for compulsions. Specifically, compulsions are behavioral perseverations that a person knows to be inappropriate and genuinely does not want to be doing: The thought comes in the gate, the gate gets stuck open, and the thought keeps coming in over and over again. People then persevere in washing their hands or checking the stove, even though it makes no sense to do so. These actions may bring them momentary relief, but then—boom—because the gate is stuck open, the urge to wash or check breaks through again and again. To make matters worse, in all probability the more compulsions they do, the more rigidly the gate gets stuck.
In the absence of a fully functioning striatum, the cortex must function in a way that requires conscious effort because unwanted thoughts and urges have a tendency to interfere. It is just this sort of conscious effort that is made in behavior therapy, when a person works to manage responses to intrusive urges.
We have good reason to think that the person with OCD can’t get rid of those intrusive thoughts and urges because the circuit from the orbital cortex, the brain’s “early-warning detection system,” is firing inappropriately. The culprit may well be the lack of proper filtering by the caudate nucleus. Evolution may play a large role in the origins of classic OCD symptoms. Think of the kinds of automatic behaviors that were hardwired into the brain circuitry of our ancestors. In all likelihood, these behaviors had to do with avoiding contamination and checking to make sure that they were safe—that the cave was neither dirty nor dangerous, for example.
STUCK IN GEAR
In behavior therapy, we try to get patients to understand what’s going on in their brains so they can use the cortex to help them stop inappropriate behaviors. Because their automatic transmission is broken, they must use the cortex to shift to another, more appropriate, task. I tell my patients, “You are cursed with a lousy manual transmission. In fact, even your manual doesn’t work great. It’s sticky. It’s hard to shift, but, with effort, you can shift those gears yourself.” It’s not easy. It’s hard work because the gearshift is stuck. But when they shift gears repeatedly, by consciously changing behaviors, they actually start to fix their transmission by changing the metabolism of the striatum. Using the cortex, they work around the glitch in the striatum. And the beauty of it is that this technique gets the transmission to slowly start working automatically once again. It becomes easier to shift gears and to change behaviors as you keep working at it. Recent research in the laboratory of my colleague Dr. Lew Baxter may indicate why this is so. He has recently investigated a pathway that sends messages to the basal ganglia from the part of the frontal cortex used for advanced thinking, like the thinking used in applying the Four Steps. This pathway seems to have the ability to help the transmission to shift gears more effectively.
With behavior therapy, there is also a change in the function of the cingulate gyrus, that part of the cortex that is responsible for the feeling that something catastrophic is going to happen if you don’t act on your compulsions. Before treatment, the cingulate gyrus is tightly locked to the orbital cortex, which is probably the reason why obsessive thoughts and urges are accompanied by such terrible feelings of dread. This is one of the major problems in Brain Lock. After the person follows the Four Steps, the orbital cortex and cingulate gyrus uncouple and start to work freely again, and the fear and dread markedly decrease.
Numerous neurological studies have found that when the basal ganglia or striatum is not working properly, automatic motor control is interrupted and the cortex must help out. Conscious thought is required to control shifts from one behavior to another. In a person with Parkinson’s disease, the broken automatic transmission in the striatum leads to motor rigidity and on-off problems. The gearshift is stuck, and the person must think about each little movement and step.
In Tourette’s syndrome, a disease that is genetically related to OCD, the person develops chronic multiple tics, or sudden movements and vocalizations that occur almost without warning. The problem—as we believe it to be with OCD—is that the striatum is not properly modulating the cortex. Furthermore, scientists know that people who have damage to their basal ganglia or to the front part of their brain will perform a behavior over and over, even when that behavior is no longer useful or, indeed, is detrimental to them. The person with OCD performs a ritual in response to an obsession, all the while knowing it makes no sense. As with these other conditions, we believe this is due to a malfunction in the modulation of the cortex by the automatic transmission and filtering systems of the basal ganglia or striatum.
Whereas one person in forty in the general population has OCD, OCD occurs in one out of five family members and relatives of those with Tourette’s syndrome and in one-half to three-fourths of those with Tourette’s syndrome themselves, lending credence to the theory of genetic association. Frequently, Tourette’s victims develop painful arthritis or tendonitis in their joints because of the intense jerking movements that motor tics cause. In essence, they get a strong intrusive urge to move and then perform tics to relieve themselves of the discomfort. Or they may get vocal tics, starting with an urge to do repetitive throat clearing, an urge that may later develop into yips, yelps, barks, or other animal sounds. Or they may start screaming obscenities or racial slurs involuntarily, causing them great stress. Stress makes the urges much worse, as it does in OCD. Preliminary data from our PET scans at UCLA indicate that the putamen, the part of the striatum that sits next to the caudate nucleus and modulates body movements, alters metabolic function in persons with Tourette’s syndrome. Many people with OCD also have motor tics, and a lot of people with Tourette’s syndrome get compulsive symptoms. What is common to both, we now believe, is that parts of the cortex—probably the motor cortex in tics and the orbital cortex in obsessions and compulsions—are not being properly modulated by the appropriate parts of the striatum (problems in the putamen are related to tics, and problems in the caudate nucleus are related to OCD symptoms). Thus, problems in two closely related brain structures that modulate and filter movement or thought seem to underlie two genetically related conditions that cause difficulty with intrusive movements (tics) in Tourette’s syndrome or thoughts (obsessions) in OCD.
THOSE PRAGMATIC PRIMATES
The front part of the brain is where sophisticated information processing and problem solving take place. Because of the nature of the brain structures that send signals to the underside of the front of the brain—the orbital cortex—it seems likely that problem solving that involves emotional issues may take place there. A study by E. T. Rolls, a behavioral physiologist at Oxford University in England, yielded some interesting data that may be relevant for understanding the brain’s role in symptoms common to persons with OCD.
Rolls wanted to find out what is really going on in the brain when repeated inappropriate behaviors, or behavioral perseverations, are occurring, so he had rhesus monkeys trained to do a simple visual task. For example, the monkeys learned that every time they saw a blue signal on a screen, they would be rewarded with black currant juice if they licked a little tube. Now, monkeys really like juice and will work hard to learn behaviors that promise this reward. So the monkeys learned fast: When the blue color appeared—bingo!—juice was in the tube. Thus, the monkeys worked along happily and efficiently, licking the tube at the proper time. Through electrodes that had been placed in the monkeys’ brains, Rolls was able to observe that once the monkeys understood that a certain color signaled that juice was coming, cells in their orbital cortex would fire as soon as that color appeared. So the orbital cortex clearly was able to “key in” on signals that meant “juice is coming.”
Rolls knew that just as monkeys love juice, they hate the taste of salt water. When he offered the monkeys a syringe filled with salt water, they made the connection—syringe/salt water—and soon the mere sight of the syringe caused other nearby cells in the orbital cortex to fire to help the monkeys back off and avoid the salt water. So, there are cells in the orbital cortex that fire when there’s something you want—and when there’s something you want to avoid. It’s pretty clear that the orbital cortex was involved in the monkeys’ learning quickly to recognize environmental stimuli and to signal the monkeys, “Hey, this is something you want. This is something you don’t want.”
Next, Rolls wanted to see what would happen when he tripped up the monkeys. Now the monkeys had to learn that it was the green signal, not the blue signal, that would get them the juice. On the first trial, when the monkeys licked the little tube for the blue signal and came up with salt water instead of juice, other cells in their orbital cortex fired much more intensely and with much longer bursts than the cells that had fired when things were going as they had come to expect.
It’s important to note that these cells in the monkeys’ brains that fired in long bursts did not respond to the taste of salt water outside the test situation. What they were responding to was the fact that the monkeys had made an error. In fact, the orbital cortex fired even when the monkeys received nothing at all at times when they expected juice. After another trial or two, the monkeys stopped licking the tube for the blue signal. They learned quickly that this signal was no longer getting the job done and that it was the green signal they wanted. And, as the monkeys consistently licked the little tube for the green signal, those orbital cortex cells that fired for the winning color started firing for the green signal instead of the blue signal. So what was happening, it seems, was that as the monkeys learned that they had been double-crossed and now had to change their behavior to get the juice they craved, the orbital cortex made a change to help them quickly recognize that green was now the winning signal. The orbital cortex is able to recognize both right answers and wrong answers. It is a genuine “error-detection system”—and it’s the wrong answers that make it fire in long, intense bursts.
Rolls speculated recently that these “error-detection” responses in the orbital cortex could be involved in emotional responses to situations that cause frustration. It seems reasonable that activity in the orbital cortex may be related to an internal sense that “something is wrong” and needs to be corrected by a certain behavior. The monkeys responded by changing their behavior. In OCD patients, this error-detection circuit may become chronically inappropriately activated—or inadequately inactivated—perhaps because of a malfunction in the filtering effects of the basal ganglia. The result could be persistent intrusive thoughts and sensations that something is amiss. The cingulate gyrus, interacting closely with both the orbital cortex and the caudate nucleus, could greatly amplify this internal, gut-level feeling of dread.
The monkey experiment helped us understand why people whose orbital cortex is damaged have problems with perseveration. If the error-detection system is broken, people have trouble recognizing mistakes and tend to repeat the same old habits over and over again. But Rolls’s experiment with the monkeys also helped us understand what’s going on with OCD. Remember, when the monkeys saw something they didn’t want, the orbital cortex fired, sending out a signal: “That’s no good—something’s wrong.” But what made the orbital frontal cortex fire really intensely was when the monkeys made an error because the blue signal was no longer associated with the juice. The orbital cortex firing intensely can give a strong feeling that “something is wrong.” If the error-detection system keeps firing over and over, it can cause a chronic intense feeling that “something is wrong” and lead a person to do desperately repetitive behaviors to try to make the feeling “get right.” What may cause this? We know that the error-detection system in the orbital cortex is strongly connected to the caudate nucleus, which modulates it and can turn it off by causing a shift of gears to another behavior. There is now excellent evidence from a variety of scientific studies that damage to the basal ganglia (of which the caudate nucleus is a part) can cause OCD, with its terrible feelings that “something is wrong,” feelings that don’t go away.
The end result of a caudate nucleus problem can be that the error-detection system gets stuck in the ON position, leading to a something-is-wrong feeling that will not go away. Our theory is that since the orbital cortex is modulated by the caudate nucleus, when the caudate nucleus modulation isn’t working right, the error-detection system in the orbital cortex becomes overactive, and the person has terrible thoughts and feelings that “something is wrong,” which lead to compulsive behaviors done in a desperate attempt to make the feelings go away. Unfortunately, these repetitive behaviors make the something-is-wrong feelings even more intense. The only way to break the vicious cycle is to change the behavior. As you’ll see, this may also be where medication can be helpful.
The important role of the orbital cortex in OCD’s terrible urges and compulsions is being documented more and more. In a recent study at Massachusetts General Hospital, PET scanning was used to measure blood-flow changes in persons with OCD. Researchers put each person in a scanner with a dirty glove or some other object that was sure to be very upsetting, and the person had to lie there with the dirty glove, fretting and worrying about contamination. What these researchers saw was a clear increase in orbital cortex activity, especially on the left side, when the patient’s OCD got worse.
This finding is of particular interest because we now have data indicating a relationship between a change in left orbital cortex metabolism and treatment response in OCD patients. In our experiment at UCLA, drug-free patients were given PET scans, undertook ten weeks of cognitive-behavioral therapy, and were then scanned again. Post-therapy, there was a highly significant correlation between decreased metabolic activity in the left orbital cortex and a lessening of OCD symptoms. The patients who showed the most improvement had the most clear-cut decrease in left orbital cortex metabolism. It was behavior therapy alone, without drugs—the same method I’m teaching you in this book—that caused the change.
UNLOCKING YOUR BRAIN
What we have also learned at UCLA is that people with OCD have what amounts to “Brain Lock” on the right side of the brain. When a person with OCD is symptomatic, the metabolic activity rate not only increases in the orbital cortex, but locks together with the activity in the caudate nucleus, the thalamus, and the cingulate gyrus. The activity in all these parts is locked together, so that changes in the orbital cortex are tightly linked to changes in activity in the other three. Behavior therapy is the key that unlocks them and allows them to work freely again. Do your therapy, unlock your brain. Add the “waterwings” (the medication), and the response rate soars to 80 percent.
We have shown that we can literally make a new brain groove. As people with OCD apply themselves to behavior therapy, abandoning the inappropriate perseverational behaviors and responding to OCD urges and thoughts with positive, nonpathological behaviors, we see changes in the orbital cortex and in the striatum. We see Brain Lock alleviated; the circuitry has shifted. The next step is to get that new circuitry to become more functional, more automatic. As the circuitry becomes automatic, the striatum shifts gears and runs the circuitry properly because that is what the striatum normally does. Change the behavior; create a new groove; get behavioral improvement; and, in time, you will change your brain and get relief from OCD symptoms.
We studied eighteen subjects and found that within ten weeks, twelve demonstrated significant clinical improvement. All were treated as outpatients. None took medication. There were three main findings.
- Those who did respond showed significant decreases in caudate nucleus metabolism that were present on both sides of the brain, but were more robust on the right side (as in Figure 3, opposite).
- Whereas before treatment there were significant correlations of brain activity among the orbital cortex, the caudate nucleus, the cingulate gyrus, and the thalamus on the right side—Brain Lock—these correlations decreased significantly, which means that the Brain Lock was alleviated.
- There was a strong correlation between the amount of metabolic change on the left side of the orbital cortex and percentage changes in patients’ scores on severity ratings of OCD symptoms. That is, the more the OCD improved, the more the orbital cortex tended to “cool down.”
These findings demonstrate conclusively that it is possible to make systematic changes in brain function with self-directed cognitive behavior therapy alone.
Figure 3. PET scan showing decreased energy use in the right caudate nucleus (which appears on the left side in a PET scan) in a person with OCD after successful treatment with the Four-Step Method. PRE shows the brain before and POST ten weeks after behavioral therapy with no medication. Note the decrease in “size,” which signifies decrease in energy use, in the right caudate (rCd) after doing the Four-Step Method. The drawings show where the caudate nucleus is located inside the head.
Copyright © 1996, American Medical Association, from Archives of General Psychiatry, February 1996, Volume 53, pages 109–113.
We have scientifically demonstrated that successful therapy, without drugs, can uncouple the “fixed-worry circuit” in the OCD brain so that the person can more easily stop doing those OCD behaviors. This knowledge has been a great motivator for people who are doing the hard work of behavior therapy to change their responses to OCD’s false messages.
OCD is the first psychiatric condition in which a successful psychotherapeutic intervention that actually changes brain function has been documented.
When people with OCD do compulsive behaviors in a vain effort to buy a little peace, they are really only exacerbating their Brain Lock. When they systematically change their behavioral responses to OCD thoughts and urges, there is a concurrent change in the value and meaning that they place on what they feel. Before treatment, the intrusive thought might have said, “Wash your hands or else!” and the patients would usually respond by repetitive washing. After treatment, their response to the same OCD thought may be, “Oh, yeah? Go to hell!” By changing behavior, they are making alterations in brain function that, over time, result in measurable biological changes and a decrease in the intensity of intrusive OCD symptoms. It is important for patients and therapists alike to focus on these truths to help keep them motivated when the going gets tough.
As I’ve said, medication certainly has a role for those who need it to help them through therapy by decreasing their urges. (OCD and medication are discussed in Chapter Nine.) Using medication in treating OCD is much like using waterwings to teach children to swim. With waterwings, children can float unafraid, which helps the process of learning to swim. Then, you slowly let the air out of the waterwings until they are ready to go it alone. We use medication to help decrease the anxiety level of patients by suppressing those intrusive urges, so they can do their therapy and change their brain chemistry. Just as the swim teacher slowly lets the air out of the waterwings, we slowly bring down the dosage of the medication. Our experience in treating many hundreds of patients has been that after doing the therapy, the vast majority can get along very well with little or no medication.
KEEPING THE FAITH
Many people wonder about the role of faith and prayer in the treatment of OCD. Certainly, almost every person who has OCD has at some time prayed for relief from the dreadful feeling their disease brings on. With deep humility, they may beg for any power, supernatural or otherwise, to grant them relief from the intense pain that obsessive thoughts and urges cause. What they need to pray for is not that the OCD symptoms will go away—they probably won’t—but that they will have the strength to fight off their OCD. There is an understandable tendency for people with OCD to become demoralized, even to begin to hate themselves because of feelings of guilt and inadequacy. One of the profound rewards of successful behavior therapy, especially from a spiritual perspective, is that people with OCD learn to forgive themselves for having these terrible thoughts because they realize the symptoms have nothing to do with their spirit or purity of mind and everything to do with a medical disease.
Using that knowledge to strengthen your will and bolster your confidence in the battle to “work around” these thoughts and urges is the critical point of mental intervention in OCD self-treatment. You need a tremendous sense of faith in your capacity to resist these urges, both to direct your mind away from the symptoms and to remove yourself physically from the site that triggers these symptoms—to leave the sink or walk away from the door. The acceptance that the painful obsessional thought is something that is beyond your capacity to remove—and that the thought is just OCD—enables you, the sufferer, to see yourself as a spiritual being who can resist this unwanted intruder. And always remember at least two principles. First, God helps those who help themselves. Second, you reap what you sow.
It is almost impossible to fight off an enemy as vicious as OCD if you are bogged down with feelings of self-hatred. A clear mind is required. Properly directed prayer can be very effective, but anything that helps you to develop the inner strength, faith, and confidence needed to reach that state of mindful awareness will further your progress along the road to recovery. The power of the Impartial Spectator can then guide your inner struggle to fight off the urge to do a compulsion or to sit, paralyzed, listening to some ridiculous obsessive thought.
Doing cognitive-biobehavioral self-treatment can truly be viewed as a form of spiritual self-purification. Remember, “It’s not how you feel but what you do that counts.” In self-directed therapy, you concentrate your effort and use your will to do the right thing, perform the wholesome action, and let go of your excessive concern with feelings and comfort level. In so doing, you perform God’s work in a very real and true sense while you perform a medical self-treatment technique that changes your brain chemistry, enhances your function, and greatly alleviates the symptoms of OCD.
Strengthening your capacity to exert your spirit and will in a wholesome and positive way has far-ranging benefits that are, in many ways, even more important than merely treating or even curing a medical disease.
FINDING ANSWERS—WITHOUT FREUD
Here are a few of our patients’ descriptions of their battles against OCD:
KYLE
Kyle, a mortgage company employee, had struggled for years with violent thoughts of shooting himself, jumping out a window, or mutilating himself. Sometimes he thought he should just kill himself and get it over with. He prayed, “If there’s a weapon around and I do it, please don’t send me to hell.” His obsessions were “like a movie running through my mind, over and over.” He described his OCD as “a monster.” But through behavior therapy, he has learned, “I can bargain with it. I can stall it.” Crossing a street, he no longer has to push the WALK button a certain number of times, afraid he will be struck dead. He says, “Okay, I’ll push it again next year,” and he walks.
DOMINGO
Domingo, whose grab bag of obsessions included the horrifying feeling that he had razor blades attached to the tips of his fingers, said, “Every day, OCD is here. Some days it comes in waves. Some days are livable, some are miserable. On the miserable ones, I tell myself, ‘You’re just having a bad day.’” Pasted to the mirror door of his bedroom closet is a color photo of an OCD brain, a PET scan—the same photo that’s on the jacket of this book. When things get rough, Domingo focuses on it. “I tell myself, ‘Okay, now that’s reality. That’s the reason that I feel like this.’” That gives him strength to cope and helps make his pain recede. “Once you know what you’re fighting,” he said, “it makes it easier.” Domingo is one of those whose brains we scanned. When he looks at his scan, he laughs and says, “It was pretty busy in there.”
ROBERTA
Roberta, who became fearful of driving because of unshakable thoughts that she had hit someone, first sought treatment with a Freudian therapist who suggested that there was something in her past that was causing her obsession. Looking into her past didn’t help her one bit. What did help her was behavior therapy. Once she understood that the problem was biochemical, she said, “I relaxed. I wasn’t as afraid. At first, it was like this thing had control of me. Now, while I can’t keep it from happening, I can tell myself, ‘This is a wrong message, and I feel I have control over it.’” Most days, she is able to drive wherever she wishes, no longer having to weigh her need or desire to go somewhere against her awful fears. “I just go on my merry way.”
BRIAN
Brian, the car salesman with the morbid fear of battery acid, also had experience with a Freudian therapist who diagnosed just about every mental aberration, but not OCD. One therapist tried to treat him with basic exposure therapy. Brian laughed as he recalled, “I walked into this guy’s office, and he had two cups of sulfuric acid on his desk. I said, ‘Adios, guy! I’m outta here!’ There was just no way I could do that.” Brian’s OCD fears and compulsions had become so overwhelming, he said, that “I just wanted to crawl right out of my skin, just crawl right out.” He told one doctor, “I don’t own a gun and it’s a damned good thing I don’t because I would blow my brains out.”
In self-directed behavior therapy, Brian began using the Four Steps. He shook his head as he described what he went through. “It’s work, I’ll tell you, it’s work. It’s a war.” The moment of truth came when, on a new job at a car dealership, he spotted six palettes of batteries right outside his office door, inches away. His first instinct was to order them moved. Then he told himself, “No, you’ve just gotta put your foot down, take a stand, and fight.” He left the batteries there, and the batteries were still there the day he left that job. Brian knew that if he didn’t hold his ground, if he didn’t Relabel and Reattribute his fear of battery acid, “I would just have to keep running away.” He was even able to joke that the batteries were still there, “and I haven’t been eaten yet.” He tries to practice the Four Steps religiously, always reminding himself, “This is OCD. This is nonsense.” Sometimes he backslides. But if he lets his OCD get the upper hand, he knows, “Everything will wind up being contaminated in my mind, from the phone to the microwave oven.”
ANNA
Anna, the philosophy student, had been diagnosed by a therapist who told her that her jealousy and doubts about her boyfriend were “just a Freudian obsession with your mother’s breasts.” Though Anna knew that this was “totally stupid,” she didn’t know she had OCD until she was diagnosed at UCLA. She and Guy are now happily married, but they came close to breaking up because of her relentless and senseless questioning of him: What had he eaten that day? Who had he dated as a teenager? What did she look like? Where did he take her? With absolutely no cause to do so, she interrogated Guy over and over about whether he looked at girlie magazines and whether he drank to excess. Although Anna understood that she clung to certain insecurities because of past relationships with men who had drug or drinking problems, it wasn’t until she learned that she had OCD that she began to understand her absurd actions.
In high school, Anna had become obsessed with Cheryl Tiegs after Anna’s first real boyfriend, who wasn’t very ardent in his affections, mentioned in passing that he thought Tiegs was good-looking. “This woman drove me mad,” Anna recalled. “It was making me physically ill.” Some time later, Anna learned that her boyfriend was homosexual, which explained why he wasn’t more amorous. But this knowledge only exacerbated Anna’s insecurities, and years later she would lie in bed with Guy and suddenly think, “What if my husband is gay?” Naturally, it was another of the questions with which she bombarded the poor man.
Each day, Anna would grill Guy about his activities, down to whether he had butter or margarine on his bread for lunch. If there were minute discrepancies in his answers, since he repeated them somewhat absentmindedly, Anna’s whole world would crumble “because there was one card in the house of cards that would fall down.” She couldn’t stop her questioning, even though she realized her behavior was “appallingly shrewish.”
Through our Four-Step self-directed therapy, Anna was gradually able to conquer her obsessions. She considered it a significant sign of recovery when a Victoria’s Secret catalog came in the mail and she was able to leave it lying around where Guy might see it. Now, if an obsession intrudes, she tells herself, “Okay, it’s not going to help me to dwell on this now. If it’s real, and there’s a real component, it’ll be clearer when the OCD is not intruding.” Of course, it never is real. This is another example of that crucial principle: If it feels like it might be OCD, it is OCD.
Anna sees “sort of a Zen aspect” to coming to a mindful awareness about OCD. “If you truly accept OCD, it’s a very profound acceptance and it really requires a certain mind control.” Anticipation helps her. She knows, “It’s not easy to remain unruffled when terror is shooting through my body.” But she has learned that “the body can do crazy things. It’s something that I have to live with, even though I really hate it. That’s my life. I’m now well acquainted with OCD’s tricks, and I don’t fall for them as I once did.”
When first told that she had a brain disorder, Anna reacted with mixed feelings. “Though it was hard to feel good about having such a brain defect, I felt enormously glad to find that the disease wasn’t me.” She could begin to rebuild her shattered self-esteem. Now happily married and a mother, she’s able to look back and say, “Though lack of character was not what got me into OCD, quite a bit of character and stamina, combined with a well-considered approach (the Four Steps) would be absolutely essential to get me out of it.”
JILL
Jill, a real estate agent in her mid-40s, has been battling a contamination obsession for twenty-five years. It started when, as a bride of 18, she went to the funeral of her husband’s best friend, who’d been killed in a car accident. Looking at the body in its open casket, she was suddenly seized by the feeling that things she came in contact with were contaminated. She would clean her house over and over, in a way that made no sense. Dirty dishes could be piled in the sink, but Jill would ignore them while relentlessly scrubbing the walls, floors, and ceiling—which were perfectly clean—with Lysol or rubbing alcohol. Sometimes, she remembers, “My lungs would hurt from inhaling the fumes.”
Jill could never explain how, or why, an object might become “contaminated.” And she knew it was crazy to spend her days scrubbing. “You’re sitting there thinking, ‘Hey, other people are out there enjoying themselves and doing things, and you’re in here cleaning this imaginary contamination!’” Still, she couldn’t stop. It was easier to clean and thus force those awful feelings from her mind for a little while.
For an entire year, she left her house only to buy groceries, and even then she could go to only one store, which she had decided was still “clean.” Her obsession started with one store being contaminated, or one neighborhood. “It grew to where I’d contaminated whole towns and states and I had to leave, I had to move. We moved an awful lot because of my sickness.” In some way she can’t explain, “I contaminated my parents, my sister, and my brothers and couldn’t see them for sixteen years.” If one of them chanced to call her, the telephone would then be contaminated, and she would have to “alcohol” her whole apartment (Jill uses that word as a verb). She’d even have to wash the cat and take the vacuum cleaner apart, pole by pole, and pour alcohol into it. If it was Christmastime, she’d have to take all the ornaments from the tree and submerge them in big pans of alcohol. She might feel an imaginary blob crawling up her arm from the hand in which she’d held the telephone and would have to shower five times to get rid of it. About the same time, Jill began to associate any official document with contamination, a throwback, she figures, to the stress of her divorce many years earlier. If she got a traffic ticket, for example, she would have to come home and “alcohol” the house and shower. She couldn’t bear to touch the registration certificate in her car or visit a government building.
Jill and her two teenage daughters were living in North Carolina at the time, but her OCD was getting worse and the rainy weather further depressed her, so she decided to drive to Florida, to see if she could find a noncontaminated place to live. She’d left the girls with friends temporarily and, anxious to make sure they were all right, she stopped regularly along the way south to telephone them. Because she had discovered that the girls had lied to her about places they had been and things they had done—to avoid the silly rituals they’d have been required to perform if they had told the truth—they had now become “contaminated,” so this was tricky. Jill always chose to make those phone calls from big hotels that she knew would have health clubs. She developed a routine for avoiding “contamination” when calling her daughters: She’d head for the health club, put her clothes in a locker, wrap herself in a clean towel, and go to a pay phone in the lobby. She laughs, “A lot of businessmen would come by and stare at me. I was hoping nobody would notice that I didn’t have a bathing suit under that towel.” After talking to her girls, she’d wash the phone with soap and water, take at least four showers, wash her hair, and dress. In this way, she avoided contaminating her clothing and herself and would not be forced to toss out all the possessions piled in her car.
Jill still has urges to shower excessively, but for the most part she has overcome her contamination fears and the fears about death associated with them. The first hurdle in behavior therapy was “just accepting OCD, not making myself feel bad that I have it.” Occasionally, she gives in to an intense urge to wash or clean. That’s when her anxiety level is so high that she reasons, “Sure, I might be OCD-free if I don’t do the compulsion, but I might have a heart attack if I keep putting myself through all this stress. So now I try to be a little bit easy on myself and, if I feel really good, I’ll tackle something a little harder. If I’m not feeling really good, I’ll try to do a little something, anything.”
If she lets her OCD have its way, she has learned, “It’s kind of like you give it more credibility. It becomes a habit, and you keep on doing it and it becomes worse and worse.” Her compromise might be one shower instead of five. “Just take those little baby steps,” she advises—with the Four Steps as the helping hand.
“So much in my life has changed by just being able to Relabel this thing,” Jill says. “If you give in to it, it snowballs. It starts out with one person contaminated, then ten people, then ten stores, then the whole state.” Often, for Jill, Relabeling is enough. She takes a deep breath, relaxes, and the intrusive urge goes away. “If you face it right away, Relabel it as OCD right away, it’s not going to get to the point where it’s going to take hours of your day to deal with it.”
Before she started self-directed therapy, Jill was on medication. But, she says, “medication was just like a cold tablet. It helped take the edge off, but it didn’t really make it better,” as behavior therapy has. “If I’d known the Four-Step technique years ago, I would have saved myself a lot of aggravation, a lot of time, and a lot of heartache.”
KEY POINTS TO REMEMBER
• Step 2 is the Reattribute step.
• Reattribute means answering the questions “Why do these thoughts and urges keep bothering me? Why don’t they go away?” The answer is, because of a medical condition called OCD.
• OCD is related to a biochemical imbalance in the brain that results in a malfunction of the brain’s gearshift: The brain gets “stuck in gear.”
• Because the brain is stuck in gear, its “error-detection circuit” keeps firing inappropriately. This causes very uncomfortable feelings.
• Changing your behavioral responses to the uncomfortable feelings and shifting to useful and constructive behaviors will, over time, make the broken gearshift come unstuck.
• As the brain starts to shift gears properly, the uncomfortable feelings begin to fade and become easier to control.