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Here's Looking At You, Kid: People With OCD Who Notice Things Too Much
Written by Administrator   
Thursday, 14 April 2011 15:05

“Here’s Looking At You, Kid”: 

People With OCD Who Notice Things Too Much

By Fred Penzel, Ph.D.

Over the years, I have written a number of articles about some of the lesser-known forms of OCD, which often fall under the radar. Although they are not as well known as some other forms of the disorder, they do affect numbers of people, and I think it is helpful for them to read about them, in order to see that they are not alone, and to help them to get some direction in finding treatment. My other hope is that clinician’s learning to treat OCD will also become more aware that these problems really are OCD, or at least OCD related, and diagnose and treat them appropriately. The following case is representative of a number of cases I have treated over the years, and is not all that unique.

When Marie, a 35 year-old accountant first came to my office, she was in a pretty bad way. She looked every part a depressed and very anxious person. “It’s getting harder and harder to get myself to go to work,” she told me. “I’ll use any excuse to stay home, and my boss is beginning to notice. I feel as if I’m losing my mind. Maybe I’m psychotic.” I asked her what the difficulty was, and she then went on to relate her problem to me, prefacing her remarks with the statement, “I know you’ll probably think I’m crazy or some kind of sicko.” She said that she had been to a psychiatrist for a consultation, and that he had sent her to me, suspecting that this might, in some way, be related to OCD, although he wasn’t entirely certain.

“I’ve always had this weird problem, but lately it’s beginning to get worse.” What’s getting worse?” I asked. “It’s really embarrassing to say this, but I have this thing about staring at people,” she replied. “Why is that so bad?” I questioned. “As human beings, it’s quite normal for us to find other human beings interesting. Some people consider people-watching an art, and may spend hours at it.” “Well, it isn’t just that I stare at them,” she replied. “It’s the way I do it. I stare at women and men, and I don’t just look in their direction. I feel as if I have to stare at them sexually in very specific ways. What I mean is, that with women, I stare at their chests, and with men, I stare at their crotches. I feel as if I can’t stop myself, as if my eyes are just drawn to these places. Sometimes I think I’m doing it without even being aware of it. When I stare at the women, I wonder if I am really gay, or some kind of a pervert. Also, all this staring makes it hard to listen or talk to people at work, and it’s really beginning to affect my concentration. Sometimes I stare at the floor instead of looking at them. I think people are noticing that I do this, and are probably thinking that there’s something wrong with me.” As if this were not enough, Marie added that she also suffered from strong doubts about whether or not she was staring at someone at a particular time. In an attempt to eliminate this doubt, she would then stare at the person on purpose to check the way it felt so she could determine if she had been staring.

Marie went on to explain that about three years previously, she became aware that she was noticing other people’s bodies, and that this had gradually progressed to pointedly staring at them. She was convinced that this behavior had already cost her a good job, where she believed that one of her coworkers had become aware of her staring and had complained to a supervisor. Obviously, Marie felt the most relieved when she was home alone, with no one to look at. In addition to avoiding going to work, she was becoming increasingly avoidant of going out for social occasions as well. Even going out in public on errands was starting to seem a bit challenging. All of this added up to a great deal of anxiety on her part, not to mention feeling depressed about a behavior she couldn’t seem to control.

As we know, OCD can occur in a great variety of forms, and it occurred to me that this was another variant, as I explained to Marie. I had observed over the years that there is another related form of the disorder where people are seen to take excessive notice of particular objects, sounds, or people (or parts of people) in their environment, and cannot seem to stop looking at or listening to them. These were not your typical cases, but met the criteria for OCD nonetheless. In one case, a patient couldn’t stop noticing how people’s mouths moved when they spoke, and was continually looking at other people when they spoke. Another patient would tend to notice how close people were to him, or in what position they stood relative to him. He would also try to determine if they were smiling, and would stare at their faces. In a third instance, a patient who worked in an open office situation couldn’t stop listening to the sounds the copy machine made, to the point where he couldn’t get his work done. He had the same problem at home with his refrigerator. In all cases, sufferers felt ‘crazy’ and ‘abnormal’ for noticing things or looking at others excessively, and felt anxious about the fact that they couldn’t seem to control themselves. Those whose target was other people in public places also feared criticism and negative judgments from these others in case their behavior became noticeable (which it actually sometimes did).

In the case of OCD, it is not unusual for some people to become overly preoccupied with what are actually normal, everyday things, and to start noticing them to excess. What happens next is that they begin obsessing about these things, and almost have to look at or listen to them repeatedly so that they can double-check whether they actually are noticing them excessively or not. They ask themselves, “Did I just stare at that person?” Then, so as to not be in doubt, they do stare at the person to be able to compare it to what it felt like before, so they can tell whether they actually did stare or not. This may then lead to more doubt, and to getting caught in a seemingly endless loop. If this sounds confusing, imagine what it must be like for someone going through this all day long.

I suspect that many such people may not receive proper diagnoses of treatments as a result of their symptoms not fitting the usual stereotypes associated with OCD. Never mind their getting a misdiagnosis; many clinicians just don’t know what to make of these behaviors at all, and can’t even come up with a diagnosis. My patient, Marie, was, herself, surprised to find out that this is what her problem turned out to be. Like many others, she held the clichéd view of OCD sufferers as people who washed their hands excessively, or who had to arrange everything perfectly. At least her psychiatrist had a partial clue. Obviously, you cannot get a good treatment without a proper diagnosis. Treatment for these problems has to be more than simply giving someone a tranquilizer or antidepressant and sending them on their way.

With that said, it should also be clarified there are some forms of this behavior that may lean more toward the impulsive end of the spectrum; forms that are performed in response to a sudden urge and that are done without purpose and are tic-like. There are also some that have elements of both compulsions and tics. A colleague, Dr. Charles Mansueto, has referred to the forms that seem to have both compulsive and impulsive characteristics as Tourettic OCD (the subject of an article in a past newsletter). This is where sudden, impulsive acts that are more tic-like are performed in very particular (and sometimes ritualistic) ways to relieve the anxiety caused by obsessive, repetitive, doubtful thoughts. Tics can be sensory in nature, and can cause a lot of discomfort if not performed immediately. It strikes me that at least some of those people who suddenly find themselves having to stare, or listen to particular things may fall into this category. On factor that may reinforce this view is the possible antisocial and potentially sexual nature of some people’s staring. It is not unusual for some of those who tic, to feel that they have to sometime perform tics that involve socially unacceptable things, or things they know would somehow embarrass them. They do not consciously want to do these things, but feel as if their symptoms are directing them to impulsively act in these ways. All this can make diagnosis a challenge, due to this gray area that exists between tics and compulsions. The distinction between the two is not always clear cut. 

In Marie’s case, it was not too difficult to make a diagnosis. She denied the presence of urges or sudden impulses to stare or to feel that she had to do something on purpose that would embarrass her. Her symptoms seemed to be driven, instead, by doubt and feelings of anxiety. What we came to learn was that she wasn’t sure that she was really staring inappropriately, would get very anxious about the uncertainty, and used staring to compulsively relieve her anxiety.

In any case, once a diagnosis has been made, there are fewer problems in choosing the appropriate treatment. Treatment can go in at least two different directions. One would be the familiar Exposure and Response Prevention (E&RP), where sufferers are directed to gradually face their fears and uncertainties in situations that are more and more challenging, while at the same time, resisting urges to compulsively avoid or neutralize their fears. This then leads them to develop a tolerance for what they fear, and for the fears to gradually diminish. Along with this, there is a decreased need to then do compulsions. I like to tell patients, “The anxiety is not the problem – the compulsions are the problem.” When they stop doing compulsions, this causes them to stay in the presence of what they fear, which then leads to even more tolerance. If they cling to the idea that the anxiety is the problem, they will be more likely to keep resorting to doing to compulsions to eliminate it. This, as we know, never works. E&RP has a well-documented track record in terms of its effectiveness in treating the symptoms of OCD. Interestingly enough, it has also been used successfully to treat tics in some cases as well. In the case of tics, it helps sufferers to build up a tolerance to the discomfort they feel when a tic is not performed. It also aids them in accepting the idea that they can observe and experience their impulses without having to always act on them. Should another approach be needed, the time-tested approach of using the technique known as Habit Reversal Training (HRT) can also be used. This is where the patient is trained to self-monitor when, where, why and how they perform their tics. Once they have begun obtaining this information on a regular basis, they are then trained to relax, breathe, and center themselves. Together with these techniques, they are also taught to use a muscular response that it incompatible with the tic and that is performed instead of the tic.

In Marie’s case, we opted for E&RP, as her symptoms appeared to be in the OCD category. I had her gradually work up to deliberately staring at her coworkers in increasingly challenging ways, and not avoiding them as she had been doing. I obviously instructed her to not be so conspicuous about it that it would cause her to be discovered doing her assignments. The key was to do it discreetly, but to still do it. Actually, before working at this level, she started by staring at pictures of men and women in her home, and then moved on to staring at people on TV or in videos. Later, she graduated to deliberately staring at strangers in public places, and eventually, as mentioned earlier, at coworkers, though this time, in a more discreet manner. As she did all this directed staring, she also had to heighten her exposure by telling herself that she was abnormal, perverted, and might be caught and have to suffer the consequences at any time. She was also instructed to look up information on the internet about voyeurism (one of her fears was that she was a voyeur), and about the social and legal problems of people caught engaging in these types of activities. She also listened to a graduated series of audio recordings (several times per day), which exposed her to the thought that she was some kind of pervert, a possible sex offender, and a thoroughly crazy person. I made the recording for her, at first, and later, she learned to write and record her own scripts. Another assignment was to view sex offender registries online. Over a period of several months, she gradually became habituated to the thoughts and feelings associate with her staring. Her tolerance for the uncertainty about her own behavior greatly increased. Even if she did stare occasionally, she was able to stay with any anxious or doubtful feelings and get on with whatever she was doing.

It should be added that along with her therapy, she took an SSRI-type antidepressant that seemed to lower the level of her intrusive thoughts and her anxiety, as well as lifting her mood somewhat. The combination of therapy plus medication can frequently work better than either one alone. Had her symptoms been more tic-like, it is probable that she would have also been prescribed one of the medications commonly used to treat tic disorders.

As can be seen, OCD is a disorder of a thousand faces, only limited by the ability to imagine. A good treatment can only be the result of a good diagnosis. There are clearly many forms of the disorder that lie beyond the popular notions of what it is supposed to be. A good hunch on the part of a psychiatrist led to a good outcome, but things could have just as easily not turned out well. It makes a good case for educating professionals and the public, alike, so that no one is denied effective treatment simply for lack of information.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and O-C related problems, and is a founding member of the OCF Science Advisory Board. Dr. Penzel is the author of “Obsessive-Compulsive Disorders: A Complete Guide To Getting Well And Staying Well,” a self-help work covering OCD and other O-C spectrum disorders. Dr. Penzel is also a frequent contributor to OC Foundation’s newsletter.


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