Mental health articles

Mr R was a 38-year-old gentleman referred to the Lancashire Clinical Psychology Services with a diagnosis of obsessional compulsive disorder. At the time of referral, he lived alone after the end of a long-term relationship. He lived in fl at, in which he was restricted to the use of three rooms as he felt unable to use other rooms which he considered to be contaminated. He held down a job as a teacher, but found it increasingly difficult to do so, as his obsessive-compulsive disorder was becoming increasingly difficult to hide and/or control. His fears related to what he considered to be symbols related to death or existential nothingness. These included a wide range of stimuli, including the numbers 6, 9, 7 (or any combination of these), blank walls (symbolizing ‘nothingness’), and people he associated with religions of various types. He attempted to avoid such stimuli by, for example, avoiding looking at car registration plates, not using supermarket aisles with the key numbers, avoiding purchases which included the key numbers, and avoiding looking at a particular white wall in the entrance to the school. If he encountered any of these stimuli, he engaged in brief safety behaviours, which were wide-ranging, and involved, for example, repetition of safe numbers, thinking of alternative ‘safe’ people, and so on.

Most safety behaviours were relatively brief and easy to engage in, although the high frequency with which they were elicited nevertheless made them extremely problematic. He could, for example, encounter a key number several times during any one lesson – and have to engage in brief safety behaviours on each occasion. Others were more disruptive – he delayed purchasing food or items he would want to keep for a long time to dates without key numbers, and would leave purchases unused if the bill total included a key number. If he noted a car registration number including a key number before making any purchase he would circle the shop three times in his car, before parking.

Mr R was an anxious child, and tended to be a worrier, although there was no particular focus to his worries. His mother, to whom he was very close, tended to be obsessive, worrying and fussing about a variety of things. He remained very close to his parents, eating most days with them and staying overnight in their house quite frequently. As an adult, he had left school and attended a local university. He established a number of friendships, although these were based around a pub and drinking culture. He enjoyed drinking, but restricted this to one or two days a week, and did not use it as a coping strategy to help him cope with his anxiety. He had had two long-term relationships, but both had eventually collapsed, partly due to his dissatisfaction with the relationship, partly because of his somewhat rigid lifestyle. Although not dominated by obsessive or compulsive behaviour, he nevertheless led an extremely ordered and rigid lifestyle.

His disappointment with these relationships led him to seek counselling. During this process, he was hypnotized and encouraged to read books exploring the existential meaning of life. During one period of hypnosis he reported being terrifi ed by an image of death and existential ‘nothingness’. He was unable, or unwilling, to provide any detail on this experience, but it was clearly terrifying and triggered his present problems. He developed a strong fear of death and ‘detachment from life’ or ‘existential nothingness’, and sought to avoid symbols or other factors associated with these thoughts. Key triggers to thoughts of death or nothingness included key numbers, religious icons and individuals, and certain books. The latter were easy to avoid; the fi rst two were more problematic.

The acute fear Mr R experienced while hypnotized triggered a strong conditioned fear to a wide variety of symbolic objects – all of which represented death, separation of the self from others, and existential ‘nothingness’. He experienced, in Wells’ terms, thought-event fusion, in that he feared that the experience of having a thought linked to death or existential nothingness implied that he would experience either death or its associated ‘nothingness’ while alive. His fear failed to habituate as he consistently engaged in safety behaviours in response to these thoughts, and never allowed himself to experience that his fears were unfounded.