COPING WITH TERRORISM -
HELP FOR PERSONS WITH OCD AND ANXIETY DISORDERS

The September 11, 2001 attacks upon the World Trade Center and the Pentagon has had an unprecedented effect upon many aspect of our daily lives. The , horrifying, almost surreal nature of the attack itself, the profoundly tragic loss of life, the massive destruction, has effected all of us in ways both subtle and profound. We are struck by feelings of outrage and despair for the cruel and senseless destruction of innocent life, followed by feelings of grief and anger and toward the perpetrators of such a despicable act on our own soil. Questions surge through our minds - how could this have happened? Who are the people who did this and why? Will they do it again? How do I protect myself and my loved ones? Can I ever be safe?

For people suffering from an anxiety disorder, including OCD, or a mood disorder such as depression, the effects can be particularly disturbing, in some cases compounding already limiting and distressing symptoms. Let's take a look at how and why, from a psychological perspective, the horrifying events of September 11^th may have a particular impact upon persons with OCD, or an anxiety disorder in general.

OCD is an neurobiologically based anxiety disorder that has the following characteristics:    

• Pervasive thoughts, feelings or impulses, "obsessions" that provoke discomfort, fear or dread, especially regarding the possibility of harm, danger or threat to oneself or others.
  
• The repetitive performance of rituals and behaviors, called "compulsions," typically hand washing and/or checking things over and over, or constant requests for reassurance. Often, there is a magical or highly idiosyncratic relationship between the compulsions performed, and the disasters they are intended to prevent or control. The person with OCD feels driven to perform these behaviors "just right" in order to contain or neutralize the anxiety of an obsessive thought or idea.
  
• Overestimation of the risk of threat, harm and danger along with persistent feelings of doubt and uncertainty regarding the safety of oneself or others.

 While not the defining symptoms of OCD, the following styles of thinking and examples of each characterize most people with OCD and anxiety disorders in general:

Insistence upon perfect control - "I must exercise nothing less than complete and perfect control over everything in life, especially that which can potentially cause harm or danger to me or those I love."

All or nothing thinking, also called black - white thinking. "If I'm not perfectly and totally safe (from potential harm), then I'm in utter danger and completely vulnerable to harm."

Intolerance of uncertainty - "Life and it’s possible adversities must be perfectly predictable and controllable at all times."

Intolerance of risk. "Risk involves the possibility of pain, danger and discomfort, therefore, therefore I must avoid it at all costs."

Hyper-responsibility. "I’m responsible for protecting others from every conceivable possibility of harm, danger or discomfort, or else I will be punished or suffer harshly for it."

Negative prediction bias or automatic anticipation of negative events. "Everything I fear may possibly happen, is certain to happen. Therefore I must remain constantly vigilant to bad things happening to me and others, and worrying all the time about it. I can NEVER relax."

It is not difficult to see how the present conditions of fear, uncertainty, and vigilance in the face of our nation’s international war on terrorism can wreak havoc on individuals who, in a sense, already live every day of their lives as if they were in a "war zone." The heightened state of fear, uneasiness and vigilance existing in our country today IS, not unlike the everyday experience of persons with OCD and anxiety disorders! However, while the "enemies" of persons with anxiety disorders are based upon distorted perceptions of risk, harm and danger, our nation now has a REAL enemy and REAL threats to face, pursue and destroy.

Perhaps most deeply effected by the events of September 11th is our sense of security and safety in our own home. 200 years of freedom from attack had fed a false sense of invulnerability and security in a dangerous world. It’s easy to see how, in a nation suddenly placed under a state of heightened alertness, that OC’s, like everyone else, feel increasingly anxious. Persons with OCD, and anxiety disorders in general, tend to absorb the anxieties around them, like a sponge absorbs water. Fear is contagious, and if anyone is going to "catch" the fear bug to an extreme, OC’s certainly will.

The fact that our present enemy is not a specific entity, but rather a world-wide network of hidden terrorist "cells," some inhabiting our own cities, is particularly unnerving. Hidden dangers and threats lurking around in modern day life are often the focus of the obsessive fears of OCD because they raise the specter of a threat that can’t be controlled or easily contained. Having but a vague sense of who the enemy is, where it resides, and what weapons of terror it intends to use, fuel the fear in all of us, and may compound already distressing OCD symptoms.

The fear of danger from dirt, germs, and disease, particularly the AIDS virus has been a focus of many with OCD. Today, with our nation facing the threat of bioterrorism, our electronic and print media are filled with daily reports of mail-in infestations and infections from diseases such as anthrax, botulism and smallpox. For many, these newly publicized threats are likely to take the place of AIDS in the repertoire of the OC’s fears and worries.

Living life as if the unlikely threat of harm or danger is likely to occur is a hallmark of OCD and other anxiety disorders. In light of the previously unthinkable, unlikely events of the Pentagon being attacked, and having two of the world’s tallest buildings fall, some patients may mistakenly use these unlikely events as "proof" to themselves that their OCD compulsions and rituals used to prevent highly unlikely, unthinkable events are now justified. Symptoms may become even more entrenched by use of the following false reasoning: "see...look what happened on September 11^th! Now I’d better redouble my compulsive checking or washing, no matter how destructive and harmful these behaviors are!"

Other persons with OCD may attach highly idiosyncratic, anxiety inducing meanings to the September 11^th attacks. For example, a patient with scrupulous or religious OCD may view the attacks as a "sign" of God’s retribution for the "sins" of not having prayed adequately, or having thought the "right" thoughts, or doing everything "just right." Some OC’s, with magical compulsions intended to ward off danger and disaster, may view the September 11^th events as a "sign" of punishment for not, for example, placing the towels in the closet "perfectly."

A defining aspect of OCD is the presence of "insight." This is the awareness, on some level, at some time, that the imagined fears and worries are groundless, senseless, even silly. Patients who are doing well with their OCD, or even fully recovered, are able to access this "insight" more readily, even easily. However, during times of stress and uncertainty, the OCDer’s degree of insight into his OCD may become more tenuous, vague, even non-existent. In such uncertain times as these, the reactive OCD mind resorts with increased intensity to the reflexive, automatic use of compulsions and rituals to manage the increased fear and anxiety. Compulsions may become more ingrained, time-consuming, and frustrating. For example, a washer may find that previously effective two minute handwash just doesn’t produce that feeling of "safety" anymore. The door lock checker finds his/her brain stifled after three checks, craving more and more "certainty" that everything is OK, hence stuck in a longer and longer checking cycle.

For some of us, the terrorist attacks have placed our prior, pre- September 11th worries, fears and concerns in proper, more livable perspective. Suddenly, our petty angers, upsets and complaints toward our boss, or in-laws seems so trivial in light of the misfortunes suffered by so many of our fellow citizens. Many persons with OCD report having these very same feelings. Ironically however, I have also encountered some OC’s who appear (by their own admission) blindly, almost blissfully detached from the dangerous events of the world around them, so caught up are they in their own obsessive preoccupations. For these patients, there is little time or energy to focus upon the international threat of terrorism and existing state of war, when there are doors, stoves and locks to check and recheck, and children, pets and parents to protect from harm and danger! OCD, at its worst, is a disease of all consuming self-preoccupation!

Certainly, in light of the events of September 11^th many OC’s have found the present state of war mentally and emotionally taxing, and as a result, find themselves struggling with an increase not only in their OCD symptoms, but in symptoms of disorders that frequently accompany OCD as well, including depression, panic disorder, post traumatic stress disorder. It’s as if the available emotional resources for coping with life plus their anxiety disorder have become seriously depleted. Symptoms of lowered energy level, disrupted sleep patterns, changes in appetite, feelings of helplessness and hopelessness, poor concentration and loss of interest in previously enjoyed activities are all classic symptoms of depression and should be taken seriously. Persons with accompanying anxiety disorders, such as panic disorder, phobias and post-traumatic stress disorder, may find themselves suffering an increase in nightmares, flashbacks to previous traumas, moodiness, agitation and irritability, social withdrawal, and physical (somatic) complaints.

The following are some suggestions for managing one’s anxiety disorder in light of the present uncertain and fearful times we are living in:

• Recognize that an increase in symptoms since the Sept. 11^th attacks is normal and expected. Do not be alarmed that your symptoms have worsened, even in spite of all your efforts to prevent it. In time, your symptoms should stabilize back to their pre-September 11^th levels. It is a good idea to have a "check in" session with a mental health professional familiar with OCD and anxiety disorders. The support of your therapist can be reassuring and fortifying in the face of the worries we are all confronting. If further intensive treatment is needed to stabilize the condition, pursue it according to your therapist’s recommendations. Perhaps a medication adjustment is needed, or perhaps a review of CBT principles to prevent any further flare-ups of your OCD symptoms
  
• Maintain daily routines and schedules. Routines provide a sense of "normalcy," comfort and stability. They are helpful in diverting you from focusing upon your obsessive thoughts and worries.
• In times of uncertainty, take control of what you can reasonably control. You can’t be in complete control of the dangers we face, nor can you control the world situation day to day. Accept it. But you can control that which is in your immediate power to control. Tending to your responsibilities effectively, eg., your job, your family can give you a sense of control.
  
• Gain control by thinking, not just reacting. Hundreds of people, upon learning of the threat of bioterrorism, are purchasing gas masks and hoarding antibiotics, having no idea how, or exactly in what situations they should or can be used safely. Similar actions are of psychological benefit, but provide no real benefit, are wasteful and potentially dangerous. According to experts, more productive is to get a flu shot, set up a safe room in your home, have an two week emergency survival pack (as if you are preparing for a hurricane or earthquake).
  
• Join or start an OCD or anxiety disorders support group. This can be very valuable. Making connections to persons with similar problems is very comforting and strengthens coping capacities. Contact the Obsessive-Compulsive Foundation regarding how to start an OCD support group.
  
• Give yourself permission to grieve, cry and release the tensions that have been built up over the past several weeks. Often sharing your honest, true feelings with others makes a difference.
  
• Take a TV News Break. We’ve all been glued to our TV sets to await the latest news on the war. But every now and then, come up for air, turn off the TV news, and do things you normally enjoy.
  
• Find something positive you can do. Give blood. Donate money to help victims of the attack. Join efforts in your community to respond to this tragedy.
  
• Manage fear by avoid focusing upon "what’s possible", in favor of focusing upon "what’s probable." Thinking about the present dangers in terms of "what’s possible" only feeds fears unnecessarily. From this perspective, ANY conceivable disaster, from nuclear bombs, smallpox infections, even a terrorist climbing into our bed at night, are "possible" (yes, here in Florida, where some terrorists lived, some people DO think this way). In fact, the anxious mind is so creative, we can easily scare ourselves to death! Instead, keep focused upon "what’s likely", what’s most possible, plausible, feasible. Battle your fears with good, solid information regarding the true risks and dangers we face. Few of these threats, including bioterrorism, while scary, are actually likely to effect any single one of us.
  
• Keep your sense of the risks in proper perspective. Remember, despite all the mass hysteria regarding bioterrorism and the Anthrax scare, keep in mind that the post office delivers over 30,000,000 pieces of mail per day, and to date, seven people have been infected, and four have died! While the loss of life is deplorable, the actual risk of physical harm while driving your car to the shopping mall is much, much higher than the risk getting Anthrax from tainted mail. As for flying, at any one time, there are over 5000 airplanes in the sky, and 23,000 flights per day. The chances of dying in an airplane mishap remains astronomically low, and security efforts are at an all-time high.
  
• Seek professional help if you find yourself unable to cope and are experiencing symptoms of depression or a worsening of you OCD symptoms. Perhaps a few supportive therapy sessions, or a medication adjustment could make a difference in the way you feel.

Most of all, realize that uncertainty and danger is the state of mind that people in many countries live with day to day. We, in the USA are not accustomed, as a nation, to the challenge of carrying on with "grace under pressure" (Hemingway). It will take time for us all to adjust to the new realities of life. As such, the opportunity exists to eventually "habituate" to the tensions and uneasiness we feel and resume our lives with a greater sense of purpose and resolve.

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