OCD: When Your Own Mind Starts Blackmailing You

By the time his wife asks whether something is wrong with dinner, he has already spent ten minutes trying to fix something she cannot see. He likes the food. He’s hungry. But an image of something disgusting passed through his mind as he picked up his fork, and now the meal feels spoiled. He knows the food itself is fine. If he can replace the image with a better thought, he will be able to eat.

She offers to warm his plate. He tells her he’ll be ready in a minute, and he nearly is. He finds a good memory, lets it settle, then checks whether the unpleasant feeling has gone. Checking brings the image back. He starts again. Meanwhile, she is clearing the other plates and trying to understand why a man who says he wants dinner cannot seem to take a bite.

If someone tells a disgusting story while you’re eating, you don’t have to believe your food is dirty to lose your appetite. Something in your mind has changed how the meal feels. Usually, the moment passes and you get back to dinner. For him, that ordinary wish to shake off an unpleasant feeling has become a rule: he must get his mind to feel right before he can eat. His attempts to do that keep restarting the problem.

His wife has tried being patient. She has also tried telling him that this makes no sense, which produces very little disagreement. He knows. He is embarrassed that an ordinary evening has become another discussion about why he cannot do something simple. She feels shut out of a problem she cannot see. He feels increasingly ashamed of explaining it.

When I explain this to families, I sometimes picture anxiety along a spectrum. Start with a specific phobia, like a fear of heights or snakes. Even if you don’t share it, you can understand it. Social anxiety is familiar territory, too. Move toward generalized anxiety disorder, and worries about work, health, or family follow you around long after you’ve done anything useful about them. Then, at the far end, there’s OCD, where a man can’t eat until he’s had the right thought. At first, it seems to have very little to do with the anxiety you know.

Perhaps you have gone back to check a locked door, reread a message to reassure yourself it sounded okay, or knocked on wood after saying something optimistic. Most of us recognize the little bargain: do this one thing, and you will feel better. With OCD, that system can get out of control. The relief lasts only briefly, and the need to get it back starts deciding how you spend your day. His evening has become a series of attempts to feel ready to eat.

Understanding what happens during those ten minutes matters more than how strange the fear sounds. In an evaluation, I want him to walk me through them. He has been replacing images, monitoring his feelings, and repeating the process until he can get a moment of relief. The recurring intrusion is the obsession. The mental work he feels driven to perform is the compulsion. Someone who asks only about handwashing or checking locks could miss most of what has been happening. iocdf.org

By then, OCD may have been mistaken for an eating problem, a relationship problem, or a person being difficult. The disorder is a chameleon partly because the people closest to him see the consequences while the repeated mental work that keeps him stuck is largely invisible.

Eventually, he asks his wife whether she thinks he can go ahead and eat. Of course he can. She says so, warmly and convincingly. His shoulders relax. For a moment, they both think the evening can finally move on.

The answer that works for five minutes

Families often arrive having answered the same question in twenty different ways.

They have explained why the food is fine, why the prayer counted, why the conversation was harmless. For a few minutes, it works. Everyone exhales. Then comes a small amendment: “But what if…”

By the fifth conversation, the parent is frustrated. By the tenth, the patient is ashamed. Both may conclude that someone is being unreasonable. The pattern is easier to understand when you notice what the answer accomplishes: a short burst of relief, followed by another request. Reassurance can become a compulsion delivered by someone else.

A clinician can get recruited, too. Spend the session proving that a particular fear is impossible, and the next appointment may become an appeal hearing.

I can spend an entire appointment answering increasingly specific versions of the same question. The patient feels heard and, for a moment, better. Then the hour is gone. We have barely explained why the answers never seem to hold, much less agreed on what to do about it. The appointment has become another place to perform the ritual.

An experienced psychiatrist may recognize the pattern immediately and have very little patience for another round. They have seen this a hundred times. “We’ve already discussed that. You’re asking for reassurance.” The observation may be accurate, but delivered curtly, it can make the patient feel foolish or dismissed. They came in frightened and ashamed; now they may leave believing the doctor never really listened. Recognizing the loop is only part of the work.

It takes a gentle but firm touch to interrupt it without losing the person. I need to convey something like: “I can see how much this is upsetting you. I also notice that every answer brings us to another version of the question. I could keep answering, but I think we’d end up back here tomorrow. Let me explain why that keeps happening, and how we can start changing it.”

The patient needs enough understanding to make sense of that change in direction. I have to leave room to explain the OCD cycle, identify the rituals keeping it going, and build a plan we can actually follow. If I spend the whole visit reassuring, or rush to shut the conversation down, that work never gets done.

Exposure and response prevention, or ERP, addresses that pattern directly. With a trained therapist, the patient practices encountering the trigger while reducing the ritual that usually follows. That includes mental rituals, which are easy to overlook. www.nice.org.uk

For the man at dinner, treatment might involve taking a bite without waiting for the unwanted image to go away. He would practice allowing the discomfort without first replacing the image, checking his reaction, or asking someone whether eating is okay.

That can sound like a small assignment to someone whose dinner has never depended on the contents of their mind.

That trust matters when treatment begins asking more of the patient. The exercises need to be agreed upon and appropriately paced. Family members need help offering support without repeatedly answering the illness’s questions.

Medication can make this work more manageable. SSRIs are established OCD treatments, and an adequate trial often requires more time and higher doses than treatment for depression, with careful monitoring. Severe OCD often benefits from medication alongside ERP. Some patients need a different medication strategy or more intensive specialist treatment.

At Highline Psychiatry in New York City, this is why I spend time on the details of an OCD evaluation and coordinate with therapists who know how to work with it. I want to understand what happens between the frightening thought and the brief relief.

Think back to the man with the cold dinner. The goal is for him to finish a meal even when his mind produces something unpleasant.

He should be able to complain about the food like everybody else.

Clinical scenes are illustrative composites. They do not describe individual patients.