by Jill Aitoro

After a 40-minute shower, you feel reasonably clean. You close the shower door, then realize you touched it with your dirty hands when you entered the shower. You wash your hands. You turn off the handle with a paper towel, but think that you might’ve accidentally touched it with your skin. Knowing people use the sink after they use the toilet, you feel dirty all over. You can feel the germs on you. You shower again.

You’re driving to the store when your heart starts to pound. The hospital is two miles away. Your heart beats faster. You never should’ve left the house. You use your cell phone to call your mother as you head toward the hospital. This is your third visit in the past month, but you’re sure it’s an emergency this time. Your heart feels like it’s going to explode. You walk into the emergency room and up to the receptionist. "I think I’m having a heart attack," you tell her.

uch behavior can seem absurd, but two to three percent of the population understand it all too well. For people suffering from one of two severe anxiety disorders, obsessive-compulsive disorder (OCD) or panic disorder with agoraphobia (PDA), their days are ruled by their illnesses, says Dianne Chambless, professor of psychology and codirector of UNC-CH’s Anxiety Treatment Center.

Those suffering from OCD have thoughts that they would agree are not rational but, nonetheless, they feel compelled to act upon over and over again. Those suffering from PDA are terrified all the time that they will have unexpected severe experiences with anxiety—panic attacks—and fear these attacks will kill them or drive them insane. As a result, they develop extreme avoidance behavior.

Treatment for OCD and PDA has about a 70 percent success rate. The standard has been to focus solely on the patient. Chambless and Gail Steketee, a professor of social work at Boston University, wanted to find out if the patients’ relationships with others in their households influenced whether the patients completed the treatment and, if so, how well they did. They treated patients with four months of exposure therapy and, for OCD patients, exposure plus ritual-prevention therapy.

"In exposure therapy, the therapist and client construct a hierarchy of the client’s feared situations," Chambless says. The hierarchy is arranged from easiest to hardest in terms of the amount of anxiety the patient anticipates experiencing. The patients suffering from PDA confront situations that they are compelled to avoid for fear of panic; the patients suffering from OCD enter situations that trigger their urges to perform rituals but resist carrying out these repetitive behaviors.

In and between sessions, the patient practices an activity until that activity no longer causes distress. Then he or she moves on to something more difficult. Say a man with OCD returns repeatedly to the route by which he drove to work and checks his bumper again and again for blood, convinced he hit a child. In therapy, he might work from driving on a highway with no pedestrians to driving in front of an elementary school as the children are let out—without the therapist in the car. He restrains any desire to return to a specific spot or check his car for damage until eventually the desire goes away entirely. "The therapist breaks the problem down into small steps and provides as much support as necessary, then gets out of the way," Chambless says. Rather than looking at patients’ pasts or what is in their psyches, psychologists help them cope now.

hroughout treatment, Chambless and Steketee interviewed the patients’ family members individually and videotaped them talking with the patients to examine communication patterns. The intent was to see if there was a relationship between how patients interacted with their families and which patients completed and improved with treatment.

Eighteen of the 101 participants in the study dropped out before the tenth session. "There was a lengthy process of consent to make sure the patients understood what was involved," Chambless says. "When they got to the point where the challenge was physically before them, some could not go through with it."

A patient was more likely to drop out of treatment or not improve if the family was either emotionally overinvolved ("your pain is my pain") or critical, with the distinction that the criticism was hostile rather than constructive. It’s the difference between saying "I don’t like how what you’re doing makes me feel" and "I don’t like you."

Next: "a fragile piece of glass"

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