By Fred Penzel, PhD
This article was initially published in the Winter 2015 edition of the OCD Newsletter.
“Doc,” began Don, a 35-year-old school teacher, “I told my wife we should sell my car because I just can’t drive any more. Every time I go anywhere, I keep thinking that I’m hitting people with my car. It could be a jogger, a pedestrian, someone on a bike, or even an animal. I have to stop to get out and check for whoever it was I hit, or else I have to drive around the block twenty times. I keep looking in the rearview mirror so much of the time that I’m afraid I really will get into an accident. I listen to the news and read the paper every day to see if there were any accidents near where I was with my car. If I hear a siren or see a cop car or an ambulance, I think they are going to the spot where I killed someone. It’s like I can never be sure.”
Don looked as if he was in genuine physical pain. Speaking mostly to the floor, he said, “You must think I’m really insane, and I’m not so sure that it isn’t true.”
Although this was only our first session, it was already apparent that Don was clearly describing a case of OCD. There are many varieties of OCD. People have even given nicknames to some of them. Don’s type specifically is referred to by some as “Hit and Run OCD.”
It is important to understand that OCD can make a person uncertain about the most basic things that they think, see, hear, touch, or experience otherwise. In the nineteenth century, it was known as “The Doubting Disease.” Hit and run obsessions fall under a subgroup of doubts about having harmed others through some kind of negligence. In this particular case, it seems to pick on people’s driving, making them wonder whether they have hit someone or run someone over, even if there is no real evidence that this has happened. Some particular situations can be more challenging than others, including:
- Driving on a street with a lot of pedestrians crossing back and forth
- Driving down a poorly lit road at night
- Cruising around a busy parking lot
- Driving over bumps or potholes in the road
- Running over a piece of trash in the street
- Going over a bump or an irregular patch of pavement
- Briefly focusing (even for a second or two) on such things as the car’s instrument panel or entertainment system instead of the road ahead (“I could have hit someone when not paying attention”)
- Driving past a jogger or bicyclist
- Backing out of a driveway or a parking space
- Looking back in the rearview mirror and not seeing someone they thought they just passed
- Hearing the screech of brakes nearby
- Having an animal run in front of or past the car
These types of situations lead to sufferers experiencing typical repetitive obsessional thoughts such as:
- How can I tell if I actually hit someone? Would I see it? Would I hear it or feel it? Maybe I did hit someone.
- How do I know I didn’t kill someone? Would I know it, and how can I be certain?
- If I did hit someone and didn’t stop and take responsibility, will I be charged with leaving the scene of an accident?
- If I’m this doubtful, I must have been driving carelessly and am clearly at fault if I did hit someone.
- What if I go to jail? What will happen to my family? Their suffering will also be my fault.
- How could I ever live with the guilt of having taken a life? I could never forgive myself. My life would be over.
- I just noticed that I may not have been fully paying attention the last few minutes while driving. Maybe this means I hit someone and am not aware of it.
Naturally, when a person is as doubtful as is the case with OCD sufferers, the only solution is to somehow find perfect certainty. This is not easy to do in an uncertain world, meaning sufferers will sometimes go to extraordinary lengths to know for sure whether they have done something bad. Along with this perfectionism can come another hallmark of OCD: guilt (as you can see from the above list of obsessions). Both of these can then lead to compulsions. Compulsions are anything a person does, mentally or physically, to rid themselves of the anxiety caused by the obsessions.
Types of compulsions often carried out by Hit and Run OCD sufferers include:
- Driving around the block numerous times after backing out of a driveway to see if anyone is lying there
- Repeatedly driving up and down the same stretch of road looking for bodies
- Getting out of the car and checking in bushes or under parked cars along the road in case a victim was flung there
- Constantly checking the rearview mirror while driving to see if anyone is lying in the road
- Asking passengers or bystanders if someone was hit by the driver
- Reading news articles in the next day’s paper after a possible incident, looking for accident reports
- Listening to news reports of accidents
- Calling the local police precinct or hospital to find out if any accidents were reported in a particular area they drove in
- Walking all around and inspecting the car many times after a possible accident looking for dents, bloodstains, etc. that would prove that someone was hit
- Avoiding driving at night or in crowded areas
- Driving extra slowly
- Trying to mentally review each moment of a possible accident event in order to determine what actually happened
- Leaving notes on people’s cars just in case they (the driver) accidentally damaged them
As it turned out, Don had many of the above worries and performed many of the listed compulsions. I explained to Don that there was no running from or canceling out this kind of doubt. Trying to not think about these things would only cause him to think about them more. His attempts to do so had not worked thus far, and it was clear that they never would. I also related that the only way to overcome his fear was to face it — through exposure and response prevention therapy (ERP) — and that this was true of many fears. He told me, “I don’t know if it’s possible. The thoughts seem so real, and this thing seems bigger than me.” I asked him to have a little faith in himself and in the method, which had worked for many people in the past, including those with his symptoms.
“If you do your ERP homework and work patiently,” I said, “we’ll have you driving again.” Luckily, he was willing to give it a try, having run out of any other options. Because his anxiety was so high, I also referred him to a local psychiatrist who prescribed an SSRI-type antidepressant, Lexapro. The purpose of medication in this case was to help Don’s willingness to try the therapy I was proposing.
After making a very detailed list of all of Don’s obsessions and compulsions, we went on to make what is called a “hierarchy.” We did this by making a separate list of all the situations we could think of that related to his OCD that made him anxious. He then rated each one of these situations from 0 to 100 in terms of how anxious they could potentially make him. He had a fairly large range, with some things being as low as a 10 and several rated as 100 — the worst fear he could imagine experiencing.
Once this list was completed, we began the work of ERP therapy, which consisted of giving Don homework assignments starting with the lowest rated items on his hierarchy list. The assignments involved having him face situations that would cause him to confront his fears in a gradual way, and then work his way up to more and more challenging work. The purpose of this was to help him develop a tolerance for the doubt created by his thoughts so as to reduce their impact and thus, reduce the anxiety they caused. It was also for the purpose of learning the truth of what would happen when he didn’t do the compulsion. Further, it helped weaken the habits he had developed around doing his compulsions so that he could more successfully resist them. His assignments included such things as:
- Backing out of his driveway and then leaving his block without driving back to check or checking his rearview mirror
- Not seeking reassurance from others
- Resisting inspecting his car after going out for a drive
- Not checking the news for accident reports
- Not calling the police to question them about accident reports
- Driving around crowded streets and parking lots without going back or checking in any way, especially at night when possible
- Never stopping to get out and check for bodies
In addition to changing his behavior, I asked Don to consider responding to his obsessions in his head differently as well. For example:
- Refraining from reviewing past driving events, agreeing instead that he might have actually hit and killed someone
- Upon hearing sirens, agreeing with the obsession that it was emergency vehicles going to pick up the bodies of those he had hit
- Generally agreeing with any thoughts of having hit people or animals
And finally to go out of his way to actively trigger the obsessions as a way to confront them by:
- Reading articles about hit-and-run drivers being convicted and going to jail
- Watching videos of cars hitting people
- Viewing ads and reading articles on the hazards of distracted driving
It took Don eight months of steady daily work to finally gain control of his symptoms and to drive normally again. There were both good and difficult days along the way. No one gets well perfectly. “I feel like I got my life back,” Don said. “I’m really glad we didn’t sell that car.”