The term ‘extreme states’ indicates a certain infrequency of occurrence for a given observer. A volcano for an inhabitant of Hawaii will not be an extreme condition, for a New Yorker or Zuricher, it will be. Hence, what is sick or extreme for one culture will not be for another. By using terms like ‘extreme states’ and ‘process work,’ we have the chance of developing a transcultural psychiatry which deals with relative deviations from the norm and which is independent of the specific cultural definitions of illness.The western world differentiates its extreme states according to the way people in these states do or do not communicate. About one half of the people in our mental hospitals are said to suffer from what is diagnosed as schizophrenia, the rest are a mixture of severely depressed or suicidal people, the aged and senile, people in manic states, chronic alcoholics, heroin addicts, people with organic brain damage, the so-called criminally insane, those laboring under subnormal intelligence, and a large category entitled ‘mixed psychoses,’ those with a mixture of the above, or the ‘generally handicapped.’ These categories vary from one hospital and community to the next.*12\227\8*

AN EIGHTEEN-YEAR-OLD freshman at Penn State presented to our University Counseling Service late in her first semester in 1992. She was accompanied by her parents, who had called earlier in the day saying that she needed to be seen immediately, that she had gone overboard in her religion and was behaving strangely.
1 introduced myself to Melissa—tall, dignified, aloof, dressed neatly in a white shirt and plaid skirt—and walked with her into my office. Ignoring my inquiry about what brought her to the clinic, she sat perfectly still for a full minute, neither talking nor making eye contact, but simply staring straight ahead. Then she suddenly looked at me and said, in a halting voice, “If I’m going to talk to someone, it should be someone from my church.”
I agreed that would be a good idea but suggested that she fill me in as well. There followed another minute or two of immersion in her own thoughts—I couldn’t tell whether she had heard what I said or not—before she glanced at me and said softly: “The problem is questions. They keep coming into my mind, and I can’t stop them.” Melissa proceeded to share her story, all the while shifting abruptly back and forth between two very different mental states. For a few minutes she would speak normally in a composed manner, carefully choosing her words, at times becoming animated or humorous; then she would lapse back into her mute, staring state, as if something very important had come up in her mind that had to be dealt with right away.
Melissa explained that she was being bombarded by questions, all dealing with what was right or wrong for her to do. The questions were incessant and overpowering, causing her mind to, as she put it, “constantly spin.” Is it right to listen to popular music? What is the greatest commandment? If someone commits suicide, do they always go to hell? Is it okay to use the telephone on the Sabbath? Should I wear a dress? The questions stopped only when she was asleep. No answers would satisfy them; every seeming solution was challenged by a new consideration. Should she decide that she could wear a dress, she would immediately have to grapple with whether it could be a colored dress. If she decided her dress should be black, she would next have to consider how long it should be. Soon she would be back to doubting whether she should even wear a dress at all.
I ended that interview by explaining to Melissa and her parents that the problem appeared to be obsessive-compulsive disorder. I told Melissa that if she wished to look at her illness as being due to Satan, then Satan was causing a chemical disorder in her brain that rendered her incapable of ridding herself of fearful thoughts. I recommended that Melissa take a medical withdrawal from school, and Melissa was quite happy to move home immediately. Since she came from a nearby town, it would be possible for her to see me regularly for treatment. Melissa agreed to see me again in two days.
In subsequent interviews, Melissa was able in a composed manner to share further details on how her disorder had started. Shortly after coming to college, she had begun to feel vaguely unsafe. It was, she explained, as if she were missing something important and something bad were going to happen. Then as the weeks passed, this fear began to focus on the idea that she was in some way living wrong. Since junior high school, she had lived according to biblical convictions. She prayed regularly, attended Bible studies and prayer groups, and memorized Bible verses that she carried in her purse on index cards. Now a feeling of dread assailed her in this most important area of her life. She would be in class, in her dorm room, or just walking down the street, when suddenly, insistently, she would experience what she came to call “the first and the greatest question”: Am I doing what’s right in God’s eyes?
She asked her pastors for advice. She cornered them in church or called them on the phone, and they patiently attempted to reassure her, suggesting Bible verses that might be consoling. “It’s spiritual warfare,” one campus minister stressed. “You can overcome it if you fight it with scripture and faith.” She took to searching for the one verse that would give her a feeling of peacefulness, a sense that she was right with God. “I can do all things through Christ who strengthens me”; “Trust the lord with all your heart and lean not on your own understanding”; “We know that all things work together for the good for those who love God.” Each verse would work for a day or two, quelling her fears, but then the first and greatest question would return.
She began to stay up late into the night sitting at the small desk in her dorm room, a study light illuminating the bulletin board, arranging and rearranging index cards of Bible verses. She would tack them up and take them down, shift their order back and forth, looking for the verse that would show her how to live perfectly for God. Many times she thought she had found it. She would grow excited, elated, after hours and hours of concentrated, intense searching. She would go to bed, some nights as the first rays of dawn were breaking, thinking that she had finally found the way she could be certain that she was always doing what was right in God’s eyes.
On one occasion, Melissa found her answer in the verse, “Abide in faith, hope, love, these three, but the greatest of these is love.” This,
Melissa thought, would cover everything. For a week she made a solid, determined effort to love everybody every minute of the day. What if her roommate left dirty clothes on her side of the room? No reason to be mad. What if people talked behind her back? She would love them, anyway. But after a week she was in shambles. “It seemed like by the end of each day I just realized how much I hate some people,” Melissa explained. “I was just exhausted. It was too hard. I gave up.”
Also severe by the time she came to see me was another type of mental compulsion: the point-by-point, minutely detailed, over-analysis of conversations. Such prolonged trains of unproductive thoughts, done to chase away obsessions, are called compulsive ruminations. Melissa had always been sensitive to other people’s feelings and had for years had the habit of apologizing to people in an overly scrupulous manner for things she feared had come out wrong. By the time she came to me, however, she herself realized that her concerns were out of control. Melissa was picking apart every encounter to see whether she may have been boastful, arrogant, insolent, a gossiper, or a slanderer. She would completely relive the words she had used, her tone and delivery, the other person’s response, the order of speaking, and every other conceivable aspect of the conversation. It was a microscopic analysis that could easily go on for an hour.
As her disastrous first semester drew to a close, Melissa accelerated her phone calls to ministers, friends, and family. Some days she would make twenty or more calls—not to socialize by now, or even to ask for help in dealing with her problems, but simply for reassurance. Had she fallen away from God? Was she being a good Christian? Had she committed slander? She needed reassurance so that her anxiety could be “filled” for a while. Her calling had become a compulsion, just like the repetition of verses, the counting, and the over-analysis.
I admired Melissa for the way she had tenaciously struggled to find answers to her never-ending questions. I also respected a certain depth and potential richness in her religious quest. Indeed, it occurred to me that in the early part of her struggles, when, prodded by a vague uneasiness, she had turned to her Bible and prayer, Melissa could have been on a path to rich spiritual growth. Perhaps it is stretching the point too far, but Melissa’s struggles did bring to my mind Saint Augustine’s comment: “Our hearts are restless until they rest in Thee.” But whatever potential there was, it was devoured by obsessive-compulsive disorder. Her questions became foolish obsessions, and her answers were reduced to meaningless compulsions.
*4/338/2*

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