The Man Who Couldn’t Stop (10 page)

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Probably the most debilitating of the OCD spectrum conditions is body dysmorphic disorder. BDD plagues people with intrusive thoughts on a specific theme – defects in physical appearances, usually their own, but sometimes those of family or friends (when it is known as BDD by proxy). It affects men and women roughly equally. Most are concerned with perceived flaws on their face or head, such as small wrinkles they see as hideous abnormalities. People with BDD can spend hours each day on compulsive rituals; they examine themselves in the mirror and camouflage their skin with layers of make-up. Sufferers usually believe that their imagined defect will provoke horror in others, so some rarely leave the house, and when they do they wear a wig, hat or sunglasses, or hold themselves in a certain position. Some find it difficult to walk past shop windows or cars without stopping to check their appearance; others cover all the mirrors in their house with towels. Most seek repeated reassurance that they look normal. About a quarter of patients with BDD attempt suicide.

It's not new. In 1891, Italian psychiatrist Enrico Morselli wrote of a patient who, ‘in the midst of his daily affairs, in conversations, while reading, at table, in fact anywhere and at any hour of the day, is suddenly overcome by the fear of some deformity'. It is thought to affect between 1 per cent and 2 per cent of the population today, but, like OCD, a combination of shame among patients and poor awareness among doctors leaves it under-diagnosed. Many patients with BDD keep their thoughts to themselves because they worry others will dismiss them as vain and narcissistic. When they do seek help, they often claim instead to suffer from depression or anxiety, which they think carry lower stigma. Patients with BDD are more likely considered delusional than those with OCD, because fewer recognize the absurdity of their thoughts and actions.

Sometimes confused with BDD is a different condition called Body Integrity Identity Disorder – which sees otherwise healthy people believe they have too many arms and legs. They ask surgeons to amputate their healthy limbs – which places the surgeon in an awkward position. If they refuse, and some do, then the person may go away and attempt to do it themselves with an axe or kitchen knife or homemade guillotine, and some do.

When the intrusive thoughts that bother someone concern not their appearance, but their health, the result can be hypochondriasis. Just like ‘a little bit OCD', the term ‘hypochondriac' has become detached from its clinical definition. Hypochondriacs, we say, are those who complain frequently of sniffles and coughs, who worry that a headache is a sure sign they have a brain tumour.

That sounds mild – a little silly even − but true clinical hypochondriacs experience life in a similar way to someone with OCD: they convert intrusive thoughts of illness into obsessions, and then develop lengthy compulsive rituals to address them. They take their own temperature, pulse rate and even blood pressure. They compulsively check they can swallow, keep a close eye on their urine and excrement and feel for cancerous lumps. In some cases, these constant prods and pokes bring on the bodily changes and discomfort they fear in the first place. They almost always ask others for reassurance – family, friends, doctors, specialists, hospital phone lines, and experts and non-experts on the Internet. Unlike OCD, which comes from thoughts, people with hypochondriasis tend to fixate on genuine physical sensations and exaggerate their impact.

Eating disorders such as anorexia nervosa and bulimia nervosa show some striking similarities to OCD. Repetitive and strongly held thoughts force people to carry out rituals and patterns of behaviour to reduce anxiety – refusal to eat or inability to stop − followed immediately by compulsions to make themselves vomit or over-exercise. Thought suppression seems to play an important role – with those who try and fail to squash negative thoughts about their eating habits more likely to show symptoms of bulimia. People with anorexia can show obsessions and compulsions unrelated to food or weight, including an irrational desire to arrange things in symmetrical patterns.

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One of the newest additions to the list of abnormalities that could relate to obsessive-compulsive symptoms is maladaptive daydreaming. Freud said to daydream was infantile and neurotic, but these days psychologists and neuroscientists see daydreaming – sometimes called undirected thought or mind wandering – as a normal and probably useful part of human cognition. It might help us to solve problems, and we can usually snap out of it when we need to. Some people turn their daydreams into something more serious. They do it compulsively; they find it hard − if not impossible – to not daydream and the behaviour has a negative effect on the rest of their lives. Rachel was one of the first people identified with this problem.

As a child in the United States of the 1970s, Rachel would spend much of her time in a self-created fantasy world. She would imagine herself in her favourite television shows and run episodes inside her head. As a teenager, Rachel started to lose control of what she and her parents had always considered a harmless hobby. She recalls how the daydreams took over until she was no longer in charge of her thoughts and her life – vividly similar to the language people with OCD use to describe their obsessions.

Rachel, later a successful lawyer, sought and received treatment, eventually taking medicine commonly given to tackle OCD. She is far from alone.
Wild Minds
, a web forum for maladaptive daydreamers, has some 2,200 members from across the world. In 2011, scientists in New York reported the first academic survey of the condition. They questioned by email 90 people – 75 women and 15 men – who described themselves as excessive or maladaptive fantasizers. These people did not know each other, but they reported a tight set of thoughts and behaviours.

The level of detail was striking – ‘I have spun tons of plot lines in this world spanning multiple generations of characters,' one said.

The parts of my daydreams I obsess over are the most intense emotional scenes … a character's parents or best friend dies, a character is injured, abused, tortured or raped, or even just has a terrible argument with a loved one … Characters fall in love, get married, have and raise children, develop deep and strong friendships.

The people who responded to the survey said they would spend, on average, more than half their time in daydreams.

Only one in five of the daydreamers saw daydreaming as harmless – the rest had tried to stop. A quarter described the activity as addiction, obsession or compulsion. ‘I have tried to limit my daydreaming in the past,' one said.

I tried hard to just focus on what was around me and keep in mind only real people, things and events that were happening in the here and now. It was a battle. Me against my daydreams. They won.

There's more. Do you check your partner's underwear to find traces of his/her sexual intercourse? Do you check up on his/her way of dressing up if he/she goes out on his/her own? Those are questions 29 and 30 of a ‘Questionnaire of Jealousy' prepared by scientists at the University of Pisa. It aims to probe a mental syndrome called obsessional jealousy; others have labelled it non-delusional pathological jealousy, and have framed it as an obsessive-compulsive spectrum disorder. People with non-delusional pathological jealousy show similar behaviours to OCD. They respond to intrusive thoughts with excessive checks and requests for reassurance. And they avoid situations that might provoke the thoughts – for example, they can keep their partner in the house so they can't meet potential suitors.

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When you add that lot up then OCD doesn't seem quite so rare and unusual. You almost certainly know someone affected. Yet people with these OCD spectrum disorders have something else in common besides their thoughts and urges. They don't tend to bring their problems up in conversation. Their conditions are socially unacceptable because they often centre on shameful and taboo subjects. Sufferers assume their dark, intrusive thoughts reveal their true nature: someone who thinks such things must be mad, bad and dangerous to know. That phrase is overfamiliar through repetition, but look again at the power of the individual adjectives.

I tried often to talk about my fear of HIV with friends. I didn't admit my worries that I had caught it from, say, a mix-up of our toothbrushes in our shared bathroom, I kept the details vague. But I thought it might help to bring up the subject more generally: ‘So what about that Aids stuff then, that's all a bit scary eh?' The usual response was a nudge and a wink and a knowing smile. ‘So, who was she?' Even today when I tell people I have had a persistent fear of HIV since my teenage years they assume it was because I was promiscuous. Hardly. My OCD was something of a passion killer.

People talk about the stigma of mental illness, and they are right to do so. While it is considered fine, encouraged even, for those with a bad cold or an upset stomach to offer details of their ailment in great detail, to bring up the subject of mental health is often not just a passion killer, it's a conversation killer. Awkward silences and awkward glances tend to follow. I have hidden it when I have applied for jobs. Do you have a mental illness? Well, which box would you tick?

The stigma is less now for some mental disorders, such as depression. People sometimes talk about how anxious they are as if it's the inevitable cost of a busy and enviable life. We are encouraged to discuss schizophrenia and bipolar disorder in less suspicious tones. But we have some way to go with OCD. As we've seen, most people don't talk about even their most fleeting intrusive thoughts, because they fear they might be labelled as violent or perverted. So how does one begin to tell the neighbours that one is obsessed that one will sodomize their pet rabbit? Or confess to school friends one's obsessive thoughts that one will turn into a rat, and so one checks compulsively for signs of a tail? Those are both genuine cases of people who sought help for OCD. Which box would you tick?

 

SIX

Cruel to be kind

In his book on depression
The Noonday Demon
, Andrew Solomon describes how he was taken to hospital with a dislocated shoulder and how he was terrified that the pain would trigger a mental breakdown, as it had done before. He knew his mind, its weak spots and vulnerabilities, and he pleaded with the emergency room staff for the chance to talk to a psychiatrist, to head off the psychological impact that he believed would follow the physical trauma. They didn't understand. They told him to relax. They told him to picture he was on a warm beach and to imagine how it felt when he wiggled his toes in the sand. Solomon's shoulder was fixed, but within days his depression returned with a vengeance.

When I first went for help with my intrusive thoughts of HIV, I was told to wiggle my toes in imaginary sand too. I had gone to a drop-in centre run by a mental health charity on the edge of the university campus, and they had made an appointment with a counsellor. This was outside the medical system and that was deliberate. I didn't want to see a psychiatrist because that was for crazy people. I didn't want to talk to a doctor, because I didn't want anything written down. Stories in the newspapers at the time warned that those who asked their doctors about HIV and requested tests were being denied health and life insurance.

The counselling was useless.
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We performed relaxation exercises and I pulled imaginary golden thread from my nose. Neither stopped the intrusive thoughts. And we talked about my childhood, my parents and my relationship with them. That's classic psychodynamic analysis – the technique developed by Freud. That didn't help me either, but then, despite the claims of Freud and those who followed him, there is zero evidence that psychodynamics works with OCD. In fact, it could probably make things worse.

In the mid-1960s, psychiatrists in London encountered a middle-aged woman with OCD who had been treated for ten years with Freud's methods. The woman had become obsessed with blasphemous intrusive thoughts when she was a child that became increasingly sexual when she was a teenager, such as thoughts about sex with the Holy Ghost. She carried out repetitive acts to reduce the anxiety – she dressed and undressed time and again and walked up and down stairs. Taught by Freudian therapists about the importance of sexual symbolization, she then found it traumatic to close drawers, insert plugs, clean tall glasses, enter trains and eat bananas.

Much of Freud's take on the causes and treatment of OCD now looks ridiculous, yet it dominated approaches to the disorder for decades after his death. That's not because he was right, it's because his sky-high profile ensured his work on obsession was translated into English, which became the most widely used language of the new field of psychiatry in the twentieth century. This translation process created a problem. Freud, who spoke German, used the term
zwangsneurose
(obsessional neurosis). The word
zwang
was translated as ‘obsession' in London, but ‘compulsion' in New York. Faced with confusion, scientists introduced the hybrid term ‘obsessive-compulsive', a label subsequently given to millions of people, as a compromise.

The popularity of Freud's suggestion that internal conflict generated obsession only started to wane in the 1960s, when a new breed of scientists muscled in on the field of OCD. They were called behavioural psychologists, or simply behaviourists. The behaviourists had their own firm belief. All behaviour was learned, even abnormal behaviour. And as such it could be unlearned. To treat obsession, they just needed to find the right trigger.

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The use of behavioural psychology to treat OCD comes directly from the famous experiments of the Russian physiologist Ivan Pavlov, who reported how dogs learned to associate food with a bell rung to announce mealtimes, so much so that they would drool at the sound of the bell even if no food appeared. Pavlov's lab called the reaction of the dogs ‘reflex at a distance', but other scientists preferred the term ‘conditioning', and they thought it could explain phobias and the irrational fears of OCD. The causes of irrational fear were not in someone's sexual history, they said, but in their environment. Someone with obsessions of catching a disease from a public toilet, for example, had probably once become severely ill after a visit to a particularly unhygienic washroom. This ‘classical conditioning' gave birth to the irrational fear, which was maintained and nurtured by a related process called ‘operant conditioning'. The person, the theory went, would start to avoid toilets to reduce stress and because this action would work, it would negatively reinforce the behaviour.