The Man Who Couldn’t Stop (13 page)

Joan is a good example of thought-action fusion. She believed that to think something was morally the same as to do it. And she believed that to think about an event made it more likely to happen. So though she made no phone call, just the act of thinking that she might have done was enough to trouble her. Joan had another type of dysfunctional belief relevant to obsessions too. She had an overdeveloped sense of responsibility.

Inflated responsibility is probably the most important dysfunctional belief in OCD. Obsessive-compulsives often feel responsible both for having thoughts and for the negative consequences of their thoughts on themselves or others – and for not acting to prevent those consequences. They believe that if they have any influence over an outcome, then they are responsible for it. This triggers a cascade of twisted secondary ideas – ‘having this thought means I want to do it' or ‘if I fail to prevent harm then it is as bad as directly causing harm'. Some people with OCD are compelled to pick up pieces of broken glass from the street. They worry that, if they don't, then someone else might cut themselves on the glass. If the person with OCD fails to prevent that happening, they think, well I may as well have walked up to the stranger and deliberately hurt them. So they take the glass home. And then they are forced to keep it. To throw it out with the rubbish could see the refuse collectors hurt themselves. That's why some people with OCD have a collection of broken glass in their house. Others gather banana skins for the same reason.

Cognitive psychologists use dysfunctional beliefs to construct theories of how minds can misfire. In the mid-1980s, a psychologist called Paul Salkovskis, then at Oxford University, built on the concept of inflated responsibility to suggest the first modern cognitive model of OCD. The model has proven very influential. It marked the beginning of the end for the dominance of the behaviourists when it came to the psychology of OCD, and it led to a whole new set of treatments. Best of all, it can be demonstrated with a famous scene from a Woody Allen movie.

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Christopher Walken had just turned 34 when the film
Annie Hall
was released to worldwide acclaim in April 1977. Walken played Duane Hall, Annie's brother, who, sitting in his bedroom, memorably asks Allen's character, Alvy, if he can confess something. Driving at night, Duane says, he sometimes has an impulse to steer his car into the oncoming traffic. He can anticipate the explosion, he says, the sound of shattering glass and the flames from the spilt gasoline. Allen's unsympathetic reply is that he's due back on planet Earth. But Duane has the last laugh when he is instructed by his father to drive the couple to the airport that evening, which he does at speed while Alvy looks nervously on from the passenger seat.
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The cognitive theory of OCD says it is not important that Duane has such thoughts – as we know, they are common. What matters is how Duane reacts to them, how he appraises and interprets them. If Duane could brush them away, think them a nuisance and dismiss or simply ignore them, then the intrusive thoughts should pass as quickly and easily as the headlights of the oncoming cars. But if he instead decided that the urges were important and that they deserved attention, then that would be a danger sign. If Duane interpreted the thoughts as having serious consequences, for which he was personally responsible, then he could turn them into a clinical obsession. He could start to think that he was a dangerous driver who must take extra care not to lose control. He might start to avoid driving; he would be distressed by his thoughts and might try to suppress them. And so the intrusive thought would return, harder and stronger and more difficult to ignore.

Unlike many ideas about the causes of OCD, this cognitive theory of obsession can be tested. It is a fairly straightforward job for a scientist to make a volunteer feel responsible for a situation. Imagine, for instance, that you are asked to sort two hundred mixed pills (twenty each of ten different colours) from a glass jar quickly into semitransparent bottles, each of which must contain a different colour. Psychologists at Laval University in Quebec reported the results of such a test in 1995. One set of volunteers were told it was just a practice exercise and that the results would not be counted. Another set was told that lives could be at stake: a pharmaceutical company planned to use the pills to fight a virus in Asia and needed to know how easily the different colours could be identified. The second group, of course, took longer and performed more checks, and also reported more anxiety, doubt and preoccupation with error.

Or imagine that you are an undergraduate psychology student and, in reward for credit towards your degree, you agree to join a study to look at fear of snakes. Your tutor removes a live snake from its cage to show you, and wants you to fill in some questionnaires. After the tutor returns the snake, he beckons you into a separate room to speak your thoughts aloud for five minutes so that your stream of consciousness can be recorded and analysed – oh, but first just close the cage door, will you?

Next door the tutor finds a form supposed to measure your anxiety while you looked at the snake. Whoops, let's go back to the other room and do that first. ‘Look at the snake and then rate your anxiety on this scale,' he says. But the cage is empty. Uh-oh. ‘OK, you go ahead with the stream of consciousness exercise and I'll go look for the snake.' How do you feel? A snake is loose – and it's your fault.

Psychologists at the University of Maine reported this experiment in 2008, carried out with a hundred of their female students and one harmless snake bought from a local pet shop. The students were not really responsible for the snake's escape – while they shuffled between rooms, someone else stole in and removed the reptile from the cage. But the students weren't to know that – or that they were involved in a trial not of snake phobia, but of the link between responsibility and intrusive thoughts.

To test the role of responsibility, the psychologists repeated the charade with a parallel group of students, with one exception: this time the tutor closed the cage door himself. The snake was still missing when the students returned to the room, but the escape was now his fault and not theirs. Sure enough, when the psychologists listened to the stream of consciousness tapes, they found that the students fooled to take responsibility for the escape reported more intrusive thoughts of snakes.

The Maine psychologists tested another feature of the OCD cognitive model, a prediction that intrusive thoughts are more likely to form if they are salient – that is, if they relate to current concerns. They subdivided the student groups according to how much they said they were afraid of snakes and described this fear as a measure of salience. Again, the results supported the theory. The more afraid of snakes they were, the more intrusive thoughts appeared. Together, the psychologists said that their study backed an important part of the OCD cognitive theory. If a person feels responsible for an event that they judge as personally relevant, they will experience increases in related intrusive thoughts. With great responsibility, comes great power.

And great fear. In April 2013, the Israeli military admitted that one of its soldiers had developed OCD because she was given the job of guarding state secrets. Her air force commanders repeatedly warned her not to disclose the classified information, and told her she would have to pass lie detector tests. The soldier began to compulsively ensure her locker was secure, checked classrooms for discarded pages and would pick up scraps of paper she found around the base in case any of her colleagues had dropped restricted documents.

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Nothing, perhaps, can bring on a sense of responsibility more than having a child. Most new parents will check their sleeping baby is breathing, and then go back to check again. That's normal. Some new parents take it too far. They turn their new sense of responsibility into OCD.

Sara had a five-month-old son called Justin. Sara had dreadful thoughts that she would strangle or drown him. But Sara loved Justin, she was responsible for him and she would never hurt him. Sara forced herself to seek help. She told a psychiatrist about her thoughts, about the images she saw of Justin's coffin and of herself in jail, about how sometimes Justin would survive her imagined attempts to murder him. She told how she could not put Justin in his bath, or be alone with him, because she could not trust herself not to kill him − especially when he was asleep and would not realize that she had put her hands around his throat. Sara told the psychiatrist that she would kiss Justin's head to try to make the thoughts go away.

When Sara told these terrible things to her psychiatrist, Sara was sectioned. She was involuntarily committed, locked away in a hospital to keep her away from Justin. But Sara was no risk to Justin. Sara had postnatal OCD. You've never heard of postnatal OCD? No, neither had Sara's psychiatrist.

Postnatal depression is now recognized as a serious problem and mothers-to-be know that they may struggle through the first few months. But postnatal OCD is almost unheard of outside the pages of scientific and medical journals. Yet it is common. As many as one in ten new mothers develop signs of it. Childbirth can worsen OCD in women who already have the condition, and it can bring it on for the first time in others.

The obsessions that strike new parents who develop postnatal OCD take a particularly distressing form. Mums and dads (and it does affect men too) take their baby home, thank friends for the cards and neighbours for the good wishes, and close the door to gaze into the sleepy eyes of their child, who utterly depends upon them. Then, from nowhere, they feel a powerful urge to throw the fragile infant into the fire, or cook it in the microwave, or hurl it down the stairs, or push their thumbs into its eyes, or squeeze it until its bones snap, or plunge a knife into its chest, or, against all of their instincts and good sense, despite them straining every neuron to shake the idea, to sexually molest their own newborn baby.

Outside their heads, none of this happens. As we saw earlier, people with OCD do not act on their intrusive thoughts. But the new parents who develop OCD don't know that. And lots of them simply don't want to take the chance. That's why hysterical new mothers with OCD can refuse to hold their babies, even though they want to do so more than anything else. And it's why new dads who develop OCD refuse to enter their child's bedroom with a pair of scissors. It's why Sara would kiss Justin, to try to undo the evil in her head. It's why she went to see the psychiatrist. And it's why the psychiatrist locked her up.

Sara's psychiatrist was no doubt concerned because one or two mums in a thousand experience urges to hurt their babies as part of genuine psychosis that emerges after they give birth. There is a big difference. Postnatal psychosis features delusions, ‘the devil is out to get my baby', and hallucinations, ‘I saw smoke and fire come out of the baby's ears.' But, most important, if the parents recognize and report the thoughts as unwanted and if they resist them, then, as with all forms of OCD, they show they are alien to their personality and so unlikely to be carried out.

Don't take my word for it. Stanley Rachman, the psychologist who performed the first survey of intrusive thoughts in the general population, probably knows more about OCD than anyone else on the planet. He has treated hundreds of people since the 1960s. And he has never had a single OCD patient who complained to him about intrusive thoughts – and he has heard the lot – go on to hurt a child. Not one.

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My baby daughter was six months old when I noticed the blood on her leg. It was summer 2010 and she wore a pair of shorts and there, above the knee, was a dull smear of red. Out of my bag came the nappies, the spare clothes, the raincoat, the various creams and wipes, the jumper, the hat, the spare hat, another nappy and a plastic box that rattled with snacks as I hunted for the sticking plasters. Strange, there was no obvious cut or graze, and she wasn't in a position to damage herself anyway – crawling was months away, let alone walking. Had she been bitten by an insect, or had I scraped her leg as I lifted her in and out of the playground swing? She would have cried out, wouldn't she? If it was blood, I realized, then it probably wasn't her blood.

I was the obvious source of the blood, and sure enough, when I looked carefully, I saw a scratch on the back of one of my fingers, probably from the spiky bushes that guarded the gate to the playground. There was a similar smudge on my finger. I must have brushed her leg against my scratched finger as I lifted her. Click. My idea generator delivered another scenario. It could be someone else's blood. And it could be HIV-positive. She could have rubbed it into her eyes.

My baby daughter enjoyed our return trips to the playground that day, and only complained about me lifting her in and out of the swing on about the eleventh time. Yes, the stained part of her leg did seem to touch part of the metal guard as I pulled her out, well, more or less. But, did she put her hand there as she swung? Once more for Daddy? I couldn't see any blood on the swing, and I couldn't see any blood on the grass underneath, any of the times I looked. I still couldn't see any when I came back with a flashlight to have another search that evening. I was 38. It was almost nineteen years to the day since that first summer night when I discovered that I could not ignore my intrusive thought. You could have Aids. She could have Aids.

Before that day with my daughter, I had settled for a life with OCD. I knew people with depression, anxiety, anorexia, bipolar disorder and ADHD; others had died of cancer or in accidents. One killed herself. I had started to accept that OCD was my thing. There is a useful cliché on mental health – don't compare your insides with other people's outsides. From the outside, I probably appeared happy. A little withdrawn, distracted or quiet in some situations, perhaps, but happy. Most people, I figured, would also have had a moment in their lives that they secretly dated events against. I would just have to accept mine. I would have to live with my OCD.