The Man Who Couldn’t Stop (16 page)

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There is no single obsession gene, just as there is no gay gene, or intelligence gene. To start with, there just aren't enough genes to go around, to map one-to-one onto the entire spectrum of human attitudes, behaviours and physical attributes. All genes work alongside other genes. A few of our traits (wet or dry earwax) and a few diseases (cystic fibrosis) have been traced to the impact of a solitary gene, but they really are a few. Even eye colour, for years a classic textbook example of single gene control, is now known to be under the control of many different genes that act together.

This helps to explain why, despite recent technological progress, most of the promised medical reward of human genetics remains on hold. The more scientists explore, the more murky and complicated the picture becomes. That means that when it comes to the genetic causes of OCD, unfortunately we don't have much to go on. There are some clues, but they are pretty abstract clues. One of these came in summer 2012, when scientists in the US looked at the genes of five generations of an obsessive family.

OCD was rife in the family. Great-great-grandpa and great-great-grandma had two children, both of whom had OCD. Four of their eight grandchildren had OCD too and so did eleven of their eighteen great-grandchildren. Of the eleven great-great-grandchildren born by the time of the study, five were judged to have OCD. None of the family had married anyone with OCD, so if there was a genetic link, and there surely was, then scientists could have expected this family, and others in the same study, to reveal it.

Detective work followed. With little more than a processed blood sample, lab researchers can automatically screen a person's DNA for more than half a million specific and common genetic variations. Nobody has every one of the half million possible variants – such a person would be very ill and very odd indeed. Instead, they are sprinkled across the population, and the different ways they appear in individuals act as flags, which draw attention to regions that might carry genetic risks. When scientists compare these genotype maps, and the symptoms in the people where the maps look similar, they can start to narrow the focus for a genetic cause for illness, down from the entire genome to a few flagged regions. That's an essential step if targets for treatment are ever to emerge.

In the US family study, when the scientists looked for patterns shared across the generations, the strongest linked OCD to specific genetic changes at the tip of chromosome 1. It was far from a smoking gun though. The association with OCD wasn't clear-cut, and other regions of other chromosomes were implicated too, just with even less certainty.

A parallel study that looked for patterns in the genotypes of 1,465 unrelated people with OCD from across the world produced equally weak results. In that research, a technique called a genome-wide association study, the scientists fingered a different genetic region, this time on chromosome 20. Genome-wide association studies often produce graphs of results named Manhattan plots after the famous pointy skyline of New York City. Each prominent skyscraper on the plot corresponds to a possible genetic cause, and so a possible step towards a treatment. In this case, the output of the OCD study looked more like the skyline of Washington, DC, which is universally flat because planners allow no building much taller than the distance across the street it stands on.

No skyscrapers in the OCD Manhattan plot indicates no clear genetic causes. That doesn't rule out that OCD is under the control of genes, but it shows the relationship is complex and not driven by a few bits of wonky inherited DNA that can easily be identified.

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Mental disorders that run in families do not need a genetic cause. There is the impact of the environment too. Some genes lie dormant until something in the environment triggers them. Other inherited traits are down to the behaviour and influence of our parents. I play golf and so does my brother. That's because my parents both play golf and they encouraged us, not because golf is in the shared DNA of our family. It's especially not in the shared DNA of my dad. You only have to watch him try to chip his ball over a bunker to see that.
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The usual way to tease apart genetic and environmental factors, to separate nature from nurture, is to study twins. Identical twins share all their genes, non-identical twins don't. Twins raised together share aspects of their environment, those raised apart don't. Throw enough of these different twins at a hereditary illness and scientists can start to work out whether their nature or nurture has the most influence. OCD has been studied in twins for decades but the results are hard to interpret. The best guess of scientists when it comes to OCD is that genes and environment are about as important as each other. So, just as someone with OCD cannot blame the nature they received from their parents, they can't blame the nurture they received from them either. Or, if they wish, they could blame both. (What matters most is that the parents do not blame themselves.)

One way that our environment − parents, preschool years and cultural background – could seed obsessions is because these early experiences frequently leave us with dysfunctional beliefs, some of which, as we saw in Chapter Seven, are implicated in OCD. Inflated responsibility could come, for example, when parents give older children too much power over their younger siblings at an early age, or conversely as compensation for giving them no power at all. In problem-solving tests, mothers of those with OCD have been seen to demand more of their children, to expect them to take the lead.

The famous OCD of aviation pioneer-turned-bearded-recluse Howard Hughes may have emerged from his childhood experiences. Hughes died in 1976 and was a fierce defender of his privacy, but details of his bizarre behaviour in later years were pieced together by psychologist Raymond Fowler, a former president of the American Psychological Association who was asked to conduct a ‘psychological autopsy' by the law firm that handled the billionaire's estate.

Hughes showed clear symptoms of OCD, which, according to Fowler, may have related to his mother's fear of polio and the extreme measures she took to protect her young son from the disease. By the time he was in his sixties, Hughes had developed severe compulsive behaviour to ward off germs. His staff had to wear white gloves, pass him cutlery wrapped in paper, and he would burn the clothes he was wearing if someone he met became ill. He gave detailed instructions on how others should feed him tinned peaches – remove the label, scrub the can and pour the contents into a bowl without touching it. He wore tissue boxes on his feet.

It is hard to pin down how parenting style contributes to OCD because to draw definitive conclusions, adults with OCD must be asked to recall how their parents behaved some twenty or thirty years or more before. A handful of studies have looked at the impact of parenting style on the mental health of children in real time, but only for the broader problem of anxiety. (High parental control and overprotection did seem to make children more anxious, but it is impossible to tease out the impact on OCD from this research.) The only known study to compare the behaviour of parents of children with OCD, and parents of children with other anxiety disorders, suggested the mothers and fathers of the OCD kids showed less confidence in their children and were less likely to reward independence. The study, however, was small (just eighteen children with OCD) and it does not prove that the parenting style was to blame.

As a parent concerned I will pass OCD on to my children, none of that is very helpful, but that's the way it is. Most parents make it up as they go along anyway. It's hard to stick to a script, even if we knew what it should say.

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There is clearer evidence on the damaging impact of what's called family accommodation of someone's OCD – parents and siblings drawn into the obsessive web of a loved one and forced to help perform their ridiculous compulsions. Mrs D, for instance, was obsessed with contamination from other people and would sit only on a single chair that she would disinfect each morning and which nobody else was allowed to touch. Mrs D's compulsions demanded that her three children stay two or three feet away from her. The children had no choice but to comply – their mother made the rules.

In their 1980 book
Obsessions and Compulsions
, Stanley Rachman and Ray Hodgson described an extreme case of accommodation of the contamination rituals of a 19-year-old man called George by his elderly father Harry. Each morning, Harry said, he would help his son dress while taking care not to touch the outside of his clothes. A trip to the toilet was next and, Harry said, it was a palaver. It was easier if George wanted only to urinate, Harry said, because his role then was then only to get down on his hands and knees with a flashlight to check his son's trousers and boots for splashes, or the floor for pubic hairs. As soon as George did up his trousers, Harry would have to wipe the zip with a pad soaked in antiseptic.

Life was better outside the house, if they could get there. If George saw a speck of brown in the car he said it was dog dirt and Harry had to scrub the seats. About to go out one day, George felt suddenly compelled to have a bath and delayed their departure by three hours. If George felt Harry had not cleaned properly he would get angry and smash crockery and furniture; he once threw a bar of soap through a window pane and then started to worry about the broken glass, which he insisted that Harry clear away.

Harry was in an impossible situation. And it's one faced time and again by the families of people with OCD. Surveys show that three-quarters of the relatives of people under the age of 17 with OCD become involved in the rituals. More than half the relatives of adult sufferers do too. Some do it because it pains them to see the person they love in such distress; distress which seems easy to lift, at least temporarily. Others indulge the compulsions for the sake of an easier life. It is much simpler, for example, for a family member to agree to leave the house last, than it is to wait for a compulsive checker to do so only after they thoroughly check all doors and windows are closed. And, like Harry, some relatives agree to participate in the rituals because it seems to make the situation worse if they don't. People with OCD can get angry and accuse others of not caring for them if their families do not obey their rules or offer the requested reassurance.

Sometimes the anger is well directed. Children and siblings of people with OCD have been known to exploit the disorder's fear and anxiety as bargaining chips – ‘If you don't let me use the car/borrow your jumper/go to the party then I'll walk in my dirty shoes all over your bed.' Together with the insults and mockery that some families hand out to relatives with OCD, psychologists describe such responses as hostile non-compliance. Not surprisingly, hostile non-compliance doesn't help. In fact, criticism can make sufferers more likely to carry out their rituals.

However, compliance – hostile or otherwise − does not help either. Family accommodation of OCD is linked to more severe symptoms and worse functional impairment. And it interferes with some types of treatment, especially behavioural techniques. Families who want to help someone with OCD must aim for the middle ground: nonhostile noncompliance, or noncritical support with no accommodation of rituals. That's easier said than done.

Just as someone with OCD does not respond to reason or appeals to their rational side – ‘look, there is no HIV on the towel, just use it' – so it's not as simple as telling a distressed and loving dad such as Harry merely not to wipe his adult son's zip with antiseptic each time he uses the toilet. It seems vital that, when people with OCD seek and receive treatment, those who live with them are made to know and understand what's involved and what's at stake.

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When it comes to the possible causes of OCD, the legacy of biology and history – DNA, early experiences and evolution − is only half the story. Biologists talk about short-range and long-range causes of behaviour. (They call them proximate and ultimate.) It's a distinction neatly demonstrated by the tale of the monkey, the snake and the flower, which sounds as if it should be a children's parable or a puzzle about how to get them across a river, but actually describes a series of famous experiments carried out in Wisconsin in the late 1980s. In the studies, psychologists found that hand-reared rhesus monkeys had no instinctive fear of snakes. Why should they have – the animals had never seen one. Pictures of snakes and toy snakes placed next to them had no effect.

That changed after the animals were shown video of the way wild monkeys react to a snake: with lip-smacking fear and restless anxiety. After they saw these images, the lab-reared monkeys quickly developed the same response. Shown the same pictures and toys as before, from then on they would react just as the wild monkeys did. They had learned fear.

When the psychologists tried to use the same mechanism to make the lab monkeys afraid of flowers, they failed. No matter how many times the lab animals watched footage edited to show wild monkeys react with panic to a flower, just as they had to the snakes, the hand-reared animals wouldn't buy it. The difference was down to evolution, the ultimate cause of the monkeys' behaviour. Millions of ancestors who ran away from millions of snakes over millions of years have left their mark on the biology of today's rhesus monkeys in a way that nonthreatening flowers simply haven't.

The ultimate causes of OCD could indeed be genetic, or evolutionary, or found in the circumstances of our family home, but this cannot fully explain why some people develop OCD and some don't. And it cannot explain why people who develop OCD do so just when they do. What are the proximate causes of obsessive and compulsive behaviour? What events in our individual lives trigger the dormant OCD threat? One thing is clear: that someone has not developed OCD so far does not mean they will not succumb to it in future.