Woman Who Thought too Much, The

by Limburg, Joanne

  Not according to Fred Penzel, an OCD expert whose book was one of the first I read. ‘A compulsion,’ he reminds the reader, ‘is basically anything mental or physical that you may do to relieve the anxiety resulting from obsessions. The truth is that many sufferers either fail to recognize many of their own obsessions or mistake mental compulsions for obsessions.’42 My ruminations, which I tried to use to neutralize my obsessions, could be seen as compulsions. As could one of my most annoying traits – my constant reassurance seeking. It was a great relief to be able to file that under the ‘symptom’ heading: it made it easier to resist the compulsion to drive everyone mad by doing it.

  When I returned to the doctor a month later, I was, as she wrote, ‘only slightly better’, but I did have a lot of research to share with her. One of my more exciting findings was that my disgusting, perverted self-harm habit, which I had so often tried and failed to find in any of the literature about ‘cutting’, was actually an OCD spectrum disorder, had a couple of names of its own – dermotillomania, or compulsive skin-picking – and was not unlike trichotillomania, its hair-plucking cousin. I wasn’t the only person in the world who did it, it didn’t mean I’d been abused and forgotten it, it had nothing to do with sadomasochistic sexual impulses, but it was a real condition, with symptoms, and, like the OCD, an entity separable from myself. That was perhaps the greatest relief of all.

  This morning, I dropped my son off at school, then I went into town and did some shopping, then I went to get my right ear syringed. When I got home, I read the newspaper I’d bought in town, then I phoned a friend and talked for half an hour while my Internet connection was down. Then I rebooted and got the connection back again. Then I phoned up the National Insurance helpline and requested a form for a new card, because I’d lost my wallet with the card in it. Then I took a look at my Facebook home page, which had nothing of significance on it. And then it was time for lunch. Now I’ve had lunch, I’ve checked Facebook again, and my email messages, and there are no more excuses to avoid this chapter. Avoidance is such an enduring symptom with me that maybe it would be more honest to call it a character trait.

  The trouble with writing, the trouble always with writing, whether it’s poetry or philosophy essays or psychoanalytic studies, dissertations or memoirs, is that you fear in advance – or rather, you know in advance – that whatever comes out on the page is bound to fall short of the fuzzily luminous piece of perfection that you plan to write beforehand. In order to write anything real, you have to kill that luminous potential, and erect something concretely disappointing in its place. It’s like Milner said: one of the necessary conditions of creativity is the ability to bear the disillusionment which an encounter with one’s real-world, unidealized products inevitably brings.43 If you can get through that, you have a something, which is better than a nothing, be it ever so luminous.

  I wanted to write something incredible about OCD and the brain at this point, something comprehensive yet concise, something which would be comprehensible and interesting to the general reader without oversimplifying the science behind it. I’ve had this perfect chapter in my head for so long: I’ve prepared for it, I’ve read books with ‘brain’ in the title, I’ve surfed and resurfed, I’ve spoken informally to a researcher from the brain-mapping unit at the local hospital, I’ve borrowed half a plastic brain from a friend of mine who teaches neuroscience – it’s on my desk right now and I can’t take my eyes off its cortex, which is implausibly pink and appears to have been sculpted out of petrified blancmange . . . Anyway, I’ve tried. I want you to know that I’ve really tried, but I haven’t been able to turn myself into Jonathan Miller in the space of twelve months. I’ve let myself down, I’ve let my publishers down, I’ve let the OCD research community down, and most of all, I’ve let you, the readers, down. Now I’ve got that out of the way, I can carry on with what I meant to do today.

  For a long, long time, as I’ve said, the mainstream view of OCD was the psychoanalytic one: deep unconscious conflicts, repressed sadism, fixation at the anal stage of development, potty training traumas, etc. Freud’s French contemporary Janet, who had a better feel for the condition than Freud ever did, was left untranslated and, at least in the Anglo-Saxon world, largely ignored. Even though it was generally acknowledged that OCD symptoms were largely resistant to psychoanalytic treatment methods, no rival theory or treatments emerged to replace them. Then, in the last few decades of the last century, things finally started to change.

  Within a few years of each other, two new treatments emerged, one psychological, one biological. A number of psychologists on both sides of the Atlantic began to apply behavioural techniques to the treatment of OCD, a form of exposure and response prevention in which the patient was encouraged to expose themselves to the stimulus that triggered their obsessions, and then try to prevent themselves from resorting to their usual response, which was to perform their compulsions. In this way, they would be able to break their obsessive-compulsive cycle and allow themselves to experience the anxiety associated with their obsessions, rather than fore-closing on it by neutralizing it with a compulsion; this would enable them to become habituated to the thought and its accompanying anxiety, and so the thought would be revealed for what it was – just a thought, no more – and lose its power. Studies were done which found that this kind of treatment, addressing the mechanisms of OCD symptoms rather than the causes, was proving to be more effective than psychodynamic forms of therapy. Behavioural approaches could not help all of the patients all of the time, but they gave new hope to many.

  Elsewhere in Europe, researchers were investigating possible medical treatments for OCD. In the late sixties, a Spanish psychiatrist, Lopez-Ibor, reported that a tricyclic antidepressant called clomipramine, administered initially to treat the depression which accompanied OCD, had been found to be helpful in relieving the obsessive-compulsive symptoms themselves. Following this, doctors at the Karolinska Hospital in Stockholm carried out a more systematic test of the drug. Judith Rapoport, who would later write The Boy Who Couldn’t Stop Washing, was a former student at the hospital and was visiting at the time of the clomipramine trial. When she returned to the States, she and her colleagues at the National Institute of Mental Health obtained a special licence to use the drug in their research into OCD. Initially, they were sceptical.

  I confess that my group and I started the study not at all confident that the drug would work. But after a few years, we were converts. Our patients did not improve when they took placebos (sugar pills that look like the drug but have no effect) or when they took another antidepressant. But when they were on Anafranil [the trade name of clomipramine], most did improve. The thoughts grew weaker. They were able to fight off the urge to carry out ritual activity. For some it was the end of a nightmare.44

  Although clomipramine is an older drug than fluoxetine or citalopram, a second-generation tricyclic, as opposed to a third-generation selective serotonin uptake inhibitor (SSRIs), all three drugs, along with others in the SSRI group, are known to relieve obsessive-compulsive symptoms. Clomipramine works differently from the later drugs, as it is known to affect the levels of another neurotransmitter, norepinephrine, but it also acts on the serotonergic system by inhibiting the reuptake of serotonin into the presynaptic neuron, so increasing its availability in the brain, and promoting better transmission between neurons. Following the success of these drugs in OCD treatment, researchers were able to hypothesize that one of the mechanisms – if not the main mechanism – behind the symptoms of OCD was biological, a result of a disorder of the serotonergic system. According to this hypothesis, serotonin reuptake takes place prematurely in the obsessive-compulsive brain, thus preventing effective electrical transmission between the cells. If this happens across a large enough number of cell junctions, the brain will not function as it should. I have taken both citalopram and fluoxetine, and have found that they both relieve my OCD symptoms. Anecdotally, I can vouch for the correlation.

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p; Further support for a biological view of OCD came from the development of brain-imaging techniques, such as positron emission tomography (PET), single-photon computed tomography (SPECT) and magnetic resonance imaging (MRI). These enable researchers and clinicians to measure relative levels of activity across different areas of the brain, and to track changes in these levels across time. Over the last twenty years or so, there have been a number of studies which have used imaging techniques to compare patterns of brain activity in OCD sufferers and non-suffering controls. The brains of OCD patients have shown characteristic patterns, with higher than normal levels of activity in two particular areas: the basal ganglia, a small cluster of structures in the middle of the brain which, among other things, enable the individual to coordinate their physical movements, and the orbito-frontal cortex, which sits above and behind the eyes, and helps to regulate ‘such things as anxiety, impulse control, meticulousness, personal hygiene, perseveration, and the starting and stopping of behaviours’ [Penzel, pp. 396–7].

  Much of the research in this area was undertaken by a research group at UCLA, lead by Jeffrey Schwartz, who came up with the ‘brain lock’ theory of OCD. This hypothesis offers an explanation of what might be going on in the brain when SAUCEPAN – HOT – OUCH! fails to turn itself off. It suggests that there is a problem with the pathway between the orbito-frontal cortex, a particular basal ganglia structure called the caudate nucleus and two further regions: the thalamus, which relays signals between different parts of the brain, and the cingulate gyrus, a part of the brain’s limbic system, which processes emotion. If my hand strays too near a hot saucepan, the orbito-frontal cortex will register that something is amiss and send a signal – you could call it a ‘worry signal’, an ‘error message’, or, if you like, an ‘alarm’ – to that effect to the thalamus; this stimulates the nerve cells in the thalamus, which start firing away and send powerful signals to various other areas of the brain, prompting the cingulate gyrus to initiate a worried feeling and all the physical sensations which come with it, and causing the orbito-frontal cortex to interpret the various bits of sensory input, the signals and sensations and signs of arousal – ‘I’ve got a very unpleasant feeling . . . Why? It must be because my hand is about to be burned’ – and initiate appropriate action: Jump to it! Take your hand away NOW!

  So, either you’ve registered that your hand is indeed about to get burned, and you’ve pulled it away, or you’ve realized that, in actual external fact, your hand is nowhere near anything hot and so there’s no real need to be alarmed. At this point, the caudate nucleus, which acts as a gate, or filter, or valve, or checkpoint – choose your metaphor – and determines which of the brain’s innumerable flickers of thought or impulse are significant enough to be relayed to the conscious mind and acted upon by it, steps in, switches off SAUCEPAN – HOT – OUCH! and enables the brain to direct its attention elsewhere. You have that ‘just right’ feeling now; the sequence is complete and you can get on with the rest of your life.

  Unless you have OCD, however, in which case the caudate nucleus is a little sleepy or maybe not quite assertive enough, or perhaps a little indecisive or wishy-washy about what it allows through, and so the orbito-frontal cortex, the thalamus and the cingulate gyrus just keep on screaming at each other SAUCEPAN – HOT – OUCH! SAUCEPAN – HOT – OUCH! even when you’ve pulled your hand away, or realized that the cooker is in fact switched off or you can see perfectly well that you are, say, in the departure lounge at Malaga Airport with your entire family and that therefore neither you nor anyone you love is any danger of coming into contact with a hot saucepan. But as you are at that very moment deeply concerned and anxious about the danger from saucepans, you feel compelled to resolve the matter, to act in some way – your brain is nudging you in that direction – so perhaps you tap the seat in front of you five times to ensure that no one is ever burned by a saucepan, or you turn to your long-suffering spouse and start a discussion about the dangers of hot saucepans so that you can get some reassurance, or alternatively, you sit there and you ruminate about it. And by obeying the promptings to action which arise out of this repeating pattern of faulty messages, you further reinforce the pattern. Your body is in the departure lounge, and you are conscious of this, but as far as your orbito-frontal cortex, your cingulate gyrus and your thalamus are concerned, you’re stuck in the kitchen, and the gas hobs are hot. They’ve made each other hysterical, and now they won’t listen to reason.

  Schwartz has developed a self-treatment method informed by this model, and has published his method in a self-help book, Brain Lock (1996). What is crucial to this method is the patient’s ability to ‘relabel’ and ‘re-attribute’ their obsessions and compulsions, so that she can come to understand them as arising from a malfunctioning organ – the brain – and in doing so detach them from her self, from her own intentionality and her own agency. As a sufferer, I find something very appealing about this view: it’s not my mind, it’s my body; my eye teeth were impacted, my thyroid conked out and now it turns out that my brain is on the fritz, and maybe always has been. The thing is, although we – by which I mean, my GP, my husband, my friends, the writers of textbooks for professional readers, the authors of memoirs for general readers, the newspapers, the BBC website, the Royal College of Psychiatrists, the government, the World Health Organization and I – talk of mental illnesses as ‘illnesses’, in the same way that we might talk about Hashimoto’s disease, or influenza, or cancer, I’m not at all sure that, down in our gut of guts, we’re really entirely convinced. I know I’m not. Can you link the symptoms to a known pathogen? Can you see anything through a microscope? Can you point to anything at all? Perhaps when we call these experiences, or patterns of behaviour, ‘illnesses’ with ‘symptoms’ we are doing so only by analogy with the proper diseases, the cancers and the influenzas. So, are they illnesses, really, or do they belong to some other category? Attention-getting strategies? Sulks? Tantrums? Lame excuses? Character faults? Moral weaknesses? Do I feel unconvinced, because I know, deep down, in my gut of guts, that I’m to blame for my suffering, that I chose my suffering, and that, if I wanted to, I could choose to lay it aside?

  But if it’s my brain, an organ, and here’s the physical evidence – the MRI scan, the PET scan – to prove it, then my suffering has been visited on me, from outside, and I didn’t do it, I didn’t choose it, and you can go ahead and feel sorry for me now. And I can feel sorry for myself. I’ve got a disease, and, like cancer patients do, I can ‘battle with’ it. I can do the best I can despite it. You can all root for me. You can admire me too, if you like. It’s a much more straightforward narrative now. It’s got a clearly identified antagonist, and a sympathetic heroine.

  Now it appears that my tone has been tragically afflicted by another bout of snideness, but I’ll try to battle that for a moment, and say that I really do find the brain view very plausible. It fits in well with the way obsessions feel. The thoughts are, as the literature says, intrusive: they are experienced as coming from the outside. An obsession45 is like a bully or a nag, standing too close to you, gesticulating in front of your face, shouting into your ear. You know they’re shouting nonsense, but you’ll do anything you can to appease them because you find what they’re doing to you, all the bullying and the nagging, so unbearable. You feel in two minds, only you can see that one of your minds, at least, has lost it.

  In my experience, depressive thoughts are quite different from obsessions, not only in content but also in form. It isn’t only, as I said in the chapter entitled ‘Sin’, that they are past rather than future orientated; sometimes they are future orientated, but without the anxious uncertainty of the obsessive rumination, that is, you are certain that you can predict the future, and that the future is going to be shit. Everyone I love is going to die; I myself am going to get old and getting old is horrible; over time, more bits of me will stop working and the exterior bits will look worse and worse; at the end of that nasty process, I’ll die; the wor
ld is full of suffering; there is no discernible point to any of this. I can find plenty of evidence in support of the first five statements and no good reason to doubt the sixth. I am always entirely in agreement with myself when I think along these lines. I’ve tried cognitive behavioural therapy for this, but it couldn’t get much of a purchase.

  I can see that I would be better off without these thoughts, that by allowing them into my mind again and again, and letting them run their course, I am helping myself to suffer. I appreciate that all this death business, as Larkin said, is ‘no different whined at than withstood’. I can even believe that, if I managed to change my thinking habits – because they are habits – in this regard, I might well be physically healthier, because habitual thoughts have a way of working themselves into the body, its posture, its sleep patterns, its digestion and its appetites. I can’t argue with them, though, and I can’t stop noticing that we are living in time, that everything changes around us, that we lose much as we go along, that in the end we lose everything, and I can’t see this as anything but irredeemably sad. I could never accept an explanation of these thoughts that was purely biological: they come out of the thinking, philosophizing, essentially human part of me – my mind, the part that writes the poems.