Woman Who Thought too Much, The

by Limburg, Joanne

  By contrast, I have no trouble at all in accepting that my obsessions might emerge, without any philosophical justification, out of the disordered activity of an animal brain. I’m thinking again about the ‘fixed-action patterns’ I touched on in ‘Habits’, the compulsive skin picking that I always felt was so senseless and seemed to come from a mute part of me. There are disorders in animals, such as canine acral lick, which have been thought to resemble OCD spectrum disorders, and so shed further light on their nature. Ethologists, who study animal behaviour, have also observed certain dysfunctional fixed-action patterns in some animals, which look, on the face of it, very similar to the compulsive behaviours of human OCD sufferers. The ethologist Konrad Lorenz kept his greylag geese in the house with him. He noticed that one of them always walked in a particular way when she returned home.

  At first she always walked past the bottom of the staircase toward a window in the hallway before returning to the steps, which she then ascended to get into the room on the upper floor. Gradually she shortened this detour, but still kept on heading toward the window before turning around and heading up the stairs.

  One day Lorenz forgot to let her in at the usual time. By the time he opened the door for her, darkness was beginning to fall. Eager to get in, she ran through the door, went straight for the stairs, and began to climb them. Then, as Lorenz tells it:

  Upon this, something shattering happened: Arriving at the fifth step, she suddenly stopped, made a long neck, in geese a sign of fear, and spread her wings as for flight. Then she uttered a warning cry and nearly took off. Now she hesitated a moment, turned around, ran hurriedly down the five steps and set forth resolutely, like someone on a very important mission, on her original path to the window and back.

  This time, she mounted the steps according to her former custom from the left side. On the fifth step she stopped again, looked around, shook herself, and performed a greeting behaviour regularly seen in Graylags when anxious tension has given place to relief. I hardly believed my eyes. The habit had become a custom which the goose could not break without being stricken by fear.

  Quoted in Rapoport, The Boy Who Couldn’t Stop Washing, pp. 217–18

  So, the argument runs: a greylag goose, unlike a human being, but like the vast majority of animals, has only a repertoire of inborn fixed behaviour patterns at her disposal. When these patterns are activated inappropriately, the resulting observable behaviour closely resembles that of a human patient in the grip of OCD; therefore, it seems plausible that what we are seeing in OCD might be evidence of what Rapoport calls ‘built-in patterns’, which normally lie dormant in us but reveal themselves in OCD, and which ‘document some stored knowledge that serves an ancient purpose. Cleaning, avoiding, checking, and repeating relate to the most basic preoccupations of cleanliness, safety, aggression and sex’ [p. 218]. If OCD really was something that we shared with other animals, if our brains really did function and malfunction along similar lines, then this would be a great gift to OCD-related brain research, for the practical reason that living human brains are not generally available for invasive manipulation and investigation, whereas, rightly or wrongly, there are large numbers of living animal brains whose owners have been reared for that very purpose.

  To recap: on the brain side, we have OCD’s response to drugs which are known to alter neurochemistry, distinctive patterns of activity as revealed by brain scans, this patient’s subjective sense of the ‘rightness’ of the brain model, anxious geese, and dogs who groom too much. There’s also Tourette’s syndrome. In the same way that, in the popular imagination, OCD is the one where you wash your hands too much and check the oven, Tourette’s syndrome is the one where you involuntarily swear. In reality, coprolalia is a relatively unusual symptom of Tourette’s, which (in Penzel’s definition) is what you have if you are unlucky enough to suffer from both chronic vocal tic disorder and chronic motor tic disorder. A tic is ‘an intermittent, repetitious vocal utterance or motor movement’. Tics are not voluntary: a sufferer may be able to hold some of them back for a certain amount of time, but tics are always driven by very powerful urges, which are experienced physically, so that until or unless they are performed, that person will be in intolerable discomfort, which can only be relieved by carrying out the tic, and carrying it out till it feels ‘just right’. Trying to suppress a tic is like trying to hold in a sneeze.

  Tics can be simple, which are relatively easy to diagnose as such, or complex, which may be harder to identify with any certainty. Simple tics on the vocal side may include grunting, sniffing, clearing the throat and squeaking; simple motor tics include eye blinking, grimacing, head turning or shoulder shrugging. Coprolalia is classified as a complex vocal tic, as it involves recognizable language. Also in this category are echolalia, the senseless repetition of words or sequences of words just heard, and palilalia, the increasingly rapid repetition of words or phrases. Like complex vocal tics, complex motor tics consist of sequences of actions, and more closely resemble intentional behaviours such as jumping, smelling or touching objects, touching other people, or self-harming behaviours – in his memoir Busy Body (2006), the musician Nick van Bloss describes how he is impelled to punch himself, hard, in the stomach. Of course it hurts. The jerking and tensing of muscles which tics involve make pain – sometimes the most terrible pain – another feature of Tourette’s.

  Van Bloss, like a significant number of ‘Touretters’, also experiences many obsessive-compulsive symptoms. Sometimes compulsions, with their repetitive, ritualistic quality, are hard to distinguish from complex motor tics. Sometimes, a distinction can be drawn in terms of the patient’s experience, in that whereas the discomfort preceding a compulsion is mental, that preceding a tic is physical, or sensory, but in practice, it is not always easy to separate the two. Tourette’s syndrome can be classified as an OC spectrum disorder, and something like 20 per cent of those with a ‘classic OCD’ (again, according to Penzel) also qualify for a diagnosis either of Tourette’s, or of one of the other tic disorders. That there may be a genetic link between the two is suggested by studies which have shown a high rate of OCD and/or tics in relatives of TS patients, and a high rate the other way round.46 Following these findings, it has been argued that Tourette’s syndrome, and at least some cases of OCD, may be different expressions of the same underlying problems.

  These underlying problems would have to lie in the brain. Tourette’s syndrome is understood, quite uncontroversially, to be a brain disorder, not a mental illness. From a neurochemist’s point of view, the two disorders appear different at first sight, as the Tourette’s brain has difficulties with dopamine levels, rather than the OCD brain’s struggle with serotonin. On the other hand, the dopaminergic and serotonergic systems are known to interlink; sometimes Tourette’s patients with obsessive symptoms respond to SSRIs, and sometimes OCD patients respond to another group of drugs called dopamine blockers. And then there’s the matter of faulty wiring. In the Tourette’s brain, apparently, there’s a certain pathway between the basal ganglia and the orbito-frontal cortex that just doesn’t function as it should . . . Is it possible, could it be possible, as some have suggested, that OCD symptoms are produced through the same mechanisms as physical tics?

  It’s a tidy notion. I took it and I ran with it. I read somewhere, and agreed wholeheartedly, that the skin picking could be classified as a complex motor tic. So could my pacing. Then there was the pulling-my-hand-down-my-face thing – remember that? – in primary school. And the hair chewing, which I don’t do any more. And the cheek biting, which I do. And the way the end of my nose is always itching so that I’m always not-quite-voluntarily rubbing it (a ‘sensory tic’, that would be). I read a list of ‘Tics Tic’s Tixs Tix’s’ on a site called www.tourettes-disorder.com and found I either had done or still do the following: animal sounds (I sometimes miaow back to cats and on one occasion cawed back to a crow before I’d had a chance to stop myself), hopping, skip stepping, chewing on clothes, nose w
rinkling, stammering and toe scrunching. Sometimes I start running before I know what I’m doing. When I think a distressing thought, I shut my eyes very tightly to make the tension go away, and this is so automatic that it’s hard to say whether it’s willed or not. I remembered a conversation I’d had with my father and my brother after I’d inadvertently danced across the living room once and been embarrassed, and we’d laughed about how we, all three of us, did these ‘involuntary movements’ – that was the word my father used – from time to time.

  You could make something of all that, or you could choose to leave it be. I’m aware that there is a certain absent-mindedness in most of the actions I’ve described, and absent-mindedness is not the same as involuntariness. Some people are just fidgets. And when I compare my experiences to those of someone like Van Bloss, it seems a little ridiculous, not to say insulting, to suggest that I understand what it’s like to suffer from real, fully expressed, diagnosable Tourette’s. For a time, though, I made quite a lot of it. I also noted that Tourette’s and OCD can sometimes be found scudding across the pages of books and websites in a loosely formed conceptual cloud along with attention deficit disorder and various forms of autism. I recognized in myself some of the characteristics of sufferers from the second two, in particular ‘sensory sensitivity’: I’d always found noise and crowds intolerable; like my father, I also hated rough fabrics, hard seams and having to swallow pills. It was a hardware fault; I just couldn’t process certain stimuli. All my problems and I, I supposed, were the products of a slightly tragically but fascinatingly abnormal brain.

  *

  I saw the consultant psychiatrist in October. The waiting area in psychiatry outpatients was ever so much nicer than the cattle-processing plant at the endocrinology clinic, where the queues were long and the nurses behaved as if thyroid dysfunction was something you were being sent down for. There were calm green walls and pot plants, the reception staff were pleasant and there was a general air of tranquillity about the place, as if the very walls understood that the patients here were fragile, and required some delicate handling. It felt like a good step up in the world.

  The psychiatrist came to fetch me. He didn’t shake my hand. I couldn’t remember if all the other doctors I’d met in my life as a patient had shaken my hand or not, and wondered if the not shaking hands was a psychiatry thing, in order to preserve sound doctor–patient boundaries. Perhaps he thought that I might, as an OCD suspect, have anxiety about contamination and so didn’t offer his hand, or maybe, on some unconscious or at the very least subconscious level, he had anxiety about mind contamination through contact with the known-to-be-mad.

  When we had sat down in his office, he explained that he would need to take notes throughout the consultation, and, if I remember rightly, apologized for the lack of eye contact that this would entail. He lifted his pen, and I began the usual recital of what he refers to, in his letter to my GP, as ‘a long history of anxiety, depression and obsessional symptomatology’. He asked about my family history, and alludes in his letter to ‘affective disorder’ in some members, and ‘some obsessional features’ in others. He mentions the bullying at school, my ‘chequered career’ and my miscarriage, but notes, on the plus side, my ‘reasonably’ happy childhood, good relationship with my husband and son, and the fact that I was continuing to write. My writing certainly was going extremely well at the time: I had so much fantastic material.

  The letter moves on to consider my psychiatric history: the ‘mood disorder’ which had first shown itself in my early teens, and my pubescent habit of unplugging appliances and taking extra care on the stairs; the more recent intrusive thoughts and the twenty-year skin-picking habit. The treatments are all there too: the various bouts of counselling and psychotherapy, the fluoxetine and the citalopram. When he comes to his own diagnosis, he describes what he sees as ‘a rather complicated picture’, which includes features of OCD, as well as ‘dysthymia and generalised anxiety’. He adds that I am sometimes ‘more significantly depressed’.

  Not long afterwards, Chris and I changed life insurance providers, and I had to get a copy of the psychiatrist’s letter from my GP for the insurance people to inspect. They also needed to know which drugs I was taking long term – fluoxetine and thyroxine – and how much of each. When I saw the letter, I remember picking up straight away on the term ‘a rather complicated picture’, and saying to Chris how that wasn’t really a term you wanted to see in a psychiatric diagnosis. The insurance company must have agreed, because my premiums went up quite a lot.

  They might have gone up for another reason. It wasn’t as if the psychiatrist had said anything about a lowered life expectancy, either to me or to my doctor. At the end of the consultation, he told me that the good news about OCD was that, if you had insight, the symptoms did improve somewhat with age, as you got used to managing and working round them. He thought that I should continue on the citalopram for the time being, as I had made a ‘partial improvement’, but added that it might be worth going back to fluoxetine if, as the letter has it, ‘the picture [you know, the complicated one] deteriorates at all’. He also agreed with my GP that the patient ‘might benefit from psychological treatment directed at her obsessional symptoms’. He didn’t say so in the letter, but I remember his telling me that my several difficulties might well continue to wax and wane, and it was quite probable that I might need to return for ‘top-up’ courses of this treatment from time to time. For now, he was referring me back to psychological treatment services.

  42. Fred Penzel, Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (Oxford University Press, 2000, p. 54)

  43. That is to say, although it is a very good poo, and Mummy knows you’re proud of it, it’s still a poo, it’s smelly, and she’s going to have to flush it now.

  44. Judith L. Rapoport, The Boy Who Couldn’t Stop Washing (Penguin, New York, 1989, p.11)

  45. The word ‘obsession’, by the way, derives from the Latin verb obsidere, ‘to besiege’.

  46. Dan J. Stein and Eric Hollander, ‘The Spectrum of Obsessive-Compulsive-Related Disorders’ in Essential Papers on Obsessive-Compulsive Disorder (New York University Press, New York and London, 1997)

  Behaviour

  18. I have to do things several times before I think they are properly done.

  The Padua Inventory

  ———

  Through hard work and determination, the symptoms can be controlled or in some cases largely eliminated, and you can maintain a normal life.

  Fred Penzel, Obsessive-Compulsive Disorders

  It had been three years since my first visit to psychological treatment services, and much had changed: they had moved into new premises, and I had a new diagnosis. Last time, I had been referred by my GP, but this time, it was a psychiatrist who’d sent me. As a genuine nut straight from the office of the certified nut doctor, I took it for granted that they would offer me treatment. I was hopeful of a good offer: fifteen sessions at least. And it was almost Christmas. I arrived in a buoyant mood.

  This is not in any way a how-to book, but allow me to pass on just one piece of advice: if you are seeking treatment, never go into a mental health assessment in a buoyant mood; if you suspect yourself of being in a buoyant mood on the day, think hard about all the things that make you most depressed or anxious, and if that fails, take yourself off to the lavatory, lock the door and hit yourself somewhere where it really, really hurts. Because if you don’t, there’s a real risk that they’ll tell you that you don’t need them, and send you on your way.

  To put it bluntly, the psychologist said, I was too well for them: here I was, writing, getting out with my child, ‘functioning’, as she said in her letter to the psychiatrist, ‘reasonably well’, and there they were with dozens of people stuck halfway up their one-year waiting lists who could barely leave their houses. I’d had plenty of therapy already. I’d had cognitive behavioural therapy, and clearly understood how it worked and h
ow to use it, so she really couldn’t see how they could possibly add anything to my understanding of my problems and how to treat them. My skin looked perfectly normal to her, I was choosing to pick it rather than to do something else, and I needed to think about why I was making that choice. As to my other problems, what I needed to do now was to apply the understanding I already had and push myself into doing the things that I feared – bathing my child, travelling with my child, travelling alone. I felt myself compelled to agree that their resources were scarce, that I had got into the habit of playing the sick, helpless one in my relationships, that there was no avoiding the hard behavioural work which no one else could do for me, that I could not expect to be happy all the time, and that there was, as she put it, ‘no substitute for suffering’. There was no need to agree – because she didn’t say so – that I was a spoiled, middle-class therapy junkie who was wasting her valuable NHS time and probably my GP’s as well, but the thought was in the room somewhere.

  She was tempted, she finished, to offer me nothing, but just to give me ‘a push in the right direction’, she would refer me to the local primary care service for a brief course of behavioural treatment. I accepted gratefully, and left, feeling not so buoyant.