Woman Who Thought too Much, The

by Limburg, Joanne

  By the way, the advice above applies only to those seeking treatment on the NHS: in my experience, if you believe that therapy will help, and you can pay for it yourself, you’ll very likely get it.

  By relying on the testimony from the psychiatrist, I had made a serious tactical error in my quest for treatment. I had forgotten that professionals prefer to make their own minds up, to assess what walks into their offices on the day, and I had forgotten, too, that they do this largely by looking for external signs, behaviours. In order for them to believe that you are depressed or anxious, you need to act the part. What they are asking from you is that, to borrow a phrase from my five-year-old son, you ‘show me the face of how that feels’. Show your sad, scared face – don’t try and save it. Where resources are scarce and waiting lists long, you’d best leave your dignity and self-restraint outside the consulting-room door.

  A few months ago, someone sent me a copy of a new book, a cultural history of obsession by an American academic, Lennard J. Davis. In a section on self-help books and memoirs, he writes that: ‘The very nature of self-help books, particularly first-person ones, is that they trace a heroic path from a low point of disease and disorder to a high point of triumph over despair.’47 I had thought that I was getting to that triumphal point: I’d had the ‘eureka’ moment in the library, I’d finally found a couple of clinically defined concepts – obsessive-compulsive disorder, compulsive skin picking – that offered an explanation for certain bewildering, frightening and shaming parts of myself, and allowed me to attribute them to something other than myself, to a bodily organ, my brain. Now all I had to do was to obtain the treatment to which that officially dysfunctional organ entitled me and then I could begin, at least, to manage my symptoms, to claim my life back from my adversaries – my compulsive skin picking, my OCD.

  As Davis points out, wider medico-historical narratives of OCD also tend to follow this kind of ‘heroic path’. This was the story I told in the last chapter, where I traced the progress of OCD from a poorly understood disease, wrongly thought to be rare, and with a poor prognosis, to a condition which is now treatable, has been revealed to be common, and is well on the way to being explained. It’s the brain, so the story goes; it’s the dysfunctional basal ganglia, it’s the abnormal serotonin system. It’s physical. Family studies suggest that it might even be inherited (we just haven’t found the relevant genes yet). So what can you do? You medicate. You pin your hopes on trans-cranial magnetic stimulation, a brain research tool which looks as if it might, maybe, one day, be an effective treatment. You look to the drug companies to keep funding that research, to keep the big, expensive scanners running.

  That’s our straw man built, now let’s give him a good kicking. The first kick is a fairly gentle one, a friendly tap from the neuroscience side. When I had put myself in the straw man’s place, I had found it tempting, for many reasons, to see myself and my problems in terms of this simple equation: BRAIN = DESTINY. I was born that way, I had grown up that way, and, if left unmedicated, that is the way I would always be. It’s a static picture: OCD is written into the body, is stable across time in the individual, and – if you apply this to the bigger picture – stable across history too. My brain is like Samuel Johnson’s brain and St Ignatius of Loyola’s brain and Martin Luther’s brain and Hans Christian Andersen’s brain and all those other brains which have been posthumously diagnosed in the last few decades.

  First of all, even if you accept that a certain proportion of human brains have been addled by OCD since prehistory, there is no need to conclude that these brains can do nothing to help themselves. It has long been accepted that a developing brain, a child’s brain, is partly shaped by nurture. More recently, as recounted in triumphal narratives such as Norman Doidge’s The Brain that Changes Itself, researchers in various fields of neuroscience have found more and more evidence that the brain retains this ‘neuroplasticity’ – the capacity to reshape itself – into adulthood. This is why and how practice makes perfect, this is why and how we develop habits; it also offers us the means of breaking them. Jeffrey Schwartz’s behavioural self-treatment method for ‘brain lock’ is based on this idea: once the patient has relabelled her invasive thoughts as OCD and re-attributed them to a fault in her brain, she can then refocus her attention, so that, for example, every time she finds herself thinking that she might stab her child, she can think of the music playing on the radio instead, or attend to her washing-up, or pick up an absorbing book, and not perform her compulsion, ruminate or run away. Schwartz describes this technique in terms of the patient’s performing a ‘manual gearshift’ in her brain, which, if performed consistently enough, will, over time, enable the patient to bypass her obsessive-compulsive circuit, rather than get sucked further into it. It’s a matter of habit: the less you perform your compulsions, the less you want to. It’s also a matter of rewiring the brain, and to make this clear, Brain Lock has before and after scans of patients’ brains prominently and colourfully displayed on its cover: You can change your brain!

  Well, maybe you can. Certainly, if your usual patterns of thinking and behaviour change, the picture on the scanner will change too. That much we know: that much has been observed. What nobody could claim to know, at this stage, is what the relationship between the changed nature of the mental activity and the changed levels of activity in different parts of the brain actually consists in. It’s like the sadness and the serotonin levels: it could be that certain patterns of brain activity cause OCD; on the other hand, it could be that what the scans are showing is the brain’s response to the anxiety generated by certain mental events, by obsessive thoughts, as it is ‘desperately trying to calm a system which is under pressure from too much anxiety’.48 When it comes down to it, a brain scan can show a researcher which regions of a particular brain happen to be metabolizing glucose at a given moment, and that is all. I don’t know if Schwartz would agree with this, but I have read and heard several OCD experts who work with a cognitive model of the disorder saying that nothing of any clinical use has yet come out of those big scanning machines. This is in spite of the fact that an awful lot of money has flowed in. Science moves pretty slowly; speculation and conjecture run on ahead.

  When advances are made, they often seem to happen accidentally, or at least incidentally. Take pethidine, for example, which was discovered to be a powerful painkiller by two scientists who were looking for a spasmolytic. Sometimes, what starts out as a drug’s side effect can end up as its main therapeutic purpose. Iproniazid was originally prescribed to treat tuberculosis; when so many patients taking it grew so cheerful that the effect had to be more than coincidental, one of the first effective anti-depressants was born. I’ve already told the story of how clomipramine emerged as a treatment for OCD only after it had been prescribed to patients to treat the depression that accompanied their OCD, and was then found to ease obsessive-compulsive symptoms in some of the patients who took it. We know that clomipramine, and many other newer drugs, act in such a way as to reduce the reuptake of serotonin throughout the brain; we also know that if you give these drugs to people who suffer from OCD, a certain proportion of them will show, or report, a reduction in the severity of their symptoms. That, again, is all we know.

  It’s all so tantalizing – the lit-up brain patterns, the response to a drug that is known to act on a particular system, the resemblance of certain obsessive human behaviours to certain animal ones, the prevalence of OCD among Tourette’s sufferers – and it’s undoubtedly fascinating, but on closer inspection, all it amounts to is a bundle of correlations, ‘links’, ‘associations’, ‘similarities’; nothing causal; little proved. It is perfectly possible – maybe even probable – that the obsessive-compulsive symptoms which Nick van Bloss experiences come from a completely different source from the ones which have been plaguing me, and are expressive of an entirely different disorder.

  And as no research has yet shown any relationship between brain activity and chemistry – or i
ndeed any other factor – on one hand and the content of particular obsessions on the other, it is also by no means certain that I am suffering from the same condition as someone who washes her hands ten times an hour, that she has the same affliction as the man who keeps stopping his car and getting out to check that he hasn’t run over anyone, or that his underlying pathology is in any way similar to the woman living next door to him who can barely move through her front hall because she’s spent the last seven years compulsively hoarding her junk mail.49 The causes may well be quite different in each case – and that’s ‘causes’ not ‘cause’. Veale and Willson describe OCD as arising from a cocktail of various psychological, biological, and social factors.

  The ingredients and quantities that make up the cocktail in the glass will be different for each unique individual, and they also mix in different ways . . .

  One day there will be an adequate model of OCD that integrates biological, psychological, and social factors, but a lot more research needs to be done before we arrive at it. For the present, when anyone tells you ‘the cause’ of your OCD, don’t believe them; the combination of causes for each person is likely to be unique, with different factors all interacting in a complex manner. [p. 42]

  OCD is a mental illness, an illness of the mind. I do not know how the mind and the brain are related, and neither does anyone else. Let’s leave it at that.

  My GP was not at all happy that I had been bounced by psychological services, and tried to find some alternative sources of support for me. She got in touch with a local mental health charity, who were able to offer me help through their befriending scheme. My son was my priority: it was all very well to hobble my own life with my avoidant habits, but I had and have no right whatsoever to keep him so confined; he was getting bigger and more curious all the time, and he needed his world to expand with him. I asked if somebody might accompany us on trips out, and for the next few months, every fortnight or so, a very pleasant and interesting woman would pick me and my son up, and we would go into town together, either on foot or in the dreaded bus. I was lucky to have this help, and lucky too in my friends, who strapped my son’s car seat into their cars alongside their own toddlers, and took us all out to harrowing out-of-town supermarkets and terrifying playparks. Back home, Chris continued to put up with me. I think that the boy must have caught a nasty cold sometime in February, because I found this conversation in my notes:

  ‘How will I know if he develops meningitis during the night?’

  ‘Why would he develop meningitis overnight?’

  ‘Well – why wouldn’t he?’

  ‘How would you tell if I developed meningitis during the night?’

  ‘I – don’t know.’

  ‘Well you’d better stay awake all night then, hadn’t you, just in case.’

  You can learn a lot about OCD by examining this little exchange, not about the causes of OCD, but about the kind of beliefs and thinking habits which, along with compulsive and avoidant behaviours, are understood to maintain it. The cognitive behavioural model of OCD focuses on these beliefs and behaviours. I have already touched on most of these elsewhere, but, following on from Veale and Willson, for quicker reference, here is a list:

  Avoidance and Safety-Seeking – I refer you to the discussion of road-crossing dilemmas in ‘Dependence’, in which I considered the theory that the only way to avoid being run over is never to cross the road when you can see a moving car; as the behaviour informed by this belief has kept me safe up till now, I am reinforcing the belief every time I engage in the behaviour.

  An Inflated or Exaggerated Sense of Responsibility and Magical Thinking – A belief that one has the power to cause or prevent bad events from happening, and that, therefore, one has the responsibility to prevent them. In the meningitis conversation, I am working from an assumption that I can prevent my child from becoming ill, that it is therefore my responsibility to prevent my child from becoming ill, and that I should try to do this by anticipating every possible scenario, and then ruminating about it. If my child falls ill, it has to be my fault, because I failed to do enough to prevent it. ‘Magical thinking’ refers to the superstitious thinking behind some people’s OCD symptoms, such as the compulsion to touch every lamp-post one passes in order to keep one’s family out of danger. Of course, many people without OCD have their little superstitious habits, just as many of them also have a habit of worrying, that is of seeking to avert all possible disasters by anticipating them in advance. In political terms, this belief in the magical power of foresight is known as the ‘precautionary principle’ and is the reason why you can never find a rubbish bin in a railway terminal, or leave your baggage unattended. It will not, however, prevent a suicide bomber from sitting down next to you on the bus and detonating his backpack. You could try never travelling on a bus, but that doesn’t mean you won’t get cancer.50

  The Over-Importance of Thoughts – It is perfectly normal to experience intrusive thoughts and images, and equally normal for these to be taboo in nature; you would only be abnormal, say Veale and Willson, if you didn’t have them. These thoughts are not the problem: the problem, for the OCD sufferer, is the importance she attaches to them, the meaning she ascribes to them. In ‘Harm’, I talked about one aspect of this, ‘thought-action’ fusion, the belief that a bad thought or image, such as the thought of stabbing one’s baby, will not only lead to a bad action, but is a kind of bad action in itself. This kind of belief can have a distinctly moralistic tinge, and can turn a young student’s fleeting, completely normal thoughts about what it might be like to have sex with her tutor into evidence of the twisted, disgusting perversity of an exceptionally dirty girl. Some people with OCD believe that the presence of the thought indicates that they could have done the terrible action already, only they don’t remember it: ‘How can I be sure that I haven’t stabbed a baby? The image is so immediate, so terrifying. Maybe it’s a memory of something real?’ For the OCD sufferer, an intrusive thought is not just some bubble of a thing that rises up to the top of your head and then pops without trace; these thoughts carry real weight, they are responsible for them; they can and should control them. These attempts at control, are, of course, self-defeating. Whatever you do now, don’t think of a white bear, I said – don’t! Stop it! No white bears! No white bears! NO. WHITE. BEARS!

  Overestimation of Danger or Risk – This is something which OCD has in common with other anxiety disorders. How likely was it that my son’s cold would develop into meningitis? That I would inadvertently step in front of a van at the next pelican crossing? That I would set my desk chair on fire, be unable to put it out, be incapable of escaping and burn to death in the loft? That I would skid on the kitchen floor with a knife in my hand and accidentally stab my husband in the heart? If you are in the habit of attaching great importance to these thoughts, and to paying more attention to them than to the evidence outside you, then this is likely to bias your answer.

  Intolerance of Uncertainty – But I have to be absolutely sure that my son won’t develop meningitis, not tonight and not ever, or the matter cannot rest.

  Perfectionism – I spent the best part of a day writing this paragraph over and over again, but I still couldn’t get it completely right so in the end I just deleted it.

  Attention, Bias in – The lion’s share of this will be focused on anxiety, and on the signs of dangers which seem to justify it. You don’t see the kitchen, because you’ve already zoomed in on the saucepan.

  Interpreting Ambiguous Information – If my son has pain in his neck, I’d better assume it’s meningitis, even if there are no other symptoms – just to be on the safe side.

  Anxiety, two habits and one attitude that make it worse – Awfulizing: It’s vile! It’s dreadful! It’s the worst thing ever! Catastrophizing: And it’s going to be the death of me! That is, if the advanced, untreatable cancer that’s making my stomach hurt doesn’t get me first.

  Low Frustration Tolerance – What I’m demonstrating,
apparently, when I call the feeling of anxiety ‘unbearable’. If the anxiety is something you believe you can’t bear, you’ll do whatever it takes to make it go away as quickly as possible, or even to stop yourself feeling it in the first place.

  So now you know you all this, you understand the cognitive and behavioural underpinning of your obsessions and compulsions, but no amount of understanding, by itself, will make them go away: even the most rational thoughts are nothing more than thoughts, and they can bring nothing about. Thinking about getting better is not the same, unfortunately, as getting better. The lessons you need to learn – that anxiety is not the worst thing in the world, that thoughts are only thoughts – can only be learned through experience. You need to start crossing busy roads, using the big knife in the kitchen, taking your baby to the supermarket, and handing in imperfect copy. You have to allow your bad thoughts in and let them follow their course.

  When I interviewed Dr Veale, he asked me if my obsessional symptoms had gone. No, I said, they were still there: I just ‘kind of swatted them away’.

  ‘Welcome them,’ he said. ‘Welcome them. Don’t fight them – just let them be there.’

  I thought about this for a moment. ‘Yeah. Well, my child – who is four and a quarter – will lie down on the floor and I’ll think, Ooh – I could stamp on his neck! – and then I think, Yes I could, but I won’t.’ And I laughed.

  Then Dr Veale said, ‘Well, you could do that, or you could imagine in your mind a nice little picture of stamping on it, and blood going all over the place, and the blood all over the place!’

  I laughed again, but first I screwed my face up as tight as it would go. I wish there were another way, a less painful way, but, as things stand, there really is no substitute for suffering. And you can’t get anyone else to suffer for you either. For any practical purposes, both the problem, and the means of dealing with it, are in your mind. We speak of the mind as something you can make up, something you can change. It is both the source of our agency, and subject to it.