Impulsive behaviors involve acting without planning or even thought, driven by pleasure seeking and an urge for immediate gratification. They have an element of risk seeking—Hey, I bet it would be a blast to swan dive off this cliff!—where the risk is expected to lead to a feeling of reward. Pyromania and kleptomania are classic impulsive behaviors because they’re all about seeking pleasure and excitement. As a result, impulsivity can be the first step toward a behavioral or substance addiction. Something (a stimulus) triggers a response, and the pathway from the stimulus to response does not pass through the cognitive or even the emotional brain, at least not consciously. Instead, an urge zips from your most primitive brain center to your motor cortex—Claim that wonderful sofa someone left at the curb; grab that luscious-looking cherry cheesecake from the dessert cart—without so much as a pit stop in regions that control higher-order cognitive functions (Where the heck would you put another couch? You know you’ll feel guilty if you eat that). You do it reflexively. Like addictions, impulsive behaviors “have a hedonic quality,” Jeff Szymanski, executive director of the International OCD Foundation (IOCDF), told me when we met in his hotel suite during the Foundation’s 2013 annual meeting. “ ‘I stole and got away with it,’ ‘I lit this fire and got all these cool fire trucks to show up’—very much like, ‘I gambled and won.’ It’s not about reducing anxiety.” We give in to impulses because we expect to be rewarded with a feeling of pleasure or gratification or excitement. Impulses make us grab the 500-calorie muffin when we were sure when we entered the store that all we wanted was a skinny latte. Like addictive behaviors, impulsive ones offer the allure of something pleasurable. Impulsive behaviors become impulse-control disorders when you repeatedly give in to your urges and suffer detrimental consequences.
Compulsions, in contrast to addictive and impulsive behaviors, are all about avoiding unpleasant outcomes. They are born in anxiety and remain strangers to joy. They are repetitive behaviors we engage in over and over and over again to alleviate the angst brought on by the possibility of negative consequences. But the actual behavior is often unpleasant—or at least not particularly rewarding, especially after umpteen rounds of it. At its simplest, the anxiety takes the form of the thought If I don’t do this, something terrible will happen. If I don’t check my BlackBerry constantly, I’ll miss seeing emails the millisecond they land, and will therefore not reply in time to an urgent invitation or demand from my boss, or will just feel like I don’t know what is going on. If I do not check my fiancé’s Web history, I will not know whether he is cheating. If I do not religiously organize my closets, my home will be engulfed in chaos. If I don’t shop, it will be proof that I can’t afford nice things and am headed for homelessness. If I don’t hang on to each precious object and instead bow to my family’s wishes that I shovel out the clutter, I will feel exposed and vulnerable, like my most treasured memories have been buried in a landfill.
Underlying every compulsion is the need to avoid what causes you pain or angst. “A compulsive behavior is one that’s done with the intent of decreasing an overwhelming sense of anxiety,” said Szymanski, who before becoming executive director of the foundation in 2008 treated patients at McLean Hospital’s Obsessive Compulsive Disorder Institute. Unlike addictions with their frisson of risk taking, he said, “a compulsive behavior is risk averse,” driven by the need to avoid harm and executed with the goal of reducing the anxiety triggered by the thought of that harm. I must do this to quell my fear and anxiety. The roots of compulsion lie in the brain circuit in charge of detecting threats. This circuit, receiving a message from the visual cortex that a stranger is lurking in the dark doorway up ahead on the deserted street where you’re walking alone, screams, danger, danger! “That’s anxiety,” said Szymanski. “It’s the feeling that something is not quite right and that you may be in some sort of danger. You have a crushing emotion that you would do anything to get rid of.”
Soon after interviewing Szymanski, I trekked up to the Bronx to meet Simon Rego, a psychologist at Montefiore Medical Center who specializes in OCD. “As long as the function is to relieve distress or anxiety or prevent a catastrophe that you firmly believe will otherwise happen, it’s a compulsion,” he said. “People will do a compulsion until ‘it feels right.’ Compulsions come from a sense that if I can’t do this, I’m terrified about what will happen. The relief from distress can be pleasurable, if you think that calling a halt to smacking your head against a stone wall is pleasurable, but not in the same way that an addictive behavior is pleasurable.”
Thus, a compulsive behavior is one that you engage in to squelch anxiety. That’s clearest in OCD, where a compulsion is paired with and preceded by a specific obsession, an anxiety-provoking thought that you can’t shake. You are obsessed with the thought that your hands are dirty and so you compulsively wash; you are obsessed with the thought that you left the stove on and so you keep returning home to check; you are obsessed with the belief that stepping on a sidewalk crack will bring a world of tragedy down upon your family and so you meticulously pick your way across the concrete.
The examples of the self-destructive rituals that OCD sufferers resort to in order to alleviate anxiety are legion. David, whom I visited in his Brooklyn apartment, apologized that he had not showered before I arrived. The reason, he said, was that when he showers he feels so compelled to scrub every square millimeter of his skin, and so certain he has missed a spot, that he will spend hours and hours under the pounding water, which would have made him late for our appointment. Others with a similar shower compulsion have it even worse: they use up the building’s hot water and put them at risk for hypothermia when they can’t leave the stall despite the freezing-cold water pouring onto them.
By the end of my taxonomic odyssey, I had settled on this: A compulsion differs from an addiction because the initial impetus is alleviating anxiety, not finding pleasure, and because how much you need to engage in the compulsive behavior in order to do that does not escalate, as it does with an addiction. A compulsion is a driven behavior where the emotion behind the wheel is a psychic itch, a sense of distress, even a sense of foreboding which grows worse and worse if you do not give in. “Compulsive behavior is a form of self-medication,” as James Hansell put it. “There are painful emotions being numbed or soothed or avoided by means of the compulsive behavior. There is anxiety underneath it.” The compulsive behavior keeps pain at bay. It’s a form of self-reassurance—Everything’s okay now that I’ve checked the BlackBerry in the elevator leaving my office all of fifteen seconds after I checked the email on my desktop, but boy, I feel much better. Oh, wait, maybe a new one has arrived . . . Compulsions become habit-forming because they work so well: my worries about being out of the loop by failing to read a text the instant it lands melt away when I check compulsively. So I’ll just keep doing it.
Complications Ensue
Just when I thought I had it all sorted out, Scott Caplan, a psychologist at the University of Delaware who studies excessive online gaming and Internet use, warned me, “Remember, ‘addiction’ and ‘compulsion’ are just words that people came up with. They may not track nature perfectly.”
Among the imperfections: an addiction can become a compulsion in the sense I’m using it. Over time, a behavioral addiction that began with thrill and pleasure seeking, driven by an overpowering desire for risk and reward, can segue into being all about assuaging the anxiety, agitation, and overall misery that come from tolerance and withdrawal. The addict uses the substance or engages in the behavior compulsively even though the reward waiting at the end of the rainbow is pleasurable only in the sense that when you stop hitting yourself over the head with a hammer it feels pleasurable. Deep into an addiction, said psychologist Nicole Prause of the University of California, Los Angeles, “a reward state changes into an aversive, craving state, and you begin to take a substance or engage in a behavior to decrease negative affect. You don’t want to do it, but you have to in order to get yourself b
ack to baseline, emotionally and psychologically.” What had been an addiction morphs into a compulsion.
Another wrench thrown into this neat taxonomy is that the same behavior can be a compulsion for one person, an impulse-control disorder for another, and a behavioral addiction for a third. One over-shopper hits the mall because of a failure of impulse control: she can’t keep herself from steering into the parking lot while driving home, can’t keep from “just checking to see if there’s anything good on sale,” and can’t keep from buying. Again. But for other over-shoppers the behavior is a compulsion: if they are not engaging in it, their anxiety rises to an intolerable level, and engaging in it assuages that anxiety.
Compulsive exercising illustrates the difficulty of trying to fit complicated, messy human behaviors into neat pigeon holes. When research on excessive exercise took off in the 1970s, about the time the jogging craze spread across the United States, scientists struggled to define what, exactly, they were studying. To some, the phenomenon of exercising to excess was “exercise addiction.” To others it was “obligatory exercise,” “compulsive exercise,” or even a noble-sounding “commitment” to exercising arising from a competitive drive, a devotion to fitness, or the love of a challenge.II
The terminological mishmash underlined the fact that scientists did not know whether they were dealing with an addiction (motivated by pleasure) or a compulsion (driven by an anxiety that only exercising could quell) or something else. A 2002 review of eighty-eight studies on excessive exercise, published over the previous twenty-nine years, found that the research had been hampered by “inconsistent or nonexistent control groups, discrepant operational criteria for exercise dependence, and/or invalidated or inappropriate measures of exercise dependence,” as researchers at the University of Florida concluded in Psychology of Sport and Exercise. In other words, attempts to study extreme exercising were so lacking in methodological rigor they were practically junk science.
But the problematic studies, in asking people to articulate why they exercised, did offer at least a glimmer of an empirically based taxonomy. People may punish their body through exercise for all sorts of complicated psychological reasons, research has shown. Some are motivated by the need to feel they are in control of at least part of their destiny, namely, their fitness and physiology. Others are driven by a need to demonstrate they can rise above common physical needs (“rest is for the weak”) or that willpower can vanquish baser desires (to self-indulgently laze around). Still others, who take up exercise to improve their fitness, are driven to ever-longer and more frequent bouts of running or using a treadmill because it brings them pleasure—the hedonic-hit model of addiction. Others exercise for extrinsic rewards such as medals and the admiration of others. In none of these cases, however, do the extreme exercisers feel like their brain is about to explode if they can’t exercise.
In contrast, compulsive exercisers tend to exercise for intrinsic, mood-altering or -stabilizing reasons. They view exercise as the focus of their lives. It is the only way to relieve unbearable anxiety, and they suffer that anxiety if unable to exercise. They might have once been motivated by the pull of fitness, but eventually they do not so much enjoy exercise as find it the only way to quell the angst they feel when they are not exercising. “We know people have various motives for starting to exercise,” said Danielle Symons Downs, a kinesiologist at Pennsylvania State University who developed an exercise dependence scale so therapists and individuals can assess whether the exercise is excessive. “And there are multiple reasons” why people do it to excess; “doing it to avoid intolerable anxiety is plausible.” These are our compulsives, people like Carrie Arnold.
Granted, the boundaries between addiction and compulsion can be fuzzy, since being deprived of an activity you deeply enjoy and want can trigger anxiety, too. But an addiction is born in joy and pleasure, a compulsion in anxiety. Compulsive exercisers experience “higher levels of anxiety when not running compared to non-obligatory runners,” as the 2002 review put it. They feel antsy or worse if they miss a workout. The purpose, as is definitionally true of any compulsion, is “alleviating negative emotions,” researchers led by Caroline Meyer of England’s Loughborough University wrote in a 2011 study in the International Journal of Eating Disorders. “A key feature of compulsive exercise is a negative mood, such as experiencing feelings of anxiety, depression, and guilt when deprived of exercising.”
Where does that come from? The psychological and personality traits that put someone at risk of “developing a compulsivity towards exercise,” as Meyer put it, include perfectionism and other elements of obsessive-compulsive personality disorder. In particular, compulsive exercisers tend to express much greater concerns over mistakes than other people do, have sky-high personal standards of achievement and morality, and feel chronic doubts about their actions—all reminiscent of the extreme conscientiousness that characterize mild compulsions.III
“Perfectionism was among the best predictors of compulsive exercise,” Meyer reported. The inevitable falling short of perfection provokes anxiety, which only exercise can quiet—and the result is a compulsion to work out to a self-destructive extreme.
* * *
To a man with a hammer, everything looks like a nail; to a reporter immersed in the science and phenomenology of compulsions, everything we do seems driven by anxiety, and every quirky extreme of behavior seems compulsive. In reporting the prevalences of the various forms of compulsion, I used the most credible numbers I could find, usually from a source such as the National Institute of Mental Health. But the recent surge in diagnoses of mental illness might not be what it seems. For one thing, psychiatrists and others have been relentless in spreading the message that we have a vast, underdiagnosed epidemic of mental illness. As a result, millions of people have taken it to heart, convinced they have a mental disorder and seeking professional confirmation of that. A loosening of diagnostic criteria is likely also fueling the reported rise in the incidence of mental disorders: over the years psychiatrists have decreed that you have to feel a certain way or experience certain symptoms for only three months instead of six, or have six symptoms rather than nine, to qualify for a formal diagnosis. The “epidemics” that the mental health industry cites reflect “changing diagnostic fashions,” psychiatrist Allen Frances, who chaired the DSM-IV task force, told me. “It’s not that more people are mentally ill, but that what counts as a mental illness changes.” Remember, too, that there are no brain scans, blood tests, or other objective biomarkers for mental disorders. Rather, to make a diagnosis, psychiatry and psychology rely almost entirely on patients’ self-report of how they are feeling. It isn’t hard to meet criteria for one or another DSM diagnosis, especially because the experts who devise the criteria worry more about missing cases than about diagnosing as “mentally ill” people who are not. To a certain extent, it seems, we’re as mentally ill as we think we are.
In speaking to people in the grip of extreme compulsions, I often felt as if I was looking into suns so bright they overwhelmed the planets and the stars. Even after I understood that compulsive behaviors so extreme as to derail lives, loves, and careers stemmed from a desperate need to keep anxiety at bay, it was hard to see that these were just the hypertrophied versions of ordinary, everyday quirks; they were too jarring, too off-putting. But just as the dimmer celestial denizens invisibly populate the daytime sky as well as the night’s, so less extreme versions of compulsive behaviors are all around us . . . and, if we look carefully enough, within us. So much of what we do, for good or ill, arises from the same spring as compulsions. By seeing our and others’ behaviors through that prism, what had seemed inexplicable becomes understandable. And what I came to understand above all is that compulsive behavior is not necessarily a mental disorder. Some forms of it can be, and people in its clutches deserve to be diagnosed and helped. But many, many compulsions are expressions of psychological needs as common within humankind as to feel at peace and in control, to feel co
nnected and to matter. And if those are mental illnesses, then we’re all crazy.
* * *
I. Soon after we spoke, Hansell died suddenly in 2013 at age fifty-seven.
II. By whatever name, excessive exercising is not as prevalent as one might think from the gyms full of people taking spin classes or sweating on ellipticals. Even among the physically active, the population from whom studies typically seek volunteers, the prevalence of excessive exercise is around 3 percent.
III. Mild compulsions are typical of obsessive-compulsive personality disorder, which itself is often driven by perfectionism, as I describe in Chapter 2.
CHAPTER TWO
Obsessive-Compulsive Disorder, or Is Fred in the Refrigerator?
FROM THE HUMAN LOGJAMS AT the doors, it seems as if every one of the 1,100 attendees at the annual meeting of the International OCD Foundation is filing into the ballroom at the Atlanta Hyatt on this July morning, but once they fan out to the rows and rows of folding chairs they aren’t exactly riveted by the proceedings. The public-service award to the elderly couple who launched an OCD group in New Jersey . . . the research award to scientists who did pioneering work on hoarding . . . the crowd is paying more attention to neighbors and phones than the speakers.
But then Shala Nicely strides across the stage, and it’s as if an electromagnetic pulse has cut everyone’s wireless connection. “It was a hot summer afternoon in 1975,” Shala says, pacing across the stage like a caged jaguar, “and I was four. Mama and I were standing at the side of a road, waiting to cross, and I was hoping we were going to go feed the ducks.” Suddenly, out of nowhere, a car smashed into them, crushing them so horrifically that Shala’s broken legs looked like raw steak rolled in gravel. “We almost died that day,” she says, “and my brain learned that the world is a very, very dangerous place. My brain decided that to protect me it had to show me all the dangers out there.”
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