Can't Just Stop

by Sharon Begley

  Among the twenty-seven case histories du Saulle offered in La Folie du Doute was a young woman whose father was one day visited by someone with “a cancerous facial ulceration,” he recounted. “[S]he was obsessed with the thought that all the clothes and objects around the house were more or less tainted and covered with cancerous matter. Weighed down by this apprehension, she . . . spent all her time brushing, rubbing and washing. She understood perfectly well that her fears were without foundation, but she was powerless to dispel them.” Years later, now married and a mother, she learned that a rabid dog had wandered into her house. She “could not bring herself to touch the ‘rabid dust’ on her furniture, on the chimney, the floors, her pockets, other people’s clothes, kitchen utensils,” du Saulle wrote. “She wiped, scoured, brushed or washed everything she touched, even when at other people’s homes, nor did she dare touch the door-knocker at her own home. She bewailed her current state (she was now thirty-six), understood that her anxieties were groundless, and beseeched the doctors to cure her,” du Saulle concluded, without indicating whether any, including himself, managed to do so.

  In America, Dr. William Hammond (1828–1900), surgeon general of the Union Army in the Civil War, described a “young lady, aged eighteen” whom he treated for compulsive behavior arising from a deathly fear of contamination in 1879. “Little by little the idea became rooted that she could not escape sources of contamination, that other persons might defile her in some way or other,” he wrote in his 1883 Treatise on Insanity in Its Medical Relations. “When she went out into the street she carefully gathered her skirts together on passing any person, for fear that she might by mere contact be contaminated. She spent hours every day in minutely examining and cleansing her combs and brushes, and was even then not satisfied that they were thoroughly purified.” She washed her hands “over two hundred times a day. She could touch nothing without feeling irresistibly impelled to scrub them with soap and water. . . .

  “In removing her clothes at night preparatory to going to bed, she carefully avoided touching them with her hands, because then she would not have sufficient opportunity for washing,” he continued. “She, therefore, had some one else to loosen the fastenings, and then she allowed her garments to drop on the floor, where she left them. Nothing would have persuaded her to touch any of her under-clothing after it had been worn till it had been washed. . . . When not washing her hands or examining her combs and brushes, she spent nearly all the rest of the day in carefully inspecting every article of furniture and dusting it many times.” The young lady admitted “the absurdity of her ideas” to him, Hammond reported, but she nevertheless “could not avoid acting as she did.”

  Madness or Eccentricity?

  By the late nineteenth century, medical opinion was coalescing around the view that compulsions were not a form of insanity, as the era understood it. Instead, as English psychiatrist Henry Maudsley put it in his 1879 textbook The Pathology of Mind, they occur when a need “to do some meaningless and absurd act” takes “hold of the fancy and will not let it go,” compelling the victim “to repeat the act over and over again, since thus only can peace of mind be obtained.”

  In 1894, Daniel Hack Tuke kicked off a debate on compulsions with a paper in the neurological journal Brain. “I refer to those cases in which a person would not be regarded as insane, although the mental trouble may be as distressing as it is in actual insanity.” Compulsion symptoms vary, he continued, and can include “certain ideas or words aris[ing] with painful frequency and vividness.” Such mental compulsions, he continued, can be accompanied by physical ones, as in “persons who invariably touch some object in passing it in the course of an accustomed walk (Délire du toucher), the antithesis of which is seen in the dread of touching certain objects at all.” Tuke also recognized “arithmomania, or the morbid desire to count without rhyme or reason, or to make interminable calculations.” He bemoaned the then-faddish tendency of “alienists” to coin terms for every compulsion, fretting that doing so could “distract our attention from the fundamental characteristics common to all,” namely, “their automatism, the overwhelming and recurring tendency to be haunted by a certain idea, to perform certain acts . . . with a consciousness of the utter uselessness and absurdity of” the compulsive thought or act.

  This was an early explicit recognition that compulsions, despite taking forms as different as checking to see if you ran over someone or pedaling your exercise bike until you drop or frantically swiping your smartphone screen . . . all reflect an underlying mental state: a profound anxiety that can be relieved (albeit temporarily) only by executing the compulsive behavior. Someone besieged by a compulsion is “utterly powerless to resist it,” Tuke wrote. The cause? “Undue mental labor, intense emotional excitement”—the key ingredients of anxiety, an emotion found in perfectly sane people. A “slight degree” of the anxiety that triggers compulsions “is not uncommon in perfectly sane people,” Tuke argued. A lab worker at an asylum, he said, had recounted how, “after shutting the door the last thing at night and having no doubt that it was shut, he would return once or perhaps twice to satisfy himself that this was the case. In the same way I have known persons open an envelope in which they had placed a cheque and had exercised great care that the date and signature were correct, in order to satisfy themselves that they were so.” Even at the dawn of science’s embrace of compulsions, the experts of the day acknowledged that they can be so mild as to make calling them madness—or, today, a form of mental illness—absurd.

  English psychiatrist Sir George Henry Savage (1842–1921) agreed that compulsions are not manifestations of madness. He called compulsions “very common” and offered that “nearly everyone has some. . . . I have the feeling, which is common I believe, about walking along a pavement. I have an inclination to avoid the cracks and at the same time I have a tendency . . . to touch the iron railings with my stick when I walk along a street. . . . Few of these cases need to be permanent inhabitants of asylums.”

  This was not a universal opinion, however. English neurologist John Hughlings Jackson (1835–1911), who founded Brain, described the compulsions that Tuke and Savage were trying to downgrade from madness as “insane delusions.” And thus was teed up a debate that continues today: whether compulsions are a manifestation of mental illness or simply a more intense form of behaviors essentially everyone carries out.

  Think of the motivation behind quotidian actions like wiping down your kitchen counters or making the bed, or buying enough food for a few days, or even of studying diligently and holding a job. Isn’t there a hint of anxiety—over germs or messiness, starving or failing—that compels us? Human behavior exists along a very long spectrum, and while those on the extremes may seem different from those clustered at the center they are still on the continuum, not tumbling off it like victims of psychosis. In the latter case, the brain has fallen into a mode of functioning that is sharply disconnected from normalcy. But a compulsion to scrub our hands after using the bathroom, or to see if any critical emails arrived since we checked two minutes ago . . . these, and compulsions arising from other anxieties, seize us all at one time or another. As Tuke wrote a century ago, “the difference is one of degree, and . . . it is a most difficult thing to determine when the boundary line has been passed.”

  Tuke carried the day. By the turn of the last century, a consensus had been reached that compulsions, and the anxieties that command them, are neuroses rather than psychoses—quirks, eccentricities, even peculiarities, but not madness. Even Hughlings Jackson, of the “insane delusions” school, backed down, embracing Tuke’s argument that while these are “departures from normal mental states or at least . . . exaggerations and persistencies of mental states,” their genesis in the sorts of anxieties that are the common condition of humankind is such that “it would be pedantic to call [them] abnormal.”

  Compulsions came into their own, scientifically, in 1903, when French psychiatrist Pierre Janet (1859–1947) published a 75
0-page treatise on obsessions and compulsions, Les Obsessions et La Psychasthénie. It was the most extensive discussion to date of what is now called OCD. Never translated into English, it described OCD symptoms exhaustively, including symmetry compulsions such as when one “chances to view a red object on his right [and then] needs to find one on his left,” in Janet’s example. He argued that compulsive behaviors arise from a sense that actions have not been completed correctly, from—as we understand it today—anxiety. (In France, OCD is still sometimes called la folie du doute, the doubting madness.) Compulsions, he argued, were the result of “lowered energy in the innermost elements of the mental organization”—essentially, the mind was too weak to block the anxiety that led to compulsions.

  His suggested treatments were nothing if not imaginative. Janet recommended that people in the grip of a compulsion be prescribed “proper nutrition, sleeping habits, fresh air, and avoidance of fatigue,” while “bromides in high doses may be useful.” He also believed that getting patients high could do wonders, occasionally prescribing opium “for those suffering from great anxiety,” he wrote. William Hammond, who described the young woman with the cleaning compulsions, prescribed sedatives. English psychiatrist Henry Maudsley, in his 1895 psychiatry textbook, recommended opium and morphine three times a day, augmented occasionally with a pinch of arsenic.

  Even as experts disagreed about treatment, by the late nineteenth century there was a consensus that compulsions “resulted from disturbances of emotions rather than thinking,” German Berrios wrote in A History of Clinical Psychiatry. “Anxiety-based explanations became acceptable because great men were espousing them, and because during the second half of the nineteenth century there was a revival of ‘affectivity’ [and] emotions” as objects of scholarly inquiry. As a result, although compulsions had been explained as a disorder of the will or intellect in the eighteenth and nineteenth centuries, by the turn of the twentieth century “the ‘emotional’ hypothesis prevailed.”

  “I Felt the Need to Walk”

  Late nineteenth-century France saw a mini-epidemic of one of the odder compulsions in the annals of psychiatry: mad travelers. For reasons that leading psychiatrists of the day debated ad nauseam, clerks, artisans, craftsmen, laborers, and other working-class men were suddenly and inexplicably seized with the compulsion to strike out for parts unknown, by foot and by rail, for weeks and even years at a time, often with nothing but the clothes on their backs and a few francs in their pockets.

  The first of the “mad travelers”—the name comes from philosopher Ian Hacking’s 1997 Page-Barbour Lectures at the University of Virginia—was one Albert Dadas, a gas fitter from Bordeaux born in the 1860s. As a young man, Albert developed an unusual mental malady: upon hearing the name of a distant city such as Marseilles, he felt compelled to head for it. And so he did, walking as much as forty miles a day. Upon arrival, he overheard conversations about Africa, and he felt compelled to board a ship for Algeria. Later walkabouts, which usually occurred in a state of amnesia about his identity, took him through Belgium and Holland, to Nuremberg in Germany, and points east—far east: Prague, Berlin, Posen, Moscow in 1881, from Bordeaux to Verdun in 1885.

  Over and over, recounts Hacking, “the need to go overpowered him.” He was, Albert told his doctor, “tormented by a need to travel”—which echoes the anxiety that drives today’s compulsions. “I only need to walk,” Albert told one physician. “A few moments ago I had a terrific desire to go. I almost left you for Liege.” When on the road, he almost always experienced “gaiety,” he told his doctors; if he was seized by a sudden sadness, after a kilometer or so of walking “my sadness suddenly disappeared.” His distress at being in one place grew unbearable when he saw others depart, as when he saw soldiers board a train to join their regiment. “I could not stand it,” he later told his doctor. “I envied the lot of the conscripts who were going to see the country.” On such occasions “I felt the need to walk, to go a long way. Every moment I felt the pressure which drives me toward the road.”

  Albert frequently wound up in one or another hospital, compulsively walking their corridors, and psychiatrists had a field day diagnosing him. A fugue state analogous to the confusion that follows an epileptic seizure, said one school. Nonsense, said another: hysteria treatable with hypnosis. No, dromomanie, a neologism (from the Greek signifying racecourse) meaning a state in which one feels compelled to take flight. The physician who studied Albert most closely, Philippe Tissie, diagnosed “pathological tourism,” which he deemed a form of madness. This was the era when travel for the masses, not only aristocrats, took off, aided by the rise of iconic companies such as Thomas Cook & Son. But where members of London’s merchant class presumably put some thought into which Cook tour they selected, Albert’s rambles were “obsessive and uncontrollable,” Hacking said, “less a voyage of self-discovery than an attempt to eliminate self.” And they “inaugurated an epidemic of mad travel.”

  Like other instances of mass hysteria, hearing about one person’s actions inspired hundreds of copycats. German and Russians doctors documented cases of mad travelers; so did physicians in northern Italy and in regions of France outside Albert’s Bordeaux. Regardless of the details of the men’s lives (for they were almost all men; women, mad or not, seldom traveled alone in 1880s Europe) or the particulars of their peregrinations, each described to his physician being “taken by an overpowering desire to walk, and off they went, in spite of themselves, abandoning everything in order to justify this need,” as an 1892 thesis on eighteen patients stricken with “l’automatisme ambulatoire, ou vagabondage impulsif” at Tissie’s hospital in Bordeaux put it. Yet mad traveling disappeared as quickly as it appeared. “Compulsive aimless wandering as a medical entity” lasted from 1887 to 1909, Hacking explained, “and then it was no more.”

  Compulsions on the Couch

  And then came Sigmund Freud (1856–1939).

  The founder of psychoanalysis deemed what we now call OCD the most fascinating of the mental disorders, and published fourteen papers on it. But he confessed in a 1909 essay “that I have not yet succeeded in penetrating a severe case” of it.

  Freud nevertheless relished the compulsions his patients brought him. He interpreted them in a way that represented a sharp break from the past, for he analyzed them as he did dreams, memories, and virtually everything else his patients brought him: symbolically. Take the compulsive bedtime ritual a nineteen-year-old woman described to him, one she could not go to sleep without. She stopped the large clock in her bedroom and removed others, as well as watches; “her tiny wrist-watch was not allowed . . . to be inside her bedside table,” Freud recounted. The door between her room and her parents’ had to be precisely half-open, which she accomplished by placing various objects in the open doorway. She moved flower pots and other vessels so they would not fall, and arranged pillows to form a diamond shape. The down-filled duvet had to be shaken so the feathers fell to the bottom, but she then anxiously evened out the down by trying to press the feathers apart. “There was always an apprehension that things might not have been done properly,” Freud reported. “Everything must be checked and repeated, doubts assailed first one and then another. . . .”

  Today, psychiatrists would likely diagnose a “just right” compulsion, probably driven by anxiety if the bedroom items were not arranged just so. But to Freud, the young woman’s compulsive bedtime ritual was packed with hidden—usually sexual—meaning. The bedding symbolized her desire to become pregnant (creating a nest for her brood). The timepieces were sexual symbols: clocks and watches have “a genital role owing to their relation to periodic processes” and because “a woman may boast that her menstruation behaves with the regularity of clockwork.” And “the ticking of a clock may be compared with the knocking or throbbing in the clitoris during sexual excitement.” The woman—whom he diagnosed as “a neurotic” with “agoraphobia and obsessional neurosis”—removed them because she wanted to banish “symbols of the fema
le genitals . . . for the night,” Freud explained in a lecture. Vessels such as flower pots and vases are likewise female symbols, he said, and the woman’s ritualistic banishing of them before bedtime arose from her anxiety that she would not bleed when her marriage was consummated on her wedding night, revealing that she was not a virgin. The woman initially rejected his symbol-laden explanations, Freud reported, but eventually “accepted all the interpretations” and abandoned “the whole ceremony.”

  Moving beyond the compulsive behavior of this patient, Freud proposed that obsessions and compulsions generally originated (as did every mental malady) in childhood. When a boy or girl wanted to engage in violence or sexual play but was stopped by a parent, the conflict between unrequited desire and stymied action produced “repression” of the mental energy behind the desire. This energy became bottled up in the unconscious, eventually popping out in adulthood as obsessions and compulsions. Most psychiatrists held to variations of Freud’s interpretation of OCD, involving the unconscious and repression and defensive ego maneuvers, well into the 1960s.

  In an ironic analogue of the shoemaker going barefoot, Freud exhibited a compulsion of his own. He “lived pen in hand; he writes everywhere, all the time, and has always done so,” biographer Lydia Flem recounted in Freud the Man. He also worked compulsively, seeing patients from morning through late afternoon and then writing from evening well into the night, typically until two or three o’clock in the morning. Freud admitted that “I really can’t imagine that a life without work would be comfortable for me: fantasizing and work are one and the same for me, and nothing else is fun for me.” In a confession that resonates with the current understanding that compulsive behaviors are born in anxiety, Freud expressed the terror that words might sometimes fail, and thoughts might refuse to come, and that it is “impossible to stop trembling at this possibility.” It has “never been the case” that he could count on “productive capacity at all times and in all moods,” but instead had days “when nothing could come” and he was “in danger of losing all ability to work and to struggle.” Notice the last phrase, reading which it is impossible not to imagine a compulsion to write and work driven by the anxiety—even the existential terror—that one day he would not be able to.