by David Adam
… she rubs her feet for ten minutes, in order to remove whatever may have insinuated itself between the toes or beneath the nails. She afterwards turns and returns her slippers, shakes them, and hands them to her chamber-maid, in order that she, after having carefully examined them, may assure her that they conceal nothing of value. The comb is passed through the hair a great number of times, with the same intent. Every article of her apparel is examined successively, a great number of times, inspected in every way, in all the folds and wrinkles, and rigorously shaken. After all these precautions, the hands are powerfully shaken in turn, and the fingers of either hand rubbed by each other. This rubbing of the fingers is performed with extreme rapidity, and repeated until the number of rubbings, which is enumerated in a loud voice, is sufficient to convince her, that nothing remains upon them. The close attention and uneasiness of the patient are such, during this minute exploration that she perspires and is almost exhausted by the fatigue of it. If, from any cause, these precautions are not taken, she is restless during the whole day.
The woman went to the theatre and on trips home to see her family. She ate and slept well. In many ways she was the life and soul of the residential clinic. Each night she would join others in the drawing room, and her conversation was ‘gay, humorous and sometimes mischievous’. The only outward sign of her inner torment came if she was forced to switch seats, or if she inadvertently touched her head or dress, or the chair of another. Then she would rub and shake her fingers.*
Esquirol said her condition was a form of monomania, or partial insanity – a concept he developed and promoted, which argued the mind could be unbalanced by a single train of thought. Someone with monomania was mad, at least partly mad, but they were aware of it. Only a part of their brain and so a specific function was affected, the rest was normal.
The concept of monomania, framed as the obsessive pursuit of an idea, caught the public imagination – as shown by its prevalence in literature written at the time. The memorably dark characters Heathcliff in Emily Brontë’s Wuthering Heights (1847) and Raskolnikov in Dostoyevsky’s Crime and Punishment (1866) are both described as monomaniacs. Perhaps the most famous depiction of monomania was Herman Melville’s Captain Ahab, who was consumed by a single-minded madness to kill the great white whale in Moby-Dick (1851).
Monomania had many types, which Esquirol and his followers used to explain a range of unusual, antisocial and illegal behaviours. They made the biggest impact in the field of law. Denied the status in society they felt they deserved, Esquirol and his cronies used monomania to gain control of the medico-legal process used to assess the sanity of defendants in the French courts – which at the time often came down to a friend or neighbour who would turn up and say that a murder suspect who claimed insanity had always seemed fine to them.
With monomania as their lever, French psychiatrists forced their way into public discussion of several grisly murder cases that captivated Paris in the early nineteenth century. In 1828, for instance, a servant girl called Henriette Cornier went on trial for the sudden and inexplicable murder of her employers’ small child. Cornier, said one medic called by the defence, was a monomaniac propelled to kill, and so should be considered legally insane.
The debate crossed the channel to London with a young French man called Louis Bordier, who was convicted of the murder of his girlfriend and sentenced to hang at Horsemonger Lane gaol in October 1867. At the time, Britain still executed some condemned prisoners in public, and the gallows at Horsemonger Lane were more public than most, set up on the roof of the gatehouse at the front of the gaol. Charles Dickens had been so horrified at the scenes at one such execution of a husband and wife there in 1849 – watched by a claimed crowd of 30,000 people – that he wrote a famous letter of protest at the death penalty to The Times.
With Bordier just days from his date with the noose, Dr Harrington Tuke, the honorary secretary to the British Medico-Psychological Association, wrote an emotional plea for clemency in the medical journal The Lancet. Bordier, he said, was a monomaniac.
If he be hung the cruel absurdity will be committed of inflicting capital punishment upon a lunatic, and fixing upon his kindred the unjust stigma of relationship to a responsible and cold-blooded assassin.
To support his case, Tuke pointed out that Bordier had listened to the jury’s guilty verdict and to the judge deliver the death sentence with ‘stolid indifference’ and deaf to the wailings of his two little girls, had walked unconcerned from the dock.
The appeal made no difference: Bordier was hanged the following week – the final execution held in public at Horsemonger Lane. His death did not finish the arguments over his state of mind. A response to Tuke’s letter from the surgeon of Newgate gaol, just across the River Thames, who had examined Bordier – and whom Tuke had criticized – appeared a fortnight later. Bordier’s conduct in the trial, the surgeon said, did not support the claim of madness, even partial madness:
When his eldest little girl was placed in the witness box, he bent his head so low as completely to hide his face from the observation of any one in court, as if he could not bear the glance of his own child, or bear to look upon her.
The glance of a child would one day prove pivotal in my life too.
* * *
When I found that I could not make my irrational thoughts of HIV go away, I spent a lot of time on the phone to the National Aids Helpline. I would ring them from the phone box at the side of the busy road opposite the house into which six of us had moved at the start of the second academic year. I would call to tell them how the fears that I had of the virus had spread, and about all of the extra ways my thoughts now told me that I could have caught the disease. It felt good to say those things out loud. It was a relief to free them from my head and expose them to the light. Was there, say, a risk when I played soccer and scraped my knee along the abrasive Astroturf? Someone else could have done the same after all, and left a smear of infected blood at that exact spot. No, they would respond, no need to worry. The risk was very low.
Thanks, I would say as I blew out my cheeks − that’s reassured me. I might even have believed it, for just as long as it took to replace the handset and turn to leave the phone box. But, wait, very low? The risk was very low, so there was a risk? Shit, what if I hadn’t explained what happened exactly right. They might have misunderstood. The risk could be higher if they realized what really had happened. I should call back, just to confirm. I would dial the number dozens of times a day. Sometimes I would hang up before they answered. I couldn’t understand why my mind would circle round, why the sense that everything would be all right was so fleeting.
The National Aids Helpline, I quickly worked out, was staffed by about half a dozen people at any one time. I learned their voices, and was encouraged when someone new picked up the phone – surely they would be the one to convince me. After a while, they started to recognize my voice too, and my feared situations. That was bad. They would tell me that they had already given me an answer and that I needed to accept it. I didn’t want that. I wanted the hit. Tell me I am not infected. So I invented new scenarios, just similar enough to real ones to bring that familiar flicker of comfort when they were dismissed. And, sorry National Aids Helpline workers circa 1991 and 1992, but I disguised my voice. I even put on different regional accents. I’m sure you knew. Not that it did any good. Reassurance, like offence, is taken not given. And my mind would not take it.
Every night HIV was the last thing I thought about before I went to sleep. And it was the first thing I thought of every morning. And it was pretty much all I thought of in between. I have few memories from that time of anything else. I lost interest in the stuff that had seemed important just a few months previously; music, books and films no longer held my attention. I no longer cared how other people’s stories ended, for I could no longer identify with anyone else’s trivial concerns. What did it matter, really, if this man in a hospital drama had hurt his leg? If I had HIV and I
broke my leg, then I would still have HIV when they fixed it. I had a rival narrative in my head in which the stakes just seemed so much higher than anything that went on in life outside.
I decided to donate blood. They would test for HIV. My anxiety spiked as they pierced my skin with the needle but then, as I watched the thick red fluid pour from my arm, a plastic cup of orange squash waiting on the shelf, I felt not fear but a surge of exhilaration – oh, I should have done this ages ago! Of course there was nothing in my blood; no virus was slowly eating away at my cells, my promise and my future. They would tell me I was all right and I would believe them.
The nurse took away the plastic bag taut with my blood and she gave me a biscuit. I heard the rain outside batter against the windows and I saw the world again as it had been before that first obsessive thought. I saw the opportunities and the hopes, I looked beyond the horizon and I smiled. The relief was so strong. And then, on the way out, I picked up the leaflet. Why did I pick up the leaflet?
The leaflet, one of a number in a plastic rack by the blood centre door, said their tests looked not for HIV, but the antibodies the immune system raised against it. And those antibodies could take three months to show up. Three months in which I could catch Aids and nobody could tell me that I hadn’t. As I read the words I loathed them. Whatever anybody said, they could not be sure. The thoughts and the terror and the desolation flooded back across my senses. The dam I had just built to hold them back collapsed. Unwilling to go forwards and unable to go back, I dropped the half-eaten biscuit onto the pavement and watched it swim with the rain.
FOUR
An emerging obsession
Is OCD truly a mental illness? Some experts say yes, some say no and some say it doesn’t matter. They’re probably all correct; this area is a mass of vague terms and a mess of overlapping meanings. It’s always been that way, dating back to the eighteenth century and the Scottish physician William Cullen, who introduced the term ‘neuroses’, a broad notion that stemmed from his idea that madness reflected damage to the nervous system. By the middle of the nineteenth century, the Austrian medic and poet Baron Ernst von Feuchtersleben argued that more severe afflictions of the mind such as delusion should be promoted into a different tier, which he called the ‘psychoses’. The division stuck, despite the obvious problem that plenty of people with neuroses seemed to have a worse time than those who had the supposedly more serious psychoses. Those terms aren’t used in medicine to classify patients any more, but the replacements aren’t any clearer.
‘Mental illness’ is a catch-all but many people don’t want to be called ‘mentally ill’. OCD is not an ‘illness’ anyway, psychologists say, it is an ‘abnormality’. Some people with OCD reject the label ‘abnormal’ and prefer ‘disorder’. But ‘disorder’ and ‘illness’, according to psychiatrists, mean the same thing. It’s clear that schizophrenia is a mental illness. Yet the UK government says that one in four of its citizens will develop a ‘mental illness’ during their lifetime. That’s more than fifteen million people and to get the figures that high they have to include the big three – substance abuse, anxiety and depression − as well as OCD. Is anxiety a mental illness? Is an alcoholic mentally ill? It’s not hard to see why most charities who work in this area prefer to call it ‘mental health’.
The best representation, though still flawed, is probably to divide mental illness from severe mental illness, with this second group made up of people who lose touch with reality. That’s close to where we were more than a century ago, with neuroses and psychoses. In this book, I use the terms ‘disorder’, ‘illness’, ‘abnormality’, ‘condition’ and ‘syndrome’ as synonyms, because it introduces variation and because, as we’ve seen, it’s hard to organize them into any hierarchy. I mean none of them to be pejorative.
* * *
Whatever we call it, it took me a long time to recognize my problem. OCD was that thing those people did when they washed their hands a lot, wasn’t it? People talked about Monica Geller from the television show Friends as having OCD because she was so uptight about cleaning and crumbs in the bed and that stuff. I didn’t think like that. I wasn’t a perfectionist. I wasn’t bothered by crumbs in the bed; I was scared that I would catch a terrible disease, which was very different. So I found it hard to accept that I had OCD and that I could be helped, even after the people on the other end of the National Aids Helpline gently suggested I should talk to a psychiatrist rather than them.
The persistent and common belief that OCD is simply an exaggerated desire for hygiene and order is not the fault of the doctors and scientists, who have been telling people it is wrong for decades. Psychologists found convincing evidence that people with OCD do not think and behave in that way in 1960, when they looked at the records of people referred to the Tavistock Clinic, a drop-in centre in London that diagnosed and treated various psychological problems. Each patient to the clinic had to answer nearly nine hundred questions on their attitudes and behaviours, and the scientists looked at the responses to those that related to obsessive and compulsive character traits, such as ‘I tend to brood for a long time over a single idea’ and ‘I take pride in having neat and tidy handwriting’. The patients had to grade them as true or false.
With a statistical technique called factor analysis, the psychologists bundled together the answers that seemed to associate with each other – to produce a picture of how someone who answered true to one question would be most likely to answer the others.
They found two separate and distinct patterns, which they labelled the A-type and the B-type. The A-type was a person more likely to fold their clothes carefully, to be thorough in everything they did and to be punctual. The B-type was someone who checked things, had bad thoughts and memorized numbers.
The B-type – described as a person whose daily life is disturbed by the intrusion of unwanted thoughts and is compelled to do things they know are unnecessary – we can recognize now as OCD. The A-type – an exceedingly systematic and methodical person, who pays much attention to detail and has a strong dislike of dirt – psychologists identify as a person with the similar-sounding, but quite different, problem of obsessive-compulsive personality disorder (OCPD).
The two are not completely separate – traits and symptoms from one can appear in someone with the other. And some people with OCPD can develop OCD – in fact, for many years it was thought that only people with obsessive personalities could develop OCD. But there is a clear difference between a person with OCPD and one with OCD. While OCD is defined by harrowing ego-dystonic ideas that clash with our sense of the sort of person we are, the thoughts of OCPD tend to be ego-syntonic – in line with one’s desires and needs − and so much easier to accept. Put another way, OCD is hell for the sufferer but, while OCPD may be hell for those close to them, the person with OCPD is usually happy to clean and tidy and takes pride in doing so.
Visit the home of someone with OCPD and not a chair or rug will be out of place. Yet people with OCD whose compulsions demand that they clean often restrict the practice to a specific room. OCD patients can have spotless toilets that sparkle with bleach next to a filthy kitchen caked with months-old food. An OCD washer who cleans his hands 200-odd times a day can wear the same underwear for weeks.
In many ways OCPD is what people mean when they use the term ‘anal personality’. Indeed, the phrase ‘anal (usually short for anally retentive) personality’ grew from Freud’s work on obsessions. Of course it did. Freud thought that children went through an ‘anal’ phase when their chief interest was their bowel movements. Unfortunately for the child, this phase coincided with the parents also taking an interest in the child’s bowel movements, and getting the child not to deposit them in their pants.
Mental conflict during this phase – sometimes just the very act of the parent interfering with how and when the child could go to the toilet − could lead to turmoil in the child’s mind, Freud said, which would resurface as personality traits that mirrored the
child’s efforts to exercise power over their excrement: orderliness, stubbornness and a need for control. These were the features of Freud’s classic anal personality type; anally retentive described when these behaviour traits lingered into adulthood.
When people hear of OCD they frequently think of anal personalities and OCPD. They see towel folding and books arranged on a shelf by genre, size or alphabetical order. In September 2011 the London department store Selfridges was selling what it called an obsessive-compulsive disorder chopping board, etched with ruled lines and a protractor for perfectly sized portions. When I talked to publishers about the idea of writing this book, one suggested we put a bar of soap on the cover. People with OCD are believed to live in spotless houses and to freak out when someone sneezes on them. The cover of the book Obsessive-Compulsive Disorder for Dummies does feature a line of neatly ironed identical white shirts on their hangers. True, OCD can show itself in these ways. But it’s a selective and self-selecting picture, and one that cannot account for the intrusive thoughts that drive the behaviour.
The close similarities, at least superficially, between the way that OCD and OCPD can manifest themselves, tied with the reluctance of many people with OCD to talk about their obsessive thoughts, is one reason why even severe cases of OCD are sometimes misdiagnosed, or not diagnosed at all. Another is that OCD can be masked by other mental disorders, which frequently coexist in the same patient − depression, anxiety and eating disorders among them.
In recent years, experts in OCD have tried to educate their fellow health-care workers to this problem: some patients who report to dermatologists with constantly chapped hands, for instance, could have OCD. But, unless they are asked the correct questions, this will not be spotted. The questions are not complex. Joseph Zohar, an OCD expert in Israel, has produced a list of five that he says should help doctors and nurses screen for clinical obsessions: Do you wash or clean a lot? Do you check things a lot? Is there any thought that keeps bothering you that you would like to get rid of but can’t? Do your daily activities take a long time to finish? And are you concerned about orderliness or symmetry? To answer yes to any of these questions does not mean that someone has OCD but it should prompt further questions − along similar lines to these but with a range of possible answers to indicate the severity of symptoms.