The Man Who Couldn’t Stop

by David Adam

  Eating disorders such as anorexia nervosa and bulimia nervosa show some striking similarities to OCD. Repetitive and strongly held thoughts force people to carry out rituals and patterns of behaviour to reduce anxiety – refusal to eat or inability to stop − followed immediately by compulsions to make themselves vomit or over-exercise. Thought suppression seems to play an important role – with those who try and fail to squash negative thoughts about their eating habits more likely to show symptoms of bulimia. People with anorexia can show obsessions and compulsions unrelated to food or weight, including an irrational desire to arrange things in symmetrical patterns.

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  One of the newest additions to the list of abnormalities that could relate to obsessive-compulsive symptoms is maladaptive daydreaming. Freud said to daydream was infantile and neurotic, but these days psychologists and neuroscientists see daydreaming – sometimes called undirected thought or mind wandering – as a normal and probably useful part of human cognition. It might help us to solve problems, and we can usually snap out of it when we need to. Some people turn their daydreams into something more serious. They do it compulsively; they find it hard − if not impossible – to not daydream and the behaviour has a negative effect on the rest of their lives. Rachel was one of the first people identified with this problem.

  As a child in the United States of the 1970s, Rachel would spend much of her time in a self-created fantasy world. She would imagine herself in her favourite television shows and run episodes inside her head. As a teenager, Rachel started to lose control of what she and her parents had always considered a harmless hobby. She recalls how the daydreams took over until she was no longer in charge of her thoughts and her life – vividly similar to the language people with OCD use to describe their obsessions.

  Rachel, later a successful lawyer, sought and received treatment, eventually taking medicine commonly given to tackle OCD. She is far from alone. Wild Minds, a web forum for maladaptive daydreamers, has some 2,200 members from across the world. In 2011, scientists in New York reported the first academic survey of the condition. They questioned by email 90 people – 75 women and 15 men – who described themselves as excessive or maladaptive fantasizers. These people did not know each other, but they reported a tight set of thoughts and behaviours.

  The level of detail was striking – ‘I have spun tons of plot lines in this world spanning multiple generations of characters,’ one said.

  The parts of my daydreams I obsess over are the most intense emotional scenes … a character’s parents or best friend dies, a character is injured, abused, tortured or raped, or even just has a terrible argument with a loved one … Characters fall in love, get married, have and raise children, develop deep and strong friendships.

  The people who responded to the survey said they would spend, on average, more than half their time in daydreams.

  Only one in five of the daydreamers saw daydreaming as harmless – the rest had tried to stop. A quarter described the activity as addiction, obsession or compulsion. ‘I have tried to limit my daydreaming in the past,’ one said.

  I tried hard to just focus on what was around me and keep in mind only real people, things and events that were happening in the here and now. It was a battle. Me against my daydreams. They won.

  There’s more. Do you check your partner’s underwear to find traces of his/her sexual intercourse? Do you check up on his/her way of dressing up if he/she goes out on his/her own? Those are questions 29 and 30 of a ‘Questionnaire of Jealousy’ prepared by scientists at the University of Pisa. It aims to probe a mental syndrome called obsessional jealousy; others have labelled it non-delusional pathological jealousy, and have framed it as an obsessive-compulsive spectrum disorder. People with non-delusional pathological jealousy show similar behaviours to OCD. They respond to intrusive thoughts with excessive checks and requests for reassurance. And they avoid situations that might provoke the thoughts – for example, they can keep their partner in the house so they can’t meet potential suitors.

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  When you add that lot up then OCD doesn’t seem quite so rare and unusual. You almost certainly know someone affected. Yet people with these OCD spectrum disorders have something else in common besides their thoughts and urges. They don’t tend to bring their problems up in conversation. Their conditions are socially unacceptable because they often centre on shameful and taboo subjects. Sufferers assume their dark, intrusive thoughts reveal their true nature: someone who thinks such things must be mad, bad and dangerous to know. That phrase is overfamiliar through repetition, but look again at the power of the individual adjectives.

  I tried often to talk about my fear of HIV with friends. I didn’t admit my worries that I had caught it from, say, a mix-up of our toothbrushes in our shared bathroom, I kept the details vague. But I thought it might help to bring up the subject more generally: ‘So what about that Aids stuff then, that’s all a bit scary eh?’ The usual response was a nudge and a wink and a knowing smile. ‘So, who was she?’ Even today when I tell people I have had a persistent fear of HIV since my teenage years they assume it was because I was promiscuous. Hardly. My OCD was something of a passion killer.

  People talk about the stigma of mental illness, and they are right to do so. While it is considered fine, encouraged even, for those with a bad cold or an upset stomach to offer details of their ailment in great detail, to bring up the subject of mental health is often not just a passion killer, it’s a conversation killer. Awkward silences and awkward glances tend to follow. I have hidden it when I have applied for jobs. Do you have a mental illness? Well, which box would you tick?

  The stigma is less now for some mental disorders, such as depression. People sometimes talk about how anxious they are as if it’s the inevitable cost of a busy and enviable life. We are encouraged to discuss schizophrenia and bipolar disorder in less suspicious tones. But we have some way to go with OCD. As we’ve seen, most people don’t talk about even their most fleeting intrusive thoughts, because they fear they might be labelled as violent or perverted. So how does one begin to tell the neighbours that one is obsessed that one will sodomize their pet rabbit? Or confess to school friends one’s obsessive thoughts that one will turn into a rat, and so one checks compulsively for signs of a tail? Those are both genuine cases of people who sought help for OCD. Which box would you tick?

  SIX

  Cruel to be kind

  In his book on depression The Noonday Demon, Andrew Solomon describes how he was taken to hospital with a dislocated shoulder and how he was terrified that the pain would trigger a mental breakdown, as it had done before. He knew his mind, its weak spots and vulnerabilities, and he pleaded with the emergency room staff for the chance to talk to a psychiatrist, to head off the psychological impact that he believed would follow the physical trauma. They didn’t understand. They told him to relax. They told him to picture he was on a warm beach and to imagine how it felt when he wiggled his toes in the sand. Solomon’s shoulder was fixed, but within days his depression returned with a vengeance.

  When I first went for help with my intrusive thoughts of HIV, I was told to wiggle my toes in imaginary sand too. I had gone to a drop-in centre run by a mental health charity on the edge of the university campus, and they had made an appointment with a counsellor. This was outside the medical system and that was deliberate. I didn’t want to see a psychiatrist because that was for crazy people. I didn’t want to talk to a doctor, because I didn’t want anything written down. Stories in the newspapers at the time warned that those who asked their doctors about HIV and requested tests were being denied health and life insurance.

  The counselling was useless.* We performed relaxation exercises and I pulled imaginary golden thread from my nose. Neither stopped the intrusive thoughts. And we talked about my childhood, my parents and my relationship with them. That’s classic psychodynamic analysis – the technique developed by Freud. That didn’t help me either, but then, despite the
claims of Freud and those who followed him, there is zero evidence that psychodynamics works with OCD. In fact, it could probably make things worse.

  In the mid-1960s, psychiatrists in London encountered a middle-aged woman with OCD who had been treated for ten years with Freud’s methods. The woman had become obsessed with blasphemous intrusive thoughts when she was a child that became increasingly sexual when she was a teenager, such as thoughts about sex with the Holy Ghost. She carried out repetitive acts to reduce the anxiety – she dressed and undressed time and again and walked up and down stairs. Taught by Freudian therapists about the importance of sexual symbolization, she then found it traumatic to close drawers, insert plugs, clean tall glasses, enter trains and eat bananas.

  Much of Freud’s take on the causes and treatment of OCD now looks ridiculous, yet it dominated approaches to the disorder for decades after his death. That’s not because he was right, it’s because his sky-high profile ensured his work on obsession was translated into English, which became the most widely used language of the new field of psychiatry in the twentieth century. This translation process created a problem. Freud, who spoke German, used the term zwangsneurose (obsessional neurosis). The word zwang was translated as ‘obsession’ in London, but ‘compulsion’ in New York. Faced with confusion, scientists introduced the hybrid term ‘obsessive-compulsive’, a label subsequently given to millions of people, as a compromise.

  The popularity of Freud’s suggestion that internal conflict generated obsession only started to wane in the 1960s, when a new breed of scientists muscled in on the field of OCD. They were called behavioural psychologists, or simply behaviourists. The behaviourists had their own firm belief. All behaviour was learned, even abnormal behaviour. And as such it could be unlearned. To treat obsession, they just needed to find the right trigger.

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  The use of behavioural psychology to treat OCD comes directly from the famous experiments of the Russian physiologist Ivan Pavlov, who reported how dogs learned to associate food with a bell rung to announce mealtimes, so much so that they would drool at the sound of the bell even if no food appeared. Pavlov’s lab called the reaction of the dogs ‘reflex at a distance’, but other scientists preferred the term ‘conditioning’, and they thought it could explain phobias and the irrational fears of OCD. The causes of irrational fear were not in someone’s sexual history, they said, but in their environment. Someone with obsessions of catching a disease from a public toilet, for example, had probably once become severely ill after a visit to a particularly unhygienic washroom. This ‘classical conditioning’ gave birth to the irrational fear, which was maintained and nurtured by a related process called ‘operant conditioning’. The person, the theory went, would start to avoid toilets to reduce stress and because this action would work, it would negatively reinforce the behaviour.

  In one bizarre case of conditioning, a man found that he was impotent when he tried to have sex with his wife – but only when the couple were at home. In therapy he described how he had previously been discovered in bed with another man’s wife and how the cheated husband had thrashed him. The man remembered how his assailant’s wallpaper, by unlikely coincidence, was the same as that on the walls of his and his wife’s own bedroom. The beating had made him classically conditioned to associate sexual desire and the wallpaper with the fear of violence. One redecoration later, the problem went away.

  Conditioning had a flip side. If someone could deliberately be made to associate undesired behaviour with an unpleasant experience, the behaviourists thought, then the drive to carry out that undesirable behaviour should cease. This spawned the era of what became known as aversion therapy. It saw compulsive gamblers play fruit machines wired up to deliver electric shocks, alcoholics given a drink together with drugs to make them vomit, and overeaters forced to watch a doughnut cooked in front of them while they sniffed at pure and rotten skunk oil.

  Most shamefully, psychologists in the 1960s and 1970s used aversion therapy to try to reverse homosexuality. Gay men were shown photographs of naked men and women, and if they looked at the man for too long, their therapist would shock them with electricity. Success of the treatment was judged by how many women each homosexual managed to sleep with over the year or so that followed, and the relative size of their erections when shown straight and gay pornography. Those who failed to convert were coached on how to chat up a woman and how to read her body language.

  There is some evidence that a form of aversion therapy was tried in ancient times. Roman citizens who drank too much alcohol would be forced to swallow an eel from a wine glass. And early Buddhist texts describe an over-talkative chaplain who was cured of his habit by a cripple who hid behind a curtain and used a pea-shooter to fire pellets of goat dung into the chaplain’s mouth whenever he opened it to speak.

  Aversion therapy was used to treat OCD. A 49-year-old obsessive-compulsive patient was equipped by a psychologist at a Birmingham, UK, hospital in the early 1970s with a device that strapped electrodes to his fingers and automatically delivered an electric shock if he washed his hands too often (the water completed the circuit). Frank Kenny, a psychologist at the Memorial University of Newfoundland, went further with aversion therapy for obsession. He thought he could use it to turn off not just the compulsions but the intrusive thoughts themselves.

  Kenny would ask his patients to form an image relevant to their obsession, or to say a repetitive phrase, and then he would blast them with painful electricity. He did it thirty or forty times in each session, for up to five sessions a week. It could produce ‘lasting change’ he reported.

  It must have been quite a sight. Mrs D, a 33-year-old housewife and one of Kenny’s first subjects, for example, would say out loud her intrusive thought: ‘I am going to have sex with my dog’ and then raise her finger. Kenny, sat behind, would take this as his cue to shock her and Mrs D would react to the pain, wait thirty seconds and repeat ‘I am going to have sex with my dog.’ Zap. ‘I am going to have sex with my dog.’ Zap. Kenny grandly called the treatment ‘Faradic Disruption’ (Michael Faraday being the scientist who invented the electric motor).

  Aversion therapy was controversial among scientists, and dynamite in the media. Anthony Burgess’s 1962 novella A Clockwork Orange graphically describes a (fictional) aversion method called the ‘Ludovico technique’, in which the book’s antihero, Alex, has his eyes pinned open and is forced to watch violent scenes and listen to his favourite classical music, while under the effect of a drug that induces nausea. Alex subsequently tries to kill himself.

  By the time the film of the book was withdrawn from British cinemas in 1972, a full-scale backlash was under way against aversion therapy, which some critics claimed was being used to brainwash people in the style of Aldous Huxley’s Brave New World. Opponents in the US labelled behavioural psychologists Rockefeller Nazis and said (with a confused take on politics) that they bred communists. One prominent behavioural psychologist at the time, Jim McConnell at the University of Michigan, was later targeted by the terrorist known as the Unabomber.

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  I had a mild brush with aversion therapy. After several years of denying that I needed to, I eventually went to see a psychiatrist. I was still in Leeds, by now studying for a postgraduate degree, and a psychiatrist came to the university’s medical centre once a fortnight. He gave me a red rubber band and told me to wear it on my wrist and snap it against my skin whenever I had an intrusive thought about HIV or Aids. That was treatment for OCD in the mid-1990s. It was called thought-stopping, and it was another idea of the behaviourists. My band lasted a few hours. The next one survived a day. I went to a budget stationery shop and asked for the biggest bag of rubber bands they had.

  Thought-stopping, scientists now accept, does not help people with OCD, any more than relaxation techniques or Freudian psychodynamics do. Still, my trip to the psychiatrist was not wasted. It showed me that I was not alone. The psychiatrist had asked me if I wanted to join one
of his group sessions for OCD. I didn’t. I wasn’t keen to hang out with hand washers because I didn’t see how it would help. My problem was different I said, and I doubted anyone with OCD would truly get it. ‘David,’ he replied, ‘I am seeing three other people at this university with OCD and they have the same irrational fear of HIV that you have.’ I felt a strange sensation; I now realize it was hope.

  He also told me the way to beat OCD. It sounds easier than it is. He told me that the compulsions, in my case the urge to make sure I had not exposed myself to HIV by checking and seeking reassurance, fuelled the obsessions. He explained the vicious circle that I was trapped inside. The way to stop the ride and get off, he said, was to resist the compulsions.

  To beat OCD was as simple as that, just as scoring a hole-in-one on the golf course is as simple as hitting the ball directly from the tee into the hole. I played a lot of golf at that stage of my life. The odds that a regular golfer like me will score a hole-in-one have been worked out as twelve thousand to one. Before I was able to properly resist any of the compulsions of my OCD, I managed to score two.

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  I never smoked but I imagine that to resist the compulsions of OCD is what it must be like to try to quit cigarettes. Like sticking to a diet, to stop the compulsive checks ultimately comes down to willpower. But what must be resisted in OCD is not a physical craving, but the mental pull of your own consciousness. In the grip of a compulsive urge there is nowhere to hide and nothing to reason with. To resist a compulsion with willpower alone is to hold back an avalanche by melting the snow with a candle. It just keeps coming and coming and coming. The obsessions and compulsions of OCD are linked by a force of nature so strong that to break the connection demands almost supernatural effort. When I was in the grip of the worst of OCD, if you had asked me not to investigate suspicious red stains on a communal towel, you may as well have ordered me to fly or to shoot thunderbolts from my fingers.