by David Adam
Some days I had more supernatural willpower than others. Some checks seemed more harmless than others. I learned which situations would prompt the thoughts and the urges, and worked out ways to avoid them. If I was unsure whether someone else had drunk from my glass, I didn’t finish it. If an opponent on the Astroturf soccer field shredded his knee, I would avoid him. In that way I muddled through. I had good days and I had bad days. I had lots more bad days. When things became especially bad, when a thought just would not budge, then I would force myself back to donate blood. The blood donor service would take it only every sixteen weeks. I would count down the days in a planner.
It’s not that OCD meant I could not function, and that I couldn’t think of or do anything else – I did well in exams, I had friends and girlfriends, furious arguments and fun conversations, and I held down some decent jobs. It’s just that I was thinking about something else at the time. I was thinking about HIV and how I might have caught it when I learned that my grandmother had died, when I found out that Princess Diana had been killed, when I saw Pulp Fiction at the cinema and when I watched rower Steve Redgrave claim his fifth Olympic gold medal on television. I was thinking about HIV and Aids in the days before I got married – I had met a climate scientist at a conference the previous week with a sore on his lip and I couldn’t be sure that we hadn’t mixed up our drinks. OCD stole something from me at that stage of my life: it took away my attention.
There is a great line in a book about famous hypochondriacs by Brian Dillon. It’s called Tormented Hope and it talks about a point in the life of a hypochondriac when things change. They begin to secretly date everything back to the moment they first realized something was wrong. Life previous to that point, he writes, looks idyllic and elusive. In a similar way, I am a world expert on the events of 1991, or more precisely whether they happened before or after the summer, before and after my first obsessive thoughts. Those before, I participated in. Those after, I watched. Obsession meant that I navigated much of life after the summer of 1991 on autopilot. I was up front and central. I looked the part and smiled at the passengers, but something else was flying the plane.
Then there was Stoke City. As I write this book in 2013, Stoke City is a soccer club that plays in the English Premier League. As you read it, I hope it still does. I’m not one for the over-intellectualization of soccer, but Stoke City helped me through my years with OCD.
I used to go and watch Stoke play before the summer of 1991, so it offered a bridge that could connect me with those idyllic and elusive days. And then there was the impact when Stoke City scored a goal. It’s tragic, I agree, but at my grandmother’s funeral, my younger brother and I stood awkwardly next to each other, we barely said a word. Yet just a few weeks later, when Peter Thorne scored for Stoke City in a match against Cambridge United, we hugged and yelled at each other at the top of our voices. A Stoke City goal, a mixture of elation, release, celebration, relief and usually, quite frankly, surprise, would penetrate. I felt it. OCD put a shock absorber on most of my emotions, especially those that I could see coming. But it couldn’t buffer the feeling of a Stoke goal.* I know, like I said, tragic. Worse, even. When you rely on goals from Stoke City to get you through life, you know you truly are fucked.
* * *
That was my way to live with OCD. And as most people with OCD never get help, and those who do take, on average, seventeen years to see the right person, most do have to live with it. In fact, we can be pretty confident that people have lived with intrusive thoughts, obsessions and compulsions for centuries. This is not the first book to describe the impact of irrational and recurring weird thoughts. Not by some six hundred years.
Margery Kempe was born around 1373 and some experts consider her book, published in 1436, the first autobiography written in English. A clergyman took her dictation and wrote the account of her life – still in print – in the third person. Kempe fought against intrusive thoughts of erect penises. ‘She was shriven [granted absolution], and did all that she might,’ the book says. ‘But she found no release, until she was near at despair.’
One of the most detailed historical accounts of the impact of intrusive thoughts was recorded by John Woodward, an early eighteenth-century fellow of the Royal Society and professor at Gresham College, London. He wrote about Mrs Holmes, a 26-year-old woman from London Bridge who became obsessed with thoughts of a porpoise that she saw in May 1716 in the River Thames:
She never awaked but this Thought first came into her Mind; and continued till she went to Sleep again … She frequently endeavoured to cast that Thought out; and to introduce another, that might be more pleasing to her; in which she sometimes succeeded; but the new Thought, however pleasant at first, became, in a little time, as troublesome and disturbing as that of the Porpoise.
An apothecary advised Mrs Holmes to ‘be cheerful and brisk’ – the eighteenth-century equivalent of ‘pull yourself together’. Woodward was not impressed with this advice, lamenting that it was the common response of ‘those who are not Judges of these things, and who do not know, that People in this Case are subject to the Fury of a Morbid Principle, and wholly under the Government of it’.
There are historical accounts of what can seem compulsive behaviour too, though we should interpret them with caution. Repetitive actions, even those that seem obsessive and irrational, say little that is precise about a person’s state of mind. Some stories of the history of OCD, for instance, include a tale from the ancient days of the Buddha, some 2,500 years ago, and an apparently obsessed monk who felt compelled to sweep the floor of the monastery continuously. That may look like OCD, but other accounts from the time describe how the Buddha told one of his disciples, Suddhipanthaka, to deliberately sweep the floor non-stop to reach enlightenment. We might say today that Suddhipanthaka was ‘a little bit OCD’ with his sweeping. But he wasn’t.
One prominent person in the past who did seem to suffer from genuinely compulsive behaviour was Samuel Johnson, the eighteenth-century English writer and dictionary compiler. His biographer James Boswell noted how Johnson would count his steps and make sure that he always started on the same foot. Often, he would stop, count again and then head back to try again, even while his companion would carry on down the street.
Many historical accounts of obsessive behaviour detail not just the presence of intrusive thoughts, but the folly of trying to suppress them. These writers may never have seen a white bear, but they knew of the effect. Martin Luther, the sixteenth-century German priest who inspired the Protestant Reformation and suffered from obsessive thoughts, gave the advice:
Grit your teeth in the face of your thoughts and for God’s sake be more obstinate, head strong and wilful than the most stubborn peasant or shrew. Indeed, be harder than an anvil … If necessary speak coarsely and disrespectfully like this: Dear devil, if you can’t do better than that, kiss my toe.
‘Kiss my toe, OCD’, that’s what I should have said. But I wasn’t ready. Not yet.
SEVEN
The God obsession
If almost everybody experiences intrusive thoughts, and intrusive thoughts are the raw materials for obsessions, then why does almost everybody not develop OCD?
The mind is a thought factory. Every day it processes a conveyor belt of thousands of thoughts, good and bad, happy and sad, useful and intrusive. The factory must decide how to act on them and then issue instructions to respond. We each do this differently, based on our unique combinations of early experience, environment and biology; our biases, preconceptions and knowledge. The thought factory must work fast. The conveyor belt always rolls and new thoughts arrive in a constant stream. Something always comes in and something always goes out.
Chemical engineers call a system like that a continuous process. It’s the opposite of a batch system, in which they dump all the ingredients in a pot and leave them largely undisturbed to do their thing. Continuous processes are more efficient because you don’t have to turn them off and start again
to change the quality and the quantity of product. Turn up the temperature, increase the pressure, slow down the flow and you can tweak how the process converts the raw materials into something useful. Our thought factory does that too. In different circumstances, under pressure or stress, when we are tired or angry, we alter the way we process our thoughts.
The thought factory works pretty well. But it has a flaw. No chemical engineer would design a continuous system in which the inward flow of raw materials could not be turned off. That is a recipe for disaster. It can turn a minor problem into a full-scale catastrophe.
To understand OCD we must look at the conditions inside the thought factory, prising off the lid to see how two different minds can process the same thought in radically different ways. This was a task beyond the behavioural psychologists. In fact it was a concept that the behaviourists firmly rejected. They had no interest in what went on between the ears, only in how it showed itself as action. The mind was a black box and the thought processes inside, they claimed, unimportant.
It took until the 1980s for a new group of scientists, cognitive psychologists, to challenge that view. They argued that thoughts and how they were processed were crucial, not just to understand mental disorder but to treat it. They were ready to lift the lid on OCD. And when they did, one of the first places they looked for an answer was religion.
I’m an atheist but I have no specific axe to grind with religion. That’s important to say because what follows could easily be construed as an attack. For the record, I’m not saying that religion is a mental illness, or that OCD and religious beliefs are the same thing. I’m not saying that OCD makes people religious, or that religion causes OCD.
Religion does not cause OCD, but, as we’ve seen, attempted suppression of intrusive thoughts probably does. Unrealistic demand for pure thoughts probably does. And to be told that if you think certain things then you will forever burn in Hell probably doesn’t help.
* * *
In 2002, psychologists risked their eternal souls for science and deliberately misled dozens of Catholic friars and nuns, scattered across the convents and nunneries of northern Italy. The psychologists wrote to religious institutions and asked for volunteers to help with a study. The scientists wanted to look at the link between religious belief and obsessive symptoms, but they didn’t admit that at first. They said only that they were interested in how people think. They kept the information intentionally vague, they said, to avoid a ‘defensive attitude’ from the pious.
Dozens of the nuns and friars came forward to help and the scientists sent them questionnaires to assess their personalities and to judge how obsessive-compulsive they were. They repeated the exercise with two other groups: citizens actively involved in church activities, and university students who said they had no interest in religion. The psychologists found that the friars and the nuns, together with the regular churchgoers, were more likely to report thoughts and behaviours consistent with OCD.
OCD and religion have walked hand in hand through the centuries. The initial spiritual interpretation of obsessions and compulsive behaviours means that most early accounts of what would now be considered medical problems are set in a religious context. Plus, it was the clergy to whom most people turned with their concerns. Obsessive thoughts of sin – that one had committed a sin or that one was perpetually tempted to sin – have long plagued the devoted. As far back as the sixth century a Mount Sinai monk called John Climacus wrote of intrusive, blasphemous thoughts, which would invade an individual’s mind against their will and which proved almost impossible to evict: ‘This deceiver, this destroyer of souls, has often caused men to go mad.’
By the fifteenth century, intrusive thoughts of sin were called ‘religious melancholy’, or ‘scrupulosity’. The latter term was popularized by Antoninus, an archbishop of Florence. A scruple, he said, was a state of fear and indecision, which arose from mental questions that were impossible to answer and doubts that could never be settled. It comes from the Latin word scrupulum, which means a small sharp stone. The church compared the stubborn moral doubt of scrupulosity to the feeling of a pebble in your shoe. No matter how often you stopped to remove it, when you next took a step it was still there. Say what you like about medieval Italian religious leaders and their contribution to science, they knew a good analogy when they saw one.
One reason we can be confident that religion does not cause OCD is that obsessions and compulsions crop up with similar frequency in both secular and strictly religious countries. But, although the total number of people with OCD is unaffected by a country’s religious leanings, the more religious a place, the more the clinical obsessions of these people centre on religious issues. Religion might not provoke obsessions, but it does provide an outlet for them.
Various studies over the last few decades display this trend. Just 5 per cent of OCD cases in England feature obsessions and compulsions that relate to religion, 10 per cent in the United States, 11 per cent in India and 7 per cent in both Singapore and Japan. Numbers shoot up in the Middle East: 60 per cent of people with OCD in Egypt report religious obsessions, 50 per cent in Saudi Arabia and Israel, and 40 per cent in Bahrain. In Turkey, a secular country with pockets of intense religiosity, the burden of religious OCD shadows the geographical influence of Muslim culture and increases as you travel from west to east.
* * *
Psychologists who have studied this link between OCD and religion say it could come down to ways of thinking called dysfunctional beliefs. Most people have dysfunctional beliefs, which we usually pick up in childhood. They are not mental disorders, they are lenses placed across our cognition. They distort the way we perceive the world and can help explain why different people interpret identical situations in different ways. Some people are more likely than others, for example, to focus on the negative outcomes of their actions, and to exaggerate the way these outcomes damage themselves and others. That’s a dysfunctional belief called catastrophizing. It makes people more likely to be anxious.
Psychologists have identified three types of dysfunctional belief important in the development of OCD. The first is an inflated sense of threat and personal responsibility. The second is perfectionism and intolerance of uncertainty. The third is a belief in the over-importance of thoughts and the need to control them. To be clear, to have one of these dysfunctional beliefs is not to have OCD, but it does increase the chance that someone will develop OCD, because they will then incorrectly process the intrusive thoughts that are common to most people. What’s more, the strength of the dysfunctional belief – how hard people with OCD cling to it in the face of contrary evidence – might influence the degree of insight they have into their condition.
The different types of dysfunctional beliefs could explain the range of symptoms seen in OCD. Perfectionism could underpin a compulsive need for symmetry, while inflated responsibility and overestimation of threat could combine to promote checking obsessions about dirt and disease. And beliefs about the over-importance of thoughts – bad thoughts lead to bad deeds – could drive obsessive thoughts of dangerous or inappropriate behaviour.
Dysfunctional belief about the over-importance of thoughts is sometimes called thought-action fusion, because it implies to someone that a thought is the moral or the physical equivalent of an action. Thought-action fusion, for example, can make people believe that to ‘think’ about having sex with someone – a married man or a child – is as bad as actually doing it. Does that sound familiar?
‘I say to you that everyone who looks on a woman to lust for her has already committed adultery in his heart.’ According to the Gospel of Matthew, Jesus Christ says that to his followers during the Sermon on the Mount. It’s a good description of thought-action fusion. Thoughts, in other words, are equivalent to actions. The tenth commandment goes further and forbids people to want (covet) property owned by somebody else. Just to think an impure thought is itself a sin.
Psychologists say that thought-action fusio
n could explain the way OCD shows itself among religious people. Some Christians, for instance, are often distressed to discover they can even conceive of sin. Their impure thoughts, they believe, must show they are not as devout as they hoped. Thought-action fusion makes these people believe that their thoughts – their thoughts alone − represent moral failure that makes them more likely to face God’s punishment. These distressing sinful thoughts are, of course, ego-dystonic, they run contrary to the individual’s faith. This makes the person more likely to try to suppress the thoughts, and so for the thoughts to return.
This link between religious belief and thought-action fusion can be tested. In 2012, psychologists asked dozens of senior figures in the Lutheran church how they would respond if one of their parishioners sought their help for scrupulosity. The scientists created a hypothetical worshipper, who they said was worried that she was going crazy because she could not get unwanted thoughts of cursing God out of her mind. She no longer read the scriptures, they said, because of the intrusive urges she felt to desecrate the pages. The thoughts caused her great anxiety and she prayed for up to eight hours a day for forgiveness.
Most of the spiritual leaders were sympathetic. They said they would reassure the woman that God was merciful and forgiving and that He understands the difference between involuntary and deliberately sinful thoughts. But significant numbers said they would also recommend action that, however well intentioned, we know (from the white bear effect of how suppressed thoughts return harder), would just make the situation worse.