by David Adam
Of particular relevance is the mental impact: how a thought can bring on disgust, with physical consequences. Someone who has spent the night vomiting because they ate some dodgy shellfish need only think of a prawn sandwich the next day to set them off again. Charles Darwin, who was interested in the emotions − as well as the origins − of people and animals, noted this effect. He reported ‘how readily and instantly retching or actual vomiting is induced in some person by the mere idea of having partaken of any unusual food’. That sounds like thought-action fusion.
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Perhaps the most famous case of contamination OCD relates to the bloodthirsty murder of a king and his guards, plotted and executed by a husband and wife. The man takes over as king, but after his wife handles the bloody murder weapon she is plagued by obsession. She feels compelled to wash her hands time and time again, yet she cannot scrub away the vision of the blood she sees there. It does not end well for either of them: she kills herself and he has his head cut off by a rival dressed as a tree. But then, that’s what happens when you take career advice from strange women you meet on a Scottish moor.
Lady Macbeth, of Shakespeare’s play and of course the woman mentioned above, might today be told she suffered from mental pollution: a sense of internal dirtiness that persists despite the absence of external dirt. Psychiatrists see mental pollution a lot with women who have suffered sexual abuse. No matter how often they shower and wash, the women still feel dirty, contaminated. In the last few years it has become clear that mental pollution can play an important role in OCD.
Andy suffered from severe OCD that was traced to mental pollution. A civil servant in London, Andy developed his condition in the 1990s after his wife left him for another man and Andy was pursued by the authorities for child maintenance payments. He became obsessed with thoughts of the brown envelopes they used to send their demands. He felt the envelopes could contaminate him. Andy would react to his feelings of contamination by washing his hands, up to eighty or ninety times a day. He had to sleep in gloves to protect his brittle skin.
Assuming that Andy was behaving in a similar way to OCD patients who fear physical contamination, germs from doorknobs for example, psychologists tried to help him with the same techniques they used for those patients. We’ll come to exposure therapies in a later chapter, but here’s a teaser: as part of the treatment, Andy would spend whole days covered in brown envelopes, from head to toe, in an attempt to make him less sensitive to them and their perceived physical threat.
But there was no perceived physical threat. It was not the physical envelopes that made Andy feel dirty, but the feelings associated with his thoughts of them. He did not even need to see one. He could conjure an image of the envelope in his mind that brought on such intense disgust that he would need to wash his hands. Just like Lady Macbeth, Andy’s washing was futile, because the source of the sense of contamination was internal.
Mental contamination is closely tied to disgust. Imagine a stranger with bad breath and crumbs at the side of their mouth who grabs you unawares and presses their mouth against yours for a sloppy kiss. As you picture the scene, can you feel as your own mouth curls and your nose wrinkles in that familiar shape of disgust? Now, would you like a drink of water? In experiments with female students, after such an exercise a significant number said they wanted to rinse out their mouth or to wash their hands. Disgust caused by the thought of the dirty kiss – the thought alone – had made them feel dirty inside. They were mentally contaminated. Out, damned spot. Out.
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If OCD is a product of shared evolutionary history, or the overreach of a natural capacity for ritual or disgust, then that might explain one of the most noticeable features of the disorder: consistency. It would mean that the condition does not crop up spontaneously in individuals, but rather as a shared biological response to some external or internal primer. We see this on the ground. Time and time again, different types of people with the same types of OCD report the same forms of obsessions and respond with almost identical rituals, even though they are separated by thousands of miles.
The nature of these shared obsessions and compulsions seems stable over time – case reports from centuries ago feature identical thoughts and behaviours to patients who report them now. And they are consistent across the world – identical forms of OCD have been found just about everywhere scientists have looked for them, from western Europe, the United States and Canada, to Latin America, the Middle East, China, India and Australia. In these cases, different cultures and experiences seem to make no difference.
A few years before I developed my OCD, Claire, a 10-year-old girl from Texas, came down with exactly the same obsession. When a schoolteacher told her class about the threat of Aids, she could not get thoughts of the disease out of her head. She would not eat in a restaurant in case someone had picked up food with bloody fingers, refused to kiss or hug anyone outside her immediate family, and had asked the school nurse about fears she would catch Aids from snot thrown in the classroom, a wet bus seat and a soiled book. When a boy in her class said: ‘Have sex with me. I hope you get Aids,’ she found she had to repeat the phrase. Only if she then added a silent ‘just kidding’ six times at the end of the sentence, she said, could she prevent harm to her six family members – herself, her mum, dad, brother, dog and fish. Claire developed other compulsive behaviour, and would feel urges to spit, hop and touch walls in sequences of six – all as a way to ward off the intrusive thoughts of HIV.
When Claire started to refuse to go to school because of her fears, her mother tried to help by explaining the sexual transmission of Aids. Claire responded by stopping the family dog from sleeping on her bed, because it was a boy. At this point, her parents took her for help. She was hospitalized but was helped to make a recovery. She will be in her thirties now.
Like Claire, I was lucky. Help for mental health in the UK is patchy, but after I saw my local doctor and told him my story it emerged that we were in the catchment area for a specialist outpatient OCD service based at a mental health unit at a hospital a few miles away. It was the same hospital where my daughter had been born. The doctor passed me along to them. This time, there would be no elastic bands. And this time, for my daughter’s sake as much as mine, I was determined to make it work.
NINE
Man hands on misery to man
By the time my case worked its way through the health service to reach the specialist OCD unit, my obsessions about HIV had spread to the many different ways I thought I could pass the virus to my baby daughter, who by then was about eight months old. If I cut myself shaving, or in clumsy attempts at home improvement, I was compelled to wash my hands repeatedly before I touched her, in my mind to remove any risk that I could pass her contaminated blood. I was distraught. I had become a hand washer. My fingers were always chapped and dry. I told people it was because I had to clean and sterilize her milk bottles so often.
One night I showed her my electric toothbrush and woke with a start the next morning to intrusive thoughts that I had flicked my blood from its bristles into her eyes. I was compelled to check if I could have done. I locked myself in the bathroom, drew a face on the mirror with shaving foam and held the buzzing wet toothbrush at various distances to analyse where the water sprayed. It didn’t help.
It wasn’t just HIV by then. When I discovered that some of the old paint I had enthusiastically stripped and burned from the cupboard doors in our bedroom contained lead, I became convinced I had poisoned her. No matter how many times I cleaned the carpet, if I dropped one of her toys or her milk bottle I considered it contaminated. More blood tests – this time my wife and I for lead (both normal). My wife drew the line at tests on the baby, as my OCD wanted, because that required a needle to be stabbed into her young head. I even found a national lead paint hotline to call. On my third enquiry to them inside twenty-four hours, afraid they would recognize my voice and refer me to the answers they had offered previously, I convinced my
wife to ask my questions for me.
I was concerned not just that I would pass HIV to my daughter, but also that I would act in a way that would make her more likely to develop obsessions and compulsions herself. On that score, I was right to worry. Studies since the 1930s have shown that OCD seems to run in families. Relatives of those with OCD are themselves more likely to show symptoms than the general population. So, here’s another question, is OCD genetic? Do I carry it in my DNA?
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There is no single obsession gene, just as there is no gay gene, or intelligence gene. To start with, there just aren’t enough genes to go around, to map one-to-one onto the entire spectrum of human attitudes, behaviours and physical attributes. All genes work alongside other genes. A few of our traits (wet or dry earwax) and a few diseases (cystic fibrosis) have been traced to the impact of a solitary gene, but they really are a few. Even eye colour, for years a classic textbook example of single gene control, is now known to be under the control of many different genes that act together.
This helps to explain why, despite recent technological progress, most of the promised medical reward of human genetics remains on hold. The more scientists explore, the more murky and complicated the picture becomes. That means that when it comes to the genetic causes of OCD, unfortunately we don’t have much to go on. There are some clues, but they are pretty abstract clues. One of these came in summer 2012, when scientists in the US looked at the genes of five generations of an obsessive family.
OCD was rife in the family. Great-great-grandpa and great-great-grandma had two children, both of whom had OCD. Four of their eight grandchildren had OCD too and so did eleven of their eighteen great-grandchildren. Of the eleven great-great-grandchildren born by the time of the study, five were judged to have OCD. None of the family had married anyone with OCD, so if there was a genetic link, and there surely was, then scientists could have expected this family, and others in the same study, to reveal it.
Detective work followed. With little more than a processed blood sample, lab researchers can automatically screen a person’s DNA for more than half a million specific and common genetic variations. Nobody has every one of the half million possible variants – such a person would be very ill and very odd indeed. Instead, they are sprinkled across the population, and the different ways they appear in individuals act as flags, which draw attention to regions that might carry genetic risks. When scientists compare these genotype maps, and the symptoms in the people where the maps look similar, they can start to narrow the focus for a genetic cause for illness, down from the entire genome to a few flagged regions. That’s an essential step if targets for treatment are ever to emerge.
In the US family study, when the scientists looked for patterns shared across the generations, the strongest linked OCD to specific genetic changes at the tip of chromosome 1. It was far from a smoking gun though. The association with OCD wasn’t clear-cut, and other regions of other chromosomes were implicated too, just with even less certainty.
A parallel study that looked for patterns in the genotypes of 1,465 unrelated people with OCD from across the world produced equally weak results. In that research, a technique called a genome-wide association study, the scientists fingered a different genetic region, this time on chromosome 20. Genome-wide association studies often produce graphs of results named Manhattan plots after the famous pointy skyline of New York City. Each prominent skyscraper on the plot corresponds to a possible genetic cause, and so a possible step towards a treatment. In this case, the output of the OCD study looked more like the skyline of Washington, DC, which is universally flat because planners allow no building much taller than the distance across the street it stands on.
No skyscrapers in the OCD Manhattan plot indicates no clear genetic causes. That doesn’t rule out that OCD is under the control of genes, but it shows the relationship is complex and not driven by a few bits of wonky inherited DNA that can easily be identified.
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Mental disorders that run in families do not need a genetic cause. There is the impact of the environment too. Some genes lie dormant until something in the environment triggers them. Other inherited traits are down to the behaviour and influence of our parents. I play golf and so does my brother. That’s because my parents both play golf and they encouraged us, not because golf is in the shared DNA of our family. It’s especially not in the shared DNA of my dad. You only have to watch him try to chip his ball over a bunker to see that.*
The usual way to tease apart genetic and environmental factors, to separate nature from nurture, is to study twins. Identical twins share all their genes, non-identical twins don’t. Twins raised together share aspects of their environment, those raised apart don’t. Throw enough of these different twins at a hereditary illness and scientists can start to work out whether their nature or nurture has the most influence. OCD has been studied in twins for decades but the results are hard to interpret. The best guess of scientists when it comes to OCD is that genes and environment are about as important as each other. So, just as someone with OCD cannot blame the nature they received from their parents, they can’t blame the nurture they received from them either. Or, if they wish, they could blame both. (What matters most is that the parents do not blame themselves.)
One way that our environment − parents, preschool years and cultural background – could seed obsessions is because these early experiences frequently leave us with dysfunctional beliefs, some of which, as we saw in Chapter Seven, are implicated in OCD. Inflated responsibility could come, for example, when parents give older children too much power over their younger siblings at an early age, or conversely as compensation for giving them no power at all. In problem-solving tests, mothers of those with OCD have been seen to demand more of their children, to expect them to take the lead.
The famous OCD of aviation pioneer-turned-bearded-recluse Howard Hughes may have emerged from his childhood experiences. Hughes died in 1976 and was a fierce defender of his privacy, but details of his bizarre behaviour in later years were pieced together by psychologist Raymond Fowler, a former president of the American Psychological Association who was asked to conduct a ‘psychological autopsy’ by the law firm that handled the billionaire’s estate.
Hughes showed clear symptoms of OCD, which, according to Fowler, may have related to his mother’s fear of polio and the extreme measures she took to protect her young son from the disease. By the time he was in his sixties, Hughes had developed severe compulsive behaviour to ward off germs. His staff had to wear white gloves, pass him cutlery wrapped in paper, and he would burn the clothes he was wearing if someone he met became ill. He gave detailed instructions on how others should feed him tinned peaches – remove the label, scrub the can and pour the contents into a bowl without touching it. He wore tissue boxes on his feet.
It is hard to pin down how parenting style contributes to OCD because to draw definitive conclusions, adults with OCD must be asked to recall how their parents behaved some twenty or thirty years or more before. A handful of studies have looked at the impact of parenting style on the mental health of children in real time, but only for the broader problem of anxiety. (High parental control and overprotection did seem to make children more anxious, but it is impossible to tease out the impact on OCD from this research.) The only known study to compare the behaviour of parents of children with OCD, and parents of children with other anxiety disorders, suggested the mothers and fathers of the OCD kids showed less confidence in their children and were less likely to reward independence. The study, however, was small (just eighteen children with OCD) and it does not prove that the parenting style was to blame.
As a parent concerned I will pass OCD on to my children, none of that is very helpful, but that’s the way it is. Most parents make it up as they go along anyway. It’s hard to stick to a script, even if we knew what it should say.
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There is clearer evidence on the damaging impact of what’s c
alled family accommodation of someone’s OCD – parents and siblings drawn into the obsessive web of a loved one and forced to help perform their ridiculous compulsions. Mrs D, for instance, was obsessed with contamination from other people and would sit only on a single chair that she would disinfect each morning and which nobody else was allowed to touch. Mrs D’s compulsions demanded that her three children stay two or three feet away from her. The children had no choice but to comply – their mother made the rules.
In their 1980 book Obsessions and Compulsions, Stanley Rachman and Ray Hodgson described an extreme case of accommodation of the contamination rituals of a 19-year-old man called George by his elderly father Harry. Each morning, Harry said, he would help his son dress while taking care not to touch the outside of his clothes. A trip to the toilet was next and, Harry said, it was a palaver. It was easier if George wanted only to urinate, Harry said, because his role then was then only to get down on his hands and knees with a flashlight to check his son’s trousers and boots for splashes, or the floor for pubic hairs. As soon as George did up his trousers, Harry would have to wipe the zip with a pad soaked in antiseptic.
Life was better outside the house, if they could get there. If George saw a speck of brown in the car he said it was dog dirt and Harry had to scrub the seats. About to go out one day, George felt suddenly compelled to have a bath and delayed their departure by three hours. If George felt Harry had not cleaned properly he would get angry and smash crockery and furniture; he once threw a bar of soap through a window pane and then started to worry about the broken glass, which he insisted that Harry clear away.
Harry was in an impossible situation. And it’s one faced time and again by the families of people with OCD. Surveys show that three-quarters of the relatives of people under the age of 17 with OCD become involved in the rituals. More than half the relatives of adult sufferers do too. Some do it because it pains them to see the person they love in such distress; distress which seems easy to lift, at least temporarily. Others indulge the compulsions for the sake of an easier life. It is much simpler, for example, for a family member to agree to leave the house last, than it is to wait for a compulsive checker to do so only after they thoroughly check all doors and windows are closed. And, like Harry, some relatives agree to participate in the rituals because it seems to make the situation worse if they don’t. People with OCD can get angry and accuse others of not caring for them if their families do not obey their rules or offer the requested reassurance.