The Man Who Couldn’t Stop

by David Adam

  Sometimes the anger is well directed. Children and siblings of people with OCD have been known to exploit the disorder’s fear and anxiety as bargaining chips – ‘If you don’t let me use the car/borrow your jumper/go to the party then I’ll walk in my dirty shoes all over your bed.’ Together with the insults and mockery that some families hand out to relatives with OCD, psychologists describe such responses as hostile non-compliance. Not surprisingly, hostile non-compliance doesn’t help. In fact, criticism can make sufferers more likely to carry out their rituals.

  However, compliance – hostile or otherwise − does not help either. Family accommodation of OCD is linked to more severe symptoms and worse functional impairment. And it interferes with some types of treatment, especially behavioural techniques. Families who want to help someone with OCD must aim for the middle ground: nonhostile noncompliance, or noncritical support with no accommodation of rituals. That’s easier said than done.

  Just as someone with OCD does not respond to reason or appeals to their rational side – ‘look, there is no HIV on the towel, just use it’ – so it’s not as simple as telling a distressed and loving dad such as Harry merely not to wipe his adult son’s zip with antiseptic each time he uses the toilet. It seems vital that, when people with OCD seek and receive treatment, those who live with them are made to know and understand what’s involved and what’s at stake.

  * * *

  When it comes to the possible causes of OCD, the legacy of biology and history – DNA, early experiences and evolution − is only half the story. Biologists talk about short-range and long-range causes of behaviour. (They call them proximate and ultimate.) It’s a distinction neatly demonstrated by the tale of the monkey, the snake and the flower, which sounds as if it should be a children’s parable or a puzzle about how to get them across a river, but actually describes a series of famous experiments carried out in Wisconsin in the late 1980s. In the studies, psychologists found that hand-reared rhesus monkeys had no instinctive fear of snakes. Why should they have – the animals had never seen one. Pictures of snakes and toy snakes placed next to them had no effect.

  That changed after the animals were shown video of the way wild monkeys react to a snake: with lip-smacking fear and restless anxiety. After they saw these images, the lab-reared monkeys quickly developed the same response. Shown the same pictures and toys as before, from then on they would react just as the wild monkeys did. They had learned fear.

  When the psychologists tried to use the same mechanism to make the lab monkeys afraid of flowers, they failed. No matter how many times the lab animals watched footage edited to show wild monkeys react with panic to a flower, just as they had to the snakes, the hand-reared animals wouldn’t buy it. The difference was down to evolution, the ultimate cause of the monkeys’ behaviour. Millions of ancestors who ran away from millions of snakes over millions of years have left their mark on the biology of today’s rhesus monkeys in a way that nonthreatening flowers simply haven’t.

  The ultimate causes of OCD could indeed be genetic, or evolutionary, or found in the circumstances of our family home, but this cannot fully explain why some people develop OCD and some don’t. And it cannot explain why people who develop OCD do so just when they do. What are the proximate causes of obsessive and compulsive behaviour? What events in our individual lives trigger the dormant OCD threat? One thing is clear: that someone has not developed OCD so far does not mean they will not succumb to it in future.

  * * *

  An American man called Mr Rossi developed an obsessional need to remember people’s names. He would write them constantly – those of friends, family, famous baseball players and colleagues from work. It was they who convinced Mr Rossi to seek help, because they were sick of him calling up day and night to check he had them right. He was 87. His obsessions and compulsions did not begin until he was 75. He waited for them almost his whole life.

  Obsessive-compulsive disorder strikes most people by early adulthood; fewer than 15 per cent of cases develop in people over 35. So Mr Rossi was unusual, but far from unique. Where did his OCD come from? Did it lie undisturbed for more than seven decades before something brought it to the surface? Or did something change in later life that unsettled him? As we’ve seen, scientists seem to have solid cognitive explanations of how people develop OCD, but what about why and when they do? Are obsessions a ticking time bomb? You probably have intrusive thoughts, so will you go on to develop OCD? If so, are there danger signs that can be spotted and acted upon? There might be, and a likely one is trauma.

  Howard shows the impact of trauma vividly. Howard was 5 years old when he developed OCD. A naturally shy and anxious child, he was intelligent and started to crawl and walk earlier than many of his peers. His OCD started a few days after he witnessed a horrific road traffic accident; a pedestrian was hit by a car and left unconscious and covered in blood. Howard was convinced the pedestrian was dead, and it took him until the next day to stop shaking.

  After the accident, Howard started to wash his hands until they cracked and bled. Sometimes he would spend most of the night at the sink. He was not afraid of germs. That was not why he washed. He did it, he said, because it was the only way he could find to make the funny feeling go away. Even that was not enough. He still had to pester his parents and his teachers about whether his hands were really clean. Howard said he wanted to stop his mind making him wash his hands. That is pretty bright for a 5-year-old.

  Just like Howard, more than half the people with clinical obsessions and compulsions can point to an earlier stressful incident they identify as the trigger for their condition. This trauma does not have to come from horrific and bloodstained events like Howard’s. More subtle psychological shocks can lead to OCD as well. Betrayal is one − to be hurt and let down by those you trusted. The mental shock of betrayal can cause mental contamination and it can bring compulsive washing. Treat someone like dirt and they feel dirty.

  Bullying has been shown to bring on OCD. Max, a 14-year-old boy from Florida, was victimized at school over his physical appearance and sexual orientation. Max started to shower after he was picked on, to cleanse himself of the insults, then he would avoid wearing clothes he had worn when previously bullied, because he considered them contaminated. He went further; whenever he thought of the bullies, Max would have to clear his throat and restart whatever he was doing. Because he had the thoughts all through the day, this compulsion seriously affected Max’s life. He started to associate other places and activities with the bullying, and by the time he was seen by a psychiatrist, he had gone more than a month without a shower, a change of clothes or a night in his own bed.

  Direct physical trauma has been linked to the onset of OCD. Mr A recovered from a month-long coma after he fractured his skull in a motorbike crash. Six months later he was back in hospital in Massachusetts, with severe intrusive thoughts of Aids and cancer and obsessions with negative news stories that began the moment he regained consciousness. And two unfortunate people in Istanbul woke from surgery to cure their epilepsy only to find the treatment left them with OCD. They showed some mild obsessive traits before, but afterwards they had to memorize numbers and count objects, or check and clean compulsively. The surgeons who performed the operations were forced to conclude that the patients’ quality of life had been better before they tried to help them.

  The anxiety of a botched surgical procedure can trigger obsessions as well – at least according to the British legal system. In September 2009, the Dudley Group of Hospitals NHS Foundation Trust agreed to pay £25,000 compensation to a teenager who said his OCD was down to traumatic delays in treatment for appendicitis when he was 8 years old.

  * * *

  If about half the people with OCD can pinpoint a specific trigger event, a trauma that led to obsessions and compulsions, then that still leaves lots of sufferers who cannot. Their OCD appears to come out of the blue. When it does, often it disturbs the innocence of childhood.

  Rituals
are normal for children. By the time they reach 30 months old most toddlers show some ritualistic and repetitive behaviour; they might line up their toy trains in the same way or pretend to prepare an identical daily meal. Baths and bedtime become a string of familiar routines and any deviation from the expected patterns leads to anxiety and tantrums. The rigid nature of these domestic routines tends to fade by age 4 to 6, but a new set of rituals emerges, commonly seen in play dictated by complex rules. Hopscotch, to someone who has never played it, probably looks like compulsive behaviour. A set number of moves that a child must perform in a specific fashion – four steps forward, touch, turn around twice – and all without a foot on the lines.

  Rules of play become more elaborate as a child grows to the age of 10 or 11, and fears of contamination and routines to avoid contagion start to appear, for example in games of tag, or in the way that gangs of girls or boys chase each other to deliver kisses, while the other group reacts by shouting and running away. There are parallels to hoarding behaviour too. Most 7-year-olds collect objects, from action figures to sports cards. Indeed, the children’s toy industry exploits this with multiple collectibles connected by a popular theme. Can you collect them all?

  Childhood and adolescence are a haven for ritual, but most young people leave them behind and do not progress to obsessions and compulsions. Yet some take them too far and do develop OCD, often while they are still children. So at what point does this normal behaviour become a problem? Some child psychologists think the transition at age 4 to 6 is particularly important. It’s a time when the frontal lobes of the brain mature, and mental ability increases.

  In 2007, psychologists in the US published the results of a study that tried to test the impact of this cognitive transition point on childhood rituals. They gave 42 children (with their own and their parents’ consent) neuropsychological tests to assess two different mental abilities. The first was to get the children to learn and respond to a rule – to sort coloured cards into piles, for instance. The rule was then changed and the children had to adapt to the new regime. The second test measured how well they could stop doing something on demand. They would be asked to match shapes in a certain way, say, and then to resist doing it.

  The psychologists gave the children a toy or a five-dollar gift voucher for the local ice cream shop as a thank you, and asked the parents to fill in a series of questionnaires about their child’s routines, habits, fears and perfectionism.

  When the scientists looked at the results they found a difference between the performances of the younger and older children. For the kids aged 5 and under, the poorer their performance in the tests, the more likely their parents said they were to carry out rituals. For those older than 6 years, a new factor emerged: the older children most likely to show compulsive behaviour were those who, according to the parents’ questionnaires again, showed the most fear.

  The psychologists interpreted the results like this: rituals and compulsive behaviour in children help them to regulate emotion. Young children, with immature and incomplete mental ability, must rely more on the comfort of familiar ritual to ease the fear and anxiety they feel because they do not yet have full control over their behaviour. Older children can regulate their behaviour better, but they have more complex fears than younger children – of animals and strangers, as well as social fear such as self-consciousness and a need to fit in. As they grow, some older children continue to respond to these new fears as they did when they were younger: with ritual, as a way to ease the anxiety they cause.

  We must file the results of this study as unproven. It’s pertinent, but the sample is small and the conclusion is pretty speculative. The psychologists themselves point out one of the study’s biggest flaws – their analysis of brain development and activity is based on the indirect evidence of test scores.

  Still, if we take the findings at face value, there are some eerie parallels to OCD. The younger children could not turn off inappropriate behavioural responses, and tried to quell the anxiety this caused them with ritual. The older children responded to (rational) external fear with an irrational response (rituals such as counting and touching that decreased anxiety only in the short term). The kids in this study were all normal; none had been diagnosed with OCD. But the underlying features of their rituals and their mental condition seem the same.

  It’s worth noting also that the children who scored the highest on the perfectionism scale showed the most social fear, and so were more likely to carry out ritual. This suggests that increased self-awareness and hypersensitivity are important. We have already seen how sensory hypersensitivity is linked to OCD through excessive disgust, which can be viewed as overreaction to taste, smell and touch.

  In 2012, a study in Israel linked the rituals of 4- to 6-year-olds to oversensitivity to everyday tactile and oral stimuli. The children who (according to their parents, again) were more likely to avoid messy play with sand and glue, complain when they had their hair and nails cut, or try to avoid having to brush their teeth were also the most likely to show repetitive behaviour. A further Internet survey of more than three hundred adults showed the most obsessive-compulsive symptoms were reported by those who, for example, didn’t like to go barefoot on sand or grass, or who did not like to be touched – and who recalled they felt the same when they were children.

  Again, let’s not read too much into a single study, but here’s what the Israeli team thought might be responsible: The brain takes the different inputs from the senses and combines them to form a picture of the outside world, a cognitive process known as sensory integration. This is a complicated procedure and some brains do it better than others. Those brains that do it worst can produce development and behavioural problems, especially in young children. Kids with these sensory dysfunction problems usually show exaggerated or inappropriate responses to normal sensations – they might refuse to wear certain clothes or to eat some textures of food. Sensory dysfunction causes a child distress and upset. So these children look for ways to calm themselves down, to create order and predictability. In doing so, they turn to excessive rituals. As kids with sensory dysfunction develop, their rituals do too; some become OCD.

  If you’re a parent and your 5-year-old won’t eat baked beans or wear socks, then please don’t panic. To reiterate, these are preliminary findings and it’s still far from clear what separates the rituals and patterns of happy and normal development from the foreshadowings of OCD. Unfortunately, it’s just difficult for anyone, parents included, to spot the difference. Officially, an adapted version of the Yale-Brown diagnostic test is used to find OCD in children. Unofficially, there are checklists of danger signs out there, but the highlighted behaviours are broad and most parents will recognize at least one – a child who spends more time than usual in their bedroom for instance, or one who insists their food is presented to them in the correct way. The core symptom to watch for is probably distress. Not the instantaneous tantrum that flares up when you interfere with one of their rituals, but premeditated and lingering unhappiness. And most parents can spot that in their kids, even if we do try to hide it from them.

  * * *

  When I turned up for my first assessment at the hospital’s mental health unit and walked across the car park, I could see the windows of the maternity ward. The door of the psychiatry unit had no handle on the inside. The staff there declared my OCD severe enough – just – for their assistance. They told me to report back for group therapy the next month. There were no guarantees, they said, but they thought they could help.

  TEN

  The runaway brain

  A popular way to visualize the brain is to clench your fist and stick your thumb out and point it at the ground, as if you are a Roman emperor passing judgement on a defeated gladiator.* Your thumb is now the brain stem and the thumbnail the end of the spinal cord. Your fingers and hand represent the cortex, with the little finger the pre-frontal cortex. Now, do the same, but first squeeze a grape in the grip of your inde
x finger. The grape contains the seat of our obsessions.

  The relationship between the mind and the brain is one of the most mysterious in modern science. At their most basic, the thoughts that cause such mayhem in OCD are just electrical and chemical signals. But to say those physical elements alone define and confine the mind would be to say that the Mona Lisa is just some paint. There is a point at which this material pragmatism seems to give way to something greater, a frontier beyond which the sum is greater than the parts. In the brain, that is the moment at which the chemistry and electricity, the nuts and bolts, combine to form the mind, to give humans the sensation of consciousness.

  Take the separation of brain and mind too far, and you hit the scientifically awkward idea of a soul – that the mind can and perhaps does exist in isolation of its physical basis. But, refuse to accept the notion of a mind−brain duality at all, and we struggle to explain the human experience. It’s a problem as much of philosophy and metaphysics as one of biology.

  Biology has one clear advantage over philosophy and metaphysics: it can be measured. But it’s natural for scientists to measure either the mind or the brain. Even as modern science scoffs at the false premise of dualism, it inadvertently reinforces it. Neurologists work with brain tissue. Psychologists grapple with functions of the mind. Psychiatrists have a foot in both camps; they diagnose problems of the mind and treat them as problems of the brain, which is perhaps why psychiatry is sometimes regarded with suspicion by both sides.