by David Adam
My paternal great-grandmother’s temper was legendary. It was said she could start a fight in an empty room. My OCD can cause me distress in an empty room. It doesn’t need a community or a culture or a family to disapprove. I’m not that fucking stupid.
Davis is not alone in the quest for possible benefits to OCD. Plenty of writers on the subject, including some who should know better, are keen to point out the upside of a personality that repetitively focuses on detail. Armed with little more than some vague references in his diaries to how his mind would fix on an object and would sometimes be taken by insane feelings of anger, some websites dedicated to mental illness claim that Charles Darwin had OCD. Others, in an apparent effort to challenge the view of OCD as a handicap, have credited Winston Churchill’s obsessional nature for giving him the strength of character to see through the dark days of the Second World War. OCD helps defeat global fascism! Way to go Winston.
I can’t think of a single positive thing about OCD. And I’ve thought about OCD a lot. In 1785, after a particularly rough Atlantic crossing to Southampton, the US inventor Benjamin Franklin designed a sea anchor – a submerged sail a ship could tow behind itself in the water to slow and stabilize itself in heavy seas.
People who live with OCD drag a mental sea anchor around. Obsession is a brake, a source of drag, not a badge of creativity, a mark of genius or an inconvenient side effect of some greater function. That’s not to say that some people with OCD don’t achieve great things. But – given what we have seen of how OCD might develop – that’s only what you would expect, just as some people with OCD are criminals, teachers, politicians and writers. Some have it worse than others and some perform better than others. Certainly, some people with severe OCD are quite brilliant.
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At Christmas 2009, a plaque was unveiled on the door of room 3327 on the 33rd floor of the New Yorker Hotel in Manhattan. It commemorates the life of electricity pioneer Nikola Tesla, who lived in the room for the last ten years of his life, and the confluence of numbers is no coincidence. Tesla was obsessed by the number three, one of a series of intrusive thoughts and compulsive behaviours that affected him his whole life.
Tesla wasn’t diagnosed with OCD, but his experiences fit the model. Aged 5, he suffered a terrible trauma when his older brother Daniel was killed. Tesla always maintained Daniel died of injuries inflicted by a horse, but another account says Daniel fell down the cellar stairs and banged his head. Drifting in and out of consciousness before he died, he accused his younger brother of pushing him. In her 1981 biography of Tesla, US writer Margaret Cheney says:
We can only speculate about the degree to which Daniel’s death may have been responsible for the fantastic array of phobias and obsessions that Nikola subsequently developed. All we can say for certain is that some manifestations of his extreme eccentricity seem to have appeared at an early age.
As a teenager in the 1870s in what is now Croatia, Tesla indulged in what sounds like maladaptive daydreaming (see page 94). He would invent complex and detailed places and live there in his head, where he would meet people and make friends. As a student he opened a book by Voltaire and then felt compelled to read his entire works, close, he discovered with dismay, to one hundred volumes. As an adult he counted steps when he walked and had to calculate the cubic volume of his food and drink to enjoy it. He tended to dine alone. He had issues with touch and tactility and said he could not bear to feel other people’s hair, ‘except perhaps at the point of a revolver’.
Tesla’s greatest invention was the alternating-current (the AC in AC/DC) motor. It revolutionized the supply and distribution of electricity and remains the basis for power in the modern world. Like many of his creations, he designed the motor in his head. ‘Ideas came in an uninterrupted stream,’ he said. ‘The only difficulty I had was to hold them fast.’
As his fame and wealth grew, so did the impact of his obsessions and compulsions. He would dine each evening at exactly eight o’clock and needed a stack of eighteen clean linen napkins to wipe his cutlery. Walking the Manhattan streets to his laboratory, if he took a certain route he felt forced to circle the block three times before he could continue on his way.
By the Second World War, just as Walter Freeman was descending to his lobotomizing pomp and the hoarding Collyer brothers were at the height of their unwanted fame, Tesla’s obsessions and compulsions ruled his life. His fear of germs meant even close friends could not approach him; he preferred the company of pigeons. He died alone in his hotel room in January 1943.
FIFTEEN
A new dimension
When I started to write this book I had an anxiety disorder. As you read it, I don’t. That change is not as positive as it might seem – I still have OCD. But OCD is no longer considered an anxiety disorder. In May 2013, the American Psychiatric Association (APA) officially reclassified OCD as a different type of mental illness. It’s now one of the obsessive-compulsive and related disorders, a new group that includes a handful of the OCD spectrum conditions we discussed in Chapter Five: body dysmorphic disorder, hair-pulling, skin-picking and hoarding disorder. It sounds a trivial change, but the implications are great – not just for OCD, but for the way we think about mental illness.
The APA reclassification, as well as the shift towards the concepts of the OCD spectrum and the autism spectrum, starts the important process of building connections between mental disorders, which traditionally have been viewed as separate. There is a strong link, for example, between OCD and post-traumatic stress disorder, PTSD. As we have seen, some people who suffer trauma develop OCD. Yet others convert precisely the same kind of experience into PTSD, a particularly vicious mental syndrome linked to intrusive thoughts. The thoughts of PTSD usually show as harrowing memories, and when they strike, the sufferer seems to lose touch with reality. They reexperience the trauma as vividly as they did the first time, with all the accordant terror, fear and shock. They relive the incident, time and time again.
PTSD and OCD can be triggered by the same event, and coexist in the same person. Soldiers with post-traumatic stress disorder are ten times more likely to develop obsessions and compulsions. Studies of Israeli combat veterans from the 1982 Lebanon war show an elevated risk for OCD.
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A US soldier called B.A. had both OCD and PTSD. By the time he received the help of Roger Pitman, a psychiatrist at Harvard University, B.A. was about 40 years old. Bored with high school, B.A. had looked for adventure in the army. He was a good soldier and a brave one. When, on a military exercise, an armoured personnel carrier fell onto its side and pinned its commander to the ground, B.A. ignored the risk of an explosion and crawled underneath to dig him out.
B.A. went to the war in Vietnam, where he served on helicopter gunships. He flew more than four hundred combat missions and won medals: two Purple Hearts and the Bronze Star. He was an all-American hero. He frequently volunteered for extremely risky missions to rescue soldiers in desperate situations and once jumped from his helicopter into an enemy boat armed only with a machete.
While he fought in Vietnam, B.A.* developed the symptoms of OCD. After he loaded his rifle, intrusive thoughts made him doubt that he had done so, which forced him to unload and load it again. He went through hundreds of bullets in this way. Further worried that a kink in the ammunition belt would jam his machine gun, while his buddies drank beer in the evenings B.A. would return to the helicopter and pass the ammunition through his hands to make sure it ran smoothly. Finished and walking back to his tent, the intrusive thoughts and the doubts would return, and so would B.A. to the helicopter to make sure. ‘He’s counting bullets again,’ the other soldiers would shout. He was compelled to order and touch the sockets in his wrench kit and hoarded so many spare parts that he earned the nickname Requisition.
B.A.’s intrusive thoughts and OCD gripped his mind even during the mortal danger of warfare. Shot at from the ground during missions, he would compulsively count the tracer rounds headed h
is way. And when he shot back, he would count the rounds in sets of threes. During what the helicopter crews called a ‘meat-run’ – the evacuation of the dead – as the landing helicopter’s downdraught would blow away the ponchos that covered the waiting corpses, often those of fresh-faced and frightened teenage recruits they had carried into the area earlier that day, B.A. could not resist thoughts to count their feet, two by two. Some bodies had only one foot, and then B.A. would become distressed that his count had been thrown off and have to start again.
B.A. served two tours of duty in Vietnam and when he returned to the US, he was a psychological wreck. But nobody noticed – or cared. On discharge from the army, a military psychiatrist said B.A. had signs of anxiety but otherwise ‘nothing unusual’. Ten years after Vietnam he went for help at a specialist mental health clinic for veterans. He was told: ‘This too shall pass’.
B.A. beat his dog, destroyed furniture and mentally played out how he would shoot, stab and strangle people he met. He worked in a helicopter repair workshop, until the day he saw a shot-up aircraft from Vietnam and his reaction – a war hero who had flown four hundred missions – forced him to hide in the toilet.
B.A. would wash and rewash his hands – to get the ‘dead stuff’ off them –and repeatedly checked the stove and locks on the doors, sometimes driving eight miles home just to do so. He kept a machete under the bed, took a gun to the bathroom at night and would compulsively check he had a knife in his pocket a hundred times a day. Despite thinking to himself: ‘This is stupid. What kind of an asshole am I?’ he could not resist the thoughts.
By the time Pitman treated him several years later, B.A. had a baby son, who he was compelled to check on ten or twenty times each night. At the same time, he had to fight intrusive thoughts to strangle him. He could not close his eyes in the shower, because of the dread that someone would grab him. When his wife zipped up her dress, B.A. heard the sound and felt the chill of a body bag.*
B.A. is an extreme case but he is far from alone. A grim parade of people with OCD and PTSD and a mixture of the two, kicked into life by all sorts of terrible events, have trooped through psychologists’ offices in recent times. Mrs Y, who was tied up and raped by a man who videoed the attack and forced her to watch it, afterwards felt compelled to arrange objects in her house into specific positions. That might seem an irrational response, but recall how the children would respond with ritual to their complex fears of situations beyond their control.
Aged 20, Miss B was enjoying a picnic with her family when an aircraft in distress looking to make an emergency landing approached. Seeing the family at the last minute, the pilot swerved, crashed and died. Miss B felt upset and guilty but her OCD only struck a few years later when, driving in heavy traffic, she inadvertently blocked an ambulance. In response, she developed obsessions about harming people, particularly by bumping into them, and found it difficult to walk through swing doors, in case she let them go and hit someone. When a friend of hers was murdered, Miss B then started to compulsively check her food to make sure it was not human flesh, and that crumbly dishes did not hide human ashes. When she menstruated, she could not shake the idea that the blood belonged to someone she might have killed. As with all cases of OCD, Miss B knew her thoughts were absurd, but she could not stop them.
In 2012, scientists discovered a possible explanation for why some people who experience trauma can develop OCD or PTSD, or both. The scientists of the University of Arkansas worked with forty-nine women who had suffered physical or sexual abuse. Many had gone on to develop psychological problems. Gently asking them to recall how they felt during the assault and immediately afterwards, the researchers found those who experienced pure fear, and a sense of disgust they directed at their attacker, showed the symptoms of PTSD. But many of the women said they felt disgusted at themselves, even while the assault was ongoing. They were the ones who developed signs of OCD.
If this finding is correct then OCD and PTSD could overlap, with the degree to which someone leans more towards one or the other determined by their emotional response to the original trauma. Already, some psychiatrists think a similar mechanism could help explain the origins of other mental syndromes too. OCD, for example, might relate to schizophrenia.
As we know, the same strange thoughts strike everybody from time to time, and it is how someone responds to them – the different settings on our thought factories – that can help dictate if someone will develop OCD. Perhaps this response could play a role in selecting who will develop schizophrenia too. Take, for instance, an intrusive thought of stabbing an old lady in the street. If someone brushes it off as a weird idea that deserves no attention then it is unlikely to lead to mental illness. If they were to fight the thought, to try to make it go away, then as we have seen, they could develop OCD. And if they were to attribute the thought to another person, or the devil, or the CIA, then they could turn that same thought into schizophrenia.
There is some evidence for this. Those patients with OCD who also show symptoms of schizophrenia are usually those who show less insight. They are less aware than others with OCD that the strange thoughts and urges originate in their own head. Up to 40 per cent of people with schizophrenia also have OCD, while some OCD patients show signs of schizophrenia. Already, psychiatrists say some people suffer from schizo-obsessive disorder.
It makes sense. The problem is that such overlap in the causes and presentation of mental illnesses – OCD with schizophrenia and PTSD, for instance – threatens to undermine the current way that doctors and psychiatrists diagnose and treat psychiatric conditions. And not just those linked to OCD, but all of the rest too.
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The American Psychiatric Association declared that OCD was no longer an anxiety disorder when it published the fifth version of what’s commonly referred to as the bible of psychiatrists, the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is a list of officially recognized mental conditions and a reference tool for hard-pressed and busy doctors and psychiatrists across the world to diagnose their patients. More, it is a powerful focus for powerful forces. It is a ticket to the asylum for some and a ticket to riches for others. The inclusion of a condition in the DSM is an official stamp of approval and one that opens doors, especially so in the USA, where health insurance policies typically insist that a mental illness be DSM listed before they pay out on a claim. A condition included in the DSM is one that psychiatrists can be paid handsomely to treat, and one for which pharmaceutical companies can supply expensive drugs.
The first DSM grew in the 1950s from the need for the postwar US military to gather information on how many of its veterans were affected by psychiatric problems. It was 130 pages long and listed 106 mental disorders, which it called ‘reactions’. OCD was listed as obsessive-compulsive reaction. The DSM has since been updated and revised several times. In the 1970s it dropped its controversial listing of homosexuality. By the time DSM-III emerged in 1980 it had swollen to almost 500 pages, which presented mental illnesses as products of the human condition in the way that the menu of a Chinese restaurant displays the products of its kitchen, with endless subcategories added to try to account for sometimes very small differences.
DSM-III had 265 diagnosable disorders. DSM-IV followed in 1994, with 297 conditions across 886 pages. The new DSM-5 (the scrapping of Roman numerals was one of its less controversial changes) has about the same. In the DSM-5 obsessive-compulsive and related disorders have their own chapter, which gives the new grouping the same status as depression and schizophrenia. The DSM change implies that OCD and its related disorders have something in common. So, therefore, must the people who suffer from them. I have a new family.
On one level, it is irrelevant whether I suffer from an anxiety disorder or an obsessive-compulsive and related disorder. Labels to some extent are just that, labels. They can be peeled off and swapped around as fashion dictates. Some psychiatrists talk of ‘treatment nihilism’: the diagnosis – the offi
cial label – is irrelevant. They have drugs and treatments and they can try each of them in different doses and combinations until something works. That’s a direct progression from the end-justifies-the-means approach of the behaviourists, and it’s as far as you can get from the probing, causal analysis of Freudian psychodynamics. In some patients it works. But to work, it needs drugs and treatments to be available. And to work with more people, it requires new and better treatments and drugs to emerge. And here’s the problem: the drugs aren’t coming.
Just as public and political awareness of psychiatric illness is rising and more people are being encouraged to acknowledge their own mental problems and seek help, the drug industry we rely on to offer some of that help is in full retreat. Mental illness is too difficult. Drugs against it are too expensive to develop, because so many fail. Just as the APA has extended the OCD family, the industry has given up on us. Since 2011, the major drug firms GlaxoSmithKline, AstraZeneca, Pfizer, Merck and Sanofi have all ended or scaled back their research to develop new drugs to treat brain disorders. It now takes more than thirteen years and more than a billion dollars to deliver a new psychiatric drug to market. Even nihilists have to pay the bills.
At present, it simply makes more financial sense for these firms to invest in areas of medicine where the chances of success and profit are higher. One reason for this retreat from mental illness is that drug companies and scientists are starting to realize that modern psychiatry is a castle built on sand.
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The first two DSM books were based on Freudian psychodynamics, which dominated the field when they were written. Psychiatrists today often airbrush them away when they talk about the history of their discipline. The modern age of psychiatry, they say, began with the DSM-III in 1980.