Most people have strange, intrusive thoughts. They can be embarrassing or completely irrational, so we don’t often talk about them. For some, however, these thoughts are impossible to stop, and can lead to Obsessive Compulsive Disorder. Lynne Malcolm and Olivia Willis report.
Mental counting. Repetitive checking. Germ eliminating. Obsessive, organised, and tidy to a fault.
These are some of the images the term obsessive compulsive disorder (OCD) brings to mind—but is that accurate?
‘I remember when my OCD began. I can tell you the date, I can tell you what I was wearing, I can tell you what the weather was like … It was the moment my life changed,’ says David Adam, the editor of leading scientific journal Nature.
They can’t make that thought go away, and so they change their behaviour and they just happen to find that by knocking on the table three times or by washing their hands or by turning the light switch on and off six times or whatever it is, that that thought goes away, and so the two become associated.
According to Adam, it all began in 1991, during his first year at university.
‘I met a girl, we went back to her house and we didn’t have sex but the next day a friend of mine said, “Did you have sex with that girl?” and I lied and said that I had, and he said, “You could have AIDS.”’
Although it wasn’t true—or at most, exceedingly unlikely—the possibility somehow wedged itself in Adam’s mind.
‘It kind of stuck, even though I knew I hadn’t had sex with this girl, I knew I hadn’t exposed myself to any risk, I knew it was irrational, I just couldn’t make it go away.’
For years after that moment, Adam was privately taunted by his strange, irrational and unstoppable thoughts.
‘It started to spread to all the different ways that I thought things that I had done could have led to me contracting it. It was on my mind all the time.’
Terrified he had caught HIV, Adam felt there was nothing he could do but seek constant reassurance.
‘At the time there was a telephone helpline that you could call and I would ring them up and I’d explain to them that I thought I could have caught AIDS or HIV from this very, very strange way, like I was playing football or soccer and I scraped my knee along the Astroturf, which had cut it and left blood,’ Adam says.
‘I thought, well, maybe someone else could have done the same, maybe they could have scraped their knee in exactly the same spot and maybe they could have been HIV positive and maybe some of their blood could have got into my knee where I scraped it.’
Adam says obsessions begin when very strange thoughts—the kind of strange thoughts that almost everybody has—get ‘stuck’ in one’s mind.
‘These are the kind of thoughts that people might get when they are waiting for the train to come and they get an urge to jump in front of the train … or if they are driving their car they might get a little voice in their head that says, “What would happen if I was to just steer off the road or steer into the oncoming traffic?”’
According to Adam, these kinds of thoughts are ‘completely normal’ and for most of us simply go away after we briefly consider them. But for others, they don’t.
‘When those thoughts don’t go away, it’s very difficult for someone because those thoughts quite often cause distress, and they wonder, “Well, why am I having them?”’ says Adam.
In an attempt to try and deal with a recurring thought, people will often begin to change their behaviour.
‘For example, in the case of waiting for the train, the easiest thing to do would be just to take a step back and then you think, well, it’s harder for me to jump,’ says Adam.
‘That kind of behavioural change can be classed as a compulsion. So you set up this cycle between a thought and a response, an obsession and a compulsion. In some people that cycle gets to the point where it really starts to interfere with their life.’
At that point, says Adam, the thought pattern becomes a disorder.
In his book, The Man Who Couldn’t Stop, Adam uses his own story of OCD, and the experiences of others, to examine how the force of the mind can seem almost impossible to resist.
He describes the case of one young Ethiopian girl who ate a wall of her home because she couldn’t rid her mind of what psychologists term ‘intrusive thoughts’.
‘She had obsessive thoughts about the wall of her house. It was a mud house, it was a mud wall. As strange as it might sound to you or I, she just found those thoughts really distressing, partly because she couldn’t make them go away.’
The girl found that although it was completely irrational, eating parts of it allowed her to make those thoughts go away.
‘On the way home from school, she’d start to suffer these very intrusive, dominating thoughts about the wall of her house, and so when she got home she would rush to it and break a piece off and eat it. She did this for years.’
By the time the girl was 19, she had eaten something like eight square metres of the mud wall.
‘It’s a terrible case, but I think it demonstrates that this really isn’t something that people would do unless they really felt like they had to do it,’ says Adam.
While intrusive thoughts aren’t impossible to stop—indeed, most people have them and do stop them—they differ from the general negative thoughts we experience.
Adam says we’re inclined to think that intrusive thoughts ‘say something about the kind of person that we are’.
‘Someone who might get the thought about steering their car into oncoming traffic would think, ‘well, that’s terrible, I must want to hurt people secretly’,’ he says.
‘The technical term for [intrusive thoughts] is ego-dystonic, and they cause distress in two ways: both the content of the thought is distressing, like “I want to hurt people”, but also just having the thought itself is distressing.’
In some ways, it’s the taboo nature of intrusive thoughts that prevents people from talking about them honestly. In turn, a ‘silent epidemic’ of people quietly struggling with OCD has been created.
According to Adam, society is broadly unaware of how common these thoughts are, yet because we don’t talk about them, most people who do have them don’t realise that virtually everybody else experiences them too.
‘I do talks about this kind of subject and when I say to people, “Do you ever get that thought to steer your car in front of oncoming traffic?”
‘People look at me like I have just read their mind. They say, “God, I thought it was just me who had that,” and it isn’t—it’s almost everybody.’
Related: Living with someone with OCD
When a cycle is established between a thought and a response and an obsession begins to instigate a compulsion, the behaviour is rarely a directly reflection of the initial thought, however.
The concept of OCD is sometimes represented in the media by a person who needs to wash their hands over and over again. But as Adam explains, it’s not that simple.
The behaviour, he says, is ‘almost always a response to a thought, and the thought could be completely different’.
‘The thought could not be, “I wonder if my hands are clean,” the thought could be, “I’m worried that my parents are going to die in a car crash,” or, “Someone I love is going to get knocked over by a car.”’
‘They can’t make that thought go away, and so they change their behaviour and they just happen to find that by knocking on the table three times or by washing their hands or by turning the light switch on and off six times or whatever it is, that that thought goes away, and so the two become associated.’
In some cases, however, there is a more direct link between the obsession and the compulsion.
‘Some people are very obsessively concerned about germs, for example, and they do wash their hands because they are reacting to thoughts about dirt,’ says Adam.
The sentiment doesn’t always apply to other parts of their life, however.
‘Someone with OCD about cleaning could have a spotless bathroom. They clean it twice an hour, and yet the kitchen is stacked high with plates with mouldy food. Or someone could wash their hands 10 times an hour, and yet wear the same underpants for three weeks.’
OCD is thought to develop from a combination of genetic and environmental factors.
‘The easiest way to explain it is that we don’t really know what causes it, although there are certain things that seem to increase the risk of developing OCD,’ Adam says.
Research into understanding the cause of the disorder is focused on why particular thoughts tend to stick around longer in some people.
‘Psychologists will tell you that the reason for that is because there are certain personality types which make some people more likely than others to really focus on those thoughts,’ says Adam.
While there’s evidence to substantiate this claim, he believes other contributing factors could be at work.
‘There seems to be an extra ingredient which would explain why that person with that personality type reacts to that thought in a way that someone with the exact same personality type doesn’t, and that’s really where we are struggling.’
After more than 20 years of privately struggling with his own fear of being infected with HIV, Adam had a realisation that saved him from a life dominated by intrusive thoughts.
‘What turned it around was that I had a baby, and when she was six months old I started to involve her in it.’
Adam recalls taking his daughter to the playground, noticing what looked like blood on her leg, and becoming obsessed with the idea that she may have somehow rubbed blood into her eyes from the swing she was sitting on.
‘To try and reassure myself that she hadn’t done that, I basically put her in and out of this swing about 10, 12 times, trying to see where she put her hands,’ says Adam.
‘I thought to myself, “What are you doing?” And I thought, “This just has to stop,” because I wasn’t going to do anything that was going to make her more likely to develop OCD.’
Adam rang the GP the next day, and began extensive OCD treatment, which included a combination of drugs and group sessions of cognitive behavioural therapy.
‘We talked about the link between the obsession and the compulsion, it’s all about breaking that link. Crudely, the way that you do that is you don’t perform the compulsions.’
In Adam’s case, his worry came about when he thought he might have accidentally touched something with blood on it, and subsequently his compulsion would be to check his hands to make sure there was no blood. Doing so would reassure him, but also reinforce his obsession.
‘To break that, what you do is you basically have to live with that very small possibility that there might be blood on your hands and you’re not allowed to look at them,’ he says.
‘That’s quite difficult to do. The therapy is partly about supporting you through that.’
The psychological process behind this particular therapy is called extinction decay. The idea is that no one can stay on high alert indefinitely, and in time that anxiety must come down because it has nowhere else to go.
‘The theory is that once someone with OCD experiences that anxiety going down by itself, then the need to perform the compulsions in the future also goes down,’ Adam says.
After receiving treatment, Adam says he’s still acutely aware of the very small risk of contracting HIV in day-to-day life but has learnt to get used to it.
‘I still have OCD but I manage it, because the thoughts are still there, I still have the anxiety about HIV, and so what I do now is try and resist the compulsions,’ he says.
’That means that some days I am quite anxious, but I have faith and confidence that even though I can have a bad day, when I wake up the next day the anxiety has gone and that is so, so much better than how it was when I was really struggling with it.’
According to Adam, OCD is a medical problem that requires medical help.
‘It is difficult to talk about. I didn’t tell anybody. That made it a lot worse.
‘If you know that you are suffering from OCD, you need to get help because it will not go away by itself.’
Adam says it’s also important for people who don’t have OCD to talk openly about the intrusive thoughts that they experience so as to normalise them for people with OCD.
‘One of the reasons that people with OCD, myself included, don’t go for help is because we don’t realise that what we are suffering from relates in any way to the normal experience. Because it’s so irrational, we think that we are the only people who could ever think anything this ridiculous.’
OCD isn’t about ‘always lining up your pencils’, and the public perception of the disorder needs to change.
‘I really don’t like the phrase ‘awareness raising’ … but I think in this case, awareness raising is pretty good, because there is a real problem caused by the misuse of the term OCD.’
Listen to this episode of All in the Mind to learn how some people’s strange, intrusive thoughts lead to obsessive compulsive disorder.
An exploration of all things mental, All in the Mind is about the brain and behaviour, and the fascinating connections between them.