Obsessions and compulsions

Lynne Malcolm: Hi, welcome to All in the Mind, I’m Lynne Malcolm. Today, obsessive thoughts and compulsive behaviours.

David Adam: 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. And this was the moment when this thought came back to me about how I could have AIDS from not having sex with that girl. And I remember the thought came to me and it was so out of place, I described in the book as being a bit like a snowflake that came from the summer sky. And that was the moment that my life changed. Because I was 18 or 19 at the time, one of the very strong memories I have of that day was being happy, because I almost felt it was the last time I was happy for a long time. And that memory was just lying on my bed before I went out that night, listening to music, and it was an album by Jane’s Addiction, the US band, and it’s a live album, and they had just transitioned from a song, their cover version of ‘Sympathy for the Devil’ into ‘Rock ‘n’ Roll’ by the Velvet Underground. I just remember that being significant because I felt happy, I was really happy listening to that at that time, and then two hours later everything changed.

Lynne Malcolm: David Adam is a writer and editor at the leading scientific journal Nature. For years after the moment he just described he was privately taunted by his strange, irrational and unstoppable thoughts. They began to overtake his life. In his book, The Man Who Couldn’t Stop, he uses his own distressing story to examine what is sometimes called the silent epidemic; obsessive compulsive disorder.

David Adam: Obsessions are the very strange thoughts that can get stuck in someone’s mind, and those of the kind of strange thoughts that almost everybody has. 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 on a high bridge and they get an urge to jump off the bridge, or if they are driving their car they might get a little voice in their head that says, ‘What would happen if I was just to steer off the road or steer into the oncoming traffic?’

Now, those thoughts are completely normal and in most people they just simply go away. In some people they don’t. When those thoughts don’t go away it’s very difficult for someone because those thoughts quite often cause them distress and they wonder, well, why am I having them? And one of the ways that they try and deal with that is by changing their behaviour. So, for example, 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.

Winston Churchill actually had that thought and he used to respond to it by hiding behind a pillar when the express train came through. And that kind of behavioural change can be classed as a compulsion. And so you set up this cycle between a thought and a response, an obsession and a compulsion. And in some people that cycle gets to the point where it really starts to interfere with their life. Then it’s a disorder.

Lynne Malcolm: You describe one case of a young girl who ate a wall because she couldn’t get these thoughts out of her head. Just describe that one.

David Adam: Yes, this was…in the case study and she is called Bira. That’s not her real name. She grew up in Ethiopia. She was a teenager, and she had obsessive thoughts, what psychologists call intrusive thoughts, about the wall of her house. It was a mud house, it was a mud wall. And 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. And her compulsion was to eat the wall because she found that although it’s completely irrational, she found that by eating bits of the wall she could make those thoughts go away.

And so 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. And she did this for years. I think by the time she was 18 or 19 she had eaten something like eight square metres of this 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. It’s a force of the mind which is almost impossible to resist.

We certainly know that people have been bothered by intrusive thoughts for as long as we’ve been keeping records. John Bunyan who wrote The Pilgrim’s Progress and others will report these thoughts about…blasphemous thoughts, like they couldn’t get this idea of worshipping the Devil out of their head. And then in more recent times we know that Nikola Tesla, the inventor who developed the electrical current that we use to run the modern world, he would have to do things in threes. If he walked from his hotel to his laboratory and he went a certain way, he knew he was going to have to walk around the block three times. He had probably what we would call OCD.

Probably the most famous example is Howard Hughes. There’s a film called The Aviator with Leonardo DiCaprio, Howard Hughes was in quite an unusual position in that he was rich enough to completely indulge all of his compulsions.

[Excerpt from The Aviator]

David Adam: If he decided that he did not want to touch a piece of food, he had someone else who could open the can for him and wipe the bowl and put it out. If he learned, for example, that someone who visited him had been ill the next day, a cold or something, then he could just burn all of his clothes and buy new ones. So he really took it to an extreme, extreme level because he could really indulge it, which is why at the end of the film you see him on this chair in this huge room, everything had to be passed to him with tissues. A terrible, terrible, terrible, sad case, but also just shows the power that this condition can have over people, because he could have done anything, and there he was, trapped by these irrational thoughts.

Lynne Malcolm: David Adam, author of The Man Who Couldn’t Stop: OCD and the True Story of a Life Lost in Thought.

[‘Grim Reaper’ AIDS public awareness commercial]

David Adam: My obsessive thoughts are about HIV and AIDS. So I grew up in the ’80s when the only weapon that governments and doctors had to try and prevent the spread of what they thought was going to be this terrible, terrible epidemic was to scare people. And so there were all these adverts and warnings. And so it’s actually quite common for someone who grew up in the ’80s or ’90s, if they have OCD, to base it around HIV and AIDS. It actually started with a girl, 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,’ which is a terrible thing to say to someone, but at the time I think it just shows how dominant it was in the culture, this fear of this disease.

And it just stuck, that idea that I could have AIDS. 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. And then it started to spread to all the different ways that I thought things that I had done could have led to me contracting it, like scratching my knee along the Astroturf.

Lynne Malcolm: So give us a sense of what your daily life was like and how much of your day and your energy and your attention was taken up with this fear of contracting HIV.

David Adam: Well, it was on my mind all the time, but that didn’t mean that I couldn’t do anything else. So some people with OCD, if you have a compulsion about cleaning things or checking things, then that is what you have to do all the time. So in some cases people aren’t able to leave the house. Mine was portable, I could take it with me, I was just very scared that I had caught a terrible disease, just my mind was elsewhere. And then when the anxiety and the terror of this disease got the point where I felt like I couldn’t do anything else, I would then seek reassurance.

For example, 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, and 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.

Lynne Malcolm: So in the book you write that obsession has no regard for rational explanation. And you’ve been editor of the prolific scientific journal Nature, you are in a job that requires great logic and rationality. How do those seemingly contrasting sides play out to you?

David Adam: That’s a rational question. It is just an irrational fear. I can use an example to explain. There was a mathematician called Kurt Gödel in the 20th century, he was a contemporary of Einstein. He used mathematics to explore the limits of logic, he lived his whole life for rationality, and he had an irrational fear that he would be poisoned. And he would get his wife to taste all of his food before he ate it. And then one day his wife became ill, couldn’t do that for him, he was left to himself, and he actually starved himself to death. He would not eat his food because he thought it might be poisoned. It is just irrational. It cuts across all sections of society and all types of people.

Lynne Malcolm: You talk about the thoughts as being…they are called intrusive thoughts, where they are just almost impossible to stop.

David Adam: Well, intrusive thoughts aren’t impossible to stop because most people have them, so that’s the thought about jumping in front of the train. The reason that they are called intrusive thoughts is because they are different from, say, negative thoughts in that we think they say something about the kind of person that we are that we don’t like. So someone who might get the urge to jump in front of a train would think, well, why do I think that? I’m not suicidal. Someone who might get the thought about steering their car into the oncoming traffic would think, well, that’s terrible, I must want to hurt people secretly.

There are really distressing cases of people who have intrusive thoughts of hurting people and even hurting their own children, and it makes them question the kind of people that they are. And so those intrusive thoughts…the technical term for them is ego-dystonic, 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. It sort of leaves people to question what kind of person they are; am I really deep down a mad, bad, dangerous person because I have these thoughts? And you’re not, by the way, because the very fact that thoughts with that kind of content challenge people’s view of themselves show that they are not the kind of person who would do that.

Lynne Malcolm: And is this the reason why it seems like almost a silent epidemic? So many people can relate to these thoughts, but they are often thoughts around…they are embarrassing, or they are not socially acceptable or they are outrageous. People don’t talk about them.

David Adam: I think it is, yes. The content of these thoughts is almost always by definition horrific. It’s not just the perception, in many cases people do get judged by the way that they talk about these thoughts. So if you are a parent and you are having these terrible thoughts about harming a child, your own child…I mean, postnatal depression is quite well acknowledged now, but most people don’t realise that there is also a postnatal OCD. And in that very vulnerable time, new mums and dads can have these terrible thoughts about harming their child, and they don’t tell anybody, with good reason in some cases. If you go to the doctor and say, ‘I’m having these thoughts about harming my child,’ then the doctor’s first reaction is to press a big button that says ‘Social Services’. That’s largely because as a society we’re not aware of these thoughts, we don’t talk about them, and most people who have them don’t realise that almost everybody else has them as well. I do talks about this kind of subject and when I say to people, you know, do you ever get that thought, I don’t know, to steer your car in front of the 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.

[Excerpt from Macbeth]

Lynne Malcolm: Something that people would relate to or at least know about, it’s depicted in all sorts of movies and stories, the compulsive checking about something. You know, have I turned the stove off, I need to wash my hands over and over again. What drives people to have to do things over and over again like that?

David Adam: Almost always that is 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 that ‘someone I love is going to get knocked over by a car’. And 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 there is more of a direct link. So some people are very obsessively concerned about germs, for example, and they do wash their hands because they are reacting just to thoughts about dirt. But what it isn’t…it doesn’t apply to other parts of their life. So, for example, 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 on them. Someone could wash their hands 10 times an hour and wear the same underpants for three weeks. So it really is a desperate compulsive response usually to these kind of intrusive thoughts that we are talking about.

Lynne Malcolm: David Adam, author of The Man Who Couldn’t Stop. You’re with All in the Mind on RN, Radio Australia and perhaps on your mobile device, I’m Lynne Malcolm. Today, obsessions and compulsions which sometimes get out of hand. Here’s David Adam on what the research says about the causes of OCD.

David Adam: 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. So one of those is it does seem to run in families, that could be genetic, it could also be just based on family experiences. I suppose the easiest way to answer the question is why is it that some of those thoughts that everybody has tend to stick around 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.

So someone who has what psychologists call an inflated sense of responsibility will react to a thought about hurting someone else differently to someone who doesn’t have that sense of responsibility. So someone who has that mindset might react to the thought about steering their car off the road by thinking, ‘Right, I need to take extra care,’ and in doing so they change their behaviour in the way that we talked about and that can then become a compulsion.

Certainly some of these personality types can be traced back to things that happen in childhood. But there also 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 personality type doesn’t, and that’s really where we are struggling. You know, people have looked at brain scans, they’ve looked at the way people respond to risk, they’ve even looked at things like autoimmune responses to physical infection, because we do know that some people have a bang on the head and wake up with OCD. It can sometimes just be a purely physical explanation. So that’s really where the science is at, is trying to understand what links all those different risk factors to make someone develop it.

Lynne Malcolm: After around 20 years of privately struggling with his fear of being infected with HIV, David Adam had a realisation that saved him from a life dominated by his intrusive thoughts.

David Adam: What turned it around was that I had a baby, I had a daughter, and when she was six months old I started to involve her in it. I took her to a playground, I noticed that there was what looked like blood on her leg, and I became obsessed that she may have somehow rubbed blood into her eyes from the swing that she was sitting on. So 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. And I just 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 are more likely to develop OCD.

So I rang the GP the next day. I had what is considered to be the best treatment for OCD, which is a combination of drugs, so I take antidepressants every day. People with OCD aren’t always depressed but those drugs just seem to help. And I had group sessions of cognitive behavioural therapy in which you explore some of these anxieties and learn techniques to try and resist them.

Lynne Malcolm: It’s hard to imagine that talking and using some of those techniques would become strong enough to counter those fears and thoughts that seem to be overtaking your life.

David Adam: Yes. It turns out that it’s not actually the talking, it’s more the support. We talked about that link between the obsession and the compulsion, it’s all about breaking that link. And crudely, the way that you do that is you don’t perform the compulsions. So in my case for example, if I worried that I might have rubbed blood into my eyes or something like that because I might have touched something with blood on it, my compulsion would be to check my hands to make sure that there is no blood on them, and that would reassure me but it would also reinforce that thought that we talked about. And to break that, what you do is you basically have to live with the very small possibility that there might be blood on your hands and you’re not allowed to look at them. And that’s quite difficult to do. And so the therapy is partly about supporting you through that.

So, for example, in the olden days when they first developed this as a therapy, there would be people who had compulsive fears of rubbish, for example, of germs from rubbish, and they would have to rummage through bin liners full of all sorts of waste. And then they would be prevented from washing their hands. It’s like Odysseus and the Sirens, you know, when they had to tie him to the mast because he wanted to listen to the song but equally that would then force him to go and kill himself. It’s a bit like that in a way. These people were desperate to wash their hands but they were prevented from doing so. Actually in the old days they used to tie them up so they physically couldn’t wash their hands. You’re not allowed to do that anymore, you have to rely on willpower.

But if you do help people not to wash their hands, the theory is that they would get so anxious about the fact that their hands might be covered in all these germs, but then that anxiety has to go down eventually. The psychological process is called extinction decay. The idea is that no one can just stay on high alert indefinitely, in time that anxiety has to come down because it has nowhere else to go. And 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.

Lynne Malcolm: In that treatment process you talk about the helicopter view. What is that and how does that help?

David Adam: So I am very, very anxious about HIV. Even though I’ve had treatment for my OCD, I’m still acutely aware of what you would call very small risks of contracting HIV. So if I have a cut on my hand I’m very conscious about where I put that hand, in a way that probably most people aren’t. But I am happy to get in my car and drive on the motorway, I’m happy to get on an aeroplane, I’m happy to cross the road, all of which equally carry a small and indeed probably a much higher risk of a pretty unpleasant fate, yet I am able to accommodate that small risk. And we all live with those kind of risks every day. In my case OCD was about on a very specific topic I couldn’t deal with those risks, however small they were, they had to be zero, because the compulsive response to the thought is also about trying to make the risk zero. So I need you to tell me that there is no way I could catch HIV in those circumstances, which of course they can’t tell you because there’s always a tiny risk of anything happening.

So in the treatment you sort of get used to that small risk, and that is where the helicopter view comes in. It’s a bit like rather than being confronted with this immediate risk and all you are thinking about is what’s going to happen if this very, very unlikely thing does happen, you sort of zoom out and realise that the chances of it happening are so small that it just isn’t worth worrying about in the way that we don’t worry about other very small risks.

Lynne Malcolm: So how would you describe yourself now?

David Adam: I still have OCD but I manage it, because the thoughts are still there, I still have the intrusive thoughts about HIV, I still have the anxiety about HIV, and so what I do now is try and resist the compulsions. And 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.

Lynne Malcolm: Many people will relate to this discussion to some extent or another. What advice would you give people who are realising that it really is a problem for them?

David Adam: It’s a medical problem, it needs medical help. It is difficult to talk about. I didn’t tell anybody. That made it a lot worse. So we do know that most people with OCD can be helped now. So I guess what I would say is do your research, understand if you go for help what kind of help you’re getting. What someone needs is good quality cognitive behavioural therapy, delivered by somebody who knows what they are doing with OCD because you do actually need a slightly different version for different mental conditions. So if you know that you are suffering from OCD, you need to get help because it will not go away by itself.

And everybody else, people who maybe are interested but don’t have OCD, just talk about these thoughts, because 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.

Another thing that people with OCD do is not go for help because they don’t think they have OCD because they see the same films and television programs as everyone else and they think that OCD is about always lining up your pencils. And so they think, well, what on earth is wrong with me because I have these terrible thoughts about harming someone or jumping off a bridge. And so I really don’t like the phrase ‘awareness raising’ because I just think it sounds rather vague, but I think in that case awareness raising is pretty good because there is a real problem caused by the misuse of the term ‘OCD’.

Lynne Malcolm: David Adam, editor of the scientific journal Nature, and author of The Man Who Couldn’t Stop: OCD and the True Story of a Life Lost in Thought, and it’s published by Picador.

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Thanks to producer Diane Dean and sound engineer Marty Peralta. I’m Lynne Malcolm. Glad you could join me today, see you next time.