JUST over a year ago, it was finally time for the builders to replace the old
metal water pipes in my bathroom with plastic ones. Cologne鈥檚 water is renowned
for its red-brown tint, but mine was especially rusty.
It had taken me seven years to build what I liked to consider was a safe
environment in which to live. My retreat. Whenever the world put the boot in, I
would crawl back to my 24-square-metre hovel and hide under the sheets.
I rarely had visitors: humans equalled dirt, and that meant washing dishes,
disinfecting the toilet, bathroom floor and sinks, changing the towels, wiping
down the walls and so on. So there was no way I could safeguard my world against
a gang of brickies intent upon demolishing it.
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And so it proved.
By the end of the fourth week, I didn鈥檛 dare venture into my bathroom unless
equipped with surgical rubber gloves. The toilet looked. . . well, suffice it to
say that the only time I used it was when there was absolutely no choice, and
then by gingerly squatting over it. If I only needed to pee, I would use a large
plastic water bottle and pour the contents down the kitchen sink.
The remaining 20 square metres of my flat rapidly took on the appearance of a
chessboard: lots of little black and white squares denoting 鈥済ood鈥� and 鈥渆vil鈥�,
areas where I could tread without fear and areas that required rubber boots as
well as gloves. The kitchen sink became the centre of my world. In it I washed
my vegetables and dishes, took regular showers and relieved myself.
By the time the work had come to a premature pause at the end of May, I was
desperate. Wiping away the dust was the least of my problems, the evidence of
blood (shed by one unfortunate tiler) on the fresh white tiles, however, was a
different story. No matter how I scrubbed the spot, it was impossible to
convince myself that there was no risk of HIV or hepatitis.
Empty bottles of bleach and disinfectant littered the tiny floor space. The
walls of my flat began to cramp my already diminished style. All notions of
autonomy, rationality and calm were being squeezed out of me as the walls closed
in. Maybe I should try harder. Maybe if I wiped a little more vigorously, fears
about disease and intrusion would all go away. It would be like starting
again.
That was the theory. In practice, the more I cleaned, the more I felt I had
to. If I had used one bottle of bleach on Monday, I would use
two鈥攔eturning to the same spot鈥攐n Tuesday. My demand for the stuff
was escalating and so was my need for new shops. The local sales assistants, I
felt, already viewed me with suspicion.
At the end of June, the builders finally finished. I had made it to the other
side, but I was left with a heightened sense of insecurity. Order, and therefore
equilibrium, had been restored, but what would it take to throw the fragile
status quo off balance again? By now, I had closed down altogether to visitors,
and the rigorous 鈥渄e-polluting鈥� rituals of hand-washing and scrubbing when I
came home were horribly time-consuming. I soon tired of going out at all.
I had been avoiding a confrontation with my obsessions and compulsions for a
decade. But this time I feared the situation was terminal. I gained strength
through that fear鈥攖his was the last time it was going to overwhelm me. I
set out to find a therapist.
So between July and August, I visited Dr K, a clinical psychologist. I tried
to remember the early, vague feelings of disgust鈥攚ay beyond the norm for a
teenager 鈥攁nd the terrible guilt at failing to do everything 鈥減erfectly鈥�.
Even as a young child I had struggled to be acceptable, to be as clean,
literally, as my brother.
I knew I was safe when Dr K told me that he, too, felt the burden of guilt.
For him, it was the first time he masturbated. 鈥淚 thought,鈥� he began, 鈥渕y
grandmother was under the sheets with me.鈥� Dr K was certain I had obsessive
compulsive disorder (OCD). He recognised the abnormal thought content
culminating in repetitive rituals, repetitive thoughts (ruminations, he called
them), anxiety and a lack of will to confront that anxiety.
At first, Dr K encouraged me to mention anything I thought was relevant. But
despite my pestering, he seldom entertained my insistence on psychoanalysing my
childhood. In fact, most therapists dealing with OCD emphasise that the question
to ask is not 鈥渨hy鈥� but 鈥渨hat鈥濃�攚hat can you do to change what. OCD affects
thoughts and behaviour, so those are what need attention. My interest in 鈥渨hy鈥�
might have been a trick I pulled on myself, a sort of OCD within OCD rather like
a set of Russian dolls.
Reluctantly, I accepted that psychoanalysis was out and cognitive behaviour
therapy (CBT) was in. This involved something called the cue exposure and
response prevention technique. Sufferers who are obsessed with a fear of
contamination and are compulsive hand-washers, for example, are made to feel
that they might have been contaminated, and then prevented from washing their
hands. The more patients tell themselves not to wash, the more they are likely
to be overwhelmed by 鈥渞uminations鈥� urging them to do just that. In CBT, they are
made to consider their actions and decide whether those actions are necessary.
If they can hold out until the anxiety subsides, they will have taken the first
step towards learning that dirty hands do not necessarily lead to illness. If
repeated often enough, this can prove a permanent relearning experience.
By my fourth session, we had reached an impasse. 鈥淲hat if my will is too weak
to sustain progress?鈥� I asked feebly. 鈥淲ell,鈥� Dr K ventured, 鈥渢here are. . .
诲谤耻驳蝉.鈥�
Allegedly, antidepressants can virtually eradicate the repetitive thoughts of
OCD, which are believed to be caused by a chemical imbalance in the brain. Such
treatment leaves only the repetitive actions to be dealt with. I thought I鈥檇
better consult an expert, Naomi Fineberg, a consultant psychiatrist at the Queen
Elizabeth II Hospital in Welwyn Garden City and founder of a self-help group
called Obsessive Action. She sees medication as the front-line treatment. She is
researching the long-term effectiveness of using drugs plus CBT to treat
OCD.
For her, the development of selective serotonin reuptake inhibitors in the
1980s was a revolutionary breakthrough. The SSRIs such as fluoxetine (Prozac),
sertraline, paroxetine and so on all boost levels of the neurotransmitter
serotonin, significantly reducing anxiety and depression.
鈥淚 don鈥檛 know. Drugs? I don鈥檛 even take cough medicine,鈥� I told Dr K. He
pondered, and replied: 鈥淟ook, you鈥檇 be able to go back to work.鈥� I was still not
convinced.
Despite my worries and the fact that many other doctors stress there is no
magic pill, a low level of serotonin is now seen as a big player in OCD and is
treated as it would be in depression. But even if OCD does lurk partly in the
genes, there is no way of knowing for sure, as I found out when I talked to
another expert, David Weeks of the Royal Edinburgh Hospital. Weeks is a clinical
neuropsychologist and he wrote a book called Eccentrics, which explores
the boundaries between obsessive behaviour and eccentric behaviour. For him, the
research into the genetics of OCD just isn鈥檛 good enough to tease apart cause
and effect.
Weeks also worries about something called state-dependent learning鈥攊n
other words, that what I might learn while I鈥檓 taking some drug or other will
not necessarily translate to the 鈥渞eal world鈥� when I stop taking it. I鈥檓 also
worried. To me this looks like a crude substitution: SSRIs for soap. How would I
regain a sense of control over my thoughts and actions with the knowledge that
the drugs were in charge?
To date, most research has been into drugs and has been largely sponsored by
the pharmaceuticals industry. Not surprisingly, these studies have shown a
success rate of up to 80 per cent, while CBT can only boast success of between
30 and 40 per cent. But then, a lack of funding for CBT studies makes it
difficult to find out how reliable it really is.
I began to wonder about society鈥檚 involvement in OCD. Newspaper articles, for
example, make things worse by offering wholly spurious checklists of symptoms so
worried people can 鈥渄iagnose鈥� themselves. Remember, obsessives are addicted to
rituals that are profoundly intimate and carried out in private. They are
terrified of being 鈥渃aught at it鈥�, and fear being misunderstood or laughed at,
or considered crazy. As a result, they might live secretly with their condition
for decades with little understanding of it. They may then turn to self-help
articles in a mistaken belief they are doing themselves good. But by continuing
to avoid admitting their problem to others they will only make themselves
worse.
Weeks agrees that people with OCD have to contend with considerable social
stigma. He argues that if you ask people whether they鈥檇 be happy to have a
neighbour with the problem, they say they鈥檇 be kind. But when it really happened
and when they witnessed OCD behaviour first-hand, they鈥檇 stigmatise the
individual and isolate them.
When my preliminary sessions with Dr K came to a close, I decided not to
undertake full therapy, but I was hungry to learn more. He told me to read the
psychologist Alfred Adler鈥檚 Der Sinn des Lebens. Adler wrote that
repetitive actions are a patient鈥檚 attempt to perfect social practices they feel
unable to carry out successfully. What they perceive as their continual failure
hinders them from feeling as socially qualified as their peers, thus forming a
negative self-image.
He also argued that as a child the patient was probably never taught how to
make independent decisions, which later contributes to their inactivity in any
form of confrontation. Back to that childhood. . .
鈥淪o is it shame, then?鈥� I ask Weeks.
鈥淵es. That鈥檚 the way stigma works鈥攕hame and guilt. It鈥檚 very potent. I
would say both of these things are a part of our culture and both are present in
obsessive compulsive disorder.鈥� It could explain a lot. I feel compelled to do
what everyone wants me to, although I know I can鈥檛. I am also terrified of being
found out because I will be ostracised.
Well, I would have been ostracised. Past tense. Because the truth is that
today, somehow, miraculously almost, it seems to have gone. I didn鈥檛 partake of
the alphabet soup鈥攖he CBT, the SSRIs鈥攏or did I go in for full-blown
psychotherapy or psychoanalysis. So what did save me?
Perhaps it was something to do with this voyage around my OCD. And everything
to do with taking responsibility rather than displacing it onto drugs or
therapy.
If that sounds improbable or like plain old-fashioned willpower, then you
come up with a rationale. I鈥檓 just happy to have washed my hands of OCD.
Obsessive-compulsive disorders are classed as anxiety disorders by the
psychiatrists鈥� bible, the Diagnostic and Statistical Manual of Mental
Disorders(DSM IV).
The obsessions cause anxiety, while the compulsions aim to prevent or reduce
that anxiety.
OCD differs from normal rituals such as finger tapping because it feels
excessive or inappropriate, even to the sufferer, and because the obsession and
compulsions can take hours out of every day.
One New Delhi study showed the obsessions involved dirt or contamination in
59 per cent of the cases. Other common themes were: violence and aggression (25
per cent), orderliness (23 per cent), religion (10 per cent), and sexuality (5
per cent).
The incidence is thought to be constant worldwide, with estimates ranging
from 2.5 to 3 per cent. And for 68 per cent of sufferers, the onset comes before
the age of 25. Men and women suffer roughly equally.
Explanations for OCD include the biological and neurological (genes, brain
damage or malfunction, neurotransmitter malfunction, streptococcal infection)
and the psychological and cognitive (a kind of runaway ego-defence mechanism, or
breakdown in normal thought patterns).
Famous sufferers are thought to include Dr Samuel Johnson, Charles Dickens
and Howard Hughes.