Obsessive-Compulsive Behaviour

At least three per cent of people suffer from obsessive-compulsive disorders (OCD), a miserable condition in which one's life can virtually be taken over by frightening, intrusive, repetitive thoughts, images or impulses and the resulting urgent need to perform specific actions, to ward off harm or to make things 'all right'.

There is also a tendency to continually seek reassurance that everything will be okay. The most common obsessive-compulsive behaviours are repeated hand washing and 'checking' activities - for instance, checking a number of times that the back door is locked or that the gas is turned off.

As we said earlier, there are many, many different ways that people respond to levels of stress that are higher than they can cope with, and OCD is just one of them. For the most common trigger for obsessive-compulsive behaviours is a steep rise in stress, which could have any number of causes -from a debilitating physical illness, say, or getting a fright or not getting enough sleep to relationship breakdown, exam worries or money problems.

Sometimes a person's stress levels may creep up almost unnoticed and it is one small, final stress that acts as the proverbial straw that breaks the camel's back. Whatever the cause, the result is worrisome thoughts: sufferers fear that a loved one will die or that their house will be repossessed or that they themselves will inflict harm on someone else.

Often, however, the thought seems to have no relationship to anything that is actually concerning them. It just seems like a mad idea, which has arrived out of the blue. Unsurprisingly, such thoughts cause the individual great anxiety and gradually a compulsive activity develops, as an attempt to compensate or block the malign power of the thought.

Sometimes there is an evident link between the alarming thoughts and the compulsive activity - for instance, it is reasonable that someone with high anxiety about picking up other people's germs and getting ill might try to alleviate this risk by washing their hands. But sometimes there is no obvious link: for instance, a woman might suddenly think, out of the blue, "I'm going to kill my son!" and then feel the desperate need to perform complex mental calculations in some particular order to ' disempower' the thought.

It is worth mentioning here that, according to research, it is extremely common for people to have momentary, highly disturbing thoughts such as, "I could hurt my child" or "1 think I might push the person in front of me on to the track, when the train comes in" - when the person whom the thought is about has done nothing whatsoever to provoke it.

Very often such thoughts, which are usually fleeting, reflect a fear of inadequacy (e.g. hurting one's child because one isn't a good enough mother) or fear of loss of control or behaving unacceptably in public (with murder certainly being the most extreme example of that!) Someone who goes on to suffer from obsessive-compulsive behaviours, however, may be particularly shocked by such thoughts and be less able than others to dismiss them. Dwelling on them and worrying about them inevitably make such thoughts all the more likely to come to mind again and harder to ignore, until eventually rituals are generated as a means of compensating for them.

Sufferers from OCD know that what they are doing is irrational. Yet this doesn't in any way help to stop them needing to put clothes in a certain order in the wardrobe to ensure someone doesn't die in a car accident; or from needing to return home, despite having already covered several miles of a journey, just to check once again that the front door is locked or that the alarm is set properly. For the fear generated if the ritual cannot be carried out is almost unbearable. And it grows.

Terrifying thoughts about germs may become so insistent for someone that, instead of washing their hands vigorously just once or twice a day, the ritual has to be perfonned 50 times a day or for periods of longer and longer duration, in a set pattern and uninterrupted - should someone enter the room, the whole procedure may have to be started again from scratch. In fact, sufferers commonly say that they lose all track of time while carrying out their rituals, unaware, for instance, that they have been washing their hands for an hour. They are in a trance state. And in such a state, they may find that they can't remember whether they have carried out the ritual 'properly' and thus have to repeat it again, and again. In these ways, as you may well have experienced, OCD takes over lives.

Research shows that even when people without OCD repeatedly check that something important has been done, they become less and less certain that they have actually done it.

Some people manage to keep their obsessive-compulsive behaviour a secret from family and friends, even though it takes up more and more of their time and energy. Others, because of the nature of the compulsion, cannot hide what is happening. Either way, there are commonly strong accompanying feelings of helplessness and guilt. The worst thing, of course, is that carrying out the ritual doesn't get rid of the intrusive, frightening, unacceptable thought. Even though sufferers know that, and may constant-ly tell themselves that they will not perform the compulsive act, they just cannot prevent themselves - for reasons we will explain. And that brings us back to the amygdala again. This tiny organ plays a huge role in keeping OCD going. Understanding how it does this will help us understand how to break the pattern.

OCD is like an addiction

As we have seen, the amygdala stores our unconscious emotional memories and matches any new experiences to these. If something is recognised as safe, because we've experienced it without any problem before, then all is well and our amygdala can relax. If a current experience matches one perceived as dangerous or life threatening, however, it sets off the alarm at once, and action gets taken. This is also what happens with the intrusive thoughts or images: the amygdala recognises a threat and raises the alarm, and so the ritual is initiated, to dissipate it. And, because there is an expectation that carrying out the ritual will deal with the threatening thought, the 'connection' between the two is embedded all the more deeply. Yet, as we know, this expectation is not fulfilled. Although the stress caused by the thought is temporarily reduced after the ritual, the thought soon resurfaces, followed each time by more ritual. So why, then, does the expectation persist?  

Suppose Kate has the repetitive intrusive thought that her son will die in a car accident that day, unless, each time she has the thought, she remakes his bed from scratch 10 times. But today, desperate to get free of the compulsion and knowing in her heart of hearts that it will make no difference, she firmly resolves not to carry out the ritual the next time the thought occurs.

The part of her brain that makes that decision is technically termed the dorsolateral prefrontal cortex but we'll call it 'the boss'. When the fearful thought comes into Kate's mind, her amygdala registers it, pattern matches to danger, as usual, and sets off the alarm that usually leads automatically to the bed-making ritual. But this time the boss says, "No, let's ignore it." The amygdala is flabbergasted. There must be some mistake. So it sends an 50S to an area of the brain known as the anterior cingulate, which we'll call 'the boss's secretary' (as the boss's secretary is usually the one who really holds all the power).

The message, begging to do the ritual, is sent in the form of a chemical cocktail. This includes a chemical called dopamine, which creates motivation and the desire to act. In effect, the presence of dopamine is like putting a priority sticker on the message. At this point, Kate is experiencing just mild anxiety about not carrying out her ritual, because that is the effect of the small amount of dopa-mine that the amygdala can muster.

When the boss's secretary gets the message, however, she is confused - the amygdala has never had to involve her in this set of circumstances before. So she acts at once to get more information on the matter. She in turn sends a message, this time to the hippocampus. This is the organ that we discussed in the context of PTSD and which, among other things, stores all of the memories from the near or distant past that we can recall at will. The message the hippocampus receives is a request for any memories that will throw light on the current situation. So the hippocampus sends back a 'file' showing how consistently terrible the experience of the intrusive thought has been and how the only way to get it out of mind and to stop terrible harm happening has been to carry out the bed-making ritual.

Horrified at the apparent danger Kate is in, the boss's secretary hastily scribbles out a letter granting permission to do the ritual, puts it in one of her 'highest priority' envelopes (i.e. adds a massive amount more dopamine to the chemical message) and brings it through to the boss for an instant signature. And, although the boss had resolved not to do the ritual, when he receives the message with all its dopamine, the desire to take action (do the ritual) is so overwhelming that he gives in, thus Kate rushes to remake the bed.

The key to recovery from OCD is in changing the dopamine-soaked expectation. Obsessive-compulsive disorders are exactly like addictions, because both involve repeating behaviours that actually belie our expectations. It is the dopamine that deceives us, by making the memory of the experience of carrying out the ritual (or smoking a cigarette or drinking 10 pints of beer) far better than it ever really was. Both rely on magical thinking: life will be wonderful if I have a cigarette or a drink; my son will be safe if I remake his bed 10 times. But rituals don't make the world a safer place, any more than cigarettes and drink ever really make life wonderful.

As we saw, when the amygdala first gets involved, there is only mild anxiety. It is only the expectation that dire consequences will follow if Kate doesn't do the ritual that keeps the whole thing going. Without that, the anxiety or fear would not be overwhelming, and Kate could learn ways to cope with it. So what needs to be done is to intervene at the point where the boss's secretary sends to the hippocampus for memories -and call up very different ones (such as "I feel just as fearful again a few minutes after I remake the bed. And I feel full of guilt after doing it, because I then don't have time to do other important things that really matter") that won't strike the boss's secretary as necessary to act on, and so she won't even bother the boss with them. (We'll explain in Part 2 about how to work with this information.)

Has my child got OCD?

Most of us, as children, will have developed certain rituals, such as not stepping on the cracks in the pavement or need-ing to see three red cars in a row, designed to 'ensure' that we will get our maths right that day or that we won't get into troUble. At a certain level, such rituals are known to be a game, and not being able to carry them out does not cause anxiety. More importantly, they are seen as fun. If a little girl enjoys lining up her soft cuddly toys in a particular order at the end of her bed, she does not have OCD. If a little boy likes running to pat every tree he passes on the walk to school, he does not have OCD. Obsessive-compulsive activities are never enjoyable, for the very fact that they are compulsions. No one enjoys doing what they feel compelled to do. 

PANDA - a specific cause of OCD

It has only relatively recently been realised that throat infections, caused by the bacterium streptococcus, can sometimes trigger obsessive-compulsive symptoms in children, as well as tics (odd, repetitive movements). This is now known as paediatric autoimmune neuropsychiatric disorder (PANDA). Researchers have found that antibodies produced in response to the infection 'cross react' with proteins in a part of the brain that is implicated in movement disorders. When the immune system has dealt with the infection, the OCD usually remits. However, the symptoms can return any time another such infection is suffered. PANDA has been identified in children aged 3-14. In some cases, plasma transfusions have successfully been used to deal with the disorder. 

Continued in this article: Psychosis