If almost everybody experiences intrusive thoughts, and intrusive thoughts are the raw materials for obsessions, then why does almost everybody not develop OCD?
The mind is a thought factory. Every day it processes a conveyor belt of thousands of thoughts, good and bad, happy and sad, useful and intrusive. The factory must decide how to act on them and then issue instructions to respond. We each do this differently, based on our unique combinations of early experience, environment and biology; our biases, preconceptions and knowledge. The thought factory must work fast. The conveyor belt always rolls and new thoughts arrive in a constant stream. Something always comes in and something always goes out.
Chemical engineers call a system like that a continuous process. It’s the opposite of a batch system, in which they dump all the ingredients in a pot and leave them largely undisturbed to do their thing. Continuous processes are more efficient because you don’t have to turn them off and start again to change the quality and the quantity of product. Turn up the temperature, increase the pressure, slow down the flow and you can tweak how the process converts the raw materials into something useful. Our thought factory does that too. In different circumstances, under pressure or stress, when we are tired or angry, we alter the way we process our thoughts.
The thought factory works pretty well. But it has a flaw. No chemical engineer would design a continuous system in which the inward flow of raw materials could not be turned off. That is a recipe for disaster. It can turn a minor problem into a full-scale catastrophe.
To understand OCD we must look at the conditions inside the thought factory, prising off the lid to see how two different minds can process the same thought in radically different ways. This was a task beyond the behavioural psychologists. In fact it was a concept that the behaviourists firmly rejected. They had no interest in what went on between the ears, only in how it showed itself as action. The mind was a black box and the thought processes inside, they claimed, unimportant.
It took until the 1980s for a new group of scientists, cognitive psychologists, to challenge that view. They argued that thoughts and how they were processed were crucial, not just to understand mental disorder but to treat it. They were ready to lift the lid on OCD. And when they did, one of the first places they looked for an answer was religion.
I’m an atheist but I have no specific axe to grind with religion. That’s important to say because what follows could easily be construed as an attack. For the record, I’m not saying that religion is a mental illness, or that OCD and religious beliefs are the same thing. I’m not saying that OCD makes people religious, or that religion causes OCD.
Religion does not cause OCD, but, as we’ve seen, attempted suppression of intrusive thoughts probably does. Unrealistic demand for pure thoughts probably does. And to be told that if you think certain things then you will forever burn in Hell probably doesn’t help.
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In 2002, psychologists risked their eternal souls for science and deliberately misled dozens of Catholic friars and nuns, scattered across the convents and nunneries of northern Italy. The psychologists wrote to religious institutions and asked for volunteers to help with a study. The scientists wanted to look at the link between religious belief and obsessive symptoms, but they didn’t admit that at first. They said only that they were interested in how people think. They kept the information intentionally vague, they said, to avoid a ‘defensive attitude’ from the pious.
Dozens of the nuns and friars came forward to help and the scientists sent them questionnaires to assess their personalities and to judge how obsessive-compulsive they were. They repeated the exercise with two other groups: citizens actively involved in church activities, and university students who said they had no interest in religion. The psychologists found that the friars and the nuns, together with the regular churchgoers, were more likely to report thoughts and behaviours consistent with OCD.
OCD and religion have walked hand in hand through the centuries. The initial spiritual interpretation of obsessions and compulsive behaviours means that most early accounts of what would now be considered medical problems are set in a religious context. Plus, it was the clergy to whom most people turned with their concerns. Obsessive thoughts of sin – that one had committed a sin or that one was perpetually tempted to sin – have long plagued the devoted. As far back as the sixth century a Mount Sinai monk called John Climacus wrote of intrusive, blasphemous thoughts, which would invade an individual’s mind against their will and which proved almost impossible to evict: ‘This deceiver, this destroyer of souls, has often caused men to go mad.’
By the fifteenth century, intrusive thoughts of sin were called ‘religious melancholy’, or ‘scrupulosity’. The latter term was popularized by Antoninus, an archbishop of Florence. A scruple, he said, was a state of fear and indecision, which arose from mental questions that were impossible to answer and doubts that could never be settled. It comes from the Latin word scrupulum, which means a small sharp stone. The church compared the stubborn moral doubt of scrupulosity to the feeling of a pebble in your shoe. No matter how often you stopped to remove it, when you next took a step it was still there. Say what you like about medieval Italian religious leaders and their contribution to science, they knew a good analogy when they saw one.
One reason we can be confident that religion does not cause OCD is that obsessions and compulsions crop up with similar frequency in both secular and strictly religious countries. But, although the total number of people with OCD is unaffected by a country’s religious leanings, the more religious a place, the more the clinical obsessions of these people centre on religious issues. Religion might not provoke obsessions, but it does provide an outlet for them.
Various studies over the last few decades display this trend. Just 5 per cent of OCD cases in England feature obsessions and compulsions that relate to religion, 10 per cent in the United States, 11 per cent in India and 7 per cent in both Singapore and Japan. Numbers shoot up in the Middle East: 60 per cent of people with OCD in Egypt report religious obsessions, 50 per cent in Saudi Arabia and Israel, and 40 per cent in Bahrain. In Turkey, a secular country with pockets of intense religiosity, the burden of religious OCD shadows the geographical influence of Muslim culture and increases as you travel from west to east.
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Psychologists who have studied this link between OCD and religion say it could come down to ways of thinking called dysfunctional beliefs. Most people have dysfunctional beliefs, which we usually pick up in childhood. They are not mental disorders, they are lenses placed across our cognition. They distort the way we perceive the world and can help explain why different people interpret identical situations in different ways. Some people are more likely than others, for example, to focus on the negative outcomes of their actions, and to exaggerate the way these outcomes damage themselves and others. That’s a dysfunctional belief called catastrophizing. It makes people more likely to be anxious.
Psychologists have identified three types of dysfunctional belief important in the development of OCD. The first is an inflated sense of threat and personal responsibility. The second is perfectionism and intolerance of uncertainty. The third is a belief in the over-importance of thoughts and the need to control them. To be clear, to have one of these dysfunctional beliefs is not to have OCD, but it does increase the chance that someone will develop OCD, because they will then incorrectly process the intrusive thoughts that are common to most people. What’s more, the strength of the dysfunctional belief – how hard people with OCD cling to it in the face of contrary evidence – might influence the degree of insight they have into their condition.
The different types of dysfunctional beliefs could explain the range of symptoms seen in OCD. Perfectionism could underpin a compulsive need for symmetry, while inflated responsibility and overestimation of threat could combine to promote checking obsessions about dirt and disease. And beliefs about the over-importance of thoughts – bad thoughts lead to bad deeds – could drive obsessive thoughts of dangerous or inappropriate behaviour.
Dysfunctional belief about the over-importance of thoughts is sometimes called thought-action fusion, because it implies to someone that a thought is the moral or the physical equivalent of an action. Thought-action fusion, for example, can make people believe that to ‘think’ about having sex with someone – a married man or a child – is as bad as actually doing it. Does that sound familiar?
‘I say to you that everyone who looks on a woman to lust for her has already committed adultery in his heart.’ According to the Gospel of Matthew, Jesus Christ says that to his followers during the Sermon on the Mount. It’s a good description of thought-action fusion. Thoughts, in other words, are equivalent to actions. The tenth commandment goes further and forbids people to want (covet) property owned by somebody else. Just to think an impure thought is itself a sin.
Psychologists say that thought-action fusion could explain the way OCD shows itself among religious people. Some Christians, for instance, are often distressed to discover they can even conceive of sin. Their impure thoughts, they believe, must show they are not as devout as they hoped. Thought-action fusion makes these people believe that their thoughts – their thoughts alone − represent moral failure that makes them more likely to face God’s punishment. These distressing sinful thoughts are, of course, ego-dystonic, they run contrary to the individual’s faith. This makes the person more likely to try to suppress the thoughts, and so for the thoughts to return.
This link between religious belief and thought-action fusion can be tested. In 2012, psychologists asked dozens of senior figures in the Lutheran church how they would respond if one of their parishioners sought their help for scrupulosity. The scientists created a hypothetical worshipper, who they said was worried that she was going crazy because she could not get unwanted thoughts of cursing God out of her mind. She no longer read the scriptures, they said, because of the intrusive urges she felt to desecrate the pages. The thoughts caused her great anxiety and she prayed for up to eight hours a day for forgiveness.
Most of the spiritual leaders were sympathetic. They said they would reassure the woman that God was merciful and forgiving and that He understands the difference between involuntary and deliberately sinful thoughts. But significant numbers said they would also recommend action that, however well intentioned, we know (from the white bear effect of how suppressed thoughts return harder), would just make the situation worse.
They said they would tell the woman to pray harder, and attempt to replace her sinful ideas with more acceptable thoughts. Some said they would warn her that God expects purity in thought and deed, while a few would go as far as to point out that to think sinful thoughts risks God’s punishment. The church elders who themselves showed the most signs of thought-action fusion were the most likely to offer this unhelpful advice.
There are different forms of OCD and so too, of course, are there different forms of religion. What’s of interest to scientists is how the demands of each faith seem to influence the way obsessions and compulsions develop among the devout. Protestant Christianity places strong significance on thoughts: beliefs, intentions and motivations. Sure enough, studies of Protestant Christians show that the more religious they are, the more likely they are to report the signs of thought-action fusion. Islam puts great emphasis on ritual. Muslims are expected to wash in a set manner and perform repetitive prayer routines several times each day. Obsessive and intrusive thoughts that interfere with these are called waswaas, or whispers of Shaytaan. They can force people to doubt whether they performed prayers properly, and so make worshippers repeat, or start actions again. The Islamic text Sahih al-Muslim addresses intrusive doubts a Muslim may have about the number of performed prayers:
If any of you doubts during his prayer and he does not know how many he has prayed, whether it is three or four, then he should discard and cast away his doubt. He is to continue upon what one is sure of [the lesser] then perform two prostrations before making tasleem.
Scrupulosity in Catholic Christians often includes a mix of thoughts about impure beliefs – an urge to worship Satan – and behavioural doubts, such as obsessive thoughts they will drop the Eucharist in Communion. Contamination fears are common in religious OCD, but again, the specific nature of the contamination depends on the demands of the religion. Jewish people can develop OCD centred on thoughts that they cannot avoid non-kosher food.
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Religious or not, most people can hold several dysfunctional beliefs at the same time. Inside our thought factories, these various cognitive biases spin our thoughts in different directions to clash, collide and bounce off each other. If the combined effect is to make people more likely to react badly to an intrusive thought, then the result can be OCD.
Joan reacted badly to an intrusive thought. A 43-year-old, Joan had worked as a training officer with a large company in the south of England when a young man who worked under her was fired for misconduct. Joan already suffered from obsessions and compulsions. She had to retrace journeys to make sure she had not hurt anyone. Now, she started to think that she had telephoned the sacked man’s parents, and told them about an embarrassing incident. She worried that the phone call would lead to him being severely punished, and that he would be driven to suicide. Joan was married with three children. She had made no such phone call. But the obsessive guilt she felt about it was so strong and so real that she tried to kill herself.
Joan is a good example of thought-action fusion. She believed that to think something was morally the same as to do it. And she believed that to think about an event made it more likely to happen. So though she made no phone call, just the act of thinking that she might have done was enough to trouble her. Joan had another type of dysfunctional belief relevant to obsessions too. She had an overdeveloped sense of responsibility.
Inflated responsibility is probably the most important dysfunctional belief in OCD. Obsessive-compulsives often feel responsible both for having thoughts and for the negative consequences of their thoughts on themselves or others – and for not acting to prevent those consequences. They believe that if they have any influence over an outcome, then they are responsible for it. This triggers a cascade of twisted secondary ideas – ‘having this thought means I want to do it’ or ‘if I fail to prevent harm then it is as bad as directly causing harm’. Some people with OCD are compelled to pick up pieces of broken glass from the street. They worry that, if they don’t, then someone else might cut themselves on the glass. If the person with OCD fails to prevent that happening, they think, well I may as well have walked up to the stranger and deliberately hurt them. So they take the glass home. And then they are forced to keep it. To throw it out with the rubbish could see the refuse collectors hurt themselves. That’s why some people with OCD have a collection of broken glass in their house. Others gather banana skins for the same reason.
Cognitive psychologists use dysfunctional beliefs to construct theories of how minds can misfire. In the mid-1980s, a psychologist called Paul Salkovskis, then at Oxford University, built on the concept of inflated responsibility to suggest the first modern cognitive model of OCD. The model has proven very influential. It marked the beginning of the end for the dominance of the behaviourists when it came to the psychology of OCD, and it led to a whole new set of treatments. Best of all, it can be demonstrated with a famous scene from a Woody Allen movie.
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Christopher Walken had just turned 34 when the film Annie Hall was released to worldwide acclaim in April 1977. Walken played Duane Hall, Annie’s brother, who, sitting in his bedroom, memorably asks Allen’s character, Alvy, if he can confess something. Driving at night, Duane says, he sometimes has an impulse to steer his car into the oncoming traffic. He can anticipate the explosion, he says, the sound of shattering glass and the flames from the spilt gasoline. Allen’s unsympathetic reply is that he’s due back on planet Earth. But Duane has the last laugh when he is instructed by his father to drive the couple to the airport that evening, which he does at speed while Alvy looks nervously on from the passenger seat.*
The cognitive theory of OCD says it is not important that Duane has such thoughts – as we know, they are common. What matters is how Duane reacts to them, how he appraises and interprets them. If Duane could brush them away, think them a nuisance and dismiss or simply ignore them, then the intrusive thoughts should pass as quickly and easily as the headlights of the oncoming cars. But if he instead decided that the urges were important and that they deserved attention, then that would be a danger sign. If Duane interpreted the thoughts as having serious consequences, for which he was personally responsible, then he could turn them into a clinical obsession. He could start to think that he was a dangerous driver who must take extra care not to lose control. He might start to avoid driving; he would be distressed by his thoughts and might try to suppress them. And so the intrusive thought would return, harder and stronger and more difficult to ignore.
Unlike many ideas about the causes of OCD, this cognitive theory of obsession can be tested. It is a fairly straightforward job for a scientist to make a volunteer feel responsible for a situation. Imagine, for instance, that you are asked to sort two hundred mixed pills (twenty each of ten different colours) from a glass jar quickly into semitransparent bottles, each of which must contain a different colour. Psychologists at Laval University in Quebec reported the results of such a test in 1995. One set of volunteers were told it was just a practice exercise and that the results would not be counted. Another set was told that lives could be at stake: a pharmaceutical company planned to use the pills to fight a virus in Asia and needed to know how easily the different colours could be identified. The second group, of course, took longer and performed more checks, and also reported more anxiety, doubt and preoccupation with error.
Or imagine that you are an undergraduate psychology student and, in reward for credit towards your degree, you agree to join a study to look at fear of snakes. Your tutor removes a live snake from its cage to show you, and wants you to fill in some questionnaires. After the tutor returns the snake, he beckons you into a separate room to speak your thoughts aloud for five minutes so that your stream of consciousness can be recorded and analysed – oh, but first just close the cage door, will you?
Next door the tutor finds a form supposed to measure your anxiety while you looked at the snake. Whoops, let’s go back to the other room and do that first. ‘Look at the snake and then rate your anxiety on this scale,’ he says. But the cage is empty. Uh-oh. ‘OK, you go ahead with the stream of consciousness exercise and I’ll go look for the snake.’ How do you feel? A snake is loose – and it’s your fault.
Psychologists at the University of Maine reported this experiment in 2008, carried out with a hundred of their female students and one harmless snake bought from a local pet shop. The students were not really responsible for the snake’s escape – while they shuffled between rooms, someone else stole in and removed the reptile from the cage. But the students weren’t to know that – or that they were involved in a trial not of snake phobia, but of the link between responsibility and intrusive thoughts.
To test the role of responsibility, the psychologists repeated the charade with a parallel group of students, with one exception: this time the tutor closed the cage door himself. The snake was still missing when the students returned to the room, but the escape was now his fault and not theirs. Sure enough, when the psychologists listened to the stream of consciousness tapes, they found that the students fooled to take responsibility for the escape reported more intrusive thoughts of snakes.
The Maine psychologists tested another feature of the OCD cognitive model, a prediction that intrusive thoughts are more likely to form if they are salient – that is, if they relate to current concerns. They subdivided the student groups according to how much they said they were afraid of snakes and described this fear as a measure of salience. Again, the results supported the theory. The more afraid of snakes they were, the more intrusive thoughts appeared. Together, the psychologists said that their study backed an important part of the OCD cognitive theory. If a person feels responsible for an event that they judge as personally relevant, they will experience increases in related intrusive thoughts. With great responsibility, comes great power.
And great fear. In April 2013, the Israeli military admitted that one of its soldiers had developed OCD because she was given the job of guarding state secrets. Her air force commanders repeatedly warned her not to disclose the classified information, and told her she would have to pass lie detector tests. The soldier began to compulsively ensure her locker was secure, checked classrooms for discarded pages and would pick up scraps of paper she found around the base in case any of her colleagues had dropped restricted documents.
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Nothing, perhaps, can bring on a sense of responsibility more than having a child. Most new parents will check their sleeping baby is breathing, and then go back to check again. That’s normal. Some new parents take it too far. They turn their new sense of responsibility into OCD.
Sara had a five-month-old son called Justin. Sara had dreadful thoughts that she would strangle or drown him. But Sara loved Justin, she was responsible for him and she would never hurt him. Sara forced herself to seek help. She told a psychiatrist about her thoughts, about the images she saw of Justin’s coffin and of herself in jail, about how sometimes Justin would survive her imagined attempts to murder him. She told how she could not put Justin in his bath, or be alone with him, because she could not trust herself not to kill him − especially when he was asleep and would not realize that she had put her hands around his throat. Sara told the psychiatrist that she would kiss Justin’s head to try to make the thoughts go away.
When Sara told these terrible things to her psychiatrist, Sara was sectioned. She was involuntarily committed, locked away in a hospital to keep her away from Justin. But Sara was no risk to Justin. Sara had postnatal OCD. You’ve never heard of postnatal OCD? No, neither had Sara’s psychiatrist.
Postnatal depression is now recognized as a serious problem and mothers-to-be know that they may struggle through the first few months. But postnatal OCD is almost unheard of outside the pages of scientific and medical journals. Yet it is common. As many as one in ten new mothers develop signs of it. Childbirth can worsen OCD in women who already have the condition, and it can bring it on for the first time in others.
The obsessions that strike new parents who develop postnatal OCD take a particularly distressing form. Mums and dads (and it does affect men too) take their baby home, thank friends for the cards and neighbours for the good wishes, and close the door to gaze into the sleepy eyes of their child, who utterly depends upon them. Then, from nowhere, they feel a powerful urge to throw the fragile infant into the fire, or cook it in the microwave, or hurl it down the stairs, or push their thumbs into its eyes, or squeeze it until its bones snap, or plunge a knife into its chest, or, against all of their instincts and good sense, despite them straining every neuron to shake the idea, to sexually molest their own newborn baby.
Outside their heads, none of this happens. As we saw earlier, people with OCD do not act on their intrusive thoughts. But the new parents who develop OCD don’t know that. And lots of them simply don’t want to take the chance. That’s why hysterical new mothers with OCD can refuse to hold their babies, even though they want to do so more than anything else. And it’s why new dads who develop OCD refuse to enter their child’s bedroom with a pair of scissors. It’s why Sara would kiss Justin, to try to undo the evil in her head. It’s why she went to see the psychiatrist. And it’s why the psychiatrist locked her up.
Sara’s psychiatrist was no doubt concerned because one or two mums in a thousand experience urges to hurt their babies as part of genuine psychosis that emerges after they give birth. There is a big difference. Postnatal psychosis features delusions, ‘the devil is out to get my baby’, and hallucinations, ‘I saw smoke and fire come out of the baby’s ears.’ But, most important, if the parents recognize and report the thoughts as unwanted and if they resist them, then, as with all forms of OCD, they show they are alien to their personality and so unlikely to be carried out.
Don’t take my word for it. Stanley Rachman, the psychologist who performed the first survey of intrusive thoughts in the general population, probably knows more about OCD than anyone else on the planet. He has treated hundreds of people since the 1960s. And he has never had a single OCD patient who complained to him about intrusive thoughts – and he has heard the lot – go on to hurt a child. Not one.
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My baby daughter was six months old when I noticed the blood on her leg. It was summer 2010 and she wore a pair of shorts and there, above the knee, was a dull smear of red. Out of my bag came the nappies, the spare clothes, the raincoat, the various creams and wipes, the jumper, the hat, the spare hat, another nappy and a plastic box that rattled with snacks as I hunted for the sticking plasters. Strange, there was no obvious cut or graze, and she wasn’t in a position to damage herself anyway – crawling was months away, let alone walking. Had she been bitten by an insect, or had I scraped her leg as I lifted her in and out of the playground swing? She would have cried out, wouldn’t she? If it was blood, I realized, then it probably wasn’t her blood.
I was the obvious source of the blood, and sure enough, when I looked carefully, I saw a scratch on the back of one of my fingers, probably from the spiky bushes that guarded the gate to the playground. There was a similar smudge on my finger. I must have brushed her leg against my scratched finger as I lifted her. Click. My idea generator delivered another scenario. It could be someone else’s blood. And it could be HIV-positive. She could have rubbed it into her eyes.
My baby daughter enjoyed our return trips to the playground that day, and only complained about me lifting her in and out of the swing on about the eleventh time. Yes, the stained part of her leg did seem to touch part of the metal guard as I pulled her out, well, more or less. But, did she put her hand there as she swung? Once more for Daddy? I couldn’t see any blood on the swing, and I couldn’t see any blood on the grass underneath, any of the times I looked. I still couldn’t see any when I came back with a flashlight to have another search that evening. I was 38. It was almost nineteen years to the day since that first summer night when I discovered that I could not ignore my intrusive thought. You could have Aids. She could have Aids.
Before that day with my daughter, I had settled for a life with OCD. I knew people with depression, anxiety, anorexia, bipolar disorder and ADHD; others had died of cancer or in accidents. One killed herself. I had started to accept that OCD was my thing. There is a useful cliché on mental health – don’t compare your insides with other people’s outsides. From the outside, I probably appeared happy. A little withdrawn, distracted or quiet in some situations, perhaps, but happy. Most people, I figured, would also have had a moment in their lives that they secretly dated events against. I would just have to accept mine. I would have to live with my OCD.
I reversed that decision the day I made my baby daughter an accomplice. I telephoned my local doctor the next morning to make an appointment. It stopped here. It stopped with me.