We think humans have free will. It’s one thing that separates us from animals. We are masters of our biology, not the other way around. Yet there is something animal about OCD, something atavistic and primitive.
Videos surface from time to time on the Internet of people engaged in compulsive behaviour: postmen dip in and out of a box to check for letters with the same jerky repetitive movements that a wading bird uses when it ducks for fish.* Drivers who return to check they locked their cars patrol the doors in the way that a bear lumbers around the perimeter of its territory. Just like humans, animals show common patterns of behaviour and ritual. They stop at the same places to eat, bathe and sleep. Some of this behaviour can appear compulsive.
In 1952, the Nobel Prize–winning Austrian zoologist Konrad Lorenz described how water shrews would travel along set paths ‘strictly bound to them as a railway engine to its tracks’. He saw how the shrews would jump over a stone that blocked their way, and how, when the stone was removed, they continued to jump. The animals, Lorenz said, would ‘disbelieve their senses’ if those senses reported a need to change their behaviour. Of course we don’t know what the shrews were thinking at the time, and because of this, some scientists in the OCD arena are sniffy about reading too much into animal behaviour. Repetitive actions are not necessarily compulsions, they insist. Compulsions are a response to an obsessive thought. There are some eerie similarities between rituals and compulsions, though. There is something very OCD about some animal behaviour.
The Japan Dog Festival is the country’s largest and most prestigious show. Run by the Japan Kennel Club, it’s a celebration of the pedigree of the nation’s finest dogs and an excuse to watch them slalom through bendy poles and scamper around an obstacle course. The 2008 show was held at the Big Sight International Exhibition Centre in Odaiba in the run up to Christmas, and owners who attended had more to worry about than how their pets would fare in the festival’s Agility Cup and the Champion of Champions event. A team of veterinary scientists from the University of Tokyo was there to ask how many of their dogs chased their own tails.
In the comics and cartoons of childhood, all dogs chase their own tails. Next to an appetite for slippers, it’s a defining feature of the species. In the real world, while most tail-chasing is harmless, some dogs take it too far. They do it several times a day, and when they catch their tails they bite repeatedly until they make them bleed. Some scientists think such behaviour is the OCD of the dog world. They call it canine compulsive disorder.
Other animal rituals resemble the behaviours of OCD. One is compulsive grooming. Birds pick out their own feathers, mice and cats pull away their hair and dogs chew their fur. Dogs lick their paws until they are raw and inflamed. Horses show a damaging compulsive behaviour called cribbing, when they grip a fence or post with their teeth and pull their head back sharply, time and time again. Mice hoard marbles and other useless objects.
In animals, these routines are known as fixed action patterns – innate behaviour sequences triggered by specific circumstances and seen across a species, even in animals raised in isolation. They often emerge when the animal is under stress. Humans are not generally considered to exhibit fixed action patterns. But some of our behavioural rituals seem compulsive too. Look at the routines of sports stars under pressure: how tennis players must bounce the ball the same number of times before they serve, and golfers waggle the club as part of a familiar pre-shot routine before they swing to hit the ball. People in the shower often wash themselves in a set pattern. And just like Lorenz’s water shrews, people heading from A to B like to stick to preferred paths.
Lorenz himself noted:
I once suddenly realized that when driving a car in Vienna I regularly used two different routes when approaching and leaving a certain place in the city. Rebelling against the creature of habit in myself, I tried using my customary return route for the outward journey and vice versa. The astonishing result of this experiment was an undeniable feeling of anxiety so unpleasant that when I came to return I reverted to the habitual route.
These are rituals, not compulsive behaviours. But they show that, just like animals, our motor response to some stimuli can be repetitive and patterned – just like the kinds of behaviour that can emerge in OCD.
Scientists think the behavioural rigidity of ritual is useful. It could help animals, and perhaps humans, to perform certain tasks with less mental effort, so allowing them to save precious energy to direct towards something else. In times of stress, that could help them survive. Here’s a question – could OCD be what happens when this primitive process goes wrong? When it is deployed at the wrong time? When I put my baby daughter in and out of the swing, to check she had not caught HIV, was I responding to some ancient survival mechanism with ritual?
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The link between OCD and rituals intrigues scientists. Some human cultures certainly show behaviours that in another place and time would look like pathological compulsions. Nepalese Sherpas place 100 miniature clay shrines, 100 food cakes, 100 butter lamps and 100 dough effigies in a symmetrical pattern; the Gujars of Uttar Pradesh bathe and then make twelve offerings of red and white substances to twelve deities; the Moose of Burkina Faso sacrifice red, black or white chickens, depending on the situation; the Zuni native Americans make offerings at six points around their village while others take six puffs of special cigarettes and wave towards the six points of the Zuni compass. Apache Indians burn all clothes worn during the dressing and burying of a corpse, as a way to keep away intrusive ideas, images or words associated with the dead person.
One of the most detailed comparisons of human ritual and OCD was performed in 1994, when anthropologists published an exhaustive analysis of the complex initiation rite of the Bimin-Kuskusmin cannibals of Papua New Guinea. Highlights of the ritual see the boys told they are contaminated with female sexual fluids, before they have their heads covered in yellow mud and are told they will be killed or that something terrible will happen to them. They are sealed inside a house, coloured pigment smeared on their heads and faces and they are made to eat and vomit up specific foods that the tribe associates with women. More face smearing – sow blood this time – follows, and further taunting of contamination, of breast milk from infancy. The boys are cut and the blood applied to their penises. They are told this will destroy their penises, while their nasal septum is pierced. Hot marsupial fat is dripped onto their arms. The pus from their burns and blisters is collected and placed onto fruit being worn by their tormentors, who then chant sacred words, during which the boys are told not to swallow their saliva. When the chants finish, the boys must eat salt and pus, are painted again, and have their septum pierced again. They are cut twice more, with their blood placed this time onto the penises of the others. Almost done, the boys now eat five ‘male’ foods, are painted again and anointed with fat, oil and boar blood. When they are not being cut, painted, pierced, burnt, insulted, force-fed or chanted at, each boy is locked away for days on end in a windowless hut with his own faeces, urine, blood and pus.
Looking at written accounts of the boys’ ordeal, the anthropologists identified eleven separate OCD-like rituals, most of which occurred multiple times. They found concern with dirt, actions to remove contaminants, disgust at bodily secretions, numbers of special significance, fear of terrible events, repetitive actions and violent images – all of which are common features of obsessions and compulsions. One of the most regular ritualistic themes was a fear that something terrible will happen, specifically that someone would cause harm to themselves or others. In other words, most of the rituals in this ceremony reflected the theme of responsibility.
This research does not show that cultural rituals are a form of pathology, just as it does not suggest that OCD patients perform culturally significant rituals. Instead, the anthropologists suggest, humans may have a specific biological capacity for ritual, just as we do for language. In a few people this universal (and culturally acceptable) ability might malfunction, and lead them to construct meaningless and idiosyncratic (culturally unacceptable) rituals on their own. That would be OCD.
Other scientists have taken this idea further. OCD, they suggest, could be more than a basic capacity gone wrong. OCD might have once been useful. OCD might be a feature. The disorder might have evolved.
It’s certainly tempting to see the main elements of OCD – wash, clean, check − reflected in ancient strategies that might have helped early humans or even earlier mammals to survive. Grooming strengthens social ties and could protect against disease, while checks on offspring, mates, territory and supplies would boost security. Those individuals who were the most aware of risk would be those least likely to succumb to hazards, and an ordered, symmetric environment is one easier to scrutinize for predators. If these traits were adaptive, if they once conferred a benefit that encouraged survival, then they would be more likely to spread through future generations. Anxiety is generally agreed to have evolved like this: The fight-or-flight response would have helped our ancestors to better respond to threat. The anxious man who runs away after he spots a lion in the distance lives to be anxious another day.
The problem with attempts to connect modern human behaviour to ancient scenarios and evolutionary processes in this way is that the link is very difficult to test – at least to the standards of proof demanded by those who protect the notion of evolution from what they see as abuse. The field – known as evolutionary psychology – hardly helps itself when it throws up headline examples that many choose to interpret as old excuses for modern bad behaviour: claims that men evolved to rape, for instance.
It’s difficult to test the evolutionary basis for human behaviour, but it can be done. In 2005, scientists in London worked out a way to examine the evolutionary platform for anxiety. They looked at the details of a post-war UK birth cohort, 4,070 men and women born in 1946, and picked out two pieces of information about the participants: whether they were judged as anxious or neurotic as teenagers, and if they had died in an accident. The researchers found the least anxious adolescents were the more likely to die in an accident before they reached 25. High anxiety was associated with reduced accidents. The study concluded that anxiety protected young people, presumably because they were more reluctant to take risks.
The work was published in 2006 in the journal Psychological Medicine, and has a confounding – though so far unreported − postscript. William Lee, the psychiatrist who led the research, has repeated the study several times since with data from different birth cohorts, from people born in Aberdeen in the 1950s to Norway in the 1990s. None showed the same protective effect for anxiety. Lee struggles to explain the contradiction – perhaps the original study was a fluke, or maybe, because the number of fatal injuries in society has fallen, the effect is now too small to detect.
There are no comparable experimental studies to test if OCD traits improve the chances of survival, and it’s hard to see how such studies could be done. But there has been plenty written about a possible evolutionary basis for OCD. Explanations like this in evolutionary psychology with no experimental backup are typically labelled ‘Just So’ stories – a reference originally to the tales of Rudyard Kipling that explained, for example, how the leopard got its spots, but a term more recently used to criticize misleadingly simple explanations. When it comes to the possible link between evolution and OCD, the psychiatrists, psychologists and anthropologists who have discussed it are generally up-front about the speculative nature of their ideas. With that in mind, let’s take a look.
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While anxiety is a response to a clear and present danger – the approach of a lion, say – the possible contribution of obsessive and compulsive traits to survival is more subtle. OCD is usually about threats that may occur in future – I wonder if there is a lion behind that rock? Still, this type of harm-avoidance might increase survival and so be passed on through evolution.
Some psychiatrists say OCD could have evolved as a psychological immune system. An individual with involuntary and repetitive thoughts about a concealed lion would experience fear and so develop a way to avoid the perceived threat, even if there was no lion there. In this way, obsessions could be ways to practise the response to threats without the risks of exposure to real-life danger. This advance preparation would give a clear advantage over others when the imagined threat became real. In this model, obsessions are akin to the antibodies generated by the physical immune system, a first line of defence prepared to counter a future threat. Compulsions are the behaviours learned to avoid or minimize the threat.
These obsessions may have been useful to early humans but, like all biological traits, they would not have been distributed evenly across the population. Just as the physical immune system can go haywire and attack the body’s own cells, so some individuals could experience obsessions and compulsions in extreme forms that do more harm than good. In this way, OCD could be as much a dysfunctional by-product of (useful and adaptive) obsession, as generalized anxiety disorder today is a dysfunctional product of the (useful and adaptive) flight-or-fight response.
Psychiatrists have suggested another way that OCD could have evolved in humans: through a process called group selection – individuals who should perish because they carry traits that have a negative effect on them, but who get a free ride from evolution because those same traits benefit a wider social network. Group selection is controversial too – it seems to go against the every-gene-for-itself principle of the survival of the fittest – but there are some proposed examples, food sharing and cooperation between ants and honeybees among them.
To combine group selection and evolutionary psychology puts an idea on the slenderest of scientific thin ice, but psychiatrists in Canada have speculated that OCD represents an ancient form of behavioural specialization – a form of group selection suggested for insects that live in complex social structures stratified into distinct groups such as workers and drones. The majority of human compulsions – checking, washing, counting, hoarding and requiring precision – the psychiatrists say, could have benefited ancient human societies, especially hunter-gatherer communities, even if they had a negative impact on the individual.
Take checking. In his 1960 book, Pygmies of the Ituri Forest, the Harvard University anthropologist Patrick Putman wrote of Congo people who did not know how to make fire. They placed great importance on the need to keep several fires alight across the countryside so one group could always borrow fire from another. ‘While on the march,’ Putman wrote, ‘the pygmies carry glowing embers with them; they can keep a brand lighted for ten miles during a rainstorm.’ In this scenario, someone with a compulsive urge to check, to make sure their fire or carried embers was still alight, could be useful. The compulsion could give them and their wider group a tiny edge in the race to survive, and, repeated often enough, that could be enough to see it passed on.
Compulsive washing could be beneficial too. People with obsessive-compulsive demands for more rigorous hygiene could have influenced the behaviour and so the survival of entire tribes. The Waica people, for example, an isolated jungle tribe who live along the border of Brazil and Venezuela, will only drink water brought from upstream of any fords. That makes sense now, given what we know about infectious bacteria, and any hiker who has scooped to drink from a babbling mountain brook knows the sickening feeling when they discover upstream the rotten carcass of an animal. But how could the Waica’s ancestors have known about this risk? People who get ill from contaminated water do not typically show symptoms straightaway, and this makes it difficult to associate one with the other. Could the practice instead have started with an irrational obsessive-compulsive action that stuck because it happened to benefit the tribe in the long run?
The actions of a small number of obsessive-compulsive people in such societies, the Canadian psychiatrists suggest, could have spread and raised sanitary standards, and so improved the health and survival chances of the entire group. It’s a long shot, but can we rule it out? It would certainly be a mistake to assume that OCD could not present itself in this way, even in such a primitive people. Charles Seligman made such an assumption, and history will not let him forget it.
Seligman was a British anthropologist who visited the islands of Melanesia at the start of the twentieth century, and famously declared its native people free of mental disorders, except where there was obvious pressure from Europeans. Later work overturned his claim, and found that schizophrenia, for one, was as common there as everywhere else. Seligman, it was widely assumed, had falsely attributed the weird behaviour of mental illness, which he must have seen, to eccentric local custom. In anthropological circles a tendency to confuse the signs of mental problems in foreign parts with bizarre and alien cultural behaviour is now known as Seligman’s error.
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In the search for a possible evolutionary explanation for OCD, in recent years scientists have focused on another primitive drive, an emotion we share with animals and one that could misfire to produce obsessions and compulsions: disgust. Disgust probably evolved as a way to stir nausea and so protect us from illness and disease – picture your favourite delicacy rotten and covered with maggots and see if you feel like eating.
This ‘core’ disgust extends to other sources of dirt and possible infection too: rats, for instance, and an unflushed toilet. There are two other disgust domains. One is animal-reminder disgust – revulsion at objects and acts that show us our mortality and animal origins, including aversion to mutilation, injury and some sexual acts: incest, perhaps, or even just a man in his twenties who has sex with an 80-year-old woman. People tend to describe that as ‘disgusting’ rather than ‘unusual’ or ‘not for me, thanks’. The third disgust domain is contamination, the fear we could catch an infectious disease from another person. Think how you feel when someone coughs over you.
All three types of disgust are powerful sensations and strong drivers of behaviour. When authorities in Ghana wanted to improve public hygiene, they broadcast television and radio adverts that graphically highlighted the way faecal material could stick to people’s hands after they had been to the toilet – and how they could then transfer it to food eaten by children. The campaign provoked a 13 per cent rise in the number of people in Ghana who said they washed their hands with soap after they used the toilet. The number who did so before they ate shot up by 41 per cent.
The link between disgust and hand-washing intrigues OCD researchers, and several have suggested that obsessions and compulsions linked to fear of contamination by germs could be down to an excessive disgust response. Results from a few small studies support this link. Volunteers who report the most obsessive-compulsive thoughts and behaviours, for example, can be the most likely to experience more severe disgust when they see images of filthy toilets or gross injuries.
Of particular relevance is the mental impact: how a thought can bring on disgust, with physical consequences. Someone who has spent the night vomiting because they ate some dodgy shellfish need only think of a prawn sandwich the next day to set them off again. Charles Darwin, who was interested in the emotions − as well as the origins − of people and animals, noted this effect. He reported ‘how readily and instantly retching or actual vomiting is induced in some person by the mere idea of having partaken of any unusual food’. That sounds like thought-action fusion.
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Perhaps the most famous case of contamination OCD relates to the bloodthirsty murder of a king and his guards, plotted and executed by a husband and wife. The man takes over as king, but after his wife handles the bloody murder weapon she is plagued by obsession. She feels compelled to wash her hands time and time again, yet she cannot scrub away the vision of the blood she sees there. It does not end well for either of them: she kills herself and he has his head cut off by a rival dressed as a tree. But then, that’s what happens when you take career advice from strange women you meet on a Scottish moor.
Lady Macbeth, of Shakespeare’s play and of course the woman mentioned above, might today be told she suffered from mental pollution: a sense of internal dirtiness that persists despite the absence of external dirt. Psychiatrists see mental pollution a lot with women who have suffered sexual abuse. No matter how often they shower and wash, the women still feel dirty, contaminated. In the last few years it has become clear that mental pollution can play an important role in OCD.
Andy suffered from severe OCD that was traced to mental pollution. A civil servant in London, Andy developed his condition in the 1990s after his wife left him for another man and Andy was pursued by the authorities for child maintenance payments. He became obsessed with thoughts of the brown envelopes they used to send their demands. He felt the envelopes could contaminate him. Andy would react to his feelings of contamination by washing his hands, up to eighty or ninety times a day. He had to sleep in gloves to protect his brittle skin.
Assuming that Andy was behaving in a similar way to OCD patients who fear physical contamination, germs from doorknobs for example, psychologists tried to help him with the same techniques they used for those patients. We’ll come to exposure therapies in a later chapter, but here’s a teaser: as part of the treatment, Andy would spend whole days covered in brown envelopes, from head to toe, in an attempt to make him less sensitive to them and their perceived physical threat.
But there was no perceived physical threat. It was not the physical envelopes that made Andy feel dirty, but the feelings associated with his thoughts of them. He did not even need to see one. He could conjure an image of the envelope in his mind that brought on such intense disgust that he would need to wash his hands. Just like Lady Macbeth, Andy’s washing was futile, because the source of the sense of contamination was internal.
Mental contamination is closely tied to disgust. Imagine a stranger with bad breath and crumbs at the side of their mouth who grabs you unawares and presses their mouth against yours for a sloppy kiss. As you picture the scene, can you feel as your own mouth curls and your nose wrinkles in that familiar shape of disgust? Now, would you like a drink of water? In experiments with female students, after such an exercise a significant number said they wanted to rinse out their mouth or to wash their hands. Disgust caused by the thought of the dirty kiss – the thought alone – had made them feel dirty inside. They were mentally contaminated. Out, damned spot. Out.
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If OCD is a product of shared evolutionary history, or the overreach of a natural capacity for ritual or disgust, then that might explain one of the most noticeable features of the disorder: consistency. It would mean that the condition does not crop up spontaneously in individuals, but rather as a shared biological response to some external or internal primer. We see this on the ground. Time and time again, different types of people with the same types of OCD report the same forms of obsessions and respond with almost identical rituals, even though they are separated by thousands of miles.
The nature of these shared obsessions and compulsions seems stable over time – case reports from centuries ago feature identical thoughts and behaviours to patients who report them now. And they are consistent across the world – identical forms of OCD have been found just about everywhere scientists have looked for them, from western Europe, the United States and Canada, to Latin America, the Middle East, China, India and Australia. In these cases, different cultures and experiences seem to make no difference.
A few years before I developed my OCD, Claire, a 10-year-old girl from Texas, came down with exactly the same obsession. When a schoolteacher told her class about the threat of Aids, she could not get thoughts of the disease out of her head. She would not eat in a restaurant in case someone had picked up food with bloody fingers, refused to kiss or hug anyone outside her immediate family, and had asked the school nurse about fears she would catch Aids from snot thrown in the classroom, a wet bus seat and a soiled book. When a boy in her class said: ‘Have sex with me. I hope you get Aids,’ she found she had to repeat the phrase. Only if she then added a silent ‘just kidding’ six times at the end of the sentence, she said, could she prevent harm to her six family members – herself, her mum, dad, brother, dog and fish. Claire developed other compulsive behaviour, and would feel urges to spit, hop and touch walls in sequences of six – all as a way to ward off the intrusive thoughts of HIV.
When Claire started to refuse to go to school because of her fears, her mother tried to help by explaining the sexual transmission of Aids. Claire responded by stopping the family dog from sleeping on her bed, because it was a boy. At this point, her parents took her for help. She was hospitalized but was helped to make a recovery. She will be in her thirties now.
Like Claire, I was lucky. Help for mental health in the UK is patchy, but after I saw my local doctor and told him my story it emerged that we were in the catchment area for a specialist outpatient OCD service based at a mental health unit at a hospital a few miles away. It was the same hospital where my daughter had been born. The doctor passed me along to them. This time, there would be no elastic bands. And this time, for my daughter’s sake as much as mine, I was determined to make it work.