Posts on obsessive-compulsive disorder

What does it feel like to be depressed? (20 October 2022)

People who don’t suffer from mental illness often think that being depressed is a bit like being sad, that being anxious is like having a touch of nerves before an exam, and that having a compulsion is simply an urge to do something. They’re all much worse.

Depression is very different from feeling a bit down, or having a moment of passing sadness. It’s an extraordinary “pain in the mind”. Imagine feeling sad, but much, much sadder than you’ve ever felt before. Imagine all the lights being turned off in your head. Imagine your mind turning black; black is the colour of depression. You’re living in a monochrome world where all feelings except pain have been turned right down. Imagine a dark ball at the centre of your being that is so cold it hurts. It’s like an icy knife in your soul; it’s worse than any physical pain. You just want to go to bed and cry, to fall asleep, or even die. Death would be a relief, because death is an end to the misery. In any case, who cares: alive or dead, what’s the difference in the end? And who would miss you anyway? You hate yourself and your life. The idea of doing anything is impossible to contemplate. There’s nothing to look forward to, and nothing gives you pleasure, not even the things that in better mental states you can rely upon to excite you. Your despair is utter. Everything is hopeless; and you are sure you’re never going to get better. You feel a terrible sense of doom, foreboding, and fear, not just that you’re never going to get better, but that the universe is a threatening, mysterious, evil place. And everything is such a fight; everyday life is exhausting. You can’t concentrate long enough to be able to complete simple tasks, and in any case you forget what you were going to do nearly as soon as you form the intention to do it.

Managing to do the little things can wipe you out after you’ve used up so much energy making yourself do them. You feel exhausted all the time; deep fatigue goes with severe depression. You make mistakes in the simplest tasks. You have no motivation do to do anything anyway, and no interest in anything. You feel nothing other than total despair, and feeling amazingly, incredibly guilty about everything, as though you’re lazy, incompetent and everything wrong with the world is your fault. So you deserve to suffer so much. Everything is overwhelming, and you are paralysed. You don’t just have very low self-esteem, you are also full of self-hatred. You are the lowest of the low and completely worthless; the world would be a better place without you. If you‘re depressed for any period of time self care tends to go out of the window: what is the point of shaving? Can you really be bothered to wash your face? Who cares if the kitchen sink is filthy? You overeat and overeat convenience food, because that’s all you can be bothered to cook. You sit, finding yourself in tears, and you’re not sure why. You feel completely alone; no one can possibly understand how you feel just now. You can’t bring yourself to speak to other people anyway. And in one final little trick of the mind, time slows down to prolong the agony. Every second is torture. So you try to sleep for as much of the day as possible, and you drink wine and take pills to try to ensure that you can sleep. You feel physically ill as well, with aches and pains exaggerated to distraction. There’s a tickle and lump in your throat. You perpetually tug at your eyebrows, and occasionally pull them out so that they contain strange bald patches. And the ear-worms - those annoying tunes stuck in your head - drive you even madder. You also worry that you’re a black hole of misery, sucking in joy around you, ruining the lives of others - so it’s fortunate that you prefer to suffer in isolation. It is paradoxical that you are lonely and yet want to be alone at the same time, but depression is full of paradoxes. When you’re severely depressed you can’t do anything. You just want to sit still and let the pain wash over you. Some people kill themselves because they can’t take the pain any more; and some people are so ill they can’t even initiate the act of suicide. You have contemplated suicide many times because everyday life hurts too much, and often you really don’t care if you wake up tomorrow morning or not.

That’s what it’s like for me at its worse, but fortunately therapy and medication has helped me enormously. It’s been a while since I’ve felt that bad, but I still get occasional relapses, occasional inklings of those feelings.

I find severe anxiety more difficult to describe. It is a bit like being anxious before an exam, or giving an important presentation or wedding speech, but much more intense and persistent. It is also highly visceral; it gets to your gut. You can’t concentrate on anything, but instead worry about everything. You’re completely on autopilot.

Anxiety often goes with depression, giving a condition imaginatively known as “anxious depression”. There is also agitated depression, which is similar but with more activity - of a bad sort.

It is my misfortune to suffer from obsessive-compulsive disorder (OCD) as well (which is occasionally co-morbid with depression). An obsession is not just like a pre-occupation; it is all-consuming, and you can think of nothing else. A compulsion isn’t simply an urge to do something, or check that you really did lock the door; you must do it, usually many times. My OCD started when I was about 11. I would repeatedly get up in the night to check that my bus pass was in my jacket pocket, and go downstairs to check that the front door was shut. I think it was about fifty times a night, possibly more. Why didn’t anybody notice? Then when a passenger in the back seat of my uncles’ cars I would worry that passing drivers would be able to read my thoughts (even though I knew that was impossible), and might be insulted by them, so I had to apologise to them by saying “sorry” mentally - in powers of three. Occasionally I would reach 243 sub-vocalisations. I suffered greatly performing these compulsions, but the prospect of not doing them filled me with even greater pain. Performing these compulsions also releases the mental pressure somewhat, perhaps in a similar way that self-harm makes some people feel a little better. Eventually the compulsions faded away, to be placed with slightly less compulsive compulsions, such as hand-washing (but much less excessively). I still tend to do things in multiples of three (such as checking the front door is locked behind me nine times), and I am still a very obsessive person, with curious obsessions like having to have complete sets of things such as books all in the same format.

Please pass details of this blog on to anyone who might find it useful. There is no need for anyone to suffer in silence.  If you are depressed, anxious, or suffer from OCD, contact your GP, or NHS 111, or a psychology or medical practitioner, or call Samaritans or Samaritans USA.

Pure O: Obsessing about obsessions (September 2020)

Do you just find yourself sometimes obsessed, thinking about the same thing and can’t stop? There was an interesting article in the (UK) Times on 2 September 2020 about George Ezra’s struggle with his “pure obsessional” thought disorder. The article then covered the debate about whether it is a distinct category of mental illness from OCD. As you might know, my view is that diagnostic criteria for mental illness are pretty messed up, and we don’t have much idea about what is going on in terms of brain dysfunction, genetics, and the effects of experience, and one of the best things about psychiatrists is that they can prescribe drugs (although even then some claim some drugs may do more harm than good). I think it’s very hard to disentangle different types of mental illness, and depression and anxiety disorders are one big blob of unwellness that manifests itself in different ways in different people at different times.

I am definitely inclined to “Pure O”, but I still have some compulsions, albeit currently weak ones that are not too dysfunctional (such as checking the door is locked in multiples of three). The key thing is that the compulsions don’t trouble me, but the obsessive thinking is horrible. When I was younger though my compulsions were much worse – going downstairs in the middle of the night when I was 12 or so checking that the front door was locked maybe a hundred times (although it would have been 99, a multiple of 3, or 81, a nice power of 3, and once or twice 243 times). I was also obsessed with the idea that other people could read my thoughts, even though I knew they couldn’t. I sat in the back of my uncles’ cars and worried that a passing driver would misinterpret my hand posture as a V-sign, and would then track me down, so I would mentally say “sorry sorry sorry” (again some power of 3 times). It was the different world then. I’d never heard of mental illness and had no idea what a clinical psychologist or psychiatrist was. There was nothing like a counsellor at school (I think i might be wrong here: there might have been a nurse in case we broke our leg in break – might).

I’m not so bad now, but I am still pretty obsessive, and occasionally something comes along that I just can’t stop thinking about. I know everyone has their worries but talking to other people about worry, obsessional thinking is completely different. It’s all consuming. It can be dangerous. It can be a form of self-harm. Mostly now I just have a “completeness obsession” – the idea that if a read a certain book or hear a particular piece of music I will be a better person. That isn’t unnatural, but then comes the idea that just owning a certain book, or worse all books in a series, or all pieces of music, will do the job. Or having every track on a music programme. That can work out to be quite expensive, and it takes a bit of time, but it doesn’t make me very unhappy. When I was 12-13 I was very, very unhappy about it all.

My experience is that obsessional thought goes with compulsive behaviour, and therefore it does make sense to talk about OCD, and the relative amount of obsession and compulsion is on a continuum. When I was young I was more compulsive; now I am more obsessional.

I wish I could be optimistic about treatment. There are no specific drugs; SSRIs and anxiolytics are usually prescribed, but they don’t seem to do much for me, and neither has CBT (although of course you might argue I’d be even worse without these).

You might also be interested in Rose Cartwright’s book Pure. Personally it didn’t tell me much new, but you might have a different view.

If anyone has come across a reliable way to stop obsessing about something, please let me know. It might be extreme, but sometimes I wonder if giving myself an electric shock every time I had a bad thought would work.

Obsession (July 2016)

Depression alone is bad enough, but unfortunately it is rarely a pure affliction: people with mental health issues are usually doomed to suffer many versions of misery. Depression and anxiety go together, so much so that many researchers believe that there is a deep relationship between the two. Unsurprisingly then, both benefit from the same sorts of pharmaceutical treatment (SSRIs).

Anxiety comes in many forms, and many of us suffer from more than one. At different times I’ve had my share of social anxiety, generalised anxiety, panic attacks, agoraphobia, and other phobias. I have found that one of the most striking – I want to avoid the word distressing because all forms of anxiety are distressing to those who suffer from them – is obsessive compulsive disorder (OCD). When I was a young teenager my life was blighted by OCD, often in florid forms. In the night I would go down the stairs dozens of times to check that the front door was shut; I would get up multiple times throughout the night to check that my bus pass was still in my school jacket pocket; I would repeat things in multiples of three. I was afraid of contamination, the idea that germs and disease could spread by touching something that touched something that touched something, or even by having seen someone with a disease. I would then wash my hands several times (in multiples of three of course). I was afraid other people could read my thoughts, or would misinterpret an innocent gesture as an offensive one, so would apologise inwardly to them (in powers of three; twenty seven sorries is bad enough, but just try eighty one).

All classic stuff. I didn’t know what OCD was then, and I just suffered, alone, in misery. OCD is, to use a cliché, living hell, and it’s even worse if you think you are alone and have no idea what’s going on. In retrospect something should have been done about it, but I just grew out of it. Mostly – I still have a tendency to overcheck things, usually three times, but no more, and only occasionally, so it doesn’t bother me. We can live with some pathology. Being obsessive even has its advantages as an academic; there’s nothing wrong with checking your data a few times, or being careful about proof reading and checking your facts are right. Being a writer is sometimes obsessive; we often feel a pressure to write. I think you need to be a bit obsessive just to overcome all the negative feedback writers get. The boundary between OCD and having an obsessive personality isn’t always clear – as ever the problems start when what we do makes us unhappy, or interferes with our lives. We also have a problem if our behaviour doesn’t make us unhappy, but affects those around us.

As with all mental illness, the precise causes are unknown, but as with depression there is almost certainly there’s both a genetic and environmental component. The brains of people with OCD look different, but again whether that’s a result or cause of the illness, or whether both result from something else, is not know.

But not all obsessions involve an obvious compulsion other than one to keep the obsession going.  We all have things we worry about from time to time. Most of us are familiar with “ear worms”, tunes that get stuck in your head. I suffer very badly from these (I speculate it’s to do with my psychopathology). It can drive me mad – or more precisely even madder than I already am. They’re the strangest tunes too – I once endured a week of John Denver singing “Annie’s song” non-stop. Worst of all though are obsessive thoughts, the rumination on particular events, ideas, or people that takes over our minds. It is horrible. The compulsion, in as much as there is one, is to continue the obsession. The thoughts – bad thoughts – involve regret, guilt, and fear. When I was in my OCD phase as a teenager at the end of every school term I would struck by the idea that I had done something wrong, and the school holiday would then be ruined by the fear of punishment that would await me on my return at the start of the next term. Of course I never had done anything, and was never punished; it was all in my head. It’s impossible to reason yourself out of OCD.

I think obsessive thinking is verging on psychosis, because things really are out of control. We might refuse to accept that the obsession is irrational, and some people might even act upon their obsessions – I assume that is how people become stalkers. I just suffer though.

Obsessions without compulsion is called “primarily obsessional OCD”. I was encouraged to see that the Wikipedia entry on OCD says that “Primarily obsessional OCD has been called one of the most distressing and challenging forms of OCD”; it’s more than distressing, it’s mental agony. I almost envy people with OCD because at least enacting the compulsion provides a little relief, no matter how short.

However illogical and crazy the behaviour might seem to someone who has never experience OCD, it is impossible to reason your way out of the illness. You can’t tell yourself that it’s irrational to wash your hands so many times. First, the compulsion is stronger than our belief system. And second, there is always a grain of truth we can cling to – it is just possible that a disease might be passed on by touching something that was touched by someone who touched someone with a disease, for example. There is though a clear treatment plan for OCD that involves breaking the link between obsession and compulsion. One of the best books I have read on OCD is Brain Lock: Free Yourself from Obsessive-Compulsive Behavior, by Jeffrey M. Schwartz. He identifies four stages in treatment: relabel (you must recognise what is obsessive and clearly label it as such); reattribute (this thought is not me – it’s my OCD); refocus (the really hard bit, where you have to shift attention, at least for a while); and revalue (to take the whole cycle as something not to be taken as face value, and to adapt the view of a more impartial observer – being mindful). He suggests gradually building up a delay between having the compulsion and having to do it – you might only be able to manage a few seconds at first, but you increase it, perhaps very slowly.

Such treatments, while effective for dealing with the compulsive actions, don’t immediately help us in being able to stop the bad thoughts coming in the first place. In a recent bout, ruminating on a mistake I had made, I tried saying internal loudly and firmly, “It was my choice”, which I eventually simplified to a loud “STOP!” in my inner speech. This approach eventually worked – or the bout blew itself out. A friend told me that a common technique is to visualise a STOP road sign, and I have since tried combining visualising the sign with thinking STOP! It is exhausting work though; bloody exhausting. At least my obsessions appear to have a natural life span, and eventually, after much pain, they eventually peter out.

The intrusiveness of thoughts is one reason why I find meditation so difficult. My thoughts just won’t go away. Even when counting breaths the thoughts overwhelm my inner voice counting. There is a paradox here because if I could just be mindful and live in the present, I wouldn’t be so obsessed by Bad Thoughts, but the Bad Thoughts stop me being able to attend to the present. Coming back to the now and trying to be present does help me when I’m being obsessive, and I think it’s a skill at which one can get better with practice.

I am grateful to and encouraged by everyone who has written to me about my blog. So many people suffer alone; it is time to stop the stigma of mental illness. For a long time I thought I was alone in suffering from obsessional thinking; if we all shared more we would be less isolated, less frightened, and maybe just a little better off. Please feel free to share this blog with whoever you might think would benefit from