No off-switch – review of “The Man Who Couldn’t Stop” by David Adam. TLS 16 July 2014

Although this is explicitly not a self-help book, perhaps the highest praise I can give is that I regularly recommend this in clinical practice and have had very positive feedback in this context (although I once wrote the title as  “The Man Who Wasn’t There” which did confuse things ) – and not only when obsessions are the main issue. Adam’s explanation of dimensional versus categorical approaches to diagnosis, as well as his nuanced but clear account of what obsessions actually are and the potential and limits of psychiatry, render this a book which really everyone could profit from reading. This is an example of what I could call a reverse Oxford Murders effect – I would give this a more positive review now. It is also an example of a review which, while I think reasonably well written, I was trying too hard to summarise as much content as I could and perhaps giving too little critical judgment (but this is again a tribute to Adam and the richness of the book)

 

Again with thanks to Maren Meinhardt for the full published text.

 

No off-switch

Nine out of ten people have intrusive thoughts that distress and shock them. Many of us, in a high place, get an urge to jump. Half of all women and 80 per cent of men have involuntary thoughts of strangers in the nude. As a mental phenomenon, obsessional thoughts are much more prevalent than the specific condition – Obsessive Compulsive Disorder – that is listed  as being characterized by them in manuals of psychiatric diagnosis such as the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM, now in its fifth edition).
Many terms from the lexicon of mental illness – hallucination, delusion, depression, to give just some examples – are not just contested terms in their own right, but have acquired a general meaning considerably looser than their technical one. Perhaps no term, except possibly “schizophrenic”, has a lay usage as divorced from the reality of the phenomenon it purports to describe as “obsession” does. Recently, Stephen Fry tweeted that he had “OCD eyes” in response to an arrangement of cakes prepared for his delectation; epitomizing the casual, often somewhat admiring use of “OCD” as a synonym for  precise, orderly and painstaking.
David Adam is a former science and environment correspondent for the Guardian and is now an editor and writer at Nature. He also has OCD. His obsessions, since his student days in the early 1990s, have been of potential infection with HIV. No matter how minor the potential contact with blood or bodily fluids, obsessional fears would strike. Fully intellectually aware of how infinitesimally low the risks were (towards the end of the book, he apologizes to those with HIV who may find the content of his obsessions insulting), Adam nevertheless suffered these intrusive, unappeasable thoughts. Only the goals of Stoke City could (occasionally) displace the thoughts, for a while. And Stoke City, at the time, didn’t score that many goals.
Adam writes that he “can’t think of a single positive thing about OCD . . . . People with OCD drag a mental sea anchor around. Obsession is a brake, a source of drag, not a badge of creativity, a mark of genius or an inconvenient side effect of some greater function”. Adam resisted the publisher’s attempt to feature a bar of soap on the book’s cover, and is no great fan of the portrayals of OCD by Tony Shalhoub (in Monk) and Jack Nicholson (in As Good As It Gets) as a repository of endearing quirks.
Adam blends memoir and popular science skilfully. His personal narrative and his account of the various attempts to understand obsession dovetail neatly. The various psychological and scientific approaches to the phenomenon are all summarized. The chapters on Freudian and behaviourist approaches to obsession dismiss these lines of inquiry as dogmatic dead ends, while the chapter on  psychosurgery includes some of Adam’s angriest writing on the ice-pick lobotomies performed by Walter Freeman.
The Man Who Couldn’t Stop is primarily an emotional book. Indeed, it is very much a book of our time. There has been significant progress in understanding the nature of obsession. Freudian and behaviourist approaches have been largely abandoned. Cognitive behavioural therapy (CBT) rules the roost, and increasingly can boast an evidence base. Yet the nature of obsession remains elusive. Adam summarizes the contributions of genetics, cognitive neuroscience and evolutionary psychology, all of which suggest intriguing lines of inquiry. Yet there is no grand narrative explaining it all, and lived experience tends to transcend and defy all the theoretical explanation. Adam takes the selective serotonin  reuptake inhibitor sertraline,  attends CBT- focused group therapy, and writes that “the psychiatrists who helped me have warned that it will be a lifelong struggle. My case is still open and I am still on their books. I am still their patient”.
This is not a work of anti-psychiatry, but it is far from uncritical of the response to OCD from the psychiatric profession. As well as  the mutilations practised by Freeman, he describes various other futile if not harmful treatment approaches that have been pursued. Not long after he initially seeks help, Adam is told by a psychiatrist  that a proposed antidepressant will make him a “happy zombie”. He is given a rubber band to snap off his wrist when he gets intrusive thoughts; he breaks boxes and boxes of bands.
For many with obsessions, the near-boast of being “a little bit OCD” raises hackles and exemplifies the common misunderstanding of the nature of obsessions. For Adam, it is not quite as offensive; rather, “our reaction when people use the phrase . . . should be: imagine you can never turn it off”. Dimensional rather than categorical approaches to mental health are increasing in influence and popularity. We all occupy places on various spectra, rather than there being some absolute divide between the mentally well and unwell.
Adam writes that for psychiatrists, you can’t be “a little bit OCD”, or even a lot OCD – the categorical approach of DSM-5 means being a little bit OCD is like being a little bit pregnant. While DSM and its WHO-approved equivalent, ICD-10, have undoubtedly been hugely influential, careful practitioners have always borne in mind that their origins and purpose were not primarily clinical, and I would argue that psychiatrists internationally are not as monolithically in thrall to DSM/ICD as is sometimes suggested. Developed mainly for clarification of research (and in ICD-10’s case, the international standardization of death certificates), undoubtedly they have been misappropriated as “the psychiatrist’s bible” and, to a degree, have replaced listening and thinking with checklisting. They have also distorted research agendas and funding.
Adam also questions Lennard Davis’s argument, made in his book Obsession: A history (2008), that obsession is primarily a cultural construct, that “if your behaviour, say the meticulous lining up of objects, is seen as an oddity, you will be distressed that you do it. If it is seen as the useful quality of a master bricklayer, then you will not be distressed”. Adam quotes the various academic replies to Davis, but his main objection is one from lived experience: “when Davis writes that the distress caused by repetitive behaviour, to line up objects say, is subjective, he misses a crucial point. In my experience, and that of most people with OCD I’ve met, the compulsive behaviour does not cause distress, it lessens it . . . . My OCD can cause me distress in an empty room. It doesn’t need a community or a culture or a family to disapprove”.
Adam has not been discharged from the clinic and continues to attend group therapy, and he did not write The Man Who Couldn’t Stop primarily as an exercise in self-help.  Nevertheless, he concludes “this book, and the journey it involves, have proven to me that OCD no longer holds my thoughts captive. They are free to dissolve in glorious mess. And from that, they can begin again”.
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