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Caught up in your own thoughts (Image: Daniel Stolle)

From ideas of murder to irrational fears, intrusive thoughts afflict most people. But when David Adam‘s fear of catching HIV persisted, he developed OCD

FOR Winston Churchill, it was an urge to leap from balconies and into the path of oncoming trains. For 20th-century mathematician Kurt Godel, his bête noire was random food poisoning, from his fridge or in general – he eventually starved himself to death. And Alfred Nobel was so terrified of being buried alive that the last words of his will state: “It is my express wish that following my death my veins shall be opened, and when this has been done and competent doctors have confirmed clear signs of death, my remains shall be cremated.”

Most people don’t talk about strange thoughts like these, at least until psychologists take the trouble to ask. A study last year of more than 700 students around the world found that . Many of us think about driving our car off the road. A third of us say we think about grabbing money. More than 40 per cent get an urge to jump from high places, an impulse so common that it has its own name: the high-place phenomenon. Psychologists dub these ideas and urges intrusive thoughts.

In most people, intrusive thoughts vanish as quickly as they come, but in some people, they don’t. Understanding this difference could change lives, because when we can’t make our strange thoughts go away they can bring misery and mental illness. I turned mine into obsessive-compulsive disorder (OCD).

Most people have heard of OCD but tend to think of it as a behavioural quirk. In fact, OCD is a severe and crippling illness, and one defined as much by the mental torment of recurring strange thoughts as physical rituals such as repeated hand-washing. For many, these compulsive behaviours are an attempt to make their intrusive thoughts go away.

Where do intrusive thoughts come from? Psychologists think that our brains have something they call a cognitive “idea generator”. Under normal circumstances, this might help us solve problems by considering all possible options – even ridiculous ones.

There is no direct evidence to support this idea because it is hard to test. But surveys do show that intrusive thoughts tend to crop up more in some situations, such as when we are under stress.

Neuroscientists in Germany reported a brain scan study in 2012 that suggested intrusive thoughts might form in the . These weird thoughts might be more common, they speculate, in people with strong “inner speech” processes, although the connection between thought and language is as much a question for philosophy as science. Some argue that thought requires language, while others suggest that language is just a way for thoughts to enter and exit the mind.

What we do know is that we can experience intrusive thoughts without the desire to act on them. A disturbing thought of sex with a child doesn’t make someone a paedophile, just as an unwanted urge to hit someone with a hammer doesn’t make someone a thug or a murderer.

My OCD is based on intrusive thoughts that I could catch HIV. I compulsively check for blood to make sure I haven’t come in contact with the virus and I steer my behaviour to make sure I don’t catch it in future. I see HIV everywhere. It lurks on toothbrushes and towels, taps and telephones. I wipe cups and bottles, hate sharing drinks and cover every scrape and graze with multiple plasters. My compulsions can demand that after a scratch from a rusty nail or a piece of glass, I return to wrap it in absorbent paper and check the object for drops of contaminated blood that may have been there. I have checked train seats for syringes and toilet seats for just about everything.

As a journalist, I meet a lot of people and shake their hands. If I have a cut on my finger, or I notice that someone I’m talking to has a bandage or a plaster over a wound, thoughts of the handshake and how to avoid it can crowd out everything else. My rational self knows that I can’t catch HIV in these situations, but still the thoughts and the anxiety flood in.

I don’t fear HIV as it is now understood – a fragile virus that leads to an infection that can be managed with drugs. The HIV I focus on is the disease of the late 1980s; a threat so severe that the UK government responded by beaming television adverts into our homes showing crashing gravestones with the catchphrase “AIDS: Don’t Die of Ignorance”.

It wasn’t just me. A generation was traumatised. The US psychiatrist Judith Rapoport wrote in her book The Boy Who Couldn’t Stop Washing that by 1989 a third of her obsessive-compulsive patients focused on HIV and AIDS. The disease, she wrote, appeared “so terrifying, so irrational that it could have been the creation of an obsessive-compulsive’s worst fantasy”.

Irrational fear

This reaction to the threat of HIV is an example of how obsessions can closely mirror society’s fears and anxieties. In the 1920s, doctors in the US reported a surge in what they called syphilis-phobia, which coincided with a campaign to highlight the dangers of the disease. In the 1960s and 1970s there was a spike in irrational fears of asbestos, just as the dangers of the material had come to popular attention. By the 1980s and 1990s it was HIV.

In this new century, society has another topic to obsess over. In 2012, Australian scientists reported the first cases of OCD in people who fixate on – a bogeyman for the new millennium and one that, like HIV in the 1980s, poses an uncertain, universal threat, depicted in lurid detail by the mass media.

In this way, external cultural factors can steer the topics that someone with OCD will fixate on, says Mairwen Jones, head of the University of Sydney Anxiety Disorders Clinic, who led the Australian study. “Since fear of contamination and illness is frequently experienced by people with OCD, it makes sense that media coverage of the HIV epidemic would have triggered these new concerns in some people,” she says. “It’s likely that reports of climate change triggered the sort of fears experienced by people in my study.”

“Syphilis, asbestos, HIV – the fears of people with OCD mirror society’s anxieties”

Some of these people worry that rising temperatures will evaporate the water they leave out for their pets, and so they check the bowls time and time again. Others feel compelled to make sure that taps, heaters and ovens aren’t left on, not because they fear the consequences for themselves, but because of the perceived impact of their negligence on water resources and greenhouse gas emissions, and so the fate of the planet. One man was obsessed with the idea that global warming would make his house fall down. He compulsively checked the skirting boards, pipes and roof for cracks, and repeatedly opened and closed his wooden doors to make sure that climate change hadn’t brought a plague of termites.

As cultural concerns shift and change, so can the intrusive thoughts of an individual with OCD. Take Mavis, a patient seen by psychiatrists in London in the 1970s. For 35 years she’d had OCD, spending almost her entire adult life carrying out cleaning rituals to counter her fears of contamination. In the 1940s, Mavis was obsessed with syphilis, and she scrubbed and disinfected herself to ward off the disease. She also avoided whole districts of the city where she lived and took particular care not to walk on discarded condoms left on the street. As cancer replaced syphilis as a public health concern in the 1960s, Mavis became preoccupied with the idea that she would develop tumours. The fears of syphilis faded but the rituals remained the same. The repeated washing, she said, was now to keep away cancer.

Many of the people Jones sees who obsess over climate change have had OCD for a long time. “These represent largely a change in their concerns, likely due to media coverage,” Jones says.

Of course, not everyone who grew up in the 1980s became plagued by obsessive intrusive thoughts about HIV. If intrusive thoughts are common, and intrusive thoughts can lead to OCD, then why is OCD not more common? About 2 to 3 per cent of people are estimated to have OCD at some point – a tiny fraction of those who experience weird thoughts.

“The problem is not the thoughts themselves, but the way that people interpret them,” says Stanley Rachman at the University of British Columbia in Vancouver, Canada, and an expert on OCD. Psychologists think that conversion of harmless weird thoughts to OCD is driven by ways of thinking called dysfunctional beliefs, usually picked up in childhood. Lots of people, for instance, overestimate the negative consequences of their actions, which can trigger anxiety.

Most of us have dysfunctional beliefs to some degree, although this doesn’t guarantee that someone will develop OCD. Different types of dysfunctional belief could help to explain the range of OCD symptoms, though. For example, perfectionism could underpin a compulsive need for symmetry, while overestimation of threat could promote compulsive checking for dirt and disease.

According to the accepted cognitive model of how OCD develops, the most important dysfunctional belief in OCD is an inflated sense of responsibility. People with the disorder often believe that if they can influence an outcome, that makes them responsible for it. Someone might pick up broken glass, for instance, because if another person cut themselves, they would feel 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”.

One reaction to recurring intrusive thoughts is to try to force them away. But countless studies have demonstrated that it is hard, if not impossible, to suppress unwanted thoughts, and they often resurface later on. Suppressing a thought before sleep can even make it resurface in a dream.

Faced with this onslaught of unwanted thoughts, most people with OCD change their behaviour. They develop compulsions, or repetitive actions.

People with OCD use their compulsions in two ways. One is to answer a question, so if you are haunted by the idea that you may have left the back door unlocked, then a compulsive and reassuring check should settle the matter. Others use them to stop the thoughts coming in the first place. For example, a 14-year-old girl with obsessive thoughts about worms entering her body avoided the threat by not opening her mouth to speak for 10 months.

Sometimes the nature of the compulsions bears no apparent relation to the subject of the obsessions. People with OCD can be compelled to tap surfaces or count or say secret words to themselves to “undo” the imagined consequences of an intrusive thought, that their best friend will die, for example.

Rachman believes that intrusive thoughts might play a role in other mental disorders too. Take an intrusive thought to stab an old lady in the street. If someone were to take responsibility for that thought, they might develop OCD. But if they were to attribute the thought to another person, or the devil, or the CIA, then the thought might develop into schizophrenia. “The key feature in schizophrenia is a failure to try to resist the thoughts,” he says.

As brain imaging tools have developed, neuroscientists have started to watch the intrusive thoughts of OCD play out in pixels. It’s far from clear what goes wrong, but based on these studies the most popular theory is that there’s a malfunction in the circuits connecting three brain areas: the orbitofrontal cortex (OFC), which processes sensory information; the basal ganglia, which selects the appropriate action; and the thalamus, which coordinates the physical action and then sends a message back to confirm this.

In this model of obsessive behaviour, OCD starts when the thalamus runs out of control and sends inappropriate instructions back to the OFC, creating a dilemma: information from the senses indicates that everything is fine, yet signals from the thalamus suggest otherwise. The resulting physical behaviour, the ritual, continues even as the senses tell the OFC that there is no need for the behaviour.

People have been seeking help for the distress caused by intrusive thoughts for centuries (see timeline). In return, they have been locked up, declared mad, given huge doses of hallucinogenic drugs, shunned or had their brains blasted with electricity.

Things have improved since then. Antidepressants called selective serotonin reuptake inhibitors seem to relieve the symptoms in about 40 per cent of people with OCD, although why they do so is unclear. Meanwhile, cognitive models of OCD have produced psychological treatments that try to break the link. Therapists help people to identify their dysfunctional beliefs and to, quite literally, think differently. This is known as cognitive behavioural therapy (CBT).

In 2012, scientists in Tennessee and Texas pooled the results of 16 randomised controlled , and concluded that the therapy was more effective than doing nothing.

I have had CBT and learned to watch my intrusive thoughts come and go. The skill is not to react to the content of my thoughts; it’s difficult, but with near-constant vigilance and practice it can be done, and it does help. I take the drugs too. But what helped the most was a photocopied list of weird thoughts the therapist handed me in an early session. Sex with animals, murder, incest, disease and child abuse all featured, as they do in OCD. Then he delivered the punchline: these thoughts all originated in the minds of perfectly normal and healthy people; inside nine in 10 of them.

“Sex with animals, murder, incest. These thoughts originated in normal people”

It was a revelation that made me feel less of a freak and put me on the long road to recovery. If more people talked about their strange thoughts, then fewer people would be so distressed by them. I, for one, am now ready to do so.

This article appeared in print under the headline “Prisoners of thought”