Tag Archives: OCD

60. Finding more cultured friends.

Image Bonnie and Clyde – eggs can be killers.

Pretty soon, the most coveted dinner party guests will be microbiologists. If you know any, you should cultivate them. Germs are coming back into fashion.

A lot of people have problems accepting that humans don’t contain any rare or precious elements, except metaphorically, like pearls of wisdom. No gold inside us, no platinum, no diamonds. No titanium, amber or crystals. Mostly water and cheap stuff, like carbon, nitrogen, sulphur and rust.

But there’s worse to come – a large part of us is not human at all – we are nine tenths made of bacteria – at least in terms of the number of cells. The gut ‘microbiotica’ is our largest organ, and possibly our most intelligent one. If the human body is run by a board of directors, the brain might be chairman, but the largest stakeholder is the colon. Definitely not a silent partner. Scientists have shown that the communication network between the gut and brain is a superhighway, the vagus nerve being the M1-near-Luton of all nerve pathways. Many neurotransmitters exist in the gut as well as the brain, and many of them were found in the gut first, such as cholecystokinin, a peptide hormone.

For decades, people were brought up to believe germs were the bad guys. After all, millions of people used to die of infectious diseases like cholera and tuberculosis, and these diseases are still prevalent in much of the world. Although such diseases are controlled mainly by public health measures rather than antibiotics, there is an awareness that resistant organisms are threatening to launch another era of infectious diseases. Already, there have been massive problems controlling outrageous punk – rocker organisms like clostridium difficile (the clue’s in the name).

I’m going to just introduce the phrase ‘faecal transplant’ and get it over with. But that’s how clostridium difficile can be treated. And that’s why there’s a website called ‘the power of poop’. The cure for bad bacteria is good bacteria. I don’t want to upset any readers who are germ phobic, though I expect they are already spraying dettol over the touchscreen and putting on a new pair of Marigolds. A small number of germs have got the others a bad name, just like badgers. We are going to have to stop killing them and start hugging them more. We will see a revolution in the yogurt industry similar to the real ale phenomenon of the seventies. Instead of Ski type products that have been sterilised and given an absurdly-soon sell by date, we will have yogurt with a bit of fizz to it with a ‘best after 2016’ label.

It’s been a while since I treated someone with a germ phobia, but I have a lasting memory of standing next to someone in their home, both of us with our hands pressed against the slimy surface of a kitchen sink, keeping them there for 20 minutes, time for anxiety levels to die down, doing some hands-on behavioural therapy. On this occasion I realised why Cognitive Behaviour Therapy was taking over – because it could provide a massive short cut. Rather than change the actual behaviour, why not look at the thinking behind the behaviour instead? This lady thought that even one germ could kill you. So, hands still pressed into the slime, we talked a bit about the germ theory of disease. People tend to assume that germs cause diseases by infecting people. This is only partly true, in that we have a powerful immune system, so that even the most aggressive organisms will not cause illness in everyone, or even a majority of people. There has to be a chink in the immunological armour, plus a sizable number of germs in the infective boarding party. This concept is called the minimum infective dose, which is usually millions of bacteria. One germ is hardly ever enough to cause an infection. In fact, landing on a human body is one of the worst things that can happen to a germ. It’s equivalent to being the first person up the ladder in an attempt to storm a castle. There are many kinds of immune response, equivalent to boiling oil. So that’s what I told her. It’s true that people can still catch cholera or tetanus, but statistically the chances of catching anything lethal from a sink in Edgbaston is national-lottery-level low (south of Hagley Road, anyway).

The problem for today though, is how to take a rational position on personal hygiene. Last week, at the seaside, I saw a child drop the ice cream out of a cornet onto the beach, only to be retrieved and replaced on the cornet and given back to the child without even a wipe. The child appeared to accept this without reaction or comment. Was the parent doing the child a favour in terms of building up immunity, or recklessly courting a nasty infection? Luckily, most germs will not get through the multiple defences of the upper GI tract, like the concentrated hydrochloric acid in the stomach. That seems to be a problem for so called macrobiotic remedies, which often fail to reach the minimal infective dose. Food outlets are stringently controlled for hygiene. In our cafe shop for instance, the volunteers had to put on plastic gloves between touching the food and the money, which slowed them down enormously, particularly if they had impaired fine movement.

This week however there has been renewed interest in raw milk, even suggesting that it may have health benefits long term. Yet, googling ‘raw milk’ suggests that it’s one of the most dangerous groceries, up there with eggs, peanuts and cantaloupes, in the food-borne infection league. All this makes it difficult to know what to tell germ phobics, in terms of psycho-education.  Recently a microbiologist told me not to eat potatoes that have gone a little bit soft or started sprouting. Apparently, they can contain very dangerous toxins. I confess, I never suspected the humble potato could be a mass murderer, though I was not surprised about cantaloupes, whatever they are.

People’s attitudes and behaviours around food hygiene seem to vary tremendously. Some of it comes down to ‘locus of control’ issues, and general perceptions of environmental threat. In the absence of a testable consensus on hygiene, we might just have to go back to old school marigolds-off behavioural therapy. If it turns out, as seems likely*, that ‘good bacteria’ can treat a range of diseases, possibly including Depression, some very careful marketing is going to be needed. For instance, the corporate colour scheme should definitely not be brown. It’s just a gut instinct.

* Dinan TG and Cryan JF, 2013, Melancholic Microbes: a link between gut bacteria and depression.  Neurogastroenterol Motil, 25, 713-719

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45. Hosing out the caves of plenty.

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Celebrating the end of the cull.

Consider this: Celine Dion has sold over 200 million albums worldwide. Kodak sold over 70 million Instamatic cameras.  And more than 5 million ZX Sinclair computers were produced. Where have they all gone? The answer is: the house on Gladstone Street, the one with the twenty-foot-high overgrown garden and council notices pinned to the door.

There’s a new diagnosis in town and its name is Hoarding Disorder. Everyone’s talking about it, but no-one is doing much about it yet. That may be because there is no recommended drug therapy, and it’s even a bit dubious whether behaviour therapy will help, unless the sufferer wants to change.

I know, the word sufferer is politically incorrect, I’ve been on the disability and diversity courses. And in this case it is literally incorrect, as the people who suffer are neighbours, relatives and carers, rather than the hoarders themselves.

In DSM5, Hoarding Disorder escaped from the OCD section and was given its own little category. It’s significantly different from OCD, so, like South Sudan, though considerably more cluttered than that country, it has gone its own way.

There are a few other categories associated with squalor, including the so-called Diogenes Syndrome. And there are some similar scenarios which are not considered mental health problems, such as Collecting and Teenage Room Disorder.

Most psychiatrists will have visited homes like the one on Gladstone Street, and sat in sticky chairs, next to overflowing ash trays the size of buckets. We get pressurised by housing departments and public health officers to assess the people who live in these conditions.

In Diogenes Syndrome, which apparently is unfairly named, as Diogenes was a minimalist and lived in a barrel, the affected person simply gives up on the fight to organise, recycle and dispose of stuff, so that a rising tide of garbage fills their house, and finally flows out of the doors and windows, past the complicated row of empty recycling bins.

We could regard these problems as brain based, as in frontal lobe dementia, or part of some other problem, such as Depression, disorganised-type schizophrenia, or Compulsive. We could take a view that such habits are eccentric, or even just lazy. I prefer to look at environmental causes. Hoarders are basically overwhelmed by modern life. It’s not so much the quality of the environment as the quantity. They are victims of what should be called ‘Stuff Inflation’.

Whereas economic inflation leads to money losing its value, stuff inflation leads to manufactured items getting cheaper per cubic inch. Combining this effect with reduced living space – British homes are small on average – gives an ever increasing stuff to bloke ratio. There’s even a magazine called Stuff. And there’s a shop called Poundland, from which Stuff flows, like water from a fountain.

If the alcohol industry creates more product than people can consume, some of it will accumulate excessively in certain individuals. If the availability of alcohol is adjusted up or down, a lesser or greater number of people will consume it to excess.

Similarly, if the world’s factories create more stuff than can be recycled or land-filled, a pooling effect will occur.

Quite how these ‘trickle down’ effects affect particular individuals is the big question for clinicians. Like Magpies, humans have an innate urge to acquire items, and there is a whole industry directed toward persuasion. Why Magpies like shiny metal trinkets is a bit of a mystery. I have never seen a Magpie wearing jewellery, or queuing up in Cash Converters, or playing a slot machine.

I suspect that, like many mental health problems, Hoarding Disorder will turn out to lie on one end of a spectrum rather than behave as a discrete disease entity. I’d be surprised to find anyone who didn’t show some signs of hoarding, if we looked in their loft, car boot or Celine Dion collection.

People hate to lose things they already have, and retain an evolutionarily useful tendency to stock up in case of a bad winter or poor harvest. People need some token or another to explain why they have been at work all day.

Faced with a tsunami of disposabilia, some people just give up trying to cope with it. Hoarding may be just one of many ways people give up on dealing with modern life.. There are so many waiting for DIY SOS, or International Rescue, or the A Team to come, but sadly, there is no De-cluttering service in Yellow Pages. The time cost of sorting through piles of possessions far outweighs the value of any items unearthed, so it even costs money to have everything taken away.

The solution probably lies at political level, with more powerful Stuff Police and a new Ministry of Trinkets. A landfill windfall tax for Poundland would be a good start. NICE could come out officially in support of Minimalism. More of the plinths in Trafalgar Square could be kept empty. I think the NHS has already adopted the slogan Less is More. David Cameron could issue an official apology to Diogenes.

On a personal level I think we should recognise that we can all go down this road if we are not careful, so some attention to Stuff Hygiene is needed.

In previous EPs we destroyed any vinyl records or cassette tapes we had left. We invited the British Heart Foundation into our homes, as bailiffs of charity.

Beyond this, the solution may lie in The Cloud. Somewhere in the world there are some very untidy banks of computers, but, importantly, they are not in Gladstone Street.

17. Giving feedback without using the hairdryer.

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The characters seemed a little two dimensional and transparent in places.

For a long while, every time I filled the kettle with cold water first thing in the morning I thought I heard someone upstairs scream. I wondered at the time whether this might be an interesting kind of hallucination.

A ‘functional hallucination’ is a false perception that occurs at exactly the same time as a real perception, such as the sound of running water. I had assumed till then it only occurred in old German text books and multiple choice exam questions.

It turned out there was a more mundane explanation. The reduction in water pressure caused by turning on the kitchen tap caused the person having a shower elsewhere in the house to experience a sudden water temperature change, first quickly upwards followed by quickly down. The culprit was and still is a poorly operating thermostatic mechanism in the shower unit.

Although the shower over-reacted in terms of temperature control, I am careful to state that the showering person reacted completely appropriately.

The thermostat is our basic model of a feedback system. It senses the temperature of the water. If the temperature goes too hot or too cold, it responds by cutting or increasing the power to the heating element.

The same sort of negative feedback system occurs in most devices, throughout our bodies, and more generally through social systems.

It requires two prongs – a sensing device, and a device that effects a change.

When we come to try and understand the word ‘dysfunctional,’ that seems to describe certain behaviours or relationships – sometimes even applied to an individual – most often we are looking at a faulty feedback mechanism.

In British culture we have a great deal of trouble knowing how to react to things. For instance, it seems the height of bad manners to criticise someone directly. That would be like sounding a car horn. Instead, we tend to use a low key grumbling approach via third parties – like trip advisor, or writing a rude letter and not sending it.

There are a few exceptions, such as talent shows, and the army. If you want a more challenging annual appraisal, perhaps Alex Ferguson would oblige, using his famous ‘hairdryer method’.

But in general it is very difficult to get honest feedback.

If you write a reference for someone who is absolutely terrible at their job, the custom is to write a glowing reference with the tiniest hint of faint praise, e.g. ‘may lack ultimate commitment’.

One guide to how to behave in a crisis is watching drama. Millions watch soaps like Eastenders on a regular basis. How far do people model their social behaviour on such programs?

Whereas stage actors tend to exaggerate voice and gesture, movie actors have to play it deadpan. TV is somewhere in between, perhaps to do with the size of the actors face relative to real life. If shows get made specially to be viewed on a smartphone, they will probably star Brian Blessed.

Like actors in Greek tragedy, people with Depression tend to ‘catastrophise’ in reaction to events. Odysseus’s mother apparently committed suicide after hearing flimsy evidence that he had died.

In drama, Greek or Soap, no-one ever responds to a crisis by calling a helpline.

British people are more likely to under-react to a crisis. David Beckham found out one of his tattoos had misspelt the word Victoria, written in Sandskrit, as Vichtoria. History records that he was not unduly concerned, merely resolving to stick to Latin for further etchings.

A gentleman with OCD I used to know told me this story. One day he had taken his long suffering ‘good lady’ to the seaside, leaving early to avoid the traffic. Having driven 120 miles to the coast, he was confronted by a completely empty car park with hundreds of spaces. He drove around several times, unable to choose a space and eventually had a panic attack. After recovering, and still not in a parking space, he drove home again.

‘I’ve been a bit silly again’, he finally told me.

I should perhaps have anticipated this kind of eventuality and suggested a simple algorithm for parking. Recently I discovered that elevator systems in large buildings have just such a system for deciding which lifts should go to each floor.

Apparently, according to Mitsubishi Electric, a person becomes irritated immediately he presses the lift button and nothing happens. However, the level of irritation is proportional to the square of the waiting time. From this we can begin to understand how people can develop rage attacks surprisingly quickly.

Remember Christian Bale’s outburst on the set of Terminator? Apparently a technician walked across his sightline during a scene.

I know the feeling, from trying to talk to acutely psychotic patients in the same hospital room where builders are operating pneumatic drills and ripping up the lino with Stanley knives.

There are a number of ways to explain why certain people seem to ‘lose it’, experiencing an acute change in mood and behaviour.

Steve Peters would call it ‘letting the chimp out’, meaning a switch in mind-set, allowing a different set of brain pathways to take over control. Thankfully, Mitsubishi have not included a Chimp Mode in their elevator systems. Though Beko appear to have included a ‘Surrealist Mode’ in their washing machines.

A more neuroscience-based model still, is the possibility of positive feedback, or kindling, where the response actually goes the opposite way from restoring the norm. This is often called a vicious circle.

One theory of panic attacks uses a vicious circle model, where mild signals of distress from around the body are over-read, cause anxiety and thus further physical distress signalling, such as breathlessness, palpitations or chest pain. Finishing with a slightly embarrassing visit to the coronary care unit.

A behaviourist could explain ‘losing it’ in terms of social learning. Previous tantrums or losses of control have been rewarded by parents or others, either in terms of letting the upset person have his way, or by way of reducing ‘messing’ with that person. Having a ‘short fuse’ can be quite useful in certain situations. I once worked for a consultant who was completely benign 99% of the time, but the word about him was, ‘watch out, he goes berserk every now and again’.

One of the triggers seemed to be handing him a post it note with a poorly worded or scribbled message and a phone number. It was not that he had been hypnotised previously and made to react this way, although this is possible, knowing the hospital involved.

It was just that being handed a post it note is a metaphor for being handed a problem, but without the information needed to act on it properly.

I’d like to think that his reputation would have worked to reduce the number of post it notes he got handed, but I never saw any sign of this. Post it notes continued to flow like confetti. Perhaps he should have set fire to them immediately or eaten them.

In the NHS, feedback loops operate comparatively slowly, so it would have taken about 20 years to see the post it notes’ eventual downturn.

Remember the film, ‘Falling Down’? Here, the character, D Fens, is played by Michael Douglas, who is a screen actor and therefore tends to play deadpan. D Fens progressively loses it after a ‘rare morning’, ending up in a spree of violence across LA. The trigger event appears to be a shopkeeper refusing to give change.

An older theory of ‘losing it’ relied on the notion of a repressed or over-controlled person, which I think is what the director had in mind. D Fens had seemingly suppressed his anger by being extremely tidy and organised, never allowing himself to become emotional, and therefore never setting appropriate limits on people.

Here I suppose the systems analogy is the pressure cooker. This has a very primitive feedback loop, so that a massive degree of change from steady state is needed before the feedback occurs, in the form of opening a safety valve.

Here the feedback loop is too coarse to make rapid enough corrections, necessitating an external over-correction, such as being gunned down, albeit reluctantly, by Robert Duvall.

CBT is designed to improve a person’s feedback system: on the cognitive side to make sure the right information is collected; and on the behavioural side to make the appropriate responses.

Luckily the government has given us a new way to make sure we react appropriately.

We’ve been used to making a 999 call, for moments where we identified a very serious crisis. However, the 999 system is abused on a daily basis. One of the problems is that TV never shows anyone calling a helpline appropriately, so we don’t know what constitutes a 999 level emergency.

People have rung 999, for instance, to ask ‘how to dial 111’; because they were not being served in Macdonald’s; to try and obtain a laptop password, and to report the theft of parts of a snowman.

Now, to create a kind of crisis scale, at the milder end, we also have the 111 call.

That gives us the potential, provided British Telecom goes along with this, to fill up the numbers in between, 222, 333, etc, with a sliding scale of catastrophisation.

Let’s put in some examples to test the system.

You are Henry VIII, the most powerful king England ever had.

You have some marital issues, and in particular no male heir to the throne.

I’m thinking 333 would be about right.

Instead of which Henry over-reacts massively, dissolving the monasteries and the catholic church, divorcing his wife and executing some of his best pals.

There is no indication that the younger Henry was overly ‘buttoned up’, casting some doubt on the over-control theory. Although if he really had cerebral syphilis, that might have damaged some of his feedback loops.

Or try this one: Confronted with a pompous email from NHS management you write a reply you misguidedly think is witty, accidentally pressing the Reply to All button, so that every person in the whole NHS gets a copy.

555, agreed?

You eat a yogurt from your fridge mistaking the sell by date 2003 for 2013?

Not even 111, I don’t think. Yogurt never kills.

We are going to need an advisory panel of some kind as arbiters of how to interpret and assign a crisis to a number scale. This would be an efficient resource, especially if we can charge a premium rate for the crisis line. I hope the NHS is working on this.

Failing that I think Mitsubishi could run something up. For indecisive parking, press 111. For misspelt tattoos, press 222. For incorrect change, press 333…

What if the elevator seems awfully slow today? Press 444. Pressing using the fingers is sufficient. It is not necessary to use the axe.

13. Less is More, more or less.

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Another shop you don’t need to go in.

A sunny, windy Saturday morning. A queue of cars waits to turn right into a muddy field, creating a hold up on the A60. Each car is full of junk. The people from the cars unload their junk onto trestle tables and tarpaulins. People exchange items of junk and money. This is not a film crew re-making ‘Grapes of Wrath’ on location. It is a car boot sale, and it’s a tragedy.

You have a car that is 99.9% working. The part that isn’t working is a warning light that comes on when it shouldn’t. Ironically, the warning light is a faulty alarm, giving warning only of its own falsehood, but it is enough to fail the MOT test and render the car worthless.

The car must be recycled, and it is not a tragedy. Gordon Brown used to pay people to dispose of cars, successfully stimulating the Korean economy. For a while cars could be handed in for a bounty, like coyote pelts.

In our town centres, piles of junk are decanted into vacant shops under the guise of charities and sold on for slightly more than you might pay at Primark, if only you weren’t phobic and dared go in.

No disrespect to charities. It is just a pity that they have been sucked into the landfill business.

One of the best things you can do to help yourself is to throw away half your stuff. So, lots of lifestyle gurus have latched on to ‘decluttering’.

However, as Tony Blair didn’t say, its not enough just to fight clutter – we have to fight the causes of clutter also, otherwise it will merely return in a new and terrible form.

Why do we have so much tat?

The economic answer is that our society values economic growth above all other measures of civilisation.

The evolutionary answer is that for most of human existence it has really paid to hoard stuff away. Our grandparents, who lived through wars, failed to adapt to the disposable society and proved unable to dispose of their empty yogurt pots and biscuit tins. Many of them were killed in hoarded item landslides.

The psychodynamic answer is that we invest emotion in objects, so that they acquire a sentimental value. Under this heading we include whatever defence mechanism is responsible for Collecting Things.

The cognitive answer is that we hate waste. In particular we hate to lose stuff that we already have.

I don’t doubt for a moment that already there are huge land fill sites, and that a lot of land fill should really be recycled, and that land fill is problematic from an environmental point of view.

It’s just that, judging by the state of many people’s houses and sheds, the land fill sites should be so much bigger. Somewhere around the size of Bedfordshire, as a rough estimate.

Borrowing a bit from Escape from New York, why not declare an area – such as Bedfordshire – an official landfill site and build a tall fence around it? Gradually, Bedfordshire would grow taller and mountainous and probably beautiful in due course – if you could find it.

I would like to see a huge re-cycling plant for vinyl records where they can be turned into food by a special fungus.

I’d like to see all the remaining cathode ray televisions collected, melted into a giant saucepan and made into comfy chairs .

And all the books – after digitising – can be made into a new Hadrian’s bookcase along the entire Scottish border.

All the coins and money could be melted down and made into the kind of shiny foil clothing people in the 1960s imagined we would all be wearing by now.

And most of all, I’d like to see all those cardboard crowns that litter the window sills in Burger King, collected, pulped and made back into trees.

Architect and designer Mies Van der Rohe is credited with the saying ‘Less is More’. He would have been a little disappointed to find so little evidence of minimalism or even room to swing cats in our houses today. Though modernists would probably have expected people to swing their cats in verdant communal parkland between the high rise blocks, or in high quality piazza spaces, rather than indoors.

Some architects have even gone as far as to question whether cats need to be swung at all.

Digitisation seems to give us the opportunity to miniaturise the storage of all our music, video, art and documents to a card the size of a postage stamp. Using ‘the cloud’, we do not even need the little card any more.

Sadly, one has the impression that the space vacated by digitising records, books and pictures will quickly be filled by gym equipment and antiques.

It is tempting to hold the media – particularly the Sunday Times – responsible for the clutter epidemic. For instance, yesterday, the paper carried an article about buying a Victorian bidet, allegedly haunted, for £325. ‘Its sad to part with it,’ the article concluded, ‘but I’m downsizing’. What, do without a bidet! However will you manage?

In truth the blame lies closer to home. Yes, psychiatrists are to blame for the landfill explosion and thus, soon, losing one of our treasured counties. This is the reason:

Some how or other, psychiatrists have convinced the world that tidy people have something wrong with them. Tidy people are called ‘anankastic’, which sounds suspiciously like ‘antichrist’.

The word ‘anankastic’ means something similar to obsessive.

Psychiatrists have not explained very well that the anankastic personality is not the same thing at all as obsessive compulsive disorder.

Implicit in OCD is the acceptance that the thinking and behaviour is silly. Whereas the anankastic person does not think there is anything wrong with what he regards as being extremely well organised.

Psychiatrists have hinted that tidy people are repressed in some way. Something to do with anal retentiveness.

Tidy people will never be competent painters, jazz musicians or good at sex.

Look at how they are portrayed in movies and television. Radar, from Mash; Dwight, from The Office; Mr Gradgrind, from Hard Times.

Psychiatrists have been generating bad press for tidy people for over a century. There is no range of perfume called Anankast, not even in Superdrug.

There is no Anankastics charity shop in town, though by now  it would have been renamed Spick and Span, to reduce stigma.

In the Mr Men series – pretty much the bible when it comes to personality classification – Mr Neat and Mr Tidy are only minor characters in the book devoted to Mr Messy.

Looking back to the late 19th / early 20th century context, when the analysts were most active, perhaps this is more understandable.

Freud and his colleagues had no PIN numbers to remember, no car insurance to renew, no DVDs to take back to the library.

They did not have to use mobile phones to pay for parking. They did not even have land lines. They had no need to keep a range of spare batteries, chargers and light bulbs, or gas cartridges for their Braun Independent beard curlers.

They had no need to use their Tesco voucher within a specific 7 day window.

Freud never had to find a 13mm ring spanner or a 30 amp fuse.

He never had to worry that Jung had hacked his facebook page.

Today’s world is so different. The need for organisation is so acute some households should think about appointing their own executive boards, complete with Venn diagrams and Mission Statements.

As a psychiatrist I feel guilty about what we have done to besmirch tidy folk, and offer the following solution:

Since we have invested a lot of emotion in objects, we cannot simply dispose of them as the de-cluttering guru suggests.

No, each item really needs a decent send- off, with a few kind words and reprisal of happy memories. This way the grief can be channelled and worked through.

The actual process would be quite like Antiques Road Show, but featuring a conveyor belt and incinerator.

That way Bedfordshire can be saved.