The Man Who Couldn’t Stop (22 page)

The therapy sessions helped me. They were a crutch to lean on: a little too much of a crutch, as it turned out. One of the ways that people with OCD centred on irrational and unlikely ways to contract diseases carry out their compulsive checks is to seek reassurance. Usually this is the simple ‘can I catch it like this' question. That was clearly banned by the strictures of exposure and response prevention. But OCD is clever, and mine found a way to break the rules.

Under the guise of chat at the group sessions, I would detail some of the obsessive thoughts that had come into my head during the past few days. I had worried, I would say, about how I picked at a spot on my leg and drew blood. What if I had any contaminated blood on my finger? Superficially, this was a way to air our inner thoughts, to open the windows and blow away the obsessive dust that had accumulated since the last session. But I was acting. When I described the thoughts I watched for a reaction, any reaction, in those who listened. I waited for what poker players call a ‘tell', for the others to smile with recognition or to laugh and roll their eyes to indicate that, yes, they thought those thoughts were ridiculous. To reassure me that they believed I couldn't catch HIV that way. That caused as much damage as explicit requests for reassurance. It short-circuited the extinction. I may as well have called the National Aids Helpline and asked them.

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You won't find this description in the textbooks, but behaviour therapy – the BT of CBT – combines two torture devices dreamed up in popular fiction. Like the Room 101 in George Orwell's
1984
, it puts you face to face with your greatest fear. It traps you next to it until you can feel its warm breath on your face. And then there is the Total Perspective Vortex. The Vortex, according to Douglas Adams's
Hitchhiker's Guide to the Galaxy
series, is a small room that shows the occupant their true place in the great, universal scheme of things. As the celestial sweep of the cosmos unfolds across trillions of light years and through millennia of time, a small dot appears with a sign that reads ‘You are here'.

We saw earlier how much OCD can come down to responsibility. What helped me the most was when somebody else offered to take responsibility for my actions. That's pretty cowardly and I'm not proud to say that it worked, but it did. ‘I have a good job and I get paid a lot of money,' the therapist boasted to us one day. ‘If I tell you to do something and something bad happens as a result, then you can blame me. I will get sacked. Do you think I would ask you to do something that will get me sacked?'

If I had blood on my fingers and touched my daughter and gave her Aids then it wasn't my fault. He told me to do it. If I rubbed my eyes in a restaurant, did not check them for blood and then rubbed my eyes again, as he told me to, it was his responsibility if I caught HIV. The end result would be the same. I would still have the disease. My daughter would still have the virus. But that didn't seem to matter as much if it was his job to stop it and not mine. It didn't seem as likely to happen.

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Boom.

*   *   *

The Total Perspective Vortex fired up. My consciousness soared above my fears, as a camera draws out from a single house on a map to show the street, the town and then the surrounds and countryside. Previously, my OCD interfered with this process. No matter how much I tried to make the camera pan out, the irrational fear stayed in view, like a dirty smudge on the lens. Now the risk of HIV from all those unlikely routes shrank as I rose above to see them in their proper context. Psychologists call this moment of clarity the helicopter view. We see the landscape and all it contains in its proper scale. We regain, in all senses of the word, perspective. From 10,000 feet up, the gap between very low risk and zero risk – so visible and so important to my OCD – is hard to distinguish.

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The six months or so of cognitive behavioural sessions helped everybody in the group. When we met a few months later, the improvement was still there. I haven't seen the others since, but I hope it still is. Such success is not unusual. The therapy, in the words of those adverts that try to sell isotonic sports drinks or spot cream, is clinically proven. In 2012 scientists in Tennessee and Texas published a comprehensive meta-analysis – the top standard for medical investigations – of cognitive behavioural therapy for OCD. They pooled the results of sixteen randomized controlled trials that featured 756 people and proved that the therapy was more effective than to do nothing. More people improved with the treatment, in other words, than chance alone would predict.

Cognitive behavioural therapy, as the name suggests, is not just about direct challenge to abnormal behaviour. The cognitive bit is important too. As psychological theories of obsessions and compulsions improved, cognitive therapy was added to exposure treatment. It aims to reveal to patients the dysfunctional beliefs they hold – inflated responsibility, for example – and teaches them how to recognize, to challenge and ultimately to restructure these destructive patterns of thought. It stresses how the interpretation and appraisal of thoughts drive OCD, not the intrusive thoughts themselves.

Some OCD patients refuse cognitive behavioural therapy because it sounds too soft. How can talking and thinking, and talking about thinking, dig out deep-rooted obsessions, overgrown with years and sometimes decades of neglect? Others find it too harsh and quit. Some people find a combination of SSRI drugs and CBT helpful; there is some evidence that OCD patients given so-called smart drugs – supposed to give a short-term boost to mental ability, and popular with college students – can improve the outcome of CBT.

It's common for people who have been through CBT to become evangelists and urge everybody to try it. I'll say only that scientists know it works. They see how the impact can be dramatic and sudden. What's more, they know it can alter the structure and function of the brain. Successful therapy shows up on brain scans – which reveal changes in the kind of activities and brain regions we discussed earlier, those that are implicated in the causes and maintenance of OCD. The mind and the brain are not so separate after all. Change the mind and you can change the brain. It worked for me. It can be hard to access good CBT and I will always be profoundly grateful that I did. And no, I never did smear blood onto my daughter.

 

THIRTEEN

Long live lobotomy

In the grip of OCD, there were times when I wanted to tear my skull to reach inside and rip the thoughts from my brain. I was desperate to find the cells that held the intrusive thoughts and to squeeze them between my fingers until they burst. I'm not the only one who has felt that way. For some people with severe OCD, the drugs – any of the drugs – and the therapy don't work. The elastic bands don't work. The psychotherapy and the psychodynamics don't work. Desperate and out of options, OCD makes some of these people open their own skulls and burn away the bits of their brains they blame for their obsession. Or at least, they get a surgeon to do it for them.

Mr V, a 62-year-old engineer from Karnataka, an Indian town about four hours' drive from Bangalore, had OCD and had tried everything. Mr V developed depression and obsessions after his father died in 1990. He felt compelled to repeatedly verify documents and count money. He spent three to four hours in the toilet every day, where he would wash his hands again and again. He could not bring himself to sign his pension, so he could not collect it. He did not leave his house for two years. He scored a shocking 38 out of 40 on the Yale-Brown test. Mr V had tried cognitive behavioural therapy more than twenty times. He had taken the highest possible doses of sertraline, Prozac and clomipramine, and a handful of other drugs. After twenty years, Mr V had had enough. And then he met Paresh Doshi, a brain surgeon at the Jaslok Hospital and Research Centre in Mumbai. Doshi drilled two holes in the top of his head, inserted a long electrical pin through each, heated them and held them in place until they melted away Mr V's brain cells. Mr V went home with two holes in his head, each about the size of one of the printed words on this page.
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Lobotomy has a dreadful reputation and one that it fully deserves. In the middle decades of the twentieth century, tens of thousands of people with OCD and other mental illnesses had their brains irreversibly damaged by cavalier surgeons armed with nothing more precise than knitting needles. Hammered up through the tops of the eye sockets, the solid metal was then ‘waggled' – there is no other term – around in a clumsy attempt to sever bits of the frontal cortex. Some improved. Plenty didn't.

This form of surgery is now generally referred to as ice-pick lobotomy, which to those of us in Europe sounds even more horrific. In Europe, ice pick is the common name for an ice axe, the mountaineering tool used to murder the Communist leader Leon Trotsky in Mexico City. In the USA an ice pick is a long, sharp needle with a handle on one end that is used to separate blocks of ice. Nobody was lobotomized with an ice axe. At least, not as far as we know.

Those who carry out brain surgery for OCD today recoil from the word ‘lobotomy'. They prefer terms like ‘anterior cingulotomy' and ‘anterior capsulotomy', which sound reassuringly complex and technical, unless you know that the anterior cingulate cortex and anterior capsule are the names of parts of the brain and that the suffix –tomy is from the Greek for slice. The procedures are certainly more precise than full-scale lobotomy. They target and destroy much smaller amounts of brain. But the principle of psychosurgery has remained the same for more than a century: let's cut here and hope for the best. The doctors responsible don't like the term ‘psychosurgery' either. They call it functional neurosurgery for psychiatric disease.

I have some experience of functional neurosurgery for psychiatric disease. In 2004 the
Guardian
photographer Don McPhee and I witnessed its use in Shanghai to treat heroin addiction. Don, who took pictures of the surgery, died in 2007, but his photographs are a fitting legacy; most famous is probably his shot of a miner who wears a toy policeman's helmet and faces up to a young policeman who tries to hold the line during the 1984 coal strike, both poised to break into smiles.

As Don and I stood awkwardly outside the Shanghai operating theatre, both in full surgical scrubs, him with a bulky camera and me with a feeble notebook and chewed Biro, I caught his eye. The smiles were about to come, when the surgeon beckoned us inside to where his medical team was struggling to hold down a tall and bald and wide-awake drug addict. The cold turkey withdrawal symptoms had kicked in. This was bad news as it meant his surgery would now be done under a general anaesthetic. The surgeon preferred to use local anaesthetic – there are no pain receptors in the brain once past the skull – so he could converse with patients while he worked on their brains.

The surgeon drilled through the man's shaved skull, inked with two crude crosses, and inserted long needles deep into the brain. With the flick of a switch, the needle tips became hot enough to burn away the surrounding tissue. It took just a few minutes. The target was the nucleus accumbens, part of the basal ganglia. It's thought to play a role in motivation, desire and reward. It's been loosely connected to addictive behaviour. So the Chinese surgeons thought the man was better off without it.

When
The Guardian
published my report of his operation – complete with Don's photographs and quotes from western neuroscientists appalled at the risk taken by their Chinese colleagues – the Chinese government stepped in and banned the surgery. But similar procedures are still carried out across the world. Not to cure heroin addiction perhaps, but to treat obsessions and anorexia and anxiety and even obesity. It's done in Dundee and Cardiff, Stockholm and Pittsburgh. Lobotomy is dead. Long live lobotomy.

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It takes about five and a half hours to travel by train from Penn Station in New York City to Rutland, Vermont, and on a beautiful day with the autumn leaves in their full glory, you may wish that it took slightly longer. That it does not is down to the backbreaking labour of the men who prepared the New England landscape for the railroad in the mid-nineteenth century, who battered the countryside's lumps and bumps into submission and pinned it down with section after section of fresh track.

One of those men was Phineas Gage, a 25-year-old construction foreman. Born and raised in New Hampshire, Gage was unlikely to have paid too much attention to the colourful leaves that started to dot the trees that provided the backdrop for the work of him and his crew in September 1848. He had seen it all before. But one afternoon, we know that something did distract him. It was a fateful mistake, and one that means his skull is now on permanent display at Harvard University, placed in a glass case next to a metre-long iron bar.

Gage was in charge of blasting away large rocks that littered the intended path of the new railway. He and his men would drill holes into the stones, fill them with explosive powder and detonate them with a fuse. Before the fuse was lit Gage would first prod the sandy mixture into the hole with a three-centimetre-wide bar called a tamping iron. In the late afternoon of 13 September, Gage pushed the tamping iron directly onto the gunpowder. There was a spark and a flash and a vicious explosion. Stunned, Gage fell to the floor. His men gathered around and were relieved to see him open his eyes and talk. They helped him to his feet. They found his tamping iron some distance away, smeared with blood and what looked like bits of sticky thick mucous. Then they found something else.

There was a hole in Gage's head. A three-centimetre-wide tunnel opened in what had been Gage's left cheek, passed through his skull and brain, the skull again, and exited through the top of his head. You could have threaded something directly through his head, which, of course, is what had happened. The iron bar, turned into a missile by the premature explosion, had struck Gage in the face, penetrated and passed through his bones and brains, and barely slowed by the experience, hurled itself high into the sky. It was not mucous that covered the bar, lying on the ground some twenty-five metres away. It was bits of Gage's brain.