Obsessive compulsive disorder

  Most of us have experienced obsessional behaviour as children – avoiding the cracks in the pavement to avoid catastrophic consequences is the commonest. Sportsmen and actors are notorious for such rituals – the tennis player who has to bounce the ball three times before serving, the leading lady who cannot play without something green in her costume. These superstitious behaviours have much in common with obsessive compulsive disorder (OCD). In this disorder the patient has to repeat activities or thoughts (classically hand washing or checking and counting rituals) a set number of times or in a set order to ward off anxiety or feared consequences. In the obsessional form (where there are often no external rituals) the problem is repetitive thoughts, often about awful outcomes (contamination with dirt or germs, or a fear of shouting out something blasphemous or offensive). The hallmark of OCD is that the thoughts or actions are repeated, resisted, and distressing. It isn’t a harmless superstition or quirk but can dominate and ruin lives. Compulsive cleaners, for instance, end up exhausted because they are never finished cleaning over and over again. Obsessional ruminators can’t hold down a job because they are distracted with repeating their thoughts or counting and may wear out their partners as they seek constant reassurance about their worries.

  OCD tends to be associated with specific personality traits – neat, tidy, conscientious. Most of us recognize obsessional features in ourselves and yet the full disorder seems so bizarre. Indeed, sufferers are often slow to seek help because they consider it so strange and incomprehensible – they are embarrassed by it. It has been subject to psychological over-interpretation (Chapter 4) and only recently have effective treatments been developed (behaviour therapy and antidepressants in milder cases).

Hysterical disorders

  Hysteria is no longer a fashionable term. In general use it often just means over-emotional (and usually in women) – ‘Oh don’t be so hysterical!’ Hysterical disorders were originally thought to be restricted to women. Hysteros is the Greek word for womb and there were once fanciful theories of the symptoms being caused by the womb wandering within the body. In psychiatry it has played an important role – particularly in psychoanalysis (Chapter 4) which still gives the best explanation of it.

  Hysterical disorders are most often striking physical or neurological symptoms for which no organic cause can be found. In ‘conversion’ disorders anxiety or conflict is expressed as (‘converted into’) a pain or disability. The most dramatic are paralyses or blindness. The patient insists that they cannot see or move their arm and yet all tests indicate that they ‘really’ can. In dissociative disorders patients deal with their conflicts by insisting that they are not in touch with some aspect of their mental functioning (‘dissociating’ from it). In the most extreme case an individual may insist they have multiple personalities and are not responsible for what different ‘personalities’ do. One of the surprising features of hysterical disorders is that the patient appears relatively content with what appear to others to be very frightening physical conditions. Charcot, the great 19th-century French neurologist, called this contentment ‘la belle indifférence’.

  Conversion and dissociation mechanisms are very common (and temporarily often very helpful) in times of enormous stress. Soldiers in war often carry on apparently calm under fire but afterwards have absolutely no memory of it. Most of us have developed a terrible headache or felt unwell inexplicably only later to realize that it was a way of avoiding something we couldn’t face. In some cases we may doubt if the mechanism is really unconscious, as when it is used in a legal defence (e.g. automatism in murder trials).

  Hysteria in adults is getting less common in more ‘psychologically sophisticated’ societies. In the First World War soldiers, who could not easily acknowledge their terror, developed shell shock (a coarse shaking of the hands and ‘jumpiness’) which was undoubtedly hysterical. They were genuinely unaware that (were ‘unconscious of’ the fact that) the fear of battle caused their symptoms. By the Second World War it was fully understood that soldiers could be terrified of battle. Those who could not cope did not develop shell shock but ‘battle stress’. They felt the terror and could not function but recognized what it was and asked for help. They did not have to deny the fear and convert it into ‘acceptable’ symptoms such as tremor or paralysis. While conversion symptoms are relatively rare now in psychiatric wards they continue to be a significant issue in other medical specialties where the more neutral term ‘somatization’ is used. Treatment is usually based on identifying the stresses and helping the patient find other ways of dealing with them. Treatment of acute hysterical disorders with abreactions (i.e. giving a sedative drug and getting the patient to talk through the situation under its influence) was often amazingly dramatic and effective.