It is called obsessive-compulsive disorder (OCD) and, as was noted in “How Big Is Yours?” it has moved from the backwaters of psychiatry to become almost a diagnostic fad. When thinking about the minor compulsive rituals that bother most of us now and then, it is hard to imagine the extent to which a life can be destroyed by these patterns writ large. Yet this is precisely what happens with the OCD sufferer. It is the severity of their bewildering symptoms that is most striking.
First and foremost, OCD patients must clean themselves. By this, I do not mean that they are fastidious, hygiene-conscious individuals. I mean that they wash their hands four, six hours a day, to the point where they cannot hold down a job for their time spent washing. They take a shower, methodically scrubbing with an array of carefully researched antiseptic soaps, each used in a proper sequence, applied in a particular manner to its designated part of the body, allowed to cleanse for a predetermined number of seconds before being washed off in water whose temperature has been picked for its antibacterial attributes. Finally, purified and fortified, the individual dresses and invariably, while leaving the room, brushes an elbow against the doorway. Who knows who else might have brushed against that spot, what germs they carried? Soiled, the person must bathe all over again.
As another frequent compulsion, the OCD individual checks. Vacations are never taken because of the endless examination of the window locks, the burner on the stove, the latch on the back door, before being able to leave; homework assignments or reports are never submitted and applications are never mailed off because they must always be checked once again for typos—there can never be enough certainty. The obsessive-compulsive will drive fifty miles out of his way, convinced that he has hit someone on the highway, that a body has flown off onto the divider, that he has unconscionably left the scene of an accident. He must go back and check and, finally convinced that there is no body and no heinous crime, he will finally drive on . . . only to become anxiously convinced that the body actually hurtled off in the other direction into the unexamined bushes on the shoulder. And thus he turns around again.
There are also compulsions of entering and leaving a place—a doorway can become an almost magically difficult threshold to cross until the individual touches the doorjamb a set number of times with the palm of her hand. There are rituals of symmetry and arranging of things—a meal cannot be begun until the utensils are perfectly, unattainably parallel. Intercalated in these rituals are ones of counting—light switches that must be turned on and off a set number of times, stairs that must be counted. In some more educated OCD patients, such numerology takes on arcane complexity. The OCD individual may find herself walking from her car to the entrance of the office building in which she is to interview for a job, and might impose a rule—she can only enter the building if she has walked an even number of steps, or a number of steps equal to a prime number, or to a prime number squared, or perhaps where the ratio of the number of steps in which her briefcase is carried in the right hand versus the left hand must conform to the Fibonacci ratio. Or else, she must start all over again . . . until she’s late for another job interview. The task of protecting one’s mother’s back by not stepping on cracks becomes trivial in comparison.
These are the compulsions, the uncontrollable acts. Along with this comes uncontrollable obsessive thoughts. It is bad enough that such obsessions are often banal drivel of nonsense words or songs—it is dizzying to contemplate an adult, sentient mind obsessively consumed with the question, “Who put the bomp in the bomp-shoo-bomp-shoo-bomp?” But the obsessions are often darker. Perhaps the OCD individual cannot stop the thought of some tragedy befalling a loved one, of inadvertently being responsible for that tragedy, of intentionally doing the awful act. The person cannot stop the thought of a violent or perverse act, hours each day filled with the unstoppable details and the recriminations for thinking such filth. Or the individual may be overwrought with obsessive thoughts of guilt, a constant need to confess something.
Perhaps hardest to imagine for the outsider is the suffering of these people. In Tourette’s syndrome, another disorder receiving a great deal of attention, individuals have a variety of emotive tics. The person curses uncontrollably, makes animal sounds, will briefly make a bizarre and strained facial expression. In Huntington’s chorea, the patient might have uncontrollable swinging of the arms. But these stigmata are superimposed on the person. The Tourette’s patient does not really wish to bark like a dog in some instant. It merely happens, an uncontrolled hiccup of the id, while he tries to ignore it and continue with his thought. But the OCD patient becomes the disease. If confronted with his behavioral patterns, an obsessive could not distance himself from the incessant symptoms by saying, “I can’t stop myself from washing for some reason.” He would embrace them, saying, “I’m always dirty.”
This is not a disease in which the person suffers because she can’t fight these destructive patterns that she recognizes as irrational. At its most extreme, when the patient has minimal insight into her disorder, she suffers because the patterns seem to be so rational, so imperative, so urgent, that she feels herself drowning in the catastrophic consequences of failing to carry them out. It is the endless array of rules and prohibitions and demands needed to hold back the floodwaters of dis-ease and disquiet.
As exemplified by the way that the American Psychiatric Association classifies OCD, this nightmarish disease is above all else a battle against anxiety, anxiety that can never be held off, no matter how much you count or check or wash. There can be brief instances of relief—when the street corner is reached during a walk and the number of steps turned out to be divisible by five, after all, there is a transient burst of comfort and safety: things are under control; things really will work out all right. But inevitably, the nameless dread returns.
The psychiatrist Judith Rapoport, author of the superb compendium of OCD case histories, The Boy Who Couldn’t Stop Washing, has theorized about the ethological roots of OCD. She draws parallels between OCD and fixed action patterns in animals, small stereotyped behaviors that are carried out mechanically. We all know one familiar example of a fixed action pattern, the involuntary circling of a dog on its blanket before being able to settle down for the night. For a human, OCD is like a dog circling, but a dog, exhausted and bewildered, who can never, ever stop.
Remarkably, the disorder is coming to be understood on a biological level. It is responsive in some cases to certain neuroactive drugs. The brains of OCD sufferers show enhanced oxygen and glucose utilization in pathways related to motoric patterns—seemingly, there is a neurological itch, a metabolic drive in those brain regions toward fueling the arranging and washing and repetitive gesturing. Parts of those brain regions are even a different size from those in unaffected control subjects. There is even coming to be recognized a genetic component to the disorder as well.
The far-from-original point I will try to make now should seem obvious: There is an unsettling similarity between the rituals of the obsessive-compulsive and the rituals of the observantly religious. This parallelism might initially be difficult for many of us to appreciate. For those readers who are religious, it is often a rather liberalized version, in which intellectual or emotive components, or the carrying out of good deeds, might take precedent over a complex jungle of daily rules and rituals. But for the practitioners of most religious orthodoxies, rituals of cleansing of self and of food, of checking, of leaving and entering places, and of numerology consume each day.
To begin to make this point, I will borrow a trick used by many cultural anthropologists when trying to emphasize something about societies as a whole, which is to start with examples from a more alien culture, one that can likely be observed from a more detached, objective distance. For most readers, classical Hinduism fits that case.
For the observant Brahman, life is filled with a staggering, near-consuming array of rituals. The day’s initial cleansing and prayers must begin two hours before sunrise, complete with i
nstructions as to what one’s first sight must be (something auspicious such as a ring, a coin, or a sacred cow) and which foot may first touch the ground (the right one). Defecation must be carried out in an open place, during which time the Brahman cannot look at the moon, at trees, at a tilled field, a temple, or even an anthill. The task completed, the washing begins—ten times of the left hand, seven times of the right hand, five times for both, followed by three washings of the feet and twelve unswallowed mouthfuls of water. More and more details follow involving bathing in the river, the proper repositioning of the loincloth, the seated position to be taken for the first prayer (which comes with complex instructions concerning pressing specified fingers against one of the nostrils and taking a certain number of breaths coinciding with recitation of one prayer, followed by pressing of the other nostril and another prayer). Hours’ worth of rituals to carry out before even the first meal, everything carefully specified, with the prohibition that if something goes amiss, it must begin all over again.
And so goes the rest of the day. Prayers that must be recited in multiples of the number of beads on a holy bead ring, rules about the number of mouthfuls of food to be taken with a designated hand, multiples of times that a sacred plant must be circled when it is encountered, rules about not touching one’s foot on the threshold of a temple when it is entered, the stone image of a bull at the doorway of the inner shrine that must be touched just so. The prescriptions go on and on.
Life for the Orthodox Jew is much the same. The rules of everyday life, the Halakha, are equally encompassing. The kosher laws are complex strictures regarding the cleansing and consuming of food—what species may be eaten, how animals are to be slaughtered and their meat prepared, the number of hours that must pass between a meat meal and a dairy meal. There are rules for the manner of hand washing, the volume of the ritual wine cup at a meal, the number of minutes before sunset that candles are lit to usher in the Sabbath. There are magical numbers—the number 18, which signifies life, the number 39, signifying the omnipotence of the Lord—that dictate the frequency of recitations of prayers, the number of times the threads of a prayer shawl are wound on themselves. Much as for the Brahman, the Orthodox Jew cannot enter sacred places without touching a holy icon, in this case a small casement containing a sanctified parchment, nailed to the doorway. And if a mistake is made, once again, there are complex requirements for making things right—for example, if utensils are contaminated by touching prohibited foods, they must be buried in soil for a certain length of time to purify them.
Among the most fascinating manifestations of the obsessiveness of Orthodox Judaism are the 613 rules that must be observed each and every day, 365 concerning things that must be avoided, 248 that must be carried out (a preponderance of things prohibited that led one medieval rabbi, perhaps of a depressive bent, to remark that we would have been better off if we had not been born). There is something remarkable about the rules that transcends the details of what they regulate. One might guess that over the years, the 613 rules accumulated, based on rabbinic decisions about proper ritual. Instead, in a fit of numerologic frenzy, the numbers came before the rules. Someone back when decided that there had to be 613 rules about daily life—365 prohibitions for the days of the year, and 248 required daily rituals corresponding to what was then thought to be the number of bones in the body—without yet knowing what the rules were. And rabbinic scholars have labored ever since to come up with the list, debating and differing with Talmudic fervor. Sometimes magic numbers emerge in religions as an aid to memory—it is not surprising that ten commandments, rather than nine or eleven, evolved among a nonliterate, nomadic tribal people who already used a base-ten numerical system. But there is no way that the 613 and its two parts are a memory device, to aid people in remembering the myriad (and still-debated) rules. The magicality of the numbers themselves is what resonates—each day, there are as many things that God requires of us as there are bones in the body, and as many things forbidden as there are days in a year. You can’t ask for a more explicit case of numerologic ritual coming before content.
Everyday life is much the same for the classically observant Muslim. The foot with which one takes the first step of the day, the step into and out of the lavatory, are all specified. The number of times water is taken into the mouth for cleaning is specified, as is the washing of each hand and the sequence in which it is done. Washing of the rest of the body follows similarly, with the usual rules about returning to Go if there is a mistake—for example, if a man inadvertently touches his penis after he is otherwise clean, the process must begin again.
Prayers occur a certain number of times a day, facing in a certain direction. Complex prohibitions occur as to which animals can be slaughtered for food and how it is done. There are, once again, magical numbers—7, 10, 70, and 100 are ripe with significance. There are rigidly quantitative aspects to the numerology: a prayer said with clean teeth is 70 times better than one said with unclean teeth; public worship is 17 times better than private worship. So goes the day, ending with curling up for bed (lying on the right side specified) and facing Mecca.
The similarly obsessive qualities of Christian religions should now be apparent. Whether the numerology of the numbers of Hail Marys, the ritualistic use of rosaries, the details of baptism, the rules for entering and leaving churches, the magic invested in the number 3 or the number of Stations of the Cross, Roman Catholicism readily fits the patterns already discussed. The same is seen with the Protestant religions. Even among Lutherans (chosen for their relative lack of ornateness), there is no shortage of detailed rules—prayers differing as to time of day, prayers differing as to even- and odd-numbered years, precise orderings of baptism and of confession, rituals of foot washing in imitation of the washing of Christ’s feet. In contrast to some of the other religions just discussed, there are also rules concerning the use of colors and of sound as part of daily ritual. For example, Lutheranism is full of precise strictures about music. The hymnal companion to the Lutheran Book of Worship contains a stern checklist of dos and don’ts for the organist, beginning with, of course, the requirement that the correct notes be played, but including strictures against allowing crisp dotted rhythms to slide into decadent triplet rhythms, and warnings to attack all the notes of a vertical chord simultaneously.
One could go on, but it is not necessary; it should be clear how the same patterns come up, again and again. The links between obsessive-compulsive rituals and religious rituals have long been noted. Naturally, Freud had something insightful to say about it. In his 1907 essay “Obsessive Acts and Religious Practices,” he explicitly linked the two. In a marvelous sentence, he describes obsessional neurosis “as an individual religiosity and religion as a universal obsessional neurosis.” In a similar vein, the psychoanalyst Robert Paul has more recently described religion as “the neurosis of civilization.” In a 1975 essay, the psychiatrist Eugene d’Aquili and the anthropologist Charles Laughlin explicitly compared the fixed action patterns of animals with religious ritual.
Lest one think that this represents the secular mental health profession pathologizing religion, the link has long been recognized by theologians as well. In her book, Rapoport devotes an appendix to the arcane Catholic concept of “scrupulosity.” As first discussed nearly five centuries ago by Ignatius Loyola and by scholars ever since, scrupulosity represents religious doubt and anxiety, manifesting itself in the pouring of energy into comforting ritual. Jeremy Taylor, a seventeenth-century theologian, gave an apt description: “They repent when they have not sinn’d. [Scruple] is a trouble where the trouble is over, a doubt when doubts are resolved.” In a rough way, scrupulosity can be defined as the manifestations of obsessive anxiety within a Roman Catholic framework.
Surprisingly, these scholars often discuss scrupulosity in order to warn clergy about it. Priests have often been told to, in effect, be on the lookout for the practitioner who comes to their religion merely to quiet the frenzied imperative tow
ard ritual. Priests are admonished to try to turn the sufferer toward the contemplation of the content of the rituals, the meaning of God, and their behaviors, rather than focusing on the sheer surface of the rituals themselves.
Similar admonitions are seen in other religions as well, in the face of practitioners who may become lost in the ritual for its own sake. In Orthodox Judaism, during the Sabbath reading of a chapter of the Torah, the reader must actually read the chapter, rather than recite it by memory. Two interpretations are traditionally given for this rule. One is practical—recitation by rote is more likely to contain errors. The other harks back to the same theme as Catholic scrupulosity—reading by memory or by rote promotes the feeling of empty ritual for its own sake. The Jewish tract the Ethics of the Fathers (2:18) warns, “Do not make your prayers routine.” A similar rule occurs in Islam, harking back to Muhammad, who, in a surprisingly quantitative approach to the issue, said that a man receives credit only for the proportion of his prayers that he actually thinks about.
Thus, while the clergy often have to rein in the subset in whom a frenzy of ritual becomes unseemly, organized religion, and especially the organized religion of myriad daily rules and prohibitions and patterns, remains a remarkable haven for the obsessive-compulsive. Outside the context of religion, the obsessive-compulsive is, by definition of the disorder and its extent of disruption, a dysfunctional outsider, cut off from the community by the demands of the illness. Reframe those same behaviors in the context of religion and it all changes—the person is able to dwell at the structured core of a shared community. One might generate the prediction, untested to my knowledge, that obsessive-compulsives who are atheists or who are members of some of the sparer, more minimalist religions (the Quakers come to mind) will not fare as well as those sheltered by the more Byzantine religions.
The solace of religious ritual for the OCD patient is the structure. Orthodox religion is a world of rules and strictures and requirements and prohibitions, a world of signposts. Again, the key to understanding OCD is its core of anxiety. And the key to understanding the solace that the obsessive-compulsive might find in religious ritual is not that it leads to a diminishing of that anxiety. That is not possible—not with our legacy of religious ritual as so often so febrile, so often the tinder for endless personal and societal immolations, not when the rules are so demanding and the punishments measured in eternity. It is an issue not of quantity of anxiety, but of quality. For the obsessive-compulsive, religious ritual provides the immeasurable comfort of the transition from nameless dread to dread that is abundantly named, measured, weighed, cataloged, and shared. It is a vast relief when the bogeyman comes with explicit instructions as to his care and feeding.
The Trouble with Testosterone Page 21
