Timothy Hillier was only seven when he began to obsess about his pillow and its position on his bed. Was it lying in the exact middle from the edges of the mattress? Were its corners aligned at a perfect 90 degrees? Were there creases in the pillowcase or was it totally flat?
Minor matters, perhaps, that most of us wouldn’t even give a thought to, but for poor young Timothy it became all-encompassing.
Every night he would lie awake for hours, frequently getting out of bed to check that the pillow was still lying in the correct place. He would straighten the pillowcase and measure its distance from the bed’s edge. He would make slight adjustments, then make some more. And when he was finally satisfied he would carefully get back into bed, only to hop out again a few minutes later.
If Hillier’s pillow had been the only thing he obsessed about, his life might have been OK, but it was merely the beginning.
“I went to a Catholic school and I was constantly tormented with obsessive thoughts about whether or not I was sinning,” he says. “I’d spend most of the day worrying about whether I was a good or a bad person, and if I was going to heaven or going to go to hell.”
Many other symptoms plagued him as he went through school: worrying about exactly how much saliva should be in his mouth before he swallowed; repeating sentences in his head over and over again; as well as social phobia and anxiety around his clothes.
When Hillier was in his second year of university, studying for a bachelor of business, his life finally reached a crisis point.
“I’d failed a subject because I couldn’t concentrate with all my distracting thoughts,” he says. “I knew I couldn’t go on like this any more. I would go to the hospital near my university and sit outside the psychiatric department and think that I should walk in.”
Eventually Hillier wrote a note to his parents in which he described every symptom he was experiencing and his fears that he must have schizophrenia.
His parents took him to see a general practitioner, who referred Hillier to a psychiatrist, and at the age of 20 he was diagnosed with obsessive compulsive disorder.
According to the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-V), OCD is defined as the presence of obsessions — which are recurrent and persistent thoughts, urges or images that are unwanted and cause anxiety — or the presence of compulsions, which are repetitive behaviours that the individual feels driven to perform.
These behaviours or mental acts are aimed at preventing anxiety; however, they are not connected in a realistic way with what they are trying to prevent, they are time consuming, and they can cause significant impairment in social and occupational functioning.
SANE Australia estimates that up to 2 per cent of the population, equivalent to a half-million Australians, suffer from OCD.
Most people with OCD start to show signs of it in their childhood or teenage years and it is a condition that affects both sexes equally, although males tend to develop it at an earlier age.
There are broadly four categories into which OCD sufferers fall. These include checkers, who will make sure that something, such as locking the door or turning off the stove, is done over and over again; counters and arrangers, who are obsessed with symmetry and spend hours ordering and counting things; and doubters, who are constantly afflicted with intrusive thoughts of a violent, sexual or religious nature.
The most common group, however, are the cleaners, those whose lives are consumed by fears of dirt and germs and the subsequent cleaning rituals. Sufferers can spend hours every day in the shower or on the toilet. Alternatively, they can spend just as long cleaning their living quarters multiple times a day.
“Instead of having a shower and thinking, ‘OK, that’s it, I’ve cleaned my body’, they have to wash their body three times, and then it becomes five times, and then it becomes 10 or 20 times,” Cairns-based psychiatrist Carlos Hojaij says. “I’ve had a patient who would get so exhausted, he would even sleep in the shower.”
The cause of OCD is unknown and likely multifactorial. Genetic, environmental and neurological factors may all play a role; while some theories suggest that compulsive behaviours are learned. Treatment usually involves medication or psychotherapy, or a combination of both; and deep-brain stimulation neurosurgery occasionally is used in severe cases.
Hillier’s psychiatrist is Scott Blair-West, who runs Australia’s only specialised OCD inpatient unit at the Melbourne Clinic, Victoria. “My view is that there is a genetic part to it, there’s a vulnerability to OCD that probably is inherited, and whether you get OCD may be determined by your environment,” he says.
“We know from PET scans that there are certain circuits of the brain, involving the caudate nucleus, the thalamus, and the frontal lobe, that are clearly affected by OCD.”
Glenn Davis has used psychotherapy in his role as a GP for more than 40 years. “As Ignatius of Loyola said, ‘Give me a child for the first seven years and I will give you the man’,” he says. “Early life can be a very anxious time for children, being at the whims of their parents and the environment. As they grow older they learn that their compulsive anxious thoughts can be relieved by ritualistic behaviour. For example, worrying about cleanliness can be relieved by hand washing, and it isn’t long before the sufferer realises that their anxiety can always be relieved by the same behaviour.”
Davis says medication, in particular a class known as selective serotonin reuptake inhibitors, which help to regulate serotonin levels in the brain, generally should be used as initial treatment for OCD. “Your thought processes are tempered so your behaviour changes,” he says. “You may not even need to see a psychologist.”
Others disagree. Gold Coast-based GP Mark Jeffery is a clinician with a special interest in mental healthcare. “It’s crucial to have psychological intervention,” he says. “There’s numerous studies to support that.”
Hojaij also urges caution with a medication-first, talk-later approach. “We can only talk about treatment if you have a proper diagnosis,” he says. He recommends that patients suspected of having OCD should be referred initially to a psychiatrist to help exclude organic diseases, such as tumour or stroke, that can sometimes mimic features of OCD.
As I undertook research for this article I began to worry about some of my own behaviours. The way I triple-check that the fridge door is closed; my need to have my clothes arranged by colour; the anxiety I feel whenever the kitchen is messy, to the point where I try and avoid cooking anything. Did these, plus other personal foibles, mean I might have OCD?
“One of the characteristics that is often seen in highly functioning people is a highly developed consciousness, so that person may be very conscious about themselves, very conscious in their work, and these kinds of people may have a certain level of anxiety,” Hojaij says. “Sometimes this type of personality can be a little bit exaggerated, and they may be called ‘control freaks’ by others. And in these kinds of cases it’s not a disease, it’s just an aspect of personality.”
People with obsessive-compulsive personality traits share many features of OCD; however, there are important differences.
People with OCD usually have insight that their thoughts and behaviours are unreasonable; they are distressed by their actions; and they waste time on their obsessions and compulsions.
Those with obsessive-compulsive personality traits believe their way is the right way to do things; they are usually comforted by adhering to their own rules and routines; and they are often quite time efficient.
Indeed, obsessive-compulsive traits such as perfectionism, attention to detail and perseverance can make people highly productive in the workplace.
On the other hand, they can just as easily be an impediment.
Perth OCD Clinic director Gayle Maloney says that of the doctors and lawyers she has seen suffering from OCD, the most frequently occurring obsessions and compulsions relate to perfectionism and associated repetitive checking rituals.
“When symptoms start to impede a person’s day-to-day functioning, they may benefit from an assessment,” she says. “A clinical psychologist or psychiatrist can focus on a specific type of cognitive-behavioural therapy, known as exposure and response prevention treatment, which is used to teach an OCD sufferer anxiety-based strategies to reduce their obsessive thoughts and to prevent engaging in their compulsions. For some sufferers, ERP is sufficient. For others, ERP needs to be combined with medication.”
Hillier relies on medication and regular visits to his psychiatrist.
“It’s important to talk about ongoing symptoms,” he says. “For example, if I’m having a thought around my clothes not fitting or the sun annoying me, I have to make sure that I’m not giving in to it. You’ve just got to keep on top of it. Exposing yourself, doing the right things.”
Hillier acknowledges he still has a long way to go. “I have a good job but I don’t really have the capacity to take on anything too stressful because with my OCD it does wear me down,” he says.
And there is something else he would like in his life. “I’ve never really pursued a romantic relationship because I’ve always thought that maybe that would be a bit much to take on. But it’s always at the back of my mind.”
Despite these challenges Hillier remains upbeat. He is a SANE ambassador and runs corporate awareness workshops for companies, teaching managers how to help staff who may be struggling with OCD.
He has important advice for sufferers of OCD. “Never give up,” he says. “There is help if you look for it.”
This piece by Suvi Mahonen was originally published on ‘The Australian‘, 20 July 2018.