Book Reviews - Winter 2009

Let Me Count the Ways

Print

Are we getting more obsessive or more compulsive about diagnosing?

By Richard Restak

December 1, 2008


 

Obsession: A History, by Lennard J. Davis, University of Chicago Press, 290 pp., $27.50

This quirky but informative book begins with an account of one of the author’s childhood rituals: his nightly counting of the illuminated windows in the adjoining apartment building. Other members of his family wrestled with their own rituals: his brother repetitively washed his hands; his father checked and rechecked door locks, faucets, and gas jets.

With this as background, it’s perhaps not surprising that Lennard Davis, a professor at the University of Illinois in Chicago in the Departments of English, Disability and Human Development, and Medical Education, argues that “countless people all over the country are doing similar things” and that we live in an “age that is obsessed with obsession.”

While Davis’s rituals and those of his family are more accurately described as compulsions—in accordance with the accepted practice of distinguishing obsessions (thoughts) from compulsions (actions)—Davis correctly observes that the distinction isn’t always easy to make, since thinking and doing sometimes blend seamlessly to­gether. The obsession of doubting commingles with a compulsion for checking; the obsession for cleanliness induces compulsive cleaning; the obsession for order provokes compulsive arrangements and rearrangements.

When dealing with obsessions and compulsions, psychiatrists refer to the DSM-IVR, (Diagnostic and Statistical Manual of Mental Disorders) that lists categories of mental illness. In this “obsessive text,” as Davis characterizes it, two related obsessive conditions are defined:

  • Obsessive-Compulsive Personality Disorder is comparatively mild and marked by perfectionism and inflexibility combined with a preoccupation with uncontrollable patterns of thought and action.
  • Obsessive-Compulsive Disorder is more seriously disabling and involves “uncontrollable intrusive thoughts and actions that can only be relieved by patterns of rigid and ceremonial behavior . . . [that] frequently cause considerable distress and interference with daily social or work activities.”

But at what point does a comparatively benign personality trait turn into a serious illness? Given that even seasoned professionals experience difficulty answering this question, it shouldn’t come as a surprise to discover a lot of ambivalence about obsession and compulsion within the larger culture.

While we may not be comfortable around overly obsessive people, we seek out lawyers who can be counted on to obsess about fine points of the law and, in response, compulsively check every relevant source of information that might be favorable to our case. We want obsessive-compulsive doctors who assiduously consider and research every possible diagnosis in order to correctly identify our illness. Thus obsession with its hyperattention to detail isn’t necessarily an illness (except in its more extreme forms); can’t always be distinguished from normality (however that is defined); and may provide, according to Davis, a vehicle (though an uncomfortable one) for creativity.

Davis isn’t the first person to suggest that obsession properly channeled can provide the impetus for creative expression. Sigmund Freud, who incorporated theories about obsession into psychoanalytic theory (The Rat Man: Notes upon a Case of Obsessional Neurosis), acknowledged that obsession was a driving force in his creative life. “For me nothing counts but my work, and I am prepared to become entirely single-minded if only I can carry it through.” Supporting this self-appraisal was the comment made about Freud by psychologist William James: “I confess that he made on me personally the impression of a man obsessed with fixed ideas.”

Among obsessive artists and writers, the novelist Emile Zola had especially ferocious obsessions and compulsions, which influenced not only his creativity but every aspect of his life. He counted gas jets on the street, taxis, steps, and objects in his drawer. He couldn’t fall asleep unless he touched certain pieces of furniture a predetermined number of times before getting into bed. Obsessions and compulsions also influenced his prodigious literary output (37 novels, 10 critical works, and thousands of articles, reviews, and letters). In Zola’s novel L’oeuvre (The Masterpiece), the main character, Pierre Sandoz—identified by critics as Zola—captures the agonies of the creative artist caught in the grip of obsession: “Do what I will I cannot escape from the monster’s clutches. . . . I haven’t a will of my own. . . . And in the end it’ll devour me.”

But what is it that sets the creative scientist or artist, who successfully harnesses obsessions, apart from the severely afflicted obsessive, who can barely get through the day? At some ill-defined point in the 19th century, according to Davis, “a split” arose in the definition of obsession. It came to mean both an undesirable disease and a desirable cultural goal. Science played an important role in this process thanks to its em­phasis on specialization (a tamed version of obsession) and its reliance on obsessive-compulsive traits like observation, counting, and measurement. Although these traits are shared by all scientists, Davis centers his attention on psychiatrists and their patients. In the interaction of psychiatrist and patient, two parallel obsessions are in play. The patient talks to the psychiatrist about his obsession while the psychiatrist obsessively takes down and classifies every detail. As a consequence, as Davis wryly comments, “Obsession sits on both sides of the consulting table.”

Because obsession poses such difficulties, can a single profession, point of view, or area of expertise fully encompass it? Currently, the neurological model holds sway because of the dramatic improvements sometimes brought about in severe obsessions through the use of medications. But Davis isn’t impressed. “Obses­sion isn’t simply a medical category; it is a category of existence.” If obsession is wholly a medical matter—resulting from what Davis refers to as a “broken brain”—then why, he asks, has the condition dramatically increased in frequency? Here he has a point. In the 1970s a mental health worker could expect to encounter perhaps one person out of 20,000 with the disorder. Today it’s estimated that three out of 100 people will meet the requirements for obsessive-compulsive disorder at some point during their lifetime. Some estimates place the number even higher, at one person in 10. “How did we go from one out of 20,000 to three out of 100 to one in 10 in 30 years?” asks Davis.

Several reasons come to mind. Fortunately, obsession no longer carries the stigma that it once did. A “democratization” (Davis’s term) has occurred, so that now “obsessive disorders are in some sense endemic, part of what it means to be human in the modern world.” Obsession has so entered the mainstream that it’s even become a routine staple of movies and television. Think of Jack Nicholson as Melvin Udall in As Good as It Gets or Tony Shalhoub as Adrian Monk.

Second, obsession is not the only mental disorder that appears to have increased in frequency. I’d wager that anyone reading this review knows someone or has heard about someone who carries a label of bipolar disorder (formerly known as manic depression). Yet two decades ago bipolar disorder was a comparatively rare condition even among people seeking psychiatric treatment. A similar explosion has occurred in the incidence of social anxiety disorder, sexual desire disorders, shopaholicism, and Internet addiction. Are these disorders really more common, or is the mental health community (along with the pharmaceutical industry) overextending the concept of a mental disorder? Finally, if we really are dealing with an increase in the incidence of mental illnesses rather than just hype or statistical legerdemain, is this because the stresses of contemporary life are simply sending greater numbers of people over the edge?

Whatever the answers to these questions, Davis favors a “biocultural model” that ex­plains obsession within a social and historical context. But in his enthusiasm for this model, Davis mischaracterizes the bio component: “If the disease is a structural and chemical disorder, as is argued by current researchers, then, by definition, it can’t be a disease that is the result of societal or familial or even individual pressures.”

Actually, social and cultural factors (poverty, malnutrition, neglect, physical and mental abuse, etc.) alter both the brain’s structure and its chemical functioning. Indeed all life experiences bring about brain modifications of one type or another. This comparatively new and exciting insight about the brain reconciles neurological and sociocultural explanations about obsession. Both social and cultural components, while contributing to obsession, express themselves within the brain as the final common pathway.

Overall, Obsession successfully accomplishes Davis’s goal of providing a “chapter in the ongoing history of obsessions written by people who are obsessed with obsession.” And, he promises us, “it won’t be the last, since obsession, like guilt, is the gift that keeps giving.”


Richard Restak is a neurologist and neuro­psychiatrist, and the author of 20 books about the brain, including Mind: The Big Questions and The Playful Brain.


Comments are closed for this post.