The Man Who Couldn't Stop: OCD, and the True Story of a Life Lost in Thought

  • David Adam
Picador: 2014. 9781447238287 | ISBN: 978-1-4472-3828-7

The adage that you can't judge a book by its cover fails with David Adam's The Man Who Couldn't Stop. The title is scrawled repeatedly in urgent letters, thrusting us into the mindset of someone suffering a near-constant barrage of intrusive thoughts — the manifestation of obsessive–compulsive disorder (OCD) that is the book's topic. In the pages that follow, Adam, editor of Nature's Editorials section, leads us on an insider's tour of the OCD brain, providing insight into the cultural and scientific evolution of how we view and treat a disorder that affects up to 3% of people worldwide.

Adam's book is equal parts historical journey, scientific discussion and stark personal memoir of his battle with often shocking thoughts that come out of nowhere, the symptom of OCD that he describes as “a snowflake that fell from the summer sky”. A common example of such thoughts is the fear of harming someone else despite having no intent or desire to do so. For Adam, they took the form of fears that he had accidentally contracted HIV. Although his book pays homage to earlier works, including Judith Rapoport's iconic The Boy Who Couldn't Stop Washing (E. P. Dutton, 1989), it has a unique voice born of first-hand observations of Adam's own changing mental processes, and his expertise as a science writer.

Credit: Venimo/Shutterstock

Although his historical anecdotes are informative and entertaining, Adam is at his best when linking the evolution of his illness with possible scientific explanations. Current theories suggest that OCD stems from abnormal communication in the brain between cortical areas involved in higher-order cognition — such as reward-based decision-making — and basal ganglia structures important for selecting actions. Human studies suggest that genetic and environmental factors contribute to this disruption. However, despite intensive efforts, it has been difficult to nail down specific genetic culprits, and the role of environmental factors, such as childhood infection with streptococcus, is unclear and controversial.

Accounts from sufferers may provide hints about how OCD evolves. In a particularly evocative story, Adam describes his attempts to combat the barrage of unwelcome thoughts about HIV by repeatedly calling the UK National AIDS hotline to check whether he was at risk. No matter how many times he called, disguising his voice to avoid recognition, he was only briefly reassured. He notes, “They would tell me that they had already given me an answer and that I needed to accept it. I didn't want that. I wanted the hit.” This comparison between taking an addictive drug and seeking reassurance highlights important potential research avenues for neuroscientists trying to understand how inexorable cycles of obsessions and compulsions are initiated and maintained.

OCD is a bit like being a recovering alcoholic. You are always a certain number of days past your most recent episode.

As Adam himself points out, the ending of the book is a little unsatisfying. There is no dramatic revelation of the root of his illness, no 'eureka' moment when scientists discover the cause of obsessions. His OCD gets significantly better with a lot of hard work, serotonin-reuptake inhibitors, exposure therapy with response prevention, and continuous vigilance, but intrusive thoughts linger in the background even though he has received the best evidence-based OCD treatment. As he puts it, “it's a bit like being a recovering alcoholic. You are always a certain number of days past your most recent obsessive-compulsive episode.”

Fortunately, misunderstanding about OCD, such as thinking that people with the condition are simply 'neat-freaks', is gradually decreasing. Adam makes an important contribution by increasing public awareness, and clarifying that OCD is not simply an exaggerated desire for hygiene and order, but rather a serious illness with many different symptoms caused by dysregulation of the brain's anxiety and cognitive-control circuits. He also helps to defuse the stigma associated with thoughts that many patients find shameful.

Another source of optimism is the abundance of innovative technologies that are being used to identify treatment targets for compulsive behaviours. For example, my laboratory uses miniature microscopes to peer inside the rodent brain and observe how neural activity changes as behaviours such as repetitive grooming develop. Such tools allow us to address long-standing questions, including how compulsive behaviours and anxiety are related.

Although the main readership of The Man Who Couldn't Stop is likely to be patients, families and clinicians, this book is also a valuable read for neuroscientists like me, who are searching for clues about the origins of OCD. There are some factual errors, such as the description of serotonergic neurotransmission, but this is a quibble compared with the book's contribution. People such as Adam hold in their brains some of the most valuable contributions to the fight against neuropsychiatric diseases: blow-by-blow accounts of how their obsessions, compulsions, thoughts and emotions are linked and evolve.

By partnering with patients, psychiatric researchers can extract testable hypotheses and recognize obsessions for what they are: not untouchable thoughts to be feared and locked up, but phenomena to be observed, understood and then let go like summer snowflakes melting in the sunlight.