Whenever my colleague, Dr Mythily Subramaniam, presents her findings from the Singapore Mental Health Study to any local audience on the number of people here who have obsessive compulsive disorder (OCD), she invariably raises a laugh when she reveals that three out of 100 adults in Singapore have the disorder.
The laughter, which is neither derisive nor mocking, comes instead from a common feeling of empathy and identification. There is a popular notion that OCD is a set of quirky characteristics that we have claimed as uniquely Singaporean - being excessively conscientious, punctilious, hyper-efficient with a need to be in control of things, perfectionistic, and with an undercurrent of anxiety. There is even a sneaking sense of pride, and a number of people who would willingly confess to being "a bit OCD".
Professor of medicine Jerome Groopman of Harvard Medical School pondered in a piece in The New Yorker magazine on "whether scientists and other driven, detail-oriented professionals" have somewhat similar neurological circuitry as patients with OCD, or whether people with these characteristics are more likely to be attracted to these fields. He interviewed well-known molecular biologist Laurence Lasky, who admitted to having "traits that are distributed at the far end of the bell-shaped curve of obsessions and compulsions" and which inflict on him constant anxiety. Dr Lasky believes that this is the fount of his creativity and drive, and he does not wish for any alleviation of this anxiety. "Who says advancing science has anything to do with being happy," he said.
Of course, Dr Lasky's "obsessions and compulsions" - as with many other overachieving and high-functioning individuals - are manifestations of a single-minded striving towards a self-chosen goal. These characteristics, however, are quite unlike those in patients with OCD where the obsessions and compulsions create nothing but psychic pain and a profound loss of self-control.
SEIZED BY EVIL SPIRIT
The obsessions of clinical OCD are distressing, recurrent, uncontrollable and intrusive thoughts, feelings or ideas. Obsessions tend to cluster around a few major themes: cleanliness and contamination; an insatiable need for symmetry or precision; pathological doubt; thoughts of carrying out acts that are actually reprehensible and repulsive to the person - such as those of a violent, sexual, sacrilegious or blasphemous nature.
There is also a dissolution and distortion of perspective. Consider an actual case - as described in a standard textbook of psychiatry - of a woman who was beset with the pathological doubt that her car door was never properly locked. An initial kernel of doubt inside her would loom large and harden as a certainty, bringing in its wake an intense anxiety that was relieved by checking the car door (an action which is called the compulsion in medical nomenclature). However, that would provide just a temporary relief as the doubt would return, and those compulsive checking needs would have to be performed again, and again, and again. The woman found it impossible to leave her car until she had checked repeatedly. She had broken several car door handles and was often late for work, which led in turn to the loss of several jobs.
While obsessions are tumultuous mental events that are invisible to the external world, obsessive behaviours are often overt, and their bizarreness and excessiveness invite ridicule from others. Perhaps that is why OCD - more than any other mental illness - is often portrayed in film and television for laughs.
One remembers Jack Nicholson playing the role of a writer with OCD in the movie As Good As It Gets with his array of fearful contamination-related obsessions and ritualistic behaviours: wearing gloves in public and frantically warding off fellow pedestrians so that they would not "contaminate" him, compulsively sidestepping the cracks in the sidewalk, and the excruciating multi-step cleansing ritual of his apartment with countless bars of soap.
English professor Paul Cefalu at Louisiana State University contemplated this in an article entitled What's So Funny About Obsessive Compulsive Disorder?, which was published in PMLA (the official journal of the Modern Language Association of America). "Not only is there something fundamentally ironic about the extent to which obsessives with OCD concentrate on tasks that they believe ridiculous, but compulsions, usually orchestrated to relieve underlying obsessions, tend to worsen the motivating obsession," he writes.
He thinks it is the "irony" and "incongruity" of the behaviour that make it funny - at least to someone without any real or direct knowledge of OCD. To the person so afflicted, it means being caught in a vicious circle of desperate misery. The old English meaning of obsession, which meant a state of being seized by an evil spirit, is perhaps an apt metaphorical description.
TRAGEDY OF OCD
In some ways, OCD resembles an addiction where the need to repeat something is not because it is pleasurable, but because not doing it is intolerable; and where the obsession sucks time, energy, attention and focus from everything else in the person's life that makes it worthwhile - family, friends, work, community and leisure. (People with OCD are, on the whole, more likely to be unemployed, unmarried, divorced and childless).
And like someone with an addiction, the rest of the family could be drawn in and embroiled in the compulsions of the one with OCD. Some accommodate or even participate in the compulsions because they want to ease the distress of the one with OCD. Others do so because that is the easier thing to do in the short run - as in the instance of a woman with an obsessive fear of contamination who compelled her husband and children to change at the doorway of their flat into a clean set of clothes before they could go in. For them, it was easier to put up with that than to face and endure the terrible scenes if they had refused.
In some ways, OCD resembles an addiction where the need to repeat something is not because it is pleasurable, but because not doing it is intolerable; and where the obsession sucks time, energy, attention and focus from everything else in the person's life that makes it worthwhile - family, friends, work, community and leisure.
People with OCD can get agitated and enraged if their rituals and rules are not obeyed. However, there can sometimes be what is known as hostile non-compliance where family members react with aggression and actual violence.
In the Singapore Mental Health Study, we found that OCD affects men and women equally. "It is an extremely distressing disorder that sets in during late adolescence, which is the earliest age of onset among the various mental disorders that we had examined in this study that has included depression and general anxiety disorder," said Dr Mythily, who co-led the study. "It is particularly of concern as it can mean a progressive, pervasive and unrelenting deterioration in the young person's functioning."
The study also found that nine out of 10 people with OCD have never sought any kind of treatment, and of those who did, they took an average of nine years to do so.
We do not really know why that is the case. It could be that they are not aware that it is a mental illness, or do not know where they can go for help, or they could be afraid of the subsequent stigmatisation and discrimination after being diagnosed with OCD. It could be that they are fearful of being misunderstood and ridiculed, or are too embarrassed by the contents of their obsessions and are afraid of being labelled violent or perverse.
Whatever these reasons might be, it is beyond sad; it is a singular tragedy as OCD is a treatable condition. With the right medications and psychological treatment that are readily available in Singapore, people with OCD do get much better or even recover. Yet at this time, we have tens of thousands among us who are still enslaved to their illness and face the prospect of a lifetime of suffering and disability.
•The writer is vice-chairman of the medical board (research) at the Institute of Mental Health.
We have been experiencing some problems with subscriber log-ins and apologise for the inconvenience caused. Until we resolve the issues, subscribers need not log in to access ST Digital articles. But a log-in is still required for our PDFs.