Compulsive Behavior Isn’t Necessarily a Sign of a Broken Brain

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In a memorable scene from Can’t Just Stop, a new book about compulsive behavior by journalist Sharon Begley, a woman named Shala Nicely is concerned about the whereabouts of her beloved cat, who, she fears, may be in the refrigerator.

Shala heard the OCD whisper, I think your cat Fred is in there, freezing to death. Oh, come on, the non-OCD part of her brain retorted; how could Fred have gotten into the refrigerator? But of course, it doesn’t hurt to look; such a tiny effort for such enormous peace of mind! There; no Fred. I think you should check one more time. Shala stood there opening the refrigerator, poking around until she had assured herself that Fred was neither in the crisper nor hidden behind the jug of orange juice — and then looking compulsively again, and again, and again, a hostage to the OCD.

As she told Begley later: “I’d say to myself, I know this is ridiculous. I know Fred wasn’t in the refrigerator. But I couldn’t walk away.”

Begley is a veteran medical journalist — she’s currently stationed at the reliably rigorous health-news site, Stat — and her book is a refreshingly nuanced, careful take on a complex and fascinating subject. She defines a compulsion, straightforwardly enough, as a reaction to anxiety, but as she explores the concept, she trusts her readers to be able to hold two truths in their minds at once. The first, and obvious, one: Compulsive behaviors can be ruinous. “Compulsions come from a need so desperate, burning, and tortured it makes us feel like a vessel filling with steam, saturating us with a hot urgency that demands relief,” she writes. “They are an outlet valve, a consequence of anxiety as inevitable as burst pipes are a consequence of water freezing within a building’s plumbing. But while compulsions bring relief, they bring little enjoyment, and while with one part of our brain we desperately wish to stop them, with another we are desperately afraid of stopping.”

But the second truth is less obvious, and therefore more interesting. As destructive as they can be, compulsions are not necessarily a sign of a malfunctioning brain. Mild compulsions are a little like “the psychological equivalent of steering into a skid: counterintuitive, initially scary but ultimately effective (at least for most of us),” Begley wrote in a recent piece for The Wall Street Journal. It’s a message that has resonated already with some of her early readers. “According to Sharon Begley - me and many people have a few compulsions that seem like understandable responses to angst that might otherwise eat ‘me/us’ alive,” one woman wrote in a review on Goodreads. “WE ARE NOT CRAZY….or even BROKEN. In fact we may be keeping ourselves together - functioning better than if we had allowed the anxiety to swallow us.”

In the below interview, Begley explains her theories on compulsive behavior.

I think you might hate this question, because you write toward the end of your book that “there is no bright line between mental illness and mental normality.” But — is there a blurry line? How can you tell when compulsive behavior is becoming a problem? So, this is of course a problem, because psychiatry — much as it wants to be a science, I think it’s fair to say it still falls a little bit short, starting with diagnoses. There is no blood-pressure cuff, there’s no blood test, there’s no objective reading for whether someone has a mental illness. All there is is a checklist of symptoms. And those too are subjective. It’s a bunch of guys —and it is mostly guys — who sit around saying, “Well, here are some descriptions of what it’s like to have generalized anxiety disorder or schizophrenia or, you know, fill in the blanks. And we think that if you meet five of these criteria, you count.”

It’s really quite ridiculous, but that’s what anyone who asks a question like yours — which people keep asking — that’s what you’re up against. The American Psychiatric Association and its changing guidelines over the decades — it really falls short of rigorous empirical science.

With those caveats, I can only say that psychiatry — mainstream psychiatry — requires that someone have either distress or impairment. So, therefore, if what you are doing is quote-unquote working for you, then psychiatry is not going to swoop down and say, “Oh, well, we don’t like what you’re doing. That means it’s a mental disorder.” As long as it’s not wrecking your life, causing you to be miserable — then it’s not a mental disorder.

Working with that, I looked at the spectrum of compulsions. And, without minimizing that many people do have a disorder — and it is horrible, and ruining their lives, and they are really suffering — there are other people who act compulsively and it’s not any of those things.

It makes me think of one of the people you interview in your book — a woman named Bianca, who gets up and does yoga for 45 minutes and rides her bike for 75 minutes, every morning, no matter what.
Right. Well, some people like that have other things going on. Like, many compulsive exercisers also have an eating disorder. And that qualifies as a mental disorder, because an eating disorder cause impairment — they just wreak horrible physiological damage. So even if you’re fine with the behavior, you still have the disorder because it’s impairing your physiology. But, anyway, yes, I think Bianca is a good example of that earlier point.

All right, I’m going to ask a personal question. I would say I check my phone — and, more specifically, Twitter — compulsively. Maybe the behavior doesn’t rise to the level of a disorder, but I also hate it and wish I could stop. So: Help.
There this idea that’s a little bit like the cognitive behavioral therapy for OCD, where you try just a little bit of something that causes you anxiety and you just try to build up tolerance to it. So the analogy for digital stuff is, okay, try to sleep for the night without your phone actually on, or without your phone on your pillow. And if you manage to get to the next morning and it hasn’t been horribly, cripplingly anxiety-producing, then maybe you want to try something else later on — maybe you’re not going to check your phone when you’re having a drink with friends. Or just fill in the blank. But the idea is to try just a little bit of time and see if you can stand the anxiety.

This is a very still-developing area because, clearly, a lot of people are bothered by how attached they are and how needy they are about digital stuff. But the people who are doing things like the National Day of Unplugging, they say that it works for them. And when they spread the word about it, other people find it effective as well.

I’ll have to give that a try. But I’m also curious to hear you talk about the connection between compulsions and anxiety — specifically, how do compulsive behaviors help to quell anxiety?Right now, the best studied examples are of course in OCD. And there, the source of the anxiety is very, very specific — it’s this intrusive thought that just kind of takes over and invades your brain. You often don’t know where it comes from, but it can be the thought that, I have touched something in the world, and my hands are covered with germs. Or, Something is amiss — the stove is still on, the door is unlocked. So this thought invades your brain, it creates anxiety, and you execute the compulsion. And presto — the anxiety drains away.

So using that model, the researchers who have looked at other compulsive behaviors — including those that don’t quite rise to the level of an actual mental disorder — have observed the same thing. So there was Amy, the neuroscience grad student I interview in the book, who is a compulsive hair-puller. She described herself as an anxious person, and she said that the anxiety builds up and builds up and builds up, and she then pulls out her hair. Now, in that case, it’s a sort of free-floating anxiety. It’s not like anxiety that “I have too much hair, and therefore I’m pulling it out.” So in that way it’s different from OCD, where the thing that you do addresses the thing that made you anxious. With hair-pulling, it’s just this free-floating anxiety, and she pulls out her hair, and then she feels normal again.

So in a less dramatic example, I interviewed people with mild compulsions, who expressed just a free-floating anxiety about, “The world is spinning out of control.” And, I should say, I conducted these interviews before last November 8. And you know, there are just countless things that we can’t control. But for one woman I interviewed, she told me, “Okay, no matter what is going on in the outside world, I can control this little bit of it here in my home. And that gives me a sense of agency — it makes me think that there are at least a few little things I can do to control the world I live in.”

You know, speaking of November 8 — have you noticed people saying their compulsive urges have increased since the election? Just speaking anecdotally, I certainly have.
Right, so this obviously is anecdotal, but for what it’s worth — I was just thinking back to the Women’s March. And a lot of people who were there said in interviews that they just could not stand to sit still, to sit in their homes and not be part of this.

I don’t think any of us are under the illusion that that alone will, you know, keep Betsy DeVos from being education secretary, or just pick your favorite example. But the feeling the Women’s March participants described really was a feeling of, “I can’t just sit here.” And it made me glad in retrospect that I included a chapter in the book on compulsions to do good things. Because if that feeling of anxiety mobilizes you to get the heck up and out and do something — well, then I think we should all be pretty grateful that that form of compulsion exists.

This interview has been edited for clarity and length.

Compulsive Behavior Isn’t Always A Sign of A Broken Brain