Lost on Repeat: Checking Boxes

Part One

The following work is directly from the book, and will be in two parts (the chapters are roughly 4000 words in total). Including the prologue, which I posted last week, that takes us up to the 10% public sharing rule of Amazon (roughly 30 pages) by the first scene of chapter two. But it’s a substantial piece that should help you get a sense of my writing.

I’ve decided to break it down into two digestible, but sizeable chunks, posted weekly. At that point, I will be writing content exclusively for this site.

Hope you like it. Feedback is always welcome.

Don't think of a polar bear, and you will see that the cursed thing will come to mind every minute

—Fyodor Dostoevsky

Who is a compulsive and obsessive person?

Everyone experiences doubt, intrusive thoughts, and repeated patterns of behaviour. Literally all of us, this is human life. Checking that the gas hob is switched off before heading to bed isn't pathological; in most cases, it's sensible. The WhatsApp message you wrote, where you complain about your boss. Double-checking that you're sending it to your friend, not your boss, that's common sense. The difference between what is typical for someone versus a clinical problem is how much something causes difficulty, distress, or significantly interrupts how you want to live.

Are you doing things to an extreme? Does it negatively impact your personal sense of well-being, causing issues in your relationships? Are you constantly getting in your own way?

Imagine, while the rest of the world has checked the front door once and now getting on with their life, you've already checked it thirty-four times, to be precise. You're sweating, fluctuating between tears and fear because you "can't be late". Still, you circle back home again to "just make sure" the door didn't magically unlock itself.

Then, you're angry with yourself because you know what you're doing is completely irrational, but you can't stop doing it. Now, having spent twenty minutes pulling the door off its hinges—you're late. For anyone who hasn't experienced OCD, of course, this sounds utterly bonkers unless you've lived it.

But it can be nearly impossible to describe to someone how hard it is to just "stop it".

This was me.

With obsessive-compulsive disorder (OCD), obsessions are the excessive attention that we pay to our own thoughts. They are typically intrusive, distressing, and unwanted. This is not to be confused with being infatuated and consumed with desire, as it is often portrayed in fiction novels and films. Nor am I talking about how someone can become dangerously fixated on another person, such as stalking.

Compulsions are the actions we take in response to disturbing thoughts, typically to manage the feelings and emotions generated by them or how we perceive and apply meaning to a particular context or situation. But it's important to understand that OCD isn't simply about illogical thoughts and peculiar habits. It can be pretty horrific and can cause a lot of problems.

Obsessions can centre on almost anything. For some, it's the fear of causing harm, such as accidentally starting a fire, missing a physical health symptom that leads to someone's death, or losing control and stabbing someone with a kitchen knife. Driving can become a minefield. I've worked with people who compulsively retrace their route via dashcam footage each day, convinced they've run someone over.

Others are tormented by thoughts of a sexual nature. These are typically shame-inducing and often overwhelming. Common themes include being plagued by distressing thoughts that they might have molested a child without realising it, or thoughts involving rape, abuse, or incest. The common denominator is the anxiety generated by them.

Then, there are those whose intrusive thoughts revolve around religion or morality. Scrupulosity can present as obsessive guilt about offending God, violating spiritual laws, or committing some form of moral blasphemy. The content often exceeds the person's cultural or religious baseline, which can make these types of intrusions all the more confusing and difficult to discuss.

Contamination fears can be common. These usually involve thoughts about the transfer of germs, bodily fluids, or unpleasant substances to the person through contact with their environment. The anxiety can be around being personally contaminated or being responsible for infecting others. Compulsions may include excessive handwashing and avoidance of touching contact points such as door handles. Some people avoid sex or perform cleansing rituals in secret.

However, not everyone can always identify a clear theme or thought that precedes their compulsive behaviours. That doesn't mean there isn't one. Our brains think constantly. But in some cases, the urge seems to arise from nowhere. People describe a need to touch, tap, adjust or blink because something doesn't feel "right" or "even". Clinically, this is common in symmetry or precision-based OCD. It's especially likely in people with a history of childhood tics.¹

One of the more contested concepts in OCD is the notion of having only obsessions without any compulsions. The urban term pure-O emerged to describe this, referring to people who experience disturbing thoughts without any outward compulsive actions. However, the label is often seen as misleading. In most cases there are usually cognitive compulsions, including rumination, checking, repeating phrases, and mentally undoing or rehearsing scenarios. They function in the same way as physical compulsions, just carried out in the person's mind.²³

Because both the obsession and the compulsion are cognitive, they can be harder to interrupt. You can redirect someone's attention, but you can't stop them from thinking altogether. Therapy focuses instead on helping people recognise when they're engaging in mental rituals and learning to respond differently to those urges.

For the vast majority of people, regardless of how disturbing the content of their thought is, the anxiety generated is the brain's misfiring alarm system. Irrespective of how intelligent or logical someone is, they can struggle to discriminate between fake news and real threat.

Similar to a smoke alarm, the life-preserving system of the brain will trigger if the house is on fire and everyone needs to escape, which is its primary purpose and function. Yet, for people with anxiety-based problems it will also activate when it senses the fumes from scorched toast, requiring a window opening rather than emergency services attending the scene.

OCD typically involves all smoke and no fire, but we still evacuate the building—just in case.

Most people with the features we more classically consider as OCD typically experience both their thoughts and actions as distressing or bothersome. They are very aware of the anxiety it generates and continue with compulsive actions despite them being irrational. That is, until you are no longer anxious and the healthier parts of the mind are back in the driving seat—until next time. Hence, many people need some help with managing the whole thing.

But imagine what it would be like to walk into a doctor's office, speak to a teacher after school, or a friend or family member. Explaining to them that you're having dark thoughts about sexually assaulting or stabbing children, that you may have grabbed your manager's genitals during a meeting of twenty people at work, or that you have the urge to plough your car into pedestrians at a zebra crossing.

That isn't easy to do.

With obsessive-compulsive personality, things are a bit different.

The concept has its roots in Freud's early psychoanalytic idea of the anal character, referring to people who were excessively ordered, rigid, and frugal. If you've ever been described as "anally retentive," this is where the term originated. Freud believed that these traits stemmed from unresolved psychological conflicts during the anal stage of psychosexual development, between the ages of twelve months to three years old.⁴

Naturally, this stage involves toilet training, where children develop a greater awareness of retention and expulsion, including external expectations around control and cleanliness. Granted, many adults have a tendency to hang onto metaphorical shit they'd be better getting rid of, but this doesn't necessarily mean that we have all been traumatised at the age of two years old. Most of us probably wouldn't even remember it if we had.

While Freud came up with some groundbreaking stuff, arguably still influential in modern practice, contemporary psychology draws from a range of models. These include varied personality trait theories and schema-based approaches to explain the development and maintenance of rigid, highly controlled personality styles.

Obsessive-compulsive personality disorder, or OCPD, isn't so much about rituals or explicit fears. It's about personality organisation rather than a list of symptoms.

Clinically, there are eight recognisable features according to the Diagnostic and Statistical Manual (DSM-5).⁵ To meet the threshold, at least four of the criteria need to be consistently present from early adulthood.

First, there's a preoccupation with rules, order, lists, and schedules, often to the point that the primary task gets lost.

Then, there's perfectionism that interferes with output and productivity. Not just high standards but standards that are so rigid that nothing ever feels good enough or complete. Reports redrafted a dozen times. Essays that cannot be submitted unless they're likely to win a Nobel prize. Perceived failure if the essay is returned with an admirable mark but falls one point short of the last benchmark. Even minor errors can feel intolerable.

Workaholism and excessive hours of productivity tend to take priority over almost everything else. Time off doesn't feel earned, deserved, or warranted. Rest is rationed, if it's permitted at all. Friendships and hobbies become peripheral. This can also be projected outward, applied to coworkers or employees.

Moral thinking can also be quite black and white. Right is right, wrong is wrong, and there's often little room for ambiguity. Again, the same standards applied internally can also be applied to others, whether consciously done or not.

Delegating tasks can also be very difficult. Not because others are objectively incapable but because, subjectively, they're unlikely to do it in the exact way the person expects. Precision and attention to detail matters. The sheer frustration of watching someone do it differently often outweighs the benefit of letting them get on with it in their own way.

People can struggle with discarding things, even when those things have no sentimental or practical value. Broken electronics, decades-old paperwork, or packaging. This is not necessarily hoarding in a clinical sense; it's more resource-based, a refusal to waste things or to avoid future regret.

Money can follow a similar pattern. Spending can be significantly restrained, not because of actual financial hardship, but because of a compulsive need to save and stockpile. The idea of wasting cash is almost as uncomfortable as wasting time. Sometimes, people live life as though they are on the breadline despite having a million pounds in the bank. Obviously, this is quite an extreme example, labouring the point.

Many people have no option but to watch their spending. Others save for specific reasons, such as university fees for the kids, and retirement plans. Yet, if you're bathing in three inches of water, sitting shivering with the heating off in winter, but have a stack of cash gathering dust under the floorboards, then it's possible you may be a little closer to the obsessive-compulsive spectrum than just being "careful with money".

Finally, there's the broader sense of rigidity and stubbornness that extends into pretty much all aspects of functioning. Changing plans, compromising on approach and feeling out of control tend to provoke a disproportionate level of distress.

Again, it's important to remember that what constitutes personality traits versus a disorder is the degree of negative impact associated with them. Many of you reading this will likely see yourself in some of the traits described. I still tick four of these boxes, but it's very unlikely that I would meet the clinical threshold for a formal diagnosis these days.

In various aspects of life, including the therapy room, I've met countless people who enjoy having things neat and tidy. My mother-in-law washes the inside of her bin, puts rubbish bags within bags and cleans everything she puts in them. Many people like a spotlessly clean house or live their lives in disciplined ways; they are always on time, hit deadlines early, and go the extra mile at work. This is not a clinical issue in the majority of cases.

Yet, you may be someone who is on your third marriage because no one can sustain your showroom standards in the house. Coworkers possibly feel redundant because you refuse to delegate tasks. A close friend or family member dies, and you first think, "I'm not sure I can take the time out for the funeral." Then, that might need a closer look.

For people with obsessive-compulsive personality traits, compulsions often present more subtly, in many cases outside of conscious awareness. Compulsive behaviours are generally more about maintaining control over an outcome and meeting internalised expectations. The actions are more typically rule-bound and MUST be done, not necessarily to manage immediate feelings.

In therapy-speak, the difference between OCD and obsessive-compulsive personality traits is commonly discussed in terms of ego-dystonic and ego-syntonic processes. This is simply a fancy way of saying that our thoughts are either contrary or out of sync with our more static traits and values (dystonic), or very much in keeping and aligned with them (syntonic).

Commonly, with OCD, the thoughts and images we experience are not aligned with our sense of self, such as intrusive thoughts about harming someone. Perfectionistic and demanding internal standards often match so well that it's difficult for people to recognise their destructive potential, often perceiving them as having benefit and value.⁶

My own patients will often arrive in therapy experiencing problems with anxiety and depression. Still, they usually won't recognise this to be the case. The catalyst for the onset of the issues will often relate to external factors: relationship problems, workplace stress, and loss, rather than excessive worry or concern about intrusive thoughts and images. Yet, when exploring the internally demanding standards, there is often pushback and resistance. I've been there myself.

Many fear that by taking their foot off the gas, even a tiny amount will somehow turn their life upside down, causing them to lose everything or be forced to accept average standards.⁷

At least, from their viewpoint.

In clinical practice, I commonly see people with overlapping characteristics of both OCD and obsessive-compulsive personality traits. From my perspective, this makes recovery, particularly from OCD, much more challenging. Whether someone is repeatedly worrying that they are a paedophile, avoiding being near children due to distressing sexually intrusive thoughts, or they're trimming the front lawn with nail scissors at 2 am to prevent perceived criticism from the neighbours, they all involve internal processes that can be very difficult to counter.

While it is necessary to understand the fundamental differences between obsessive-compulsive problems, the evidence base behind the concepts and treatment approaches is somewhat shaky. Aside from the conflicting approaches from different schools of thought, the wealth of outcomes from randomised controlled research trials, while encouraging, rarely transfer to the reality of clinical practice.

As a clinician, I've commonly encountered large organisations wafting evidence-based speak at me. Which is important, and I get why. Research shows us what works.

Yet, both patients and practitioners are often sold popular methods of treatment, commonly cognitive and behavioural approaches. They can work, just not for everyone. For some people, particularly those with milder symptoms of OCD or more recent onset, approaches such as exposure and response prevention (ERP) can bring relief. It can be effective longer-term with the right balance of pace, intensity, and ongoing application around flare-ups.⁸

But these aren't the clients who typically walk through my door—nor was that the case for me in the early stages of my own therapy, often labelled "treatment resistant".

In clinical trials, outcomes are mixed. Around a third of participants show significant symptom reduction, and another third achieve full remission. But relapse is common. Within a year of treatment, about half will experience a recurrence of symptoms.⁹ There are many likely contributors to this: co-occurring mental health conditions, social stressors, and physical health issues.

Teenagers tend to fare a little better, with around two-thirds experiencing significant improvement and nearly a third fully recovering.¹⁰ That said, the rates of suicidal ideation are disproportionately higher in younger people, with around half reporting suicidal thoughts and nearly a quarter engaging in self-harm.¹¹

Medication can help, but not without limits. Selective serotonin reuptake inhibitors (SSRIs), and sometimes SNRIs, are commonly prescribed to treat OCD. Like with many anxiety and mood-related conditions, these medications can reduce symptoms by dampening the nervous system's physiological response. This can make obsessions and compulsions feel more manageable. But they don't stop intrusive thoughts or directly alter the compulsions.

For people with perfectionistic personality traits, medication may be more effective in easing generalised anxiety or low mood related to chronic internal pressure. Arguably, SSRIs don't change personality.

It doesn't surprise me that the relapse rates following medication discontinuation are often much higher.¹²

Combining ERP with medication may improve outcomes slightly, but the long-term benefit often hinges on continued support. Side effects are also common. Most people I've worked with report some degree of emotional numbing of positive emotions as a trade-off for reduced negative feelings.

Sexual side effects are also frequently reported. They don't discriminate by gender, including lowered sex drive, vaginal dryness, problems with erections, orgasm and ejaculation—brilliant! Needless to say, many of the patients I've worked with choose to switch or stop taking medication for these reasons. However, it's very important that people discuss any issues or unwanted side effects of taking medication with their prescriber before doing so.

While I may sound like a massive mood hoover here, I'm not anti-medication, nor am I averse to using CBT. Most of the guidance, particularly from the NHS, is that combining these treatments is typically the most effective for OCD. If you can tolerate them and you find it helps—great!

If not, hopefully, the rest of the book will give you some hope that this is not the end of the road.

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. Hezel, D. M., & Simpson, H. B. (2019). Exposure and response prevention for obsessive–compulsive disorder: A review and new directions. Journal of Clinical Psychology, 75(1), 1–25.

3. Williams, M. T., Farris, S. G., Turkheimer, E., & Pinto, A. (2011). Symptom dimensions in obsessive–compulsive disorder: Phenomenology and treatment outcomes with exposure and ritual prevention. Psychopathology, 44(2), 81–89.

4. Freud, S. (1959). Character and anal erotism. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 9, pp. 169–175). London: Hogarth Press. (Original work published 1908)

5. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.

6. Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14(5), 449–468.

7. Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process: A clinical review. Clinical Psychology Review, 31(2), 203–212.

8. Gros, D. F., Szafranski, D. D., Mims, B. A., & Morland, L. A. (2022). A systematic review and meta-analysis of exposure therapy outcomes for obsessive-compulsive disorder. Journal of Anxiety Disorders.

9. Ferrando, S. J., Wachtel, L. E., & Martino, D. J. (2023). Advances in obsessive-compulsive disorder treatment: Current strategies and emerging approaches. Current Psychiatry Reports, 25(1), 45–56.

10. Futh, A., Simonds, L. M., & Schaefer, J. D. (2022). Outcomes of psychological therapies for obsessive-compulsive disorder in children and adolescents: A systematic review and meta-analysis. Clinical Child and Family Psychology Review, 25(1), 1–19.

11. Torres, A. R., Prince, M. J., Bebbington, P., Bhugra, D., Brugha, T. S., Farrell, M., ... & Singleton, N. (2020). Obsessive-compulsive disorder and suicide risk: Results from the British National Psychiatric Morbidity Survey. Journal of Affective Disorders, 260, 724–729.

12. Fineberg, N. A., Hollander, E., Pallanti, S., Walitza, S., Grünblatt, E., Dell'Osso, B., ... & Stein, D. J. (2020). Clinical advances in obsessive-compulsive disorder: A position statement by the International College of Obsessive-Compulsive Spectrum Disorders. International Clinical Psychopharmacology, 35(4), 173–193.