SPENCER: David, welcome.

DAVID: Hello.

SPENCER: Do you have OCD, also known as obsessive-compulsive disorder?

DAVID: I definitely used to have it. I used to have it quite severely. One of the reasons that I'm here talking to you now is that I got treatment, I felt better, and I wrote a book about it. Do I still have it? I think I would say that I manage the symptoms of OCD. A slightly longer answer would be that OCD tends to be one of the ways they diagnose it is that you do a test called the Yale-Brown Obsessive Compulsive Scale, and it's a series of questions that asks how long someone spends both obsessing and then performing compulsive behaviors, and the numbers are way higher than you might think. It's hours and hours a day to even get diagnosed as having moderate OCD. So I suspect if I were to do that test, I probably wouldn't be diagnosed with OCD, because, as we can talk, the symptoms are much lower level than they used to be, but I still take the pills that I took when I was diagnosed. If I were to stop taking those, then maybe I would have a relapse. Who knows? So that's a slightly longer answer, but I think the best answer is not today, but I can't guarantee anything about tomorrow. That's the way it works.

SPENCER: Now, just for our listeners, we did an episode previously on OCPD, which is often confused with OCD, but just to make our listeners clear, OCPD is a personality disorder. It's a disorder of rigid perfectionism. Could you talk for a moment about how that differs from OCD?

DAVID: I'll talk a bit about OCD to start with. Most people have heard of OCD. Most people are familiar with it, but a lot of people don't quite grasp that essentially, it's a disorder of thought. The most visible part of OCD is often the behaviors, the compulsions, because you can see people perform them; sometimes people have no choice but to perform them in public. But it's actually the thought, the obsessive, intrusive thoughts that we can discuss later, that really cause the distress. And those can be, I like to say, limited only by the human imagination, that they're completely irrational. They're just weird and, again, sort of fast-forwarding. One of the ways that we have to deal with those thoughts is to perform compulsive checks to try and answer that thought or to try and dismiss that thought. Very quickly, those two come together into a cycle. You get the obsessions, the thoughts, and then the behaviors, the responses, the compulsive responses, and those two reinforce each other. So that's OCD. I think the biggest difference when it comes to OCPD is motivation. I don't know that much about OCPD, but as I understand it, the people who clean in OCPD really like to clean. They like things to be clean. Their entire house will be clean. They themselves will be clean. Everything they touch is clean, and they are proud of that, whereas with OCD, usually the cleaning, if it is a compulsive behavior, is a response to an irrational thought. You could hate doing it. You only do it because it helps to relieve the anxiety in your head. You get zero pleasure from the act itself. In fact, in some cases, with OCPD, someone might think, "I want my kitchen to be clean," and they will clean their kitchen. Someone with OCD might have thoughts about terrible consequences to their parents or their loved ones. They might think, "My parents are going to die," and the way I deal with that thought is cleaning the kitchen. There's often very little logic. It's a very irrational disorder anyway, but there's very little logic often between the nature or the content of the obsession and the apparent response to it. Also, OCD can be very, very targeted. Someone could have a spotless kitchen, but their bedroom is just a complete state. Maybe they haven't had a shower for three weeks. It's not a love of whatever it is that you're doing; what you're doing is a consequence of what you're experiencing, the dreadful thoughts in your head.

SPENCER: I think this idea of ego syntonic versus ego dystonic is really interesting. As I understand it, people with OCPD, their thoughts about controlling things, about being perfectionist, et cetera, are ego syntonic. They view this as part of who they are. They view this as a good thing, whereas with OCD, people often have ego dystonic thoughts where they say, "I don't want these thoughts. I know these thoughts are irrational." Could you elaborate on that?

DAVID: Yeah, I think a really good way to illustrate that would be, let's say there are two people in church. One is very religious, very devout, and the other one is an atheist. They both have the same thought about something obscene with a religious figure, okay, a nun, or Mary Magdalene, or whoever it might be. The person who is very devout finds that thought ego dystonic because it clashes with who they think they are and who they want to be. They think, "Why am I having that thought? That goes against everything that I believe in and stand for," and therefore there is something wrong with their brain or thinking, or they are a bad person. The same thought to an atheist would just be, "Oh, that's weird," but it wouldn't in any way clash with who they are. So that would not be ego dystonic for them. A very common example is that new parents can get ego dystonic thoughts about harming their child. They know they never would, but they can't avoid the thoughts that they might. This is one of the real cruel ironies of OCD. I like to say that you have kind of a double effect. You have the content of the thought, which is usually upsetting. In my case, it was about catching an infectious disease. To me, that was ego dystonic because I like to think of myself as a very rational person, and it was this wildly irrational thought that was striking me. I knew it was irrational. I didn't believe it. I knew it was counter to everything that I believed in. It made me question, "Why am I having these thoughts? What is wrong with me?" This is doubly distressing. For example, Winston Churchill used to have ego dystonic thoughts about jumping in front of a train or jumping off a balcony. He wasn't suicidal in any way, and yet just having those thoughts, just having ego dystonic thoughts, can shake people in a way that they reach for a solution, which is often the compulsive behavior.

SPENCER: If we look at the DSM-5 criteria for OCD, which is the Diagnostic and Statistical Manual that doctors in the US use for diagnosis, we see that there are really only two primary criteria for OCD. We've got the obsessions, which you mentioned, described as persistent ideas, thoughts, impulses, or images that are experienced as inappropriate or intrusive and that cause anxiety and distress. Then we have compulsions, the second piece, which are repetitive behaviors or mental acts that are carried out to reduce or prevent anxiety or distress and are perceived to prevent a dreaded event or situation. Could you tell us a little bit more about how they interact? What is the connection between the obsessions and the compulsions? What are the compulsions doing?

DAVID: The best way is with an example. Let's say you are waiting for the subway. You're on the platform, you hear the rattle of the train coming along the tracks. A very common response to that is to get an urge to jump in front of the train. A lot of people have that. A lot of people don't talk about it. That's an ego dystonic thought, an ego dystonic urge, because you're not suicidal. You don't want to do that. Now, where that comes from is a different question that we can discuss later, but let's just focus on you've experienced this thought. Okay, and let's say a hundred people on the platform experience that thought. Most people, the train comes, they get on it, and they never think about it again. They might mention it if they're a stand-up comedian; they often talk about this kind of stuff. But let's say there's one or two people, and they're waiting for the train the next day, and they get the same urge. They think, "That's that same urge. What's going on? That's really weird." They start to respond to it. They start to think about it because they're very distressed by this thought that they've had. So all through the day, they're thinking about it. They're thinking, "Why did this happen to me? What does it mean?" The next day, they get the urge again, and they find that they can't make that thought go away. They mark it — jumping in front of the train — as an issue. It's bothering them. As they're focused on it, they're thinking about it, and they're finding it hard to think about anything else. It's very unusual for us to have thoughts that fix in that way. We're so used to our thoughts just sort of coming and going almost at random. In fact, many people find it difficult to focus on one thought; they find themselves distracted. So when that thought is very distressing, it's a very unusual situation because you can't outthink it. You can't not think of a thought. If we say to your listeners now, "Don't think of a banana." Well, what happens? The only real tool available to you is to change your behavior. So the next day you're waiting for the train, you get that urge to jump; you might take a step back. The next day, you might take two steps back. Winston Churchill, as we talked about, used to put a pillar between himself and the edge of the platform when the express train was coming through. With each of those behavioral changes, unfortunately, you're encouraging the thought to come back essentially because you're giving it credibility. You're giving it credence. You're making it salient and relevant, and pretty soon, it could be the case that the person can't even bear going to get onto the platform. They can't get the train; they lose their job. This is the kind of spiral that people go through. In that case, what happens is you have the thought. You cannot make the thought go away except by performing some kind of compulsion. In that case, the compulsion seems logical. If you're worried about jumping in front of a train, then you might stand further away from the edge of the platform. But very often, the compulsion, as we've mentioned, is not a logical response to the thought. For example, people might have thoughts about their parents dying in an accident, and they find it comforts them to turn the light on and off three times, or to touch something, or to rub a piece of metal, or to say something to themselves. That infinitesimally makes them feel better because they've taken control. They've got some reassurance. It's addictive. When you have the thought the next time, you reach for the compulsion as a habit, as an addiction, because it makes you feel better. This is why they operate together. You get locked in a cycle. The key, though, with OCD is the D. Everyone focuses on the C, the compulsions. I talk about the O, the obsessions, but actually what matters is if the O and the C combine in such a way that they have a real impact on the quality of your life, which is when it becomes a disorder. When I do talks, people will come up to me and say, "I do this thing. Is that OCD?" I say, "Well, what impact does it have on you?" Someone might say, "I have to get up and check that the back door is locked in the middle of the night, but I only have to do it once, and I can go back to bed." It's not really a clinical level of disorder having an impact on the quality of your life, but it can be. It's exactly the same mechanism. It's this idea of, and what's interesting is we said that maybe a hundred people have this thought, but only two or three might turn that thought into OCD. That's the question for the psychologist: What is it about my brain or other people's brains that turns? I like to think of them as seeds scattered across the population. In some people, those thoughts just sort of take root. Why that happens is an interesting question.

SPENCER: Sounds like, fundamentally, what you're pointing at is this feedback loop where we're learning to do these behaviors because they relieve anxiety, and so then when it relieves your anxiety, you get rewarded, essentially, and then you're doing it again, and it relieves anxiety again. And you get locked into it. OCD, I think, was often thought of as an anxiety disorder, I suspect for that very reason.

DAVID: Yeah. Anxiety is certainly a defining feature of it, but it's also just the sheer irrationality of it. So someone who has a phobia, for example, however irrational it might be, you might have a phobia of, I don't know, cats, okay, but that doesn't affect you unless there is a cat present, whereas, with OCD, you can have irrational thoughts about cats that are there all the time. So you can be anxious all the time with no obvious external trigger. Usually, people get anxious about legitimate events, and anxiety is seen as sort of an exaggerated response. An anxiety disorder is seen as an exaggerated response to what people might get anxious about, quite justifiably, like an exam or a driving test or a breakup with a partner, but OCD adds that level of irrationality. What you are anxious about is something that 98% of the population never would be.

SPENCER: I think with almost everything, with humans, we can think of them as spectrums, rather than a binary. You have it or you don't. And I think the same is true of OCD, that many people will have some of these tendencies, to some degree, but only a very small percent, maybe 2-3% of the population, will actually truly have OCD. And so just in my own life, I can think of little examples that seem to fit this pattern. For example, when I'm copying numbers, for some reason, I'll recheck them often, five times that I've copied the number correctly, and every time I recheck it, it kind of lowers my anxiety because I worry, "Oh, did I miscopy the number? Am I going to get it wrong?" But of course, it only comes up every once in a while. It only wastes a minute or something. So it's no big deal. But would you think that's right, that many people are going to have these little OCD-like tendencies that don't become a full-blown disorder?

DAVID: Absolutely, it's what we just talked about. I would describe them as obsessive and compulsive tendencies, rather than OCD tendencies. They are traits, just as people can have traits of anxiety and traits of depression or traits of anything that doesn't quite elevate to the level of a clinical disorder. So this is where it is binary, and I appreciate that it's not a firmly dividing line. It's not a highly defined line, but you are diagnosed with OCD, or you're not, and if you are, that unlocks treatment pathways and options and things like that. And if you're not, then, unfortunately, you don't. So that's an artificial way of categorizing. Psychiatrists like to say that the world does not carve nature at the joints or something. It's like, we the patients don't follow the manual. So, yes, there's certainly a binary element of whether someone has OCD or not, but there's a spectrum of how severely they experience those traits. Some people might not experience intrusive thoughts at all. Other people would get intrusive thoughts that they're not bothered about. Some people are bothered about them partly. In your case, I don't know if there's an intrusive thought or whether you just are feeling weird about the numbers, so you respond to it. OCD would be to the level where you were doing it for hours and hours a day, probably to the detriment of other things, and also there's usually a consequence. Although many people experience OCD as just kind of "that's not quite right," very often there is a more sinister motive behind it, like the thing that's not quite right is something which they are thinking about in a very serious and disturbing way. The compulsion is a way of trying to ease that anxiety, that fear. But fundamentally, the answer to your question is that, yes, it's a spectrum. Everybody experiences some of these elements to a degree, and in some people, they combine to the point where it tips them into the clinical version.

DAVID: I had OCD for a long time before I was diagnosed with it, but I didn't recognize it as such. When I was about 19 years old, I started having intrusive thoughts about HIV and AIDS. For anyone younger than 40, this is baffling, but I grew up in a world where AIDS was an unknown, scary, terrifying public health issue that governments really didn't understand and didn't know what was going to happen. Their only real weapon to try to protect people and change people's behavior was to terrify them into certain behaviors. The HIV that I worry about even today is still the HIV that I grew up with in the late 80s. It's not the virus that can be treated now, as long as you can get hold of the drugs. People with HIV have it at virtually undetectable levels. They cannot pass it on if they're taking the drugs. But to me, it's still this unknown, terrifying boogeyman that's going to come and claim people in their sleep, because that was how it was presented to us. I had intrusive thoughts about HIV, and I was definitely performing compulsive responses. I thought it was more of a phobia because to me, OCD was something I had heard of. I think I probably heard of it in the late 80s, but I thought it was about symmetry, arranging things, and being neat, and in no way am I neat. It actually took going to a psychiatrist and saying I was having these horrible thoughts about HIV, and they were the ones who diagnosed me with OCD, which, now that I know what OCD is, makes a lot of sense. I was a clear-cut case, but I think there is something like a 10-year delay between people experiencing the symptoms and seeking help. Part of that is not recognizing what you have as something that can be treated because so much of the way OCD is presented to people is based around compulsive behaviors, cleaning, and hand washing. People who have intrusive thoughts about harming their children or catching HIV from a razor blade are sort of left out of that, and they think, "What's wrong with me? I don't have that. So what is going on with me?" That is both a deterrent to getting help and a deterrent because people don't talk about the thoughts that are usually behind OCD. Going to a doctor and saying, "I'm having thoughts about harming my children" used to be incredibly risky. Some of these doctors had a big red button on their desk that, the moment you said you were thinking about harming a child, it was alarming. It's not like that so much anymore, luckily. There is much more awareness, and certainly in the US, the US is ahead. I think people are more comfortable talking about the kind of thoughts that can drive OCD, but it is a bit of a jump to sometimes recognize them as OCD because, as I said, OCD is often presented as a behavioral issue, and for people experiencing OCD, the distress comes from the thoughts. It's like, where are these thoughts coming from? Why won't they stop?

SPENCER: I know that now you've gone through treatment, but if you think back to pre-treatment, could you walk us through what a day was like for you? How did these thoughts appear? What kind of thoughts were they, and how did they affect your behavior?

DAVID: So I'll give you a really good example. Let's say I was playing soccer on astroturf, the artificial grass, which back in the 90s was like sandpaper. If you fell over on it, you would just scrape your leg. Let's say I was playing soccer, and I scraped my leg. While I was playing soccer, it was fine, but afterwards I'd look down at my leg, which was bloody and shredded, and think, "Well, I did that. Someone else could have done that. Someone else could have fallen over on that exact spot of the astroturf and left behind blood. They could have been HIV positive, and when I fell on that same bit of grass, that blood could have gotten into my system." One of these things, if you were to take it theoretically at every step, is just about plausible. But in reality, most people would never even consider that. It's one of those things that's so unlikely that we dismiss it. But OCD puts a huge gap between zero and very, very, very unlikely. Pretty much all of our territory operates within that, and what's worse is a huge chasm. I would have these thoughts and seek reassurance. That was my compulsion. At the time, there was a telephone number, a helpline that you could call to get advice about HIV, usually about people who were genuinely at risk or had genuine concerns. I would call them and say, "This thing has happened. What do you think?" They would say, "Don't worry about that. The risk is very low." I would get that little burst of reassurance when they said, "Don't worry about it." I would hang up the phone, but then I'd go to sleep and think, "Well, hang on a minute. They said the risk is very low, so it's not zero, so I better call them back just to explain, because maybe I missed something. Maybe the risk is higher than I thought." Comically, they started to recognize my voice and say to me, "It's you again. We've told you this. You need to accept it." I would call them back and pretend to be other people. I would put on different accents and invent stories that were just close enough to try to get away with telling it all over again. That was how I lived my life for years. My OCD was very portable, so I wasn't one of those people who were trapped at home or having some people can't go more than 10 minutes away from a toilet because they get intrusive thoughts about soiling themselves. Mine was I could take it with me, so I could do whatever I was doing. I was at university, I was having friends, I was having relationships. I was living life, but I wasn't really experiencing it. I was always thinking about something else. I was always thinking about HIV in my head and how I might have caught it. I would save up these thoughts, and I would seek reassurance. Sometimes, if I worried about cutting myself on a piece of barbed wire, I'd go back and check there was no blood on that piece of barbed wire, just to try and squeeze that gap between very, very low and zero. I wanted it to be zero, only there to be zero risk. That went on for a long time. One of the things we mentioned, the gap between people experiencing the symptoms and seeking help, I think one of the reasons is that we know that it's utterly wrong. We know that it's completely alien and irrational. I thought that tomorrow it would go away because most things do when you're worried about them. You get reassurance, and the next day you wake up and everything's fine. I just kept waiting for it to go away by itself. Sadly, one of the things we know about OCD is it just doesn't. Hour after hour becomes day after day, becomes week after week, becomes month after month, becomes year after year. Even I, as someone who went through it, still find it hard to accept and believe just how much of someone's life it can dominate. It really is the first thing you think about when you wake up, the last thing you think about when you go to bed. Sometimes during the day, you can get distracted. I used to like going skiing because that distracted me. I used to like watching soccer games because that distracted me. But you can't live your life around skiing and watching soccer. Most of the time I couldn't distract myself, and I was just obsessed. It's such a good word for it. We use it quite casually, but it really was. One of the things about obsession is that it's from the original Latin word meaning to besiege. To obsess was something that was done to something; you were obsessed by a city. It's a very invasive, active thing that is being done to you. That's how it feels. One of the defining characteristics of OCD is you have to resist. When the siege was complete, and people would go in and sack the city, that was then said to possess the city. To obsess, you were still getting resistance, and that was my life. I was resisting. I was pushing back against these thoughts from my own head.

SPENCER: The example where you cut your knee on the astroturf is a good example, but I think there's a way in which it's hard to understand how that became a daily thing for you because you can see the causal mechanism. You were bleeding on the ground, and you can kind of see the thought process. What would a more typical day be like when nothing happened that could, even in theory, contaminate you with HIV?

DAVID: I'd be thinking about the last one that had happened.

SPENCER: So going back to the last time you had a cut or something, yeah.

DAVID: Then what would happen was, let's say the thing with the astroturf. I'd be thinking about it for a week, going over it in my head, trying to replay the exact circumstances. Maybe I'd go back to the site and look at it the next day, two days later. But then something else would happen, like, we mentioned, cutting my finger on a piece of barbed wire. And then the whole kind of tower of anxiety that I built around the astroturf just dissolved, went away. I was now fixated on the latest thing, and I could see that the previous one was irrational, so I didn't really worry about that anymore, but now I had this new one. So basically, I was just like serial monogamy. You have one of these thoughts that's just so dominant in your head, but then it's replaced by another one, which becomes just as severe, just as quickly.

SPENCER: If we zoom in on kind of the thought process, as you're living your life, you're having these thoughts, what are the kinds of thoughts that would be popping into your head that would be taking up so much of your time?

DAVID: It would almost be a physical sensation in that stomach. I can feel it doing now, as I'm talking about it, just that tightening in the stomach. I became so familiar with the thoughts that I almost didn't need to explicitly think them. They were just there in my subconscious, and the impact was there, the physical impact, and then very quickly, you're seeking a way out. You're trying to replay in your head, or you feel overwhelmed and decide you're going to go for a run, or you're just going to break down and cry. You're going to beat your fist against the door. You're going to react to it in some way. Or you're going to sit there and not think about it. You're going to watch TV, not thinking about the banana. There are lots of different ways that you can respond by not responding directly, even though you know that you are responding. It's all very layered with the thought process because you kind of convince yourself that you're not doing this, but really you are. I would sometimes drop crazy, irrational situations about HIV into conversation with people just to see how they responded as a way of seeking reassurance, asking people, 'Do you ever worry about HIV when you kiss someone or something like that?" They would go, "No, not really." I'd go, "Oh, great, you're in my head." It was a topic that was on the news. It was everywhere in the early 90s. It was in the plot of a soap opera. People were encouraged to talk about this stuff. You were encouraged to get tested. You were encouraged to talk about the number of sexual partners and all this stuff. It wasn't like dirty thoughts about religious figures that you were kind of ashamed of. What was shameful was that I knew all mine were irrational. People were going out having unprotected sex and being told, "Oh, it's probably nothing to worry about," and they would get on with it. I wouldn't do any of that, and yet I still had all the anxiety.

SPENCER: Do you think that replaying it in your mind was the kind of compulsion where by replaying it, it would somehow lower your anxiety, and then that would get reinforced?

DAVID: Absolutely. Yeah, because, let's say the barbed wire thing, or I'll give you a better example. I once went on holiday with some friends, and a friend of mine had the same color toothbrush. I started to worry when we got back that maybe he had used my toothbrush, which to me was a risk of HIV infection. I had no way of reassuring myself about that, absolutely not, because he did have the same color toothbrush, and it was possible. So what I did was I basically tried to replay in my head each night, who went to bed first? Did I go to bed first? Who brushed their teeth first? Did he even brush his teeth? Did he use the sink? All this stuff, just trying to squeeze out that very low anxiety when actually you can never do that. It's impossible. It's impossible, and which is part of the reason you just keep going because you never reach the end. It's slightly lower diminishing returns than the more effort you put into it, the harder it becomes to make that difference. So, yeah, I was almost certainly experiencing that. There are some people who say they don't have OCD, kind of vanilla OCD. They have pure O because they don't think they have any compulsions. But actually, mental compulsions can be compulsions. There are people, and this isn't an OCD thing, but if you say to people, take a piece of paper, your listeners could do this right now. Take a piece of paper. Think of someone you really love, and write down on a piece of paper, I want my dad, my dog, my grandma to die. Some people can't do that to start with, which is an interesting idea because it's one of the psychological patterns that could lead to OCD, believing that to think something is as bad as to do it, or thought-action fusion. Other people will kind of do it, but then they'll secretly say something to themselves in their head, not really, or they'll cross their fingers. We all have this ability to reassure ourselves or to try and reassure ourselves over anything. You see it with people in sports; before they have to take a penalty kick or kick a field goal, they'll sort of tell themselves it's all going to be okay. They're breathing, they're going through that routine, and so much of that is mental. It absolutely does not have to be a physical behavior to be a compulsive response.

SPENCER: You mentioned thought-action fusion, which I think is really interesting. There are a lot of people who are superstitious on some level, and they might think, "Oh, if you say something about something bad happening, you should knock on wood to make sure it doesn't happen." It seems like almost an extension of that. Could you elaborate on what is thought-action fusion?

DAVID: So we mentioned earlier my idea that these intrusive thoughts are seeds and they're scattered across the general population, but only in some people do they turn into OCD. One of the explanations for that is psychological models, so the kind of personality that people have, and there are some personality types which seem to be more susceptible to OCD. One of them is thought-action fusion, the belief that to think something is somehow equivalent to doing it. This goes right back; this is in one of the Ten Commandments: Thou shalt not covet thy neighbor's ox. To want something, to think about wanting something, is up there with to kill, to steal, and the line about adultery in the mind being as bad as in the flesh. To think about having sex with someone is the equivalent of actually going and doing it. This is the thing about if you get the intrusive thought that you might want to stab someone with a knife. Thought-action fusion implies that I want to do that. It makes me more likely to want to do that. So I need to stop myself from doing that somehow, either by throwing away all the knives, locking the drawer, hitting the wall five times when I think about it, or whatever it is. People who think that thoughts are just thoughts, that they don't pose any sort of relevance to our intentions, actions, and behaviors, are less likely to do that. It's very simplistic, but you can see why someone who thinks thoughts are more important than others might respond to an irrational thought in a different way.

SPENCER: It seems to me there are different ways of thinking of thoughts as important. One is you can think of them as morally important. If a mother has a thought of killing her child, then it makes her a bad person, even if she doesn't kill her child. If you believe that, then having random thoughts would be really scary. I think you're absolutely right that most humans have lots of weird, random thoughts that don't really signify anything. But there's another way to think, which is that maybe having certain thoughts makes the thing more likely, like a kind of superstition. If you have a thought about something bad happening, it increases the probability of it happening through some magical mechanism. Then there's a third thing, which is you could think that having the thought means that you're going to do the thing. You could think, "Oh, if I have the thought about killing my child, that might mean that one day I'm actually going to do it and not be able to control myself." All subtly different.

DAVID: Yeah, I agree. What seems to matter in OCD is how salient the thought is to you. I don't know if there's a difference in salience between the different kinds of thoughts or the different spins of thoughts, largely because we're kind of told in treatment to almost ignore the thoughts. For someone with OCD, the thoughts are the most important part, and you want the thoughts to be taken away. When you find out that they're normal, that most people have them, and they're probably not going to go away, that's really quite disturbing. It's only really helped by learning that almost everybody has them, because then it makes you feel a bit more normal, and you realize this is a problem about how I deal with it. The exact character, nature, form, and intention of the thought are less important when it comes to understanding OCD, I think, from the treatment point of view. This is how it is viewed in almost all the work on OCD, unless you're a Freudian and you go into the philosophical or sexual interpretations of your thoughts. Most people just don't do that. They start with the fact that you're having these thoughts. How you're processing the thoughts is what matters. This is what we're going to do about it.

SPENCER: Do you still have thoughts about HIV all the time?

DAVID: All the time. I become a world expert at spotting a band-aid on someone's finger. Yeah, every day, not just now.

SPENCER: So what's the difference now?

DAVID: So the difference is that I don't perform the compulsions because that's the only thing I have under my control. I cannot control the thoughts. I can control whether I go looking on the internet to see whether such and such poses a risk of HIV, which is what I want to do when I have these thoughts, and that's one of the things you get in therapy. It sounds so blissfully simple; all you need to do to crack OCD is not perform the compulsions, but it's just so, so difficult. I like to tell a story about a guy called Kurt Gödel, who was a mathematician. He was a friend of Einstein, a contemporary of Einstein.

SPENCER: He was known for completing his theorems, right?

DAVID: Yeah. His whole purpose was rationality and the limits of rationality. He used to have intrusive thoughts. He'd have intrusive thoughts about being poisoned. He thought that gas might escape from his refrigerator or someone might poison him. So he would get his wife to taste all of his food for him. He was a 50-year-old man. His wife would taste his food for him. He might have been older than 50, I don't know. One day, his wife became ill and couldn't do that for him. So Kurt Gödel starved himself to death. That's the power of those thoughts. When people say, "Why don't you just stop doing it?" If it was that easy, people like Kurt Gödel would not starve themselves to death over these thoughts; people would not lock themselves in these self-destructive routines for their entire lives.

SPENCER: There's also the irony of starving yourself to death to avoid being poisoned as though starving yourself to death is better than being poisoned.

DAVID: Yeah. Now I'm 53. HIV is effectively a curable disease in the UK. If I were to catch HIV tomorrow, it would not kill me. I would live with it without ever probably knowing, without ever suffering any medical consequences. And yet it still terrifies me.

SPENCER: People might wonder, "Okay, but you're still having these thoughts so much throughout the day. You're not engaging in the compulsions. How is your reality really different now? What makes it so much better now that you've been treated?"

DAVID: The irony of OCD is that because we reach so quickly for the compulsion when we have the intrusive thoughts, we never know what we're worried about is never going to happen. So if you worry about your parents dying in an airplane crash, and then you shake your hands around and your parents don't die in an airplane crash, you think that's because you did that. You never actually don't shake your hands and realize the plane does not crash, that you do not have that power. It has nothing to do with you. In therapy, they basically get you not to shake your hands, to continue this example. All the time the plane is in the air, you're hugely anxious. But then the plane lands, and you realize that anxiety can go away by itself, and it doesn't have to be because of the consequences. In my case, I would be having intrusive thoughts about catching HIV from something like barbed wire, and I'd want to go and check it. If I don't check it, I stay anxious. But that anxiety has to go down at some point. It's just physiologically impossible for somebody to stay at that level of sort of DEFCON 1 indefinitely. You just cannot do it.

SPENCER: Now, think of it as if you were put into a pit of snakes. Most people would be terrified, but imagine you've been in there for three days. The snakes haven't bitten you. You'd actually be bored at some point.

DAVID: So they call it extinction decay, psychologists, so that the fear, the anxiety, whatever it is, just goes away by itself. To use your example, when you've gone through that, if you've been in there for three days and no one's bitten you, the next time someone says, "Oh, I'm going to throw you in a pit of snakes," you don't get quite as anxious about it because you think, "Well, that happened last time and ended okay." That's the theory behind the treatment for OCD: if you can break that cycle between the obsessions and the compulsions. In many cases, in the old days, they would physically break it; they would restrain people so they could not wash their hands. They would be screaming, "Let me go, let me go. I need to do this." And then they didn't, and the anxiety, the desire to wash their hands, went away. You can't do that anymore. It now relies on willpower, which is why it's so difficult. Essentially, once you don't perform the compulsions and realize the anxiety can go away by itself, you have more confidence next time that that will happen. So two things happen. One is, because this gets back to your question about why is my life any better? Firstly, because I know the anxiety will go away by itself, I don't feel the need to perform the compulsions, which stops that reinforcement, so the thought doesn't come back. I'm not encouraging it to come back by performing the compulsion. The thought itself tends to go away much quicker, and the thought is the source of the anxiety. Therefore, the anxiety goes away much quicker. Most importantly, almost always, I think I've been in recovery now for 10 years. I think maybe once or twice this has not happened, but almost always, you wake up the next day and it's completely reset. Everything is fine again, which is not the case in OCD. With OCD, you have that split second when you wake up and everything's fine, and then crash, it's all straight back into you. The one you were thinking about before you went to bed is right there, and you start again, whereas that doesn't happen anymore. It's such a wonderful, liberating feeling to start each day without that kind of thought and that anxiety in your head. Yes, I do have bad days. I can get to the stage where I'm really struggling. Sometimes I will say to my wife, "I'm having an OCD moment" or whatever. Sometimes it will last for a day or two, but I try really hard not to perform the compulsions. So far, the anxiety has gone away each time.

SPENCER: So the treatment methodology you're talking about, I believe it's Exposure and Response Prevention, ERP, is that correct?

DAVID: That's right.

SPENCER: How did they do that with you? What kind of exercises did your therapist give you?

DAVID: It's very difficult, obviously, because with Exposure and Response Prevention, if someone is worried about germs from trash, you can expose them to that by rummaging through the trash bin. The response prevention is saying, "Don't wash your hands," either physically restraining, which you can't do anymore, or just encouraging people not to wash their hands. With mine, because I was usually worried about blood, HIV-infected blood, you can't splash me with blood and things like this. It kind of became, with me, more like when you have one of those thoughts anyway, which I do, you just cannot respond to it. One happened when I was in therapy, in the group, and I had one of these thoughts. I had rubbed my eyes and thought there could be blood on the chair. I could have just rubbed blood into my eyes. I knew that the compulsive response was to look and check to make sure there was no blood on the chair. But I thought, "I'm not going to do that." I interrupted the guy who was talking and said, "I'm having one of those thoughts right now. I'm having an intrusive thought right now, live." He said, "Okay, what is it?" I explained what it was. He said, "Just stand up and put your arms out to the side like this." You probably can't see, but he said, "Don't look at your hands and then rub your eyes again." That was the exposure. As ridiculous as it sounds, he may as well have asked me to shoot lightning bolts from the ends of my fingers. There was no way I was rubbing my eyes. No way at all. He said, "Okay, well, you can't look at your hands." That was the response prevention. "You can't look at your hands until the anxiety goes away." It's completely irrational because I went home, bathed the baby, I had a shower, I did the washing; any blood that was on my hands would have long gone, and yet I wanted to look at them, and I didn't look at them. It took about two or three days of desperately wanting to look at my hands. It sounds utterly ridiculous. I work as a freelance journalist. I'm probably losing clients as we talk. We need to tell you about how irrational my brain was.

SPENCER: No, I think it's incredibly brave to talk about this. I think it's really a service.

DAVID: So two or three days, and then the thought, the anxiety did start to go away by itself. I didn't even notice it. It was just there, and then it wasn't. That's kind of the breakthrough moment. That was the first time I'd ever really had one of these intrusive thoughts that I sort of went toe to toe with and won. That did give me more confidence. If it were a film, that would be the moment in which everything becomes better lit. But it wasn't as simple as that. Of course, I still had to get better at it, and I still had failures, breakdowns, and regression, but that was the moment that things tipped, and that gave me the confidence, the tools, the skills, and the experience to then not perform the compulsions. I describe it as a bit like being a recovering alcoholic. You're always a certain number of days since your last drink, and every day you could have a drink. OCD is a bit like that. When someone's offering you a drink, your mind is offering you a drink. "Take it. Take it." And you have to say no each time. It can be quite hard work, but knowing that you don't have to take the drink to feel better is the key, ultimately, because that's what we do the crazy stuff for, to feel better.

SPENCER: Not looking at your hands for two days requires tremendous willpower. What motivated you to really stick with that? Is it that you believed that this treatment was going to work, or were you just in such desperation?

DAVID: We have to go back in a couple of months. The reason I was in that treatment in the first place was because I had a baby, and I started to involve my baby girl in some of these rituals, and that was the point at which I said, "No, this stops." So I went to get help. I went to the doctors. I said, I've got OCD. He kind of looked over his glasses and said, I'm not sure there's much we can do, but I'll see. It turns out I lived in the catchment area for a world-leading treatment center. In the UK, we have the NHS, and I was able to basically get it for free. I was able to get the treatment. At that point, because I was no longer doing it for myself, I was doing it for my child. Again, it sounds like a horrible Hollywood cliché, but I would have done anything at that point, anything they told me to do, because there was no way I was going to do anything that would make her more likely to pick up some of this stuff from me.

SPENCER: Let's talk about OCD and facts.You could read all kinds of statistics about how unlikely it is that you would get HIV, and I'm sure you're well aware of all the statistics. Also, as you point out, HIV is now very well treatable. Talk about how facts do or don't interact with the thoughts that you would have.

DAVID: It's horribly trite, but I saw this on a TV show last night. Think of it as a difference between knowing and feeling right. Facts help people know things, but if I feel that my football team Stoke City is going to win the Premier League one day, the facts don't interfere with that. That's what I think. That's what I believe. That's what I want to happen. So that's one way of thinking about it. The other is that it's not all facts. I had this irrational fear of HIV because I thought it would kill me, but I didn't worry about doing things that were much more likely to kill me, like driving on a motorway or going on an airplane. All these things did have statistical justification that it's a very small risk, but people die on the roads every single day, and yet it never bothered me whilst driving a car, I certainly would go faster than the speed limit. I would increase my risk of being in an accident. So I didn't have a generalized fear of risk, I suppose, or intolerance for risk. Mine was very laser-focused on HIV, and that's often the case with OCD and not other blood-borne diseases. I didn't worry about hepatitis B, for example.

SPENCER: It almost seems like a loop because it's so specific; it almost seems like something in the brain that's looping on some very narrow little circuit.

DAVID: Yeah. We mentioned that there are some psychological explanations for why those thoughts turn into OCD. Some people, if you ask a psychologist, that's the answer you get. If you ask a neuroscientist, they will point to certain loops in the brain. Everything in the brain does so many different things. You have to be very skeptical about saying we've isolated this and that. But there's some crossover between what they think happens in OCD and addiction. You mentioned it's like a hit. You get a little addiction to that bit of reassurance. There are certain animals that will perform compulsive behaviors. There are some very controversial surgical brain procedures that seem to help with OCD. You can cut away a part of the brain to physically interfere with the loops, with the cycles.

SPENCER: Or electrical stimulation, right? As a newer treatment modality.

DAVID: This is another one. So anything that is designed to reroute, block, divert, or expand on those little circuits and the way they work. The difficulty there is that I don't have one of those circuits for HIV and one for hepatitis C and one for getting on an airplane. It's very hard to understand why, if it's just a brain circuit, it would be just that bit of the great universality of the world. Why is it just this one disease which my brain hadn't even heard of until a couple of years before? It can't just be circuitry; there has to be, I think, some kind of conscious awareness. HIV was associated with sex, and I was a teenager, and there's a kind of shame associated with it. There has to be a role for the emotional response to it. The thing about the facts is that I knew the facts, but I hadn't accepted them. I thought if this person tells me the fact, that will help me accept it. That's why I would call up the phone line and get them to tell me things I already knew, because that gave me that little hit of reassurance. It was an external force; somehow it never lasted. The more we talked about this off air, about how sometimes you have to check things, there was this feature that the more you focus on something, the less you actually remember it or take it in. If you say any word over and over again, like "table," after a while, it just sounds bizarre. Why would we call this thing that? It detaches from its meaning and just becomes sounds. I think facts are a bit like that in the brain; the more we think about them, the more slippery they become. You start to interpret these ideas and not explain this very well, but I guess the facts kind of become a little bit detached from the impact they should have and just become more like philosophical ideas that can be challenged. It's very hard to explain some of this stuff.

SPENCER: Some people might think that these kinds of OCD thoughts might almost sound like psychosis, like some kind of delusion. How is it different from psychosis?

DAVID: It's a good question, and there is a very clear distinction, and it comes back to that idea about obsession being besieging and there being resistance. Essentially, when I have intrusive thoughts, I know they come from me, and I fight against them, whereas, as I understand it, with psychosis, someone with psychosis can experience the exact same thought, and it's as real to them as someone just saying it to them, as if I were to meet you. It's as real to them as if they were to meet someone in the street and that person would say it to them. They think that it's from outside, so they've given up resisting them, which is why possession, it's the distinction between obsess and possess. In military terms, it was carried over into clinical terms, essentially with obsession being you're aware and you resist, and possession in psychosis is that you're just fully immersed in it, and you're not aware that you're generating these thoughts and you don't push back against them.

SPENCER: Sometimes OCD is referred to as a doubting disease, and you can see this with, for example, people who will lock their door when they leave their house, but then they think, "Well, did I really lock my door?" And then they go back, and then they lock it again. And maybe they do this 12 times. It's kind of mysterious to someone who doesn't have OCD. You might think, "Well, okay, but don't they know they locked it? I mean, they just did it. How could they not know that they locked it already?"

DAVID: So we talked before about the word "table," how it can lose its meaning. They have shown in experiments that if you ask someone to turn a faucet off and then go and ask them to do it again and again and again, and then ask them if they did it or not, the more people do it, the less able they are to remember doing it. They think this is because when we first see something, we see the features of it, the shape, the color, and those are much easier to remember. So when someone says, "If you don't turn the faucet off, did you turn it off?" You remember in your head, "Yeah, it was facing that way. Now it's facing this way, yeah, I turned it off." Whereas, if you look at the thing again and again and again, your brain starts to not see the thing in terms of its shape and its visual features. It seems in terms of its function, more kind of abstract ideas, which I think will be different from person to person, but they're harder to remember. It's harder to remember these abstract concepts that you associate with something than it is to just remember its shape and size and color. But also the doubting comes down to another thing we mentioned: the personality types that can develop OCD. One of the personality types that seems to be more likely is people who have an inflated sense of responsibility. It's their fault if things happen, even though it's really not. This seems to play a really big part in OCD. So when anyone leaves, they close the door. They might want to check it, and part of that is because you don't want to be the one responsible for leaving it open. Very rarely does anyone call their wife and say, "Did you close the door? Are you sure?" It's like the iron. When I've been ironing, I will double-check it off because I don't want to be responsible for burning down the house when I'm away. I don't call home and say, "Has anyone turned the iron off?" Which is much more likely if I'm not here. OCD can be very local sometimes, or it can be dependent on certain people who trigger this idea of responsibility. I give an example from therapy. I mentioned I had a baby, so one of the things I was worried about at the time was if I was shaving and cut myself, I might get blood on my hand. I might touch the baby with it; I didn't want that to happen. The therapist said, "No, no, next time you cut yourself, smear the baby in blood."

SPENCER: It's going to the therapeutic recommendation.

DAVID: And I said, "No, I can't do that." He said, "No, no, I'll tell you why, because I've asked you to do it. Look at me. I've got a nice suit, I've got a nice job. Would I do anything that's going to get me fired? Right? No, but if it happens, I will take responsibility. I will resign, I will leave." And I never did it, but in my head, and I'm not proud to say this, it made it so much easier to think about doing it, to think about going and smearing my baby and possibly HIV-infected blood.

SPENCER: Because it was a responsibility.

DAVID: Yeah. And I think that's partly when people, of course, can see it's locked, but they're not worried about the door being locked. They're worried about the consequences of it not being locked. And very often those in our head are so big compared to the tiny effort of just going to check if it's closed.

SPENCER: Right. It's like, even if there's a one in a thousand chance, someone could break into my home and kill my child or whatever. So it's that one in a thousand chance, which really might be a one in a billion chance, but you want to keep getting that probability as close to zero as possible.

DAVID: Yeah.

SPENCER: There seems to be also something around intuition, where my understanding is that people with OCD have been tested and they don't have worse memories than the average person, but they do trust their intuition and trust their memory less.

DAVID: Yeah, I think that's right, and I think it partly comes back to what we were talking about. I mean, these people would not trust their memories less for non-specific memories. It's usually to do with what they're obsessing about. I think you can't get away from this idea that they will have performed certain checks again and again, and that will have had an impact on their memory and whether they believe that or not. I think also confidence is something we're talking about, really trusting your memories, confidence that your memories are correct. You can lose confidence quite quickly, and it's quite difficult to regain it. Once you've had to go back and check your door is locked 10 times, if someone says, "Do you trust your memory?" You're gonna say, "Well, actually, probably not." No, because the evidence shows that I don't.

SPENCER: Is there anything that you can do to help a loved one who has OCD? What would you have wished your friends or family members would have done? Obviously, they didn't necessarily know what to do, but what would be the ideal thing for them to have done?

DAVID: So it's a really difficult question to answer. It's a really important question, and it's one I get a lot from people who want to help loved ones. You have to realize that OCD is a serious psychiatric condition and it needs professional medical help. If by "what can I do to help this person" means I want to help them feel better about themselves and have a long, fulfilling, and happy life, then you just have to somehow steer them into medical treatment. Again, it's the slightly tried answer. Sometimes, people think that they're helping by indulging the obsession. What I would have wanted would be someone to talk to about it, and it's entirely my own fault that I did not. I don't put that blame on anybody else except for me, but listening and understanding or trying to understand is a big comfort. It doesn't address the symptoms, but it does address a sort of secondary pain that comes with OCD, which is keeping it to yourself and your secret, and living a lie, and people don't really know you, which is how I felt for a long time. Just being open and talking about it with family members is a big help, but it does not remove the problem itself. There's a whole kind of — I can't remember the technical term for it — it might be accommodating when family members or friends, let's say someone has OCD around locking the door, accommodate that by saying, "Don't worry, I'll check it for you. I'll go and check the door. I will shut the door. You go and get in the car." That can be helpful on a day-to-day level because it means you can leave the house and do what you want to do. You can get your kids to school. But ultimately, I think, anyway, I've not looked at the literature for a while, but I think accommodation is still viewed in the same way as performing the compulsion — people performing the compulsion themselves. In a sense, you're feeding the fire. You're encouraging the obsession to come back. That is not a judgment in any way on people who do it. Because I've got children, I completely understand you need them to leave the house. I'll go and check the windows; you get in the car. But that, I think, is more likely to make intrusive thoughts about the windows being open more likely to come back.

SPENCER: I imagine that many people with OCD keep their obsessions secret, but suppose someone is talking to you about their obsessions and they're saying, "I fell the other day and I cut my knee, and now I'm thinking of HIV." What is the right way to talk to someone about their obsessions? You don't want to feed it, you don't want to reinforce it, but you also don't want to be unempathetic or dismissive.

DAVID: So I can only talk from my own experience, and I was clever when I was in therapy because you weren't supposed to seek reassurance. That was a no. That was your compulsion. So what I used to do was, when they would say at the beginning of the week, "How's your week been?" I would say, "Oh, it's really weird. I had this thought where I fell over and hurt my knee, and I was worried about the astroturf," waiting for someone to go, "Oh, that's silly, isn't it?" As a way of seeking reassurance. This is why now, when I have intrusive thoughts and I say to my wife, "I'm having one of these episodes," I won't tell her what the content of the thought is. I won't say I'm having these intrusive thoughts that I shook someone's hand and I might have got blood in a cup because she'll just go, "Well, that's silly, isn't it?" And I'll go, "Yeah, isn't it?" And that'll be the reassurance, and I'll make the thought more likely to come back. So from my own experience, if I were to say to someone, I'm having these really weird obsessive thoughts that I just hurt my knee and I might have got blood in it, if they were to say, "Oh, well, that's ridiculous." That's never going to happen, that wouldn't help me, and then it would hurt me because it's just like me being told that on the telephone. I think what would help is, "Oh, I get thoughts like that as well. Aren't they weird?" Not that it will take away the symptoms of OCD, but that it helps to build a connection back to people who feel as if they're very isolated because I didn't tell anybody this stuff for years, and now I talk to complete strangers about it, and it's because it's lost its salience. It's lost its emotional resonance when I talk about it through just repetition. But the first time I told someone I had OCD around HIV, I remember it was in an email to my book agent, and I emailed it, and then I deleted the email, and then I deleted it from the trash, and I turned the computer off again. And now I can say it. I must have said it about 100 times in this one interview. And so never underestimate what it has taken someone to say that to you because you might be the first person they've ever told, and it might have been something that bothered them for years, and they finally thought, "I'm going to tell someone," and you're that person. You don't know you're that person. But to them, this is the most important conversation they've had in five years.

SPENCER: I feel it, feeling connected and feeling like what you're thinking is acceptable and that people will reject you, I think is really powerful.

DAVID: I said it won't take away the anxiety that it's causing them about the content of the thought, but it does make them feel less weird about having the thought.

SPENCER: One thing that we didn't mention is this idea of a not just right experience where for some people with OCD, there'll be something that's not lined up perfectly, and it will really, really bother them, and they'll feel like they have to make it just right. Did you have experiences like that, or is that not related to your kind of OCD?

DAVID: No. Mine were all driven by obsessions. It is worth saying that the main sort of stream view of OCD is what I've mentioned about the thought leading to the compulsion. However, there is a degree of skepticism around that with some people, and some psychiatrists and psychologists think that people can experience OCD where they almost get the compulsion first. They get the feeling, and then they have to justify it somehow by coming up with a thought. That might be an example. "These blocks aren't quite right. It makes me feel weird, and that's because I don't like the way they look, or that's too obvious." But it's triggering thoughts about something bad happening. Maybe I'm making this up because I do not experience that. I'm just trying to describe it. I know that there are some psychiatrists who, when they hear me say on the radio that thoughts lead to the obsession, sorry, thoughts lead to the behaviors, they go, "No, no, no, that's not right." Some people don't get it that way, but most people I've met with OCD do.

SPENCER: I just want to point out that OCD takes many different forms. Some people have it around patterns. Some people have it around fear of harming others. We talked about that with our parents. There's also pedophilic OCD where people are not actually attracted sexually to children, but they have OCD around the fear that they're attracted to children. What other ways have you seen it manifest?

DAVID: Oh, every way you can imagine. Since I wrote the book, I have been contacted by people. I've met people who think when they close their eyes, the entire world is going to change. I've met people who think they could be growing a tail. I've met people who can't park their car unless it's next to a green car. I've met people who worry they've knocked someone off their bike on the way home from work in their car, and they call all the hospitals to make sure they haven't knocked anyone off their bike, even though they didn't even see a bike. What is interesting about OCD is that it does seem to run along cultural themes and temporal themes. OCD around HIV was a really big one in the 90s because of what happened in the 80s. I found examples of people from the 20s who had OCD with the exact same symptoms around syphilis. They worried about it even though they hadn't done anything to contract syphilis, and they tested negative for syphilis. They worried about giving it to their wife. Most recently, we've seen people with OCD around COVID. There was an example that sounds ludicrous and racist, but this is what happened. There was this guy who couldn't eat Chinese food because of the irrational fear that, because the virus originated in China, there was some kind of risk there. As far as he was concerned, it was irrational. He knew it was irrational; he just couldn't do it. The pedophilia cases over here were a very high-profile series of cases of people in the public eye who were exposed as being historical pedophiles. There was a big surge in the number of people who get OCD around, I may have done something in the past. I don't think I did, but I can't quite rule it out, even though they didn't. To be clear, these are not pedophiles. You even get OCD around climate change. The content of the thoughts is around the consequences of climate change, and people have to compulsively fill up their dog's water bowl in the middle of the night because they're worried it's all going to dry up. Although it is, as I said earlier, limited only by the content of human imagination, it definitely runs along certain themes. Mine, unfortunately, is quite a boring sort of average theme. The fear of disease and contamination is probably one of the most common ones.

SPENCER: We mentioned exposure and response prevention, but there are also SSRIs, which are often called antidepressants. They're used for OCD. Could you comment on that?

DAVID: Yeah, so I take a very high dose of an SSRI. I take 200 milligrams a day for depression; maybe you get 50 or 100, so it's quite a high dose. I'm not depressed and never have been depressed, but it just seems to work. With OCD, most of these drugs seem to work, and then they reverse engineer an explanation for it. These drugs are noted to change the levels of serotonin. Therefore, maybe serotonin is involved with OCD, which gets mistranslated as OCD is all down to serotonin, which it might be, but we don't know. You can't prove that from the SSRIs; they do seem to help. I couldn't tell you why. I only really notice the effect they're having when I forget to take them for a couple of days, and then everything just seems a bit off-kilter. I don't know if the OCD symptoms get worse if I don't take it. I suspect not, and that's just more of an acute effect of brain chemistry. But, yeah, I've had the treatment we talked about over 10 years ago, and I still take the drugs every day. The reason for that is I don't experience particularly severe side effects. I'm not aware of any negative consequences of taking them long term, although, to be fair, there aren't many people who have taken them for 20 or 30 years, so there might be something horrible in store, but we don't know about it, although it's unlikely, mainly because my psychiatrist says, "You know what gets you well, keeps you well. Why take the risk?" The consequences of OCD returning are just too great to risk. So I will keep taking them. They're not a perfect fix, and it's very difficult to differentiate the difference they make because you get given the SSRIs at the same time as you usually start the therapy. So I can't distinguish in my head which helped and to what degree it all came as a package.

SPENCER: My understanding, though, is that the prognosis is quite good for OCD, that many people do recover through a combination of SSRIs and exposure response prevention. Is that right?

DAVID: I think so. I like to say that the treatment helps most people most of the time, but there are people who are treatment resistant, and they turn to all sorts of more extreme solutions, including, we talked about surgery. I think it's rare to meet people who think they've been cured of OCD. In pediatric cases, it's different. If you have adversity as a child, I think you can be freed of it, at least. That's my experience from talking to people. If you develop it as an adult, I think it's less convincing that you can be completely in remission. You can be in remission, but I described it at the beginning as managing it. I think that's what I do. I'll always be a managing OCD patient, even though I don't show the symptoms. I don't think that I'm fixed.

SPENCER: But your life is dramatically improved, it sounds like.

DAVID: My life is fixed. My life is fixed. Yeah, I have good days and I have bad days. And that's a lot better than only having bad days.

SPENCER: Final question for you. If a listener to this thinks, hey, I might have OCD, what would you advise them to do?

DAVID: They could read my book that might help.

SPENCER: The Man Who Couldn't Stop?

DAVID: Yeah, if they do have OCD or not, I would say, being flippant, go and get help. Go to the doctors, get help. I know it's not as easy as that in many parts of the world because there are issues of access and cost. So what I would say is that if what you are going through is OCD, then millions of other people have been where you are sitting. And most of us, when we've had the treatment, have felt better, mostly better, most of the time. So what you are going through, the bad news is it will not go away by itself. But the good news is that if you can get access to the treatment, then there's a good chance that you will feel better than you are now. And if you think you've got OCD, you probably do, to be honest, because it's so severe that you know if you've got a problem.

SPENCER: David, thanks so much for coming on.

DAVID: Thank you.