306 CHAPTER 7
stress and are more likely to be rejected by their families (Calvocoressi et al., 1995).
Note, however, that the direction of causation is not clear: Although stress in the
family may cause the greater severity of symptoms, it is also possible that the more
severe symptoms led the families to reject the patients. In fact, a more recent study
found that the more severe the patient’s OCD symptoms, the less hopeful and more
depressed were family members (Geffken et al., 2006). People with OCD often im-
pose various restrictions on the behavior of friends and family members to ensure
that it conforms to the patient’s “rules,” as Hughes did. For instance, someone who
compulsively checks that doors and windows are locked may demand that family
members similarly—and repeatedly—check the locks throughout the day.
Stress greatly affected the course of Hughes’s symptoms. For much of his 20s,
30s, and early 40s, he was able to function relatively well, given the freedom his
wealth and position provided. Although he was often preoccupied with work—stay-
ing up for 40 hours at a time to work on a fi lm or on a design for a plane—he was
able to keep his obsessions and compulsions at bay well enough to do his work.
However, there were occasional periods of time when the external demands of his life
became intense—deadlines, fi ghts with associates, or legal problems—and his symp-
toms worsened. During one particularly stressful period in his late 30s, “Hughes
began repeating himself at work and in casual conversations. In a series of memo-
randa on the importance of letter writing, he dictated, over and over again, ‘a good
letter should be immediately understandable... a good letter should be immediately
understandable... a good letter should be immediately understandable.. .”
(Bartlett & Steele, 1979, p. 132).
By the time Hughes was in his 50s, however, the stressors increased and his func-
tioning diminished. There were periods when he was so preoccupied with his germ
phobia that he couldn’t pay attention to anything else. At other times, his symptoms
ebbed enough that he was able to focus somewhat on running his empire. But he
couldn’t reliably attend to the day-to-day demands of his businesses.Culture
Different countries have about the same prevalence rates of OCD, although culture
(Weissman et al., 1994) and religion can help determine the particular content of
some obsessions or compulsions. For instance, religious obsessions and praying com-
pulsions are more common among Turkish men than French men (Millet et al., 2000)
and more common among Brazilians than Americans or Europeans (Fontenelle et al.,
2004). And a devoutly religious patient’s symptoms can relate to the specifi c tenets
and practices of his or her religion (Shooka et al., 1998): Someone who is Catholic
may have obsessional worries about having impure thoughts or feel a compulsion to
go to confession multiple times each day. In contrast, devout Jews or Muslims may
have symptoms that focus on extreme adherence to religious dietary laws.FEEDBACK LOOPS IN ACTION:
Understanding Obsessive-Compulsive Disorder
One neurological underpinning of OCD appears to be a tendency toward increased
activity in the neural loop that connects the frontal lobes and the basal ganglia
(neurological factor). A person with such a neurological vulnerability might learn
early in life to regard certain thoughts as dangerous because they can lead to obses-
sions. When these thoughts appear later in life at a time of stress, someone who is
vulnerable may become distressed and anxious about the thoughts and try to sup-
press them. But a conscious attempt to suppress unwanted thoughts often has the
opposite effect: The unwanted thoughts become more likely to persist (Salkovkis &
Campbell, 1994; Wegner et al., 1987). Thus, the intrusive thoughts cause additional
distress, and so the person tries harder to suppress them, creating a reinforcing cycle
(psychological factor).
The content of a person’s unwanted thoughts determine the extent to which
those thoughts are unacceptable. When a person wants to suppress the unwanted
thoughts, he or she develops rituals and avoidance behaviors to increase a sense ofP SN