23 April 2007

Monk’s odd behaviour: real or exaggerated?

The detective Monk in the TV series with the same name, suffers from obsessive-compulsive disorder. Health24 gives us a glimpse into the lives of real Monks.

The brilliant and entertaining detective Monk in the popular TV series with the same name clearly suffers from obsessive-compulsive disorder (OCD).

This condition sometimes makes his life hell, but, on the other hand, his obsession with precision helps him in his detective work to see details that other people fail to notice. What are the Monks like in real life? Health24 gives us a glimpse into their lives.

Monk has obsessive thoughts or ideas about almost everything. And these thoughts create extreme anxiety, which can only be reduced by engaging in “compulsive” behaviours. For instance, he constantly worries about germs. He refuses to walk barefoot. He removes every speck of dust from his jacket, refuses to touch anything without gloves, shudders at anything that seems dirty and is obsessed with symmetry.

He signs his name over and over on a cheque until he is satisfied that each letter is perfect. He counts and rearranges objects repeatedly until everything is or feels “just right”. His obsessions and compulsive behaviour are so bad that it borders on paranoia.

Is Monk a typical OCD sufferer? Do we find such people in real life, or are his obsessions and compulsions exaggerated to make for better viewing?

OCD is an anxiety disorder that occurs in two to three percent of all people. Some people present with subclinical OCD, i.e. they have obsessive-compulsive symptoms that are not severe, time consuming or impairing enough to justify a diagnosis of full-blown OCD. Therefore, more than one out of every 30 people who read this article or people you know may show symptoms of this anxiety disorder.

It is characterised – as the name indicates – by obsessions and compulsions, which take up a significant amount of time and cause considerable distress and impairment.

Obsessions are unwelcome ideas, images or impulses that arise repeatedly and involuntarily and cause intense anxiety. The person cannot prevent these thoughts from constantly appearing. Most of the real Monks realise that these thoughts are senseless, but are mostly unable to suppress, control or ignore them.

Monk’s exaggerated concerns about germs, neatness, hygiene and order are typical obsessions. These types of obsessions are typically followed by compulsive cleaning, washing and ordering (see “Compulsions”).

Many people worry excessively about either a number of things or even just one aspect of life (e.g. religious / moral concerns, or sexuality), and if this obsessive worrying (and the resulting anxiety-reducing behaviours such as praying) takes up more than an hour per day, or if it interferes significantly with their normal routine, career, functioning or social behaviour, they may be suffering from OCD. It is one of the most limiting psychiatric conditions.

OCD usually develops during one’s childhood or teenage years, although it may only emerge in adulthood. People with OCD are often embarrassed about their symptoms since they realise the irrationality thereof and attempts to hide their symptoms as best they can. Many people may thus have OCD without other people ever realising it. That is why it is also known as a “secretive illness”.

Compulsions are repeated, ritualistic behaviour (including mental rituals such as praying or counting) that follow the obsessions – usually as an attempt to reduce the anxiety caused by their obsessions.

Examples of general compulsions are the repeated washing of hands, repeated checking if doors are locked, repeated checking if the iron or some other electric appliance is switched off or the repeated ordering of objects in neat rows and. (That pain-in-the-neck friend of yours who keeps on putting everything “in its place” may be more than just a tidy person!)

In real life
In real life people who suffer from OCD often don’t have such a wide spectrum of symptoms as Monk. People suffering from OCD can become fixated on one primary obsession or and/or compulsion.

The topic of the primary obsession/compulsion may change during the course of time – a boy could, for example, cope with fears of contamination by exaggerated washing and cleaning during his teens and in his twenties shift his focus to an obsession with symmetry and tidiness. The severity of obsessive-compulsive symptoms also often changes over time, i.e. has an episodic course.

Monk presents with a series of obsessions and compulsions. In fact, the situation is so bad that it borders on paranoia. It doesn’t often happen in real life that OCD approaches paranoia. Rather, paranoia is considered a delusion or hallucination - these symptoms are part of the spectrum of psychotic disorders, where there is a break with reality.

The difference can briefly be explained as follows: If the patient refuses to shake people’s hand because of contamination fears and realises that his fears are irrational or excessive, a diagnosis of OCD would probably be appropriate.

On the other hand, if he thinks that other people purposely seek him out to shake his hand for some reason, it probably is a delusion and may he may be suffering from paranoia or a delusional disorder. He has crossed the border between an anxiety disorder (OCD) and a psychotic condition.

Anxiety disorders are still stigmatised
Although Monk’s range of obsessions and compulsions are exaggerated, some psychiatrists and psychologists psychologists still maintain that the series did much to bring OCD to the attention of the public.

It shows that people who suffer from OCD often are extremely intelligent and highly functional members of society. Monk’s character gives the public a glimpse into the impact that OCD can have on the life of a sufferer (and his family).

OCD can be brought under control with a combination of antidepressants and psychotherapy. Psycho-education (i.e. providing accurate information on OCD, its causes, course and treatment to the patient and his/her significant others) is the third equally important aspect of treatment.

The cause of OCD
An increasing number of studies indicate that a specific part of the brain, namely the basal ganglia, as well as specific neurotransmitters (e.g. serotonin or dopamine) function slightly differently in people with OCD.

It also appears that OCD might have a strong genetic or heritability component. According to Dr Christine Lochner, co-ordinator of the MRC Unit for Anxiety and Stress Disorders (Department of Psychiatry, University of Stellenbosch), research has shown that 35% of people with OCD have at least one close family member who also suffers from OCD or displays obsessive-compulsive symptoms.

Although several genes have been implicated in terms of anxiety disorders, OCD has not yet been connected to a specific gene. It increasingly appears that OCD may be caused by the interaction between a multitude of factors, e.g. environmental factors (like trauma during childhood or after repeated streptococcal infections) and neurobiological factors (like neurotransmitters).

In other words, if someone has a higher risk for OCD because of a family history of this condition, a trigger such as extreme trauma or even pregnancy or childbirth can set off OCD. Without these triggers, a person could theoretically spend his whole life without displaying any symptoms of OCD.

You can help
The MRC Unit for Anxiety and Stress Disorders is currently busy investigating the connection between genetic predisposition and obsessive-compulsive symptomatology.

If you are interested in taking part in this study, please call Dr Lochner on (021) 938 9179 or email:

- Ilse Pauw, Health24

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