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Obsessive–Compulsive Disorders

Obsessive-Compulsive Disorders

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A descriptive definition of the obsessive-compulsive disorders was provided by K. Schneider (1939): an obsession exists whenever a person cannot exclude thoughts from consciousness and, although he distinguishes them as unreasonable or without basis, is mastered by them (see Ingram 1961).

Obsessional phenomena range from trivial everyday acts, such as knocking on wood, stepping on lines, special ritualistic procedures for dressing, toiletry, or going to bed, and repetitions of such ordinary precautionary measures as turning off the gas or light, to well-organized behavioral and intrapsychic systems that dominate the person in the obsessional neuroses or character disorders.

In terms of a dynamic definition, an obsessional disorder is one of the reaction types of psychoneurosis in which the individual suffers from the need to perform either logically unnecessary ritualistic acts (compulsions) or experiences repugnant thoughts (obsessions). The element that distinguishes these disorders from similar ones often found in conjunction with them is a drive to repetition that is irresistible even in the face of strong conscious suppressive efforts and that is senseless or inappropriate, and only imperfectly adjustive in reducing tension and anxiety. Often present in these disorders are various grades of doubt, indecision, ambivalence, guilt, magical thinking and superstition, sadistic and masochistic tendencies, rumination about order and disorder, right and wrong, cleanliness and soiling, love and hate; all these elements contribute to the conflict, usually without being understood or subject to control by the individual even though he thinks them silly, ridiculous, painful, or humiliating (Cameron 1963; Fenichel 1945; Freud 1905; 1917; Jones 1953-1957).

Such neurotic reactions are not totally determined by hereditary (genetic) mechanisms, as Slater’s studies on identical twins demonstrates (see Shields 1962); however, Tienari (1963) and Woodruff and Pitts (1964) believe the question remains open. [SeeMentalDisorders, article onGeneticAspects.]

Historical background . Because the obsessivecompulsive disorders occupy such a wide spectrum of behavioral manifestations in the spheres of thinking, acting, and feeling, definitive identification of crucial criteria is precluded. The terms “obsessional neuroses” and “obsessional illness” became common in Great Britain, while “compulsion neuroses” was used more frequently in the United States, but all these terms were derived from the German terms psychische Zwangsvorstellung (introduced by Krafft-Ebing in 1867), Zwangsneurose, Zwangserscheinung, and Zwangsaffection (see Loewenfeld 1904). Adolf Meyer introduced the more inclusive term “obsessive-ruminative tension states” as a category in his dynamic classification of reaction types (Collected Papers, vol. 3, p. 297). Other designations used since 1941 are obsessive or compulsive behaviors, defenses, mechanisms, systems, conditions, or reactions. The term “psychasthenic” was popularized in France after Pierre Janet used it in his classic descriptions to cover a wide range of repetitive, anxious behavior in the ideational, emotional, and motor areas, but this term is little used in English-speaking countries (Janet & Raymond 1903). Schneider’s definition is derived from the work of Westphal (see Loewenfeld 1904), with its negation of any emotional or affective basis for these conditions. A. Lewis stressed the subjective feeling of resistance rather than the recognition of senselessness (see Ingram 1961). The French, following Morel, insisted on the emotional foundation of obsessions and distinguished them from phobias, or obsessions consisting of fears [seePhobias]. Most English-speaking writers did not pursue these lines of thought because there was increasing recognition that these distinctions between thinking (obsessions) and feeling and acting (compulsions) were artificial: upon close inspection over time, all three were found together.

Pavlov related repetitive actions such as human obsessions and compulsions to the pathological conditions of the cerebral cortex: mechanisms that would normally obliterate an impulse failed to do so, with the result that persistent repetitive activity occurred or, in some cases, lesions produced pathological isolation and fixation of ideas (Wortis 1950). Particularly during the last ten years of his life Pavlov wrote papers on neuroses and psychoses. His thesis of “second order” activity (speaking, thinking, abstract ability) gave sanction to psychotherapy as we know it (because it uses words ) which thus received approval from the Soviet government.[See the biography ofPavlov; see also Seredina 1955.]

Biological, evolutionary process concepts . Current American writers on obsessive-compulsive disorders on the whole adopt Freud’s view that behavioral syndromes are processes rather than discrete entities. However, careful physical examinations must be performed to determine the presence of neurological lesions, since D. Denny-Brown (1952; Denny-Brown & Banker 1954; Association for Research... 1958) and H. Klüver and P. C. Bucy (1937) have shown that obsessive, catatonic, and oral behavior may be considered as release phenomena; O. R. Langworthy (1964) has reviewed the clinical importance of this work.

Obsessional processes may be thought of as organized psychological systems, operating to help maintain internal and external equilibria for the survival of the person. This view is based on a broad evolutionary perspective: man is a member of the biological world, and is both a product and an architect of evolutionary biological and cultural development. As a result of the work of Freud, Eugen Bleuler, and Adolf Meyer, psychiatrists have learned to study man as a biological organism whose developmental history is intimately related to his motivation and behavior. This permits the reordering of massive volumes of meticulous description into more comprehensible families of behavior aligned according to principles. Developmental periods—autoerotic, narcissistic, oral, anal, phallic, latency, genital—and specific phenomena of the periods can be grouped in relation to the critical periods of behavioral change—Oedipal, pubertal, mature (Freud 1905). Other functional principles, such as an ascending order of complexity; the clustering of defense mechanisms, such as regression, displacement, isolation, reaction formation, undoing, and self-punishment; and other recurrent patterns—all can be used as bases for organizing overt behavior. Formally these patterns are those of the classic theoretical descriptions; informally they may refer to the characteristic ways in which a person may use time, money, or clothes and other possessions, exert power, or choose an occupation, leisure and hobbies, or any other activity (Fenichel 1945; Freud 1905; 1917; Jones 19531957).

Domestication ( socialization ) of the basic hereditary components is required in order for a person to achieve sufficient maturity to live at the cultural level required by his peers. This maturity is not a stable, enduring state but must be maintained by numerous adaptive devices such as are found in the physiological system for the regulation of oxygen supply, blood pressure, or pH levels. The writings of Frank Beach (1958) offer a sophisticated introduction into the problems of design and interpretation inherent in the subtle interactions between physiological and psychosocial systems.

[SeeDevelopmentalPsychology; Homeostasis; Personality; Socialization.]

Dynamics of obsessional disorders . There is no wholly satisfactory classification of the underlying dynamics of obsessional disorders. Until the appearance of Freud’s monograph “Three Essays on the Theory of Sexuality” (1905), the descriptions of the obsessional, sado-masochistic, and related fetishistic or perverse symptom patterns were a collection of unrelated, often bizarre, but very puzzling exhibits in the museum of human behavior. Freud’s brilliant insight that these behaviors were intelligible in the developmental process, and were akin to similar processes in biology and psychology, made possible an examination of them in naturalistic terms. The general principles that have been established for such other neurotic reactions as anxiety states, phobias, conversions, and dissociative reactions also apply here. Psychiatric and psychoanalytic textbooks usually list subgroups of the obsessional disorders according to the presenting symptom or the major defense processes in the conflict between instinct and defense. These action patterns are immensely helpful to the clinician in the intricate task of describing and observing the progress made by the patient. Because the symptoms usually reflect ambivalent motives and exhibit opposing emotions simultaneously (obedience and rebellion) or in biphasic fashion (behaving alternately as a rebellious child and a stern parent), it is not a simple task to chart their course. Understanding the motivations, such as the child’s love for, and fear of, parents, makes the transformations much more intelligible. Such paradoxical behavior as not being able to brush one’s teeth for obsessional reasons and then slapping and scolding oneself for this failure, or excessive and ritualistic handwashing, or concern for external cleanliness occurring together with soiled underwear, or time-consuming ritualistic bathroom or bedroom behavior are seen as logical sequences in terms of the patient’s personality organization. The patient is re-enacting fragments of earlier behavior, when the angry, frustrated child’s thinking was dominated by the talion principle and the rules of word magic, and before the more realistic logical rules of adult life were established. This interplay can also be seen daily in normal equivalents.

Norman Cameron (1963) has attempted a threelevel classification which, with some justification, represents ascending levels of complexity of evasive maneuvers each with its more prominent behavioral characteristics. A fourth category is appended which does not fit into the scale because much of the emotional component of the obsessional reactions has been repressed.

(1) The first level consists of regression, displacement, and isolation. These are unconscious defensive techniques used in an attempt to relieve intolerable tension and anxiety. Isolation is related to denial and ego-splitting and may be a variant of the same general process. Regression and displacement are used when adult sexual or aggressive problems are shifted to the infantile scene where the patient feels more competent to handle them, or to change the focus from a crucial conflict to a less threatening sphere, such as reckless driving, body-contact sports, or a chess game, rather than to direct assault. Isolation can be used to fragment opposing elements of a conflict so that they will be less threatening or to steer away the fearful emotional components from the obsessional defense systems. This is aimed at preventing the confrontation of opposing attitudes, such as I love (hate) my father, mother, boss, country. The results are similar to those seen in the dissociative reactions (hysterias) of denial and splitting of the ego. [SeeHysteria.]

(2) The second level deals with the overt use of one neurotic maneuver as a countermeasure in an attempt to offset the effects of some other neurotic maneuver. This technique is present to some extent in most obsessive—compulsive reactions. In addition to the first-level defenses, which are used when repression is deficient, the countermeasures are often necessary to help prevent further disintegration of the ego because of excessive tension and anxiety. The patient will invent rituals to avoid unpleasant thoughts. These may take many forms, such as thinking about something else or indulging in behavior to ward off the feared thoughts. This is particularly evident in the patient with excessive, crippling overconcern with germs, viruses, broken glass, knives, poison, gas, feces in the toilet, organic fertilizer, or other substances that might be lethal weapons against those who are closest to the patient and who are simultaneously hated and loved.

(3) The third level involves more complex defensive measures: reaction formation, ritualistic undoing, and sado-masochistic self-punishment. A handwashing compulsion utilizes all these processes.

(4) A fourth level involves phenomena such as obsessive doubt and rumination, where many of the emotional components of the obsessive-compulsive reactions have been repressed. This results in what Cameron calls “caricatures of magical, scientific, artistic and religious practise.” Especially in highly cultivated people, remnants of superstitions and the rigid retention of antiquated and useless practices in commerce, law, medicine, science, and philosophy are present. In such patients, apparently profound questions about the nature and meaning of life, death, immortality, time, space, eternity, sin, sex and reproduction, justice, and God may be displaced symptoms related to primitive childhood perplexities about their own identity and relations to members of the family. Clergymen have long since learned to separate the genuine seeker after truth from an obsessive doubter, who is referred to a psychiatrist (1963, pp. 373-411).

Etiology. Freud viewed the neuroses, including obsessional disorders, as processes consisting of adjustive defense mechanisms to protect the person’s conscious and moral life-activities from the onslaughts of the basic internal drive states, e.g., libido, instincts (Fenichel 1945; Freud 1905; 1917; Jones 1953-1957). Neonates can be observed to differ in their innate ability to control these impulses. (Inherent in this evolutionary view, when one considers the potentials for the emergence of new properties, qualities, and configurations—as in our embryologic development from a single fertilized egg to an extraordinary complex organization in which the central nervous system alone has about 1010 elements—is the probability of defects in all the human systems during the tumultuous growth period.)

Obsessional disorders are similar to other neurotic symptoms in being compromise formations between the libidinal wish and the repressing mechanisms that form a part of the organized ego. Typically, these libidinal wishes belong to childhood, and then and now are members of the cluster of early partial components making up the adult drive (instinct) and are therefore easy to overlook. Symptoms provide tension reduction (but do not lead to mature behavior) at two levels: (1) the primary or internal relief experienced by the ego faced with some painful situation, even though the symptoms represent a flight into a disordered, uncomfortable state, and (2) the secondary, external gain which derives from advantages in power, prestige, or material things. External stress may also play a vital part in the precipitation and continuance of an obsessional reaction, but seldom is the reaction a simple function of such things as overwork, unreasonable expectations, domestic discord, underutilization or overutilization of special talents, or lack of rewards or recognition. Precipitating causes and the background causes are multidetermined. Altered value systems concerning spouse or children, work associates, and the pieties that provide hope or faith may be crucial as powerful initiators of regressive defenses against a real or fancied stress.

Relation to other reactions. An estimated maximal prevalence of obsessional reactions in the general Caucasian population is 5/10,000 or 0.05 per cent (Woodruff & Pitts 1964). However, the number of persons with character disorders is probably greater. When there is a blending of active obsessional symptoms into habitual attitudes or patterns of behavior, we speak of obsessional character.

Phobias, the avoidance of situations that create anxiety, although dynamically differentiated from obsessional disorders, also serve the ego as one means of defending itself against anxiety. The transition of a phobia into a compulsion is readily noticeable. A phobia develops when obsessional persons displace and project a fear of an internal conflict into a fear of an external object or situation and then compulsively avoid it. [SeePhobias.]

Depressive episodes as responses to increased stress are common in obsessive persons during periods of illness since many of the same defense systems are involved, namely, the activation of early childhood conflicts and the severe, archaic superego acting upon an ambivalent ego. [SeeDepressiveDisorders.]

Although there have been continued efforts to link the obsessional reactions to schizophrenia, the genetic evidence is unconvincing (Roth 1960; Shields 1962; Tienari 1963). Some authors state on clinical grounds that a psychosis appearing in the course of an obsessional illness is probably schizophrenic, but most psychiatrists do not take the position that all nonorganic delusional psychoses are schizophrenic. [SeeSchizophrenia.]

Prognosis and treatment . Most obsessional reactions do not come to the attention of physicians or psychiatrists. The more severe cases usually appear early in life and are missed by the family or the physician at a time at which continuous intervention is indicated, and thus they run a course of remissions and exacerbations. Psychotic episodes are relatively rare in the series of studies published in English-speaking countries as com pared with those published in Germany and Sweden. More than 70 per cent of the severe cases in one English series were sufficiently well to lead fairly normal lives (Roth 1960). Improvement usually occurs regardless of the method of treatment. There are no reliable figures from a sufficiently large number of cases to warrant dogmatic conclusions about the value of any one treatment method compared with others (Cremerius 1962; Fenichel 1945; Gottschalk & Auerbach 1965; Ingram 1961). Psychotherapy undoubtedly is more effective in the early stages of acute cases and may be prophylactic. Suicide is not common, being related more to the depressive reactions, and the incidence reported varies with the country (Cremerius 1962; Roth 1960).

Much skill is required to deal with well-developed obsessional systems, so that either formal psychoanalytic therapy or therapies based on psychoanalytic principles probably offer the best opportunity for recovery, for abatement of the acute symptoms, and for helping the patient free his energies for character maturation. Rehabilitative and supportive therapies, including use of spas, accompanied by rituals such as colonic flushing, often have symbolic meanings that fit into the patient’s obsessional system and thus bring partial relief from symptoms. Leucotomy and lobotomy may help very advanced cases, but the evidence is not uniform, and the procedure is rarely used in the United States. Electric shock may be used in a limited fashion for patients with severe obsessional pathology who are psychotically immobilized as a result of their indecision, ambivalent rage, and such practices as incessant handwashing. There are successes reported, but there are also disappointments. Insulin shock therapy has not been helpful in the advanced cases. [See Mental Disorders, Treatment of, article on Somatic Treatment.]

Obsessional disorders in other cultures . It is appropriate to mention in an international encyclopedia the world-wide distribution of obsessional practices. Although many individual papers have appeared since Freud’s Totem and Taboo in 1913 and T. Reik’s Ritual in 1931, there are no comprehensive surveys; however, Erikson’s study of the Yurok Indians (1950) and Mead’s of the Pacific cultures (1964) are excellent guides.

Henry W. Brosin

[See alsoDefense Mechanisms. Other relevant material may be found inAnxiety; Mental Disorders; Neurosis; Phobias; Psychoanalysis; Religion.]

bibliography

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Cameron, Norman A. 1963 Personality Development and Psychopathology: A Dynamic Approach. Boston: Houghton Mifflin. → See especially pages 373-411.

Cremerius, Johannes 1962 Die Beurteilung des Behandlungserfolges in der Psychotherapie. Berlin: Springer.

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Denny-Brown, D.; and Banker, Betty Q. 1954 Amorphosynthesis From Left Parietal Lesion. A.M.A. Archives of Neurology and Psychiatry 71:302-313.

Erikson, Erik H. (1950) 1964 Childhood and Society. d ed., rev. & enl. New York: Norton. → See especially “Fisherman Along a Salmon River,” pages 141160.

Fenichel, Otto 1945 The Psychoanalytic Theory of Neurosis. New York: Norton. → See especially “Obsession and Compulsion,” pages 268-310.

FReud, Sigmund (1905) 1953 Three Essays on the Theory of Sexuality. Volume 7, pages 123-245 in The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan. → First published as Drei Abhandlungen zur Sexualtheorie.

Freud, Sigmund (1917) 1963 The Sense of Symptoms. Volume 16, pages 257-272 in The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan.

Gottschalk, Louis A.; and Auerbach, Arthur H. (editors) 1965 Methods of Research in Psychotherapy. New York: Appleton.

Ingram, I. M. 1961 Obsessional Illness in Mental Hospital Patients. Journal of Mental Science 107:382-402.

Janet, Pierre; and Raymond, Fulgence (1903) 1919 Les obsessions et la psychasthenie. 2 vols., 3d ed. Paris: Alcan. → Volume 1 was written only by Janet.

Jones, Ernest 1953-1957 The Life and Work of Sigmund Freud. 3 vols. New York: Basic Books. → Volume 1: Formative Years and the Great Discoveries, 1953. Volume 2: Years of Maturity, 1955. Volume 3:Last Phase, 1957.

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Loewenfeld, Leopold 1904 Die psychischen Zwangserscheinungen. Wiesbaden (Germany): Bergmann. → Contains “Die Freud’sche psychoanalytische Methode” by Sigmund Freud and reviews of the French literature from Esquirol (1839) to the more detailed articles following 1866.

Mead, Margaret 1964 Continuities in Cultural Evolution. New Haven: Yale Univ. Press.

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Seredina, M. I. 1955 Disturbances of the Neurodynamics in Obsessive Neurosis. Akademiia Nauk SSSR, Institut Vysshei Nervnoi Deiatel’nosti, Trudy (Institute of Higher Nervous Activity, Works) Patho-physiological Series 1:88-106. → First published in Russian in the same year. The English translation is available from the Office of Technical Services, Washington, D.C.

Shields, James 1962 Monozygotic Twins Brought Up Apart and Brought Up Together: An Investigation Into the Genetic and Environmental Causes of Variation in Personality. With a foreword by Eliot Slater. Oxford Univ. Press. → A valuable review of a difficult subject.

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