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Obsessive Compulsive Disorder (OCD) has a long and rich history. It has had many identities and names throughout centuries. It is important to reflect on this history so we can understand this is not a “modern” problem. Like many mental health disorders. OCD has been around for a long time, but we are just now starting to understand it and form better treatments. We will also discuss the current and future perspective of OCD. Let’s get started!
Ancient History
The earliest possible description of OCD comes from Babylonian cuneiform medical text known as Shurpu (1350–1050 BC). The Babylonians did not understand the brain or psychological function as we do today, but they were remarkable describers of medical disease and behavior. Although they had both physical and supernatural theories of many medical disorders and behaviors, they had an open mind on these particular behaviors which they regarded as a 'mystery' yet to be 'resolved'. The Babylonian thought these behaviors might have stemmed from the concept of the māmīt or 'oath' idea, that these behavior habits were so unbreakable it appeared that the subject had sworn an oath to do or not to do the action involved. These behavioral accounts were entirely objective, including obsessional categories of contamination, aggression, orderliness of objects, sex and religion. They do not include subjective descriptions of obsessional thoughts, ruminations or the subject's attitude to their own behavior. There are not known comparable accounts of these behaviors in ancient Egyptian or classical medicine.
1300s
Other early historical records of OCD were from the 14th century from religious rather than medical literature. It was known as scrupulosity, the obsessive concern over sins and compulsive performance of religious devotion. The term derives from the Latin ‘scrupulum’, a sharp stone, implying a stabbing pain on the conscience. Historically, clergy members were the ones who observed or were confided in about symptoms of OCD by their students and parishioners. Without today’s medical understanding of mental health, the clergymen relied on religious and philosophical teachings to advise OCD sufferers.
Saint John Climacus wrote about a monk who suggests his pupil simply “pay no attention to [obsessive thoughts] whatever.” A very unhelpful suggestion that is often still given to OCD individuals by perhaps well meaning but uninformed friends and family members.
Additionally, individuals who displayed obsessive thoughts or compulsions were considered possessed. Some early descriptions of OCD come from an instruction manual about witch hunting, and another attributes obsessive behaviors to being possessed by evil spirits. A common treatment for obsessive behavior or thoughts during this time was exorcism.
1400s-1500s
Several historical and religious figures suffered from doubts of sin, and expressed their obsessional suffering. One notable example is Martin Luther (1483–1546), a German priest and professor of theology who initiated the Protestant Reformation.
Personal and secondhand accounts show he experienced “blasphemous” thoughts during his prayers (intrusive thoughts) and repeatedly confessing them to other priests (compulsions) and demonstrating reassurance seeking behaviors. At this time it was not understood that OCD thoughts are ego dystonic (or ego alien) which is referring to thoughts and behaviors (dreams, compulsions, desires, etc.) that are conflicting with a person's ideal self-image. In other words, these thoughts did not reflect a person’s values, wants, or beliefs and therefore were extremely distressing.
1600s
In the seventeenth century, obsessions and compulsions were often described as symptoms of religious melancholy. Robert Burton, reported a case in the Anatomy of Melancholy (1621): "If he be in a silent auditory, as at a sermon, he is afraid he shall speak aloud and unaware, something indecent, unfit to be said." It is very common for OCD individuals to be afraid they will blurt out something embarrassing or inappropriate during inopportune times.
In 1660, Jeremy Taylor, Bishop of Down and Connor, Ireland, was referring to obsessional doubting when he wrote of "scruples": [A scruple] is trouble where the trouble is over, a doubt when doubts are resolved." In his 1691 sermon on religious melancholy, John Moore, Bishop of Norwich, England, referred to individuals obsessed by "Blasphemous thoughts [which] start in their minds, while they are exercised in the Worship of God [despite] all their endeavors to stifle and suppress them ... the more they struggle with them, the more they increase." These accounts from centuries ago are experiences that still hold true for those with OCD today. OCD is nicknamed “the doubting disorder” and the more someone attempts to suppress these intrusive thoughts, the worse they become.
Scrupulosity is a form of OCD that still exists today and includes non-christians.
During the seventeenth and eighteenth centuries, OCD started to become recognized more as a mental health disorder rather than simply as religious scruple. Physicians attempted to cure obsessions, intrusive thoughts, and compulsions by adjusting bodily fluids, called “humors”, through bloodletting. Humors were thoughts to regulate a person’s emotions and behaviors. When the symptoms became disruptive, people with OCD were placed in asylums, often against their will.
1700s-1800s
Toward the end of the eighteenth century and going into the nineteenth century, clinicians started to note that the patient’s obsessive thoughts began to center around fears of biological contamination and aggressive and distressing thoughts. Obsessions surrounding religious fears became less commonplace.
Physicians were divided on whether OCD had its origins in emotional issues, problems regarding a person’s willpower or self-control, or if they were indicative of an intellectual defect.
Protoscientific tools such as were used during this time to study mental illnesses such as:
Faculty Psychology (mind is separated into faculties or sections, and that each of these faculties is assigned to certain mental tasks)
Phrenology (study of the shape and size of the cranium as a supposed indication of character and mental abilities),
Mesmerism (aka Animal magnetism, claims invisible natural forces called “Lebensmagnetismus” possessed by all living things could have physical effects, including healing)
In his 1838 psychiatric textbook, Esquirol (1772-1840) described OCD as a form of monomania, or partial insanity. He fluctuated between attributing OCD to disordered intellect and disordered will. Morel (1809-1873) placed OCD within the category, "delire emotif " (diseases of the emotions), which he believed originated from pathology affecting the autonomic nervous system. He felt that attempts to explain obsessions and compulsions arising from a disorder of intellect did not account for the accompanying anxiety.
The French psychiatrist Valentin Magnan (1835–1916) considered OCD a “folie des degeneres” (psychosis of degeneration). This was after the discovery of genetic principles by Gregor Mendel. Abulia, or the lack of will or initiative, is seen in neurological states (such as strokes), and a disorder or failure of will was considered part of obsessions. The argument was made that OCD was a degenerative disorder of the brain of hereditary origin. This concept of neurodegeneration increased the stigma associated with OCD and other mental illnesses, and individuals continued to hide their condition due to these claims.
German psychiatry regarded OCD and paranoia as a disorder of intellect (i.e., a disorder of thinking). In 1868, the German neurologist and psychiatrist Wilhelm Griesinger (1817–1868) published three cases of OCD, which he termed “Grubelnsucht,” a ruminatory or questioning illness.
During this time, obsessions (in which self awareness was preserved) were gradually distinguished from delusions. Compulsions were distinguished from "impulsions" or irresistible behavior.
In 1877, Westpahal ascribed obsessions to disordered intellect. Westphal's use of the term Zwangsvorstellung (compelled presentation or idea) gave rise to the current terms we use for OCD, since the concept of "presentation" encompassed both mental experiences and actions. In Great Britain Zwangsvorstellung was translated as "obsession," while in the United States it became "compulsion." The term "obsessive-compulsive disorder" was later used as a compromise.
Sigmund Freud, the Austrian founder of psychoanalysis, drew upon his ideas of mental structure, mental energies, and defense mechanisms. In Freud’s view, the patient’s mind responded maladaptively to id impulses. OCD sufferers, frequently “compelled” to carry out actions giving only temporary relief from anxiety, still know it is ridiculous to do so.
It was thought that the ego used certain defenses mechanisms such as i.) intellectualization and isolation (warding off unacceptable ideas and impulses), undoing (carrying out compulsions to neutralize the offending ideas and impulses) and reaction formation (adopting character traits exactly opposite of the feared impulses). These imperfect defenses gave rise to OCD symptoms: anxiety; preoccupation with dirt or germs or moral questions; and, fears of acting on unacceptable impulses.
Late 1800s- 1900s
Toward the end of the 1800s, OCD was starting to be treated with more humane methods, which mostly included forms of psychotherapy and talk therapy that were popular in Freudian psychology. Perhaps the most popular case in OCD history was Mr. Ernst Lanzer, who was treated by Sigmund Freud himself, beginning in 1907. Lanzer became known as the “Rat Man,” as he had developed an irrational fear that his father and girlfriend would suffer from rats entering their bodies. To cope with this fear, Lanzer engaged in compulsions, namely counting and praying. Lanzer’s condition was so debilitating that he had difficulty focusing on his studies in law school, and Freud diagnosed the patient with what he called “obsessional neurosis.” Neuropathological conditions were often referred to as types of “neurosis.” Freud conducted psychoanalysis with Lanzer, tracing his fears back to unresolved childhood issues. Freud claims that his method was successful for treating Lanzer, but his treatment methods have lost some popularity over time.
After Freudian theory lost its place at center stage, OCD treatment continued to evolve, with behavioral therapy becoming more common for treating symptoms of OCD. Freud’s psychoanalytic theory has received some criticism, but even so, some therapists today have reported that clients with OCD do just as well with psychoanalytic methods as they do with SSRIs medications or behavioral therapy.
In the 1960s and 1970s, talk therapy was the most common treatment option for OCD. Talk therapy started to evolve to comprehensive and personalized forms of cognitive and behavioral therapy. Eventually it was discovered that a more effective behavioral treatment method was to convince OCD patients to expose themselves to the situations that triggered their OCD and then work with them on not responding with compulsions. This technique came to be known as exposure and response prevention (ERP).A central figure in the development of ERP therapy, Stanley "Jack" Rachman, has spoken about the history of the technique. In a 2005 speech, reported in the Obsessive Compulsive Foundation Newsletter, he pointed out that ERP therapy can trace its roots to work done in the 1960s by Victor Meyer. Dr. Meyer, was a former World War II fighter pilot shot down in France and taken as a prisoner of war. In 1966, he began ERP therapy with two hospitalized patients. One of them incapacitated by fears of disease and dirt, spent most of the day cleaning. She had not been helped by shock treatment, drugs, or supportive therapy and was being considered for surgery, according to Dr. Rachman. Dr. Meyer, and later a nurse, exposed her to objects that triggered her anxiety and prevented her from carrying out her cleaning rituals. They turned off the water in her room and severely limited her access to cleaning agents. Meyer was influenced by the success of so-called flooding treatments in extinguishing fears in animals and had the boldness to try it on patients where other clinicians hesitated.
Today, OCD is mostly treated with a combination of cognitive behavioral therapy, or CBT, and sometimes medications for anxiety and depression. In treatment-resistant cases, transcranial magnetic stimulation is sometimes used to lessen symptom severity and induce remission of symptoms when medication and CBT do not work.
2000s and onward
The DSM’s fifth edition, which was published in 2013, ushered in several new stances in the field of mental health. The manual as a whole moved toward a more developmental approach, detailing which disorders tended to appear before other disorders became apparent. OCD was given a section of its own, outside of the anxiety disorders family.
There were several reasons that contributed to the extra focus now granted to OCD. First, OCD research has uncovered unique familial, genetic, and neural commonalities among OCD and other OCD-related disorders. In particular, a strong association was found between OCD and abnormalities in brain structures found to be connected to impulse and motor control, as well as self-regulation. A second contributing factor was the emerging Executive Functioning Hypothesis, which convincingly asserts that OCD evolves out of a disturbance in one’s self-regulatory abilities—while other anxiety-based disorders are more associated with emotional processing.
Overview of Current Treatment Options
CBT is a type of talk therapy that can be broken down into more specific treatment subtypes. For OCD specifically, the CBT therapy Exposure and Response Prevention, or ERP, is the most effective. ERP is typically administered on an outpatient basis, where patients meet with a licensed therapist once or twice per week for about an hour for each session.
Ideally, a prescribing physician will work closely with a patient’s therapist to determine the best medication for the patient’s specific needs. About 70% of OCD patients see a significant improvement in their symptoms from this first line of treatment. For the remaining 30%, there are many treatment options available.
Patients who aren’t seeing any improvement with outpatient care can attend day programs, where they can attend group and one-on-one therapy for most of the day up to five days per week. Patients can live at home, but attend therapy for more extended, and frequent periods until they see an improvement in symptoms.
Another option is partial hospitalization. This option is similar to a day program, but the patient attends treatment in a mental health hospital. Here, they have access to a larger pool of mental health professionals and therapists. Patients still live off-campus.
The final two options if outpatient therapy doesn’t work for patients is to participate in either a residential or inpatient treatment program. Residential programs allow patients to live voluntarily in a treatment unit in a hospital.
Inpatient treatment programs offer the highest levels of care for patients suffering from intense and debilitating symptoms. These programs are sometimes conducted on a voluntary or involuntary basis. Care is provided in a locked unit of a mental health hospital. Inpatient treatment is a final resort for patients who are a danger to themselves or others. The goal of inpatient treatment is to stabilize the patient and transition them to either a residential program, day program, or outpatient treatment model. Most patients will stay in an inpatient treatment facility for several days to several weeks.
The Challenges of Treating OCD
Some practitioners may not recognize all the symptoms of OCD, especially for particular subtypes. Most can identify common external compulsions like hand washing or repeating an action a certain number of times. However, there are other ways obsessions and compulsions can reveal themselves that are internal and harder to identify.
The term Pure O or purely obsessional was coined by Dr Steven Phillipson in 1988 to help those people who didn’t have obvious physical compulsions get diagnosed as having OCD. The term has proven very useful in raising awareness around intrusive thoughts, and mental compulsions being part of OCD. No doubt countless lives have been saved because of this term.
It does need some explaining however, as the term can also confuse some people.
OCD is made up of obsessions and compulsions. So the term Pure O unintentionally implies people are ‘purely obsessional’ which isn’t true. They have compulsions, but the compulsions are mostly not physical (visible). Some people with Pure O will ask for reassurance, ruminate, make mental lists, do mental checking and many other compulsions in their head. So they are doing compulsions, it’s just not physical or visible.
In a lot of cases, practitioners don’t go through much or any training on the “Pure O” subtype of OCD, and aren’t told how to look for more subtle obsessions that people can have. This means a lot of those symptoms go undiagnosed, and the correct treatment plans aren’t put in place.
The compilation with the “Pure O” subtype is that it’s often mistaken for—and treated as—a more general anxiety disorder. A lot of clients will come in saying “I’m anxious,” or “I worry a lot about X.” This makes it easy to try treatment for general anxiety first, but it’s critical to find ways to differentiate what’s just a worry, and what’s actually an obsession.
OCD is not the only disorder that has been overlooked and misunderstood for years, but well-informed and compassionate care is the first step to easing the way for future generations.
Modern Misconceptions of OCD
Unlike the language of a lot of other mental health conditions, the term “OCD” is casually used in our societal vernacular quite often. You’ve probably heard someone say “I’m so OCD about organizing my notes,” or “I love cleaning my apartment, I’m practically OCD about it.” In reality, these people just prefer that their things be organized or clean.
To throw around language like this without considering its impact is insensitive to people who actually do have OCD, and, more importantly, it actually can be damaging to people who should seek treatment.
It dismisses the severity of OCD to confuse obsessive moments or tendencies—which many people have—with actual obsessions and compulsions. Especially for children, it can be difficult for themselves or their family members to differentiate between a symptom that needs to be addressed or just a personality trait.
All of this is not to say that practitioners don’t take OCD seriously, or that the field is ignoring people who have OCD. But in society at large, there are stereotypes of the disorder that are inaccurate, and that makes it difficult for people to recognize if their behavior is something they should seek help for. The stigma surrounding OCD might also make it harder for people to buy into their diagnosis, especially for less common manifestations.
Note: Some of the text had been directly used from the original source, or mild paraphrasing for clarity.
Citations:
https://med.stanford.edu/ocd/treatment/history.html [https://med.stanford.edu/ocd/treatment/history.html]
https://www.ocduk.org/ocd/history-of-ocd/ [https://www.ocduk.org/ocd/history-of-ocd/]
https://pulsetms.com/resources/ocd-history/ [https://pulsetms.com/resources/ocd-history/]
https://www.simplepractice.com/blog/history-of-ocd/ [https://www.simplepractice.com/blog/history-of-ocd/]
https://pubmed.ncbi.nlm.nih.gov/21965523/ [https://pubmed.ncbi.nlm.nih.gov/21965523/]
https://www.ocdhistory.net/20thcentury/behaviortherapy.html [https://www.ocdhistory.net/20thcentury/behaviortherapy.html]
https://theocdstories.com/illustrations/pure-o/#:~:text=The%20term%20Pure%20O%20or,compulsions%20being%20part%20of%20OCD [https://theocdstories.com/illustrations/pure-o/#:~:text=The%20term%20Pure%20O%20or,compulsions%20being%20part%20of%20OCD].
Discussion
Thank you for reading this post in its entirety! It is a lot of information to digest, but I hope this has put into perspective how we have arrived at how OCD is currently viewed and treated.
I am listing some optional questions/discussion point for the comment section:
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What was the most surprising fact you learned from the history of OCD. Did it change your perspective in some way?
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Do you have experience with OCD treatment, and if so, how has that gone for you? (if willing to share).
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What do you think about the current challenges facing individuals with OCD?
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Any other points you would like to discuss in more detail?
