Obsessive-Compulsive Disorder

   Physicians and non-physicians alike have always recognized the existence of obsessive thoughts and compulsive behavior. Across the ages, examples are common in religion of praying compulsively or dwelling obsessively on salvation or damnation, but religious practices are customarily exempted from psychiatric diagnosis. James Boswell (1740–1795) spoke in 1791 of "the anxious care" of his friend the famous English lexicographer Samuel Johnson (1709–1784) "to go out or in at a door . . . by a certain number of steps from a certain point . . . so that either his right or his left foot (I am not certain which) should constantly make the first actual movement when he came close to the door." When Johnson had miscounted, "I have seen him go back again, put himself in a proper posture to begin the ceremony, and, having gone through it . . . walk briskly on and join his companion" (Life of Johnson, pp. 127–128).

   Similarly, physicians during the years have been well familiar with patients who had obsessions and compulsions. Buried within Pinel’s amorphous category of "mania without madness," for example, were patients with obsessive thoughts. Yet, in the nineteenth and twentieth centuries, psychiatry has broken into ever smaller descriptive units these great phenomena of obsession and compulsion. For the sake of convenience, this Dictionary distinguishes between anxiety-phobic-type illness, panic, and obsessive-compulsive illness. Yet in reality, the three kinds of disorders interblend and tend to occur in the same patients.

   Esquirol’s "instinctual monomania" (monomanie instinctive, or monomanie sans délire) (1838). "Sometimes there is a lesion of volition," Étienne Esquirol said in volume two of his work On Mental Illness (Des maladies mentales). Esquirol noted that intelligence was preserved. "Acting abnormally, the patient is led to actions dictated by neither reason nor sentiment, that his conscience says is wrong but that his willpower no longer has the force to suppress. The actions are involuntary, instinctive and irresistible. It is monomania without madness (monomanie sans délire), or instinctual monomania" (p. 2). (Note that Esquirol’s monomania in general [Psychosis: Emergence: monomania (1816, 1838)] permitted the existence of delusions and hallucinations.)

   Morel’s "emotional delusions" (délire émotif ) (1866). Bénédict-Augustin Morel described in the General Archives of Medicine (Archives générales de médecine) in 1866 "emotional delusions" (délire émotif ), a category for patients with anxiety as well as with obsessions and compulsions. (See Anxiety: Morel [1866].) One of Morel’s patients, for example, had "reduced his life to habits of stereotypical silliness and was known for his ridiculous tics. . . . This man did not dare touch copper coins, and when he went out alone in a taxi coach, his friends had to pay the coachman in advance or else wrap the money in a piece of paper. He never dared open a door or window without wrapping a cloth about his hand." The patient was led to these "stupid automatic acts of which I have seen so many in ‘emotive’ patients, such as stopping fixedly in front of a door without daring to open it, hovering over a piece of paper without putting pen upon it, stopping in front of a carriage without stepping on the running board, etc." (p. 400). Morel believed that these patients suffered from a "heightened affective state."

   Falret fils’ "fearfulness disorder" (maladie du doute) (1866). This is the first full-blown description of obsessive-compulsive disorder in the literature, yet Jules Falret (1824–1902), Jean-Pierre Falret’s son, has never really been credited properly for it because he buried the disease label amidst a rambling account of "intelligent insanity" (la folie raisonnante) and defined it as "partial insanity with a fear of contact with external objects" (l’aliénation partielle avec prédominance de la crainte du contact des objets extérieurs) (p. 413). Nonetheless, in an article in the Annales médicopsychologiques (1866), he clearly describes compulsive actions and obsessive thoughts, the pathological nature of which the patient is fully aware, and yet from which he is unable to refrain. Falret singled out as an example touching doorknobs only with a handkerchief for fear of contamination. He noted of the multiplicity of phobic "fears," "These patients have a perfect awareness of their state; they recognize the absurdity of their fears and they seek to distance themselves from them, but they are unable to and are, despite themselves, always constrained to come back to the same ideas and to repeat the same actions." Falret also said that "this variety of mental affection is more frequent than one might think," merely that these patients rarely come to the attention of asylum physicians. It was because of the state of "perpetual internal hesitation," Falret said, that his father, Falret père, had proposed the term "fearfulness disorder" (maladie du doute; douter in French means among other things "to fear") (p. 414).

   Krafft-Ebing’s "obsessive thoughts" (Zwangsvorstellungen) (1867). In his psychiatry textbook Contributions to the Recognition of Pathological States of Mind (Beiträge zur Erkennung . . . krankhafter Gemüthszustände) published in 1867, Richard von Krafft-Ebing, then a staff psychiatrist in the Illenau asylum, coined the term "obsessive thoughts" from the German "Zwang-", meaning compel. "To the degree that an idea [eine Vorstellung] imposes itself ever more strongly and frequently, it enforces its in-fluence upon the will, a matter that even in healthy individuals essentially constricts the action of free choice, but in illness must turn the patient into a pure automaton" (p. 19). In his 1872 Textbook of Psychiatry, Krafft-Ebing amplified his concept: obsessions and compulsions were "primary," meaning not a secondary effect of some other illness; and they had a powerful constitutional component, arising from the same soil as neurasthenia. "Compared to delusions, where the content of thought is pathological, in obsessive thoughts it is merely the form of thought that is pathological. The justification for classifying this form of disturbance under delusions [die Verrücktheit] is that the illness is genuinely constitutional, thus long-lasting and relatively unchanging, and is not part of the conditions that progress to psychic deterioration. Here as well, obsessive thoughts are primary, meaning that they do not have an affective basis, and spring from the depths of unconscious mental life" (quote from 1879 edition, vol. II, p. 95). (For these writers, an "affective basis" meant derived from melancholy or mania.)

   Griesinger’s "obsessional brooding" (Grübelsucht) (1868). In one of his last papers, Wilhelm Griesinger described a small number of patients who kept brooding about nonsensical questions. He had never encountered this in an asylum, but had recently seen several cases in the community. Acknowledging that it was similar to Falret père et fils’ "maladie du doute" (see above), Griesinger baptized it "Grübelsucht" (grübeln, meaning brooding about something, plus sucht, or addictive) after one patient himself put a finger on the diagnosis: "I cannot free myself from my eternal brooding [Grübeleien]; the thoughts persecute me constantly and give me not a minute’s rest."* The article "On a Little-Known Psychopathic State" ("Über einen wenig bekannten psychopathischen Zustand") appeared in the first volume of Griesinger’s new journal, the Archive of Psychiatry and Nervous Diseases (Archiv für Psychiatrie und Nervenkrankheiten).

   Legrand du Saulle’s "fearful insanity and the psychosis about touching things" (la folie du doute et du délire du toucher) (1873). Here it is "fearful insanity" rather than the Falrets’ "fearfulness disorder" (see above). Henri Legrand du Saulle (1830–1886) was previously an assistant of Bénédict-Augustin Morel at the St. Yon asylum; by 1873, he had become an assistant physician in Ernest Lasègue’s psychiatric emergency ward of the Paris Prefecture of Police. In 1873, he described in a series of articles in the Paris Hospital Gazette (Gazette des hôpitaux) (a series that 2 years later, in 1875, appeared as a book) patients subject to irresistible thoughts with psychotic feelings of uncertainty about whether one has performed some specific act (maladie du doute) and fear of touching objects (délire du toucher). "Many of those with partial madness," he noted in his monograph, "are in fact very curious to study, having a quite profound personal awareness of their condition and not being any less unhappy for it; they drift about without an apparent diagnosis and navigate with some inquietude on the fragile ground of circumscribed sanity" (p. 5).

   As for the course of the illness: "Uncertainty opens the scene," he wrote. "Much later, eccentricities about touching things close it" (p. 7). He saw the disorder evolving in three stages, whereby the third "is characterized by a serious and permanent state of illness. The patient’s symptoms become daily more intolerable: all social contacts tend to disappear; many routines of daily living are impossible; leaving the house becomes a matter of severe distaste, then absolute refusal; the patient’s activities become slower and slower, and a number of hours become taken up in the act of dressing or for each of the day’s meals" (p. 8). The patients who Legrand saw in the emergency department were largely psychotic, and so, unlike Falret fils (see above), he interpreted this as a formal variety of insanity (folie, délire). This began the French tradition of seeing obsessive-compulsive disorders as delusional.

   "Obsessive ideas" (Zwangsvorstellungen) as a disorder of intellect, not emotion (1877). Carl Westphal (1833–1890), by now professor of psychiatry in Berlin, de-fined obsessive ideas in 1877 as "ideas which, in the presence of intact intelligence and with no disorder of the emotional life or affect, intrude into the foreground of consciousness against the will of the concerned individual; they do not allow themselves to be banished, and they obstruct and divert the normal course of ideas. The patient sees them as abnormal and alien as he contemplates them with his healthy consciousness."

   * In 1903, Pierre Janet, recognizing Griesinger’s priority (though misdating it as "1848"), called this "la manie d’interrogation," or "la manie de la recherche," patients who endlessly tortured themselves with senseless questions (Les Obsessions, vol. II, pp. 291–292). Westphal did not mention Krafft-Ebing but acknowledged that Legrand had already described the same illness as folie du doute. He said that Griesinger’s 1868 description of "Grübelsucht" represented a subform of this larger concept of obsessive ideas. Unlike the relatively unknown publication of Krafft-Ebing in 1867, Westphal’s article, published in the Berlin Medical Weekly (Berliner Medizinische Wochenschrift), reached a huge international public and sufficed, incorrectly, to give him for a long time the priority for first description of obsessive-compulsive disorder. Westphal is remembered for having fully characterized the disorder.

   Kaan’s differentiation of treatable neurasthenia and obsessive thoughts (1892). Some authors described obsession as a hereditary trait that could turn into madness, others as a form of acquired neurasthenia that was quite treatable. In 1892, Hanns Kaan (1861–?), a former assistant of Richard von Krafft-Ebing at the university clinic in Graz and now a staff psychiatrist at a private nervous clinic in Vienna, said that the two forms were distinct. To understand the neurasthenic variety, Kann reached back to Morel’s 1866 notion of obsessions as a disturbance of the visceral (sympathetic) "ganglia." Kaan suggested that the pathological anxiety of neurasthenia provided a kind of somatic platform for cerebral obsessiveness that went via the sympathetic nervous system. In his book The Affect of Neurasthenic Anxiety in Obsessive Thoughts and in Primary Obsessional Brooding (Der neurasthenische Angstaffect bei Zwangsvorstellungen und der primordiale Grübelzwang), Kaan downplayed the inborn elements and said that obsessive ideas arise from the general fearfulness created by neurasthenia-driven disorders of the sympathetic nervous system. Distinguishing among phobias, obsessive impulses (Zwangsimpulse), and formal thought disturbances, Kaan hypothesized that the mechanism of obsessions was "irritability of the motor centers" of the brain. "The feeling of lessened cortical inhibition produces fear of one’s self, through mistrust of one’s ability to resist this toxic feeling." These contrasting psychological "associations" result in "obscene and sacrilegious obsessive thoughts" (p. 49).

   As for the second form, Kaan said there existed also "primary obsessional brooding" (primordialer Grübelzwang) that Krafft-Ebing had described in 1868 alongside obsessive thoughts (Zwangsvorstellungen); this was not the same thing as obsessive impulses. Primary brooding represented a hereditary condition that Krafft-Ebing believed frequently turned into insanity; Kaan added that this primary form of obsession could also turn into Legrand’s psychotic "folie du doute." This distinction between good-outcome and bad-outcome obsessions was important for therapists. Also, Kaan pointed out that obsessions had an affective component, which Westphal had denied. Kaan’s views on the pathophysiology were highly speculative and were not taken up.

   Psychoanalytic interpretations of obsession and compulsion (from 1896).

   See Freudian Interpretations of Obsession and Compulsion; Neurosis.

   The "obsessive ideas" of Janet’s "psychasthenia" (1903). In the context of a theory about psychiatric illness that emphasized "lowered psychic tension" and "abulia" or loss of will, Pierre Janet, director of the psychology laboratory at the Salpêtrière hospice, argued that obsessive ideas were core symptoms. In his twovolume work Obsessions and Psychasthenia (Les Obsessions et la psychasthénie), the second volume written with Fulgence Raymond (1844–1910) who was the professor of nervous diseases in the Charcot chair at the Salpêtrière, Janet said obsessive ideas that involuntarily invaded one’s consciousness represented an advanced stage of psychasthenia. Illness, shame, crime, and sacrilege, he said, were the main content of obsessive ideas. He had a separate analysis of the "form" of obsessions. Janet laid out a whole treatment program involving simplifying one’s life, hypnosis and other forms of suggestion, and the increasing of "psychological tension."

   DSM-I on "obsessive compulsive reaction" (1952). The first edition of the DSM series accepted the by now familiar usage of calling the symptoms "obsessive compulsive" and applied the Meyerian term "reaction" to them. The disorder, said the Manual, "is associated with the persistence of unwanted ideas and of repetitive impulses to perform acts which may be considered morbid by the patient" (p. 33). The Manual also accepted the existence of a "compulsive personality" (p. 37).

   Mayer-Gross et al. distinguish between "obsessional" (constitutional) states and "compulsive" (minor neurotic) symptoms (1954). In their influential textbook Clinical Psychiatry, Willi Mayer-Gross, Eliot Slater, and Martin Roth distinguished between "compulsive symptoms," widespread in persons suffering from various illnesses and among normal people, and patients with inborn "obsessional" traits subject to a variety of psychiatric syndromes ("states"). On compulsive personality traits they wrote: "The outstanding features of this type of personality are its rigidity, in-flexibility and lack of adaptability; its conscientiousness and love of order and discipline; and its persistence and endurance even in the face of obstacles" (p. 143). As for the more severely ill patients with obsessional personalities in the grip of major obsessions: "There may be a history of actual nervous breakdown, an anxiety state, a mild depression or an obsessional state, earlier in life" (p. 146).

   DSM-II on "obsessive compulsive neurosis" (1968). The gist was the same as in DSM-I, except for calling it a "neurosis." The section on "obsessive compulsive personality" also called it "anankastic personality" (after the term "Anancasmus— psychic compulsions" [Zwangszustände]) coined in 1897 by Budapest psychiatry lecturer, later professor, Gyula (Julius) Donath [1849–1945] in the Archiv für Psychiatrie).

   DSM-III on "obsessive compulsive disorder" (1980). Except for the term "disorder," the essence remained the same as in previous editions. This applied also to the section on "compulsive personality disorder." There were no important changes in

   DSM-III-R (1987) or DSM-IV (1994).

   Scientific study of obsessive-compulsive disorder (OCD) with brain imaging begins; an animal model (ca. 1989). Judith Rapoport, chief of pediatric psychiatry at the National Institute of Mental Health, is associated with use of modern neuroimaging techniques such as magnetic resonance imaging in the study of OCD. (See Women in Psychiatry.) She and her group developed the first animal model for studying OCD. This work put the study of OCD on a scientific basis and raised awareness of the disorder, so that currently there are about 500 treatment clinics specifically for OCD across the United States. In 1989, she wrote a best-selling book, The Boy Who Couldn’t Stop Washing. (See Women in Psychiatry: Rapoport.)

   The cerebral localization of obsessive-compulsive disorder (1994). A group of researchers led by Scott L. Rauch (1960–) and Michael A. Jenike (1945–) of the psychiatry department of the Massachusetts General Hospital, using a short half-life tracer oxygen 15-labeled carbon dioxide, first measured the cerebral blood flow of OCD patients while giving them a clean towel, then measured blood flow again after the towel had been "contaminated by touching after defecating." Such challenge stimuli provoked contamination obsessions in the patients, and the tracer localized the increased blood flow of those obsessions in several sites in the brain, including the right caudate nucleus. This work, published in the Archives of General Psychiatry, provided strong circumstantial evidence that these areas of the brain were part of a "loop" mediating the symptoms of OCD.