In previous episodes, I’ve hacked a path through Electroconvulsive Therapy and Transcranial Magnetic Stimulation, trying to reveal some of the secrets in those jungles. Now I am turning my machete to a different landscape: Obsessive Compulsive Disorder or OCD for short. The name is confusing, because the writers of the DSM decided to name a personality disorder Obsessive Compulsive Personality Disorder or OCPD, but this podcast is not about a personality disorder. It is about a neuropsychiatric disorder. I’m going to try to wrap our collective heads around the concept of the OCD itself. And for that, we’ll need a little history lesson which starts by asking the question: What’s in a name?
Please leave feedback at https://www.psydactic.com.
References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.
In previous episodes, I’ve hacked a path through Electroconvulsive Therapy and Transcranial Magnetic Stimulation, trying to reveal some of the secrets in those jungles. Now I am turning my machete to a different landscape: Obsessive Compulsive Disorder or OCD for short. The name is confusing, because the writers of the DSM decided to name a personality disorder Obsessive Compulsive Personality Disorder or OCPD, but this podcast is not about a personality disorder. It is about a neuropsychiatric disorder. I’m going to try to wrap our collective heads around the concept of the OCD itself. And for that, we’ll need a little history lesson which starts by asking the question: What’s in a name?
Please leave feedback at https://www.psydactic.com.
References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.
Welcome to PsyDactic - Residency Edition - Your podcast resource to survive and thrive in your psych residency.
I am Dr. O’Leary, and as of this recording I am a 2nd Year Resident in the National Capital Consortium Psychiatry Residency Program. However, make no mistake, I do not speak for this program, nor do I speak for the Department of Defense or the Federal Government or anyone else for that matter. What I say is my opinion, and I reserve the right to be wrong, so trust me at your own risk. It’s a risk some are willing to take.
References and recommended readings can be found at the end of the show transcript, located at psydactic.buzzsprout.com.
I am also going to do a horrible job trying to pronounce some old French and German terms in this episode, so please do laugh at me, and then forgive me my linguistic ignorance.
In previous episodes, I’ve hacked a path through Electroconvulsive Therapy and Transcranial Magnetic Stimulation, trying to reveal some of the secrets in those jungles. Now I am turning my machete to a different landscape: Obsessive Compulsive Disorder or OCD for short. The name is confusing, because the writers of the DSM decided to name a personality disorder Obsessive Compulsive Personality Disorder or OCPD, but this podcast is not about a personality disorder. It is about a neuropsychiatric disorder. I’m going to try to wrap our collective heads around the concept of the OCD itself. And for that, we’ll need a little history lesson which starts by asking the question: What’s in a name?
Indeed! What do we mean when we say obsession or compulsion. I’m going to start with our contemporary definition and then jump back a few hundred years to look for some common threads. For a modern definition, I will consult the bible of psych definitions, the DSM 5.
Criterion A for OCD defines OCD’s primary characteristic as the presence of obsessions alone or compulsions alone, or both together, so we need to establish a clear difference between an obsession and a compulsion.
In the DSM, both obsessions and compulsions have two components. I’ll start with the two components of obsessions.
Obsessions are defined as:
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
If this aspect of the definition of obsession seems broad to you, you are not alone. The logical structure of this sentence leaves it open to many interpretations. Try to draw a Venn diagram starting with a circle around thoughts, urges, or impulses one might have, and then draw another circle encompassing those that are “at some time” intrusive and unwanted. The persons who qualify are everyone on earth [and those currently on the international space station as well].
Now limit those same thoughts, urges, or impulses to those that “in most individuals cause marked anxiety or distress.” Suddenly, you have to compare your patient to most individuals! Now I’m being instructed to imagine a majority of people. So, does that mean if someone has recurrent, intrusive and unwanted thoughts of silk sheets passing over their bare skin this doesn’t qualify as an obsession? I’m just assuming this wouldn’t bother most individuals. Maybe I’m not in touch with the norm of silk-sheet-avoidance. What if the thought of silk sheets was distracting you in class at school: that cool, smooth surface frightens you? You’re going to lose your financial aid because you can’t pay attention.
If you can’t tell, I am very disturbed by the in-most-individuals criteria, but let's move on to the second part of the definition for obsessions.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
This means that an obsession can be defined by the presence of a compulsion or not. If there is no clear compulsion, you just have to identify some attempt to ignore or suppress the undesirable thought, urge, or image. Also, rather broad, but combined with criterion B, which I’ll talk about soon, it makes some sense.
But first, on to compulsions…
Compulsions are defined as:
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
It seems hard to imagine that a person can have a compulsion without an obsession but the DSM gets around this by making an implicit difference between an obsession and “rules that must be applied rigidly.” Compulsions are not necessarily tied to obsessions if obsessions exclude “rules that must be applied rigidly.” Including “rules applied rigidly” may be a way for the writers of the DSM 5 to tie OCPD to OCD by making inflexibility of moral rules without stereotypical ritualized behavior also count as a criteria for OCD.
Moving on to the second aspect of a compulsion:
For a compulsion to be a compulsion:
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
If you want to make a criteria so vague that a provider can with minimal effort force a patient to meet it, this is one. First, it relates a compulsion to the first aspect of an obsession: that it causes anxiety and distress. The action/compulsion must in some way relieve said anxiety or distress. But then, they go further to say that a compulsion is not necessarily related to anxiety or distress caused by an obsession. Instead, it might just be related to preventing some dreaded event or situation. I wonder how this is different from relief from something causing anxiety or distress. This opens the gates of OCD to those who compulsively do something for some vague reason not counting as a specific, definable, reproducible obsession that might bother most people.
If you are a little confused as to what the definitions of obsession and compulsion are, then you are not alone. It seems the history of OCD is one of confusion and difficulty in definition [as are many psychiatric diagnoses]. The remaining criteria help to improve the validity of the diagnosis and I’ll briefly touch on them before moving on to some tid-bits of history.
Criterion B states:
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
By saying, “e.g. take more than 1 hour per day” they make 1 hour a soft cut-off and then go on to say that even if they are not time consuming they cause “significant distress or impairment.” This is one of the major important additions to many psychiatric illnesses that prevents people who aren’t particularly bothered by their obsessions or compulsions from getting a diagnosis and corresponding unnecessary treatment or stigma.
The next two criteria are the obligatory not-caused-by-something-else disclaimers. Certain drugs, medical conditions, and other mental disorders might better explain a person's symptoms and these should be systematically ruled out during the diagnostic process.
Imagine for a moment that a patient is complaining of having to shower twice before going to work, having to shower again on their lunch break (back at home, which makes them late for some of their duties), and then showering two or three times more when they go home. Their body feels filthy constantly. Merely washing hands doesn’t help. Only a shower will suffice. They have to use a clean towel to dry themselves so waste tons of time on the weekend washing and folding towels.
Now imagine how this patient may have lived 2 to 6 hundred years ago before showers or baths were much of a thing. What might make them feel dirty? OCDuk.org paints the history of OCD as one that was first identified as excessive religious scruples, although obsessions and compulsions were certainly present into human prehistory. Parishioners may be so fearful of stains on their immortal souls that they are often chronically indecisive or waste hours of a priest's time in confession, or in prayer, or conducting rituals. Two reasons why these are some of the earliest examples of OCD symptoms are likely that (1) Religions guaranteed their influence over the populace in alliance with the governments of the time and (2) If you wanted to be educated and able to write down your observations, you’d need a religious education. Therefore, the substrate of obsessions and compulsions were necessarily often religious. The culture was forcefully religiously oriented in content.
By the 18th century, academics with interests outside of religion were flourishing and so the extent of their observations was also broadening. Obsessions of checking and re-checking, illness anxieties, and cleanliness among others were being reported. Patients with obsessions and compulsions were described not as scrupulous, but as possessing a limited form of mania or insanity. Terms like monomania, folie impulsive (impulsive insanity), or folie du doute (madness of doubt) were common. A French psychiatrist Valentin Magnan (1835–1916) considered OCD a part of the more broad term “folie des degeneres,” which basically meant degenerate insanity or madness.
Others variously merged OCD with other kinds of illnesses or separated it out. More recently, The DSM 5, took OCD out of the anxiety chapter, and elevated it along with some other obsessional or compulsive disorders to its own chapter. It appears the struggle to categorize OCD continues.
So far, I’ve mentioned how OCD was considered a disease of scrupulosity, a form of insanity, or a degeneracy. None of these definitions bodes well for a patient seeking help at the time.
The late 1800s and early 1900s saw a proliferation of attempts to explain obsessions and compulsions. OCD was often lumped into a poorly circumscribed disease category called “neurasthenia,” which basically meant exhausted nerves. According to David Schuster in a 2003 article in JAMA, European neurologists believed in a kind of energy that was delivered to the body through the nerves. Neurasthenia was the exhaustion of this energy. American neurologists applied this term to patients to explain how the demands of their contemporary society contributed to physical and mental illness. OCD was just one of the ways this was manifest. What we would define as somatic illnesses today including GI symptoms, fatigue, chronic inexplicable pain were the main part of neurasthenia, resulting in a plethora of treatments including 6 weeks in bed eating fatty foods (for women, who were, of course, considered fragile) or trips to expensive retreats in the mountains.
Another French Psychiatrist, Pierre Janet, used the term psychasthenia to give better definition to the psychiatric components of the exhausted energy. His formulation had different competing energies and predictable stages. Obsessions and compulsions were considered part of the third and worst stage. For Janet, OCD was a triumph of nervous energies over the energies of higher mental faculties. Metaphorically this is not too different from how we conceptualize OCD today, but in practice, it really doesn’t explain anything.
In 1877, a German, Karl Friedrich Otto Westphal, was the first to really capture the essence of what is the modern formulation of OCD calling it Zwangsvorstellung (compelled or forced presentation or idea), leaving open the possibility of both mental and bodily behaviors to compensate for undesirable thoughts or impulses.
It’s nearly impossible to discuss an historical understanding of mental illness without mentioning the psychoanalytic perspective. Freud’s formulation also contained competing mental faculties, like Janet’s, but Freud, of course, proposed that OCD started in childhood and was manifested as unresolved conflict between primal urges and ego demands. Specifically, Freud conceptualized OCD as resulting from some kind of repression related to shameful, but pleasurable sexual acts in childhood.
Freud used the term zwangsneurose. The root Zwang meaning “forced or compelled” was translated to “obsession” in the UK and “compulsion” in the US, resulting in the compromise “obsessive-compulsive disorder,” which further reveals the confusion between what constitutes an obsession versus a compulsion, because they were both derived from the same term. What they share is the forced or involuntary nature of their appearance.
Another term which may be hard to distinguish from an obsession is a delusion. The important part of distinguishing an obsession from a delusion is that patients with obsessions are by definition aware in some way that their thoughts (e.g. that I am dirty, that something terrible might happen, etc.) are either not reasonable or not desirable. A delusion, on the other hand, is an immutable belief that does not necessarily cause it’s holder any internal distress whatsoever. Someone with OCD will likely want their obsession to go away and welcome some kind of help. Someone with a delusion will likely detest you for trying to convince them that it is not reality based.
In this episode I’ve tried to give a face to OCD by briefly discussing our current and historical understanding of it. We have a long way to go in defining this illness. Even so we have enough evidence now to know that at least a subset of what we call OCD is, in fact, a disorder we can track through historical time. The next logical question, then, is, “What causes OCD?” I’m going to go out on a limb here and say it’s not your daddy issues and it's not exhausted nervous energy.
In the next episode, I am going to demonstrate what I feel is compelling evidence that OCD is an organic brain disease, and while your daddy issues or cultural pressures might give you a substrate for your OCD to work on, the primary problem is the ability for your brain’s checks and balances and networking systems to function normally.
This has been a presentation of PsyDactic - Residency Edition. I am your host, Dr. O, and until next time, be safe (but not too safe).
2. The history of OCD | OCD-UK. Accessed January 25, 2022. https://www.ocduk.org/ocd/history-of-ocd/