A Comprehensive History of OCD: From Religious Scruples to Modern Treatment

OCD earned itself a new classification in the newest edition of the DSM, but the disorder itself is far from new; there are written records describing people who suffered from what sounds like OCD going as far back as the 14th and 15th centuries. Mankind has had a long-standing relationship with this disorder, but it’s only in the last century or so that we’ve developed an accurate understanding of OCD.

Here’s a comprehensive history lesson on Obsessive-Compulsive Disorder: from the 15th century, when OCD was mostly thought of as a religious problem, to the modern developments that we have today.

The 15th Century: OCD as Religious Scrupulosity

The obsessions that people tended to report having back then were mostly of a religious nature, and were referred to as “religious melancholy”. Religious melancholy described when people were suddenly overcome by thoughts that they felt were anti-Christian or blasphemous, even though they tried to push them away. These people, understandably, felt almost unbearable guilt and shame because of these thoughts, and turned to clergymen for advice.

It makes sense that most recorded obsessions back in that day were about religion, because OCD tends to attack things that we love and value; religion was a very important part of people’s lives and identities back then. Because of this societal context, it’s impossible to say whether people who suffered from “religious melancholy” back then would be diagnosed with OCD today. Their descriptions of their experiences, though, sound all-too-familiar for anyone who has lived with OCD – even centuries later.

Interestingly, the idea of “religious scruples” was also first named in this era, with the Bishop of Norwich defining it as “trouble where the trouble is over, a doubt when doubts are resolved”. This, no doubt, sounds very familiar to OCD sufferers even today; in fact, OCD themes of religious and moral scrupulosity continue to be very common.

The Earliest Account of Unwanted “Blasphemous” Thoughts

The first time that something clearly resembling OCD appears in written records is often thought to be in Margery Kempe’s autobiography. Kempe was overcome by intrusive images that invaded her mind, like images of the local clergymen naked, and she felt so much pain and guilt about these images that she found herself praying incessantly to try to feel better.

Her autobiography (written in the third person because Kempe herself was illiterate) describes the obsessions and compulsions that Kempe suffered through:

“She thought these horrible sights and cursed memories were delectable to her, against her will. Wherever she went, or whatever she did, these cursed memories remained with her. […] She was shriven, and did all that she might, but she found no release, until she was near at despair…”

Even though the understanding of OCD as a mental health disorder was inaccurate in a lot of ways back in Kempe’s day, it’s clear that people who experienced these types of obsessions suffered just as much as people with OCD today.

Clergymen Gave Advice For Early OCD Sufferers

Because these obsessive thoughts were usually thought of as a religious affliction rather than a medical disorder, people who lived with OCD during this time turned to clergymen for advice instead of doctors. One of those clergymen was the English Richard Baxter, who published pamphlets filled with advice for people suffering from “religious melancholy,” as OCD was known back then. “Every possible danger they take for probable, and every probable one for certain; and every little danger for a great one, and every calamity, for an utter undoing,” he wrote. Sound familiar?

John Moore, an Anglican bishop, also famously delivered a sermon about a “disorder of the mind” which was eventually published as a well-selling pamphlet titled Of Religious Melancholy. The pamphlet described people suffering from “naughty, and sometimes blasphemous thoughts,” which made these people feel “without hopes of remedy, and to fear that God hath utterly cast them off”. Anybody with OCD reading Moore’s sermon today would instantly recognize their own symptoms in his words.

Another English scholar and clergyman, Robert Burton, published a work called The Anatomy of Melancholy, which continues to be well-known today. Burton suffered from depression throughout his life, and the book was actually speaking about his experience of that disorder, not OCD. However, there are a few parts in his work that sound more like OCD than depression. Take, for example, this quote: “If he be in a silent auditory, as at a sermon, he is afraid he shall speak aloud & unaware, something indecent, unfit to be said.” OCD or depression? We’ll never know for sure, but it’s undeniable that these irrational, obsessive fears are characteristic of OCD in many ways.

Some of the advice that these clergymen gave people suffering from “religious melancholy” was actually pretty sound; for example, some clergymen advised their parishioners to stop trying to push the thoughts away and to distract themselves with other activities – which is in line with some behavioral techniques that are backed by science today.

Some leaders in the Roman Catholic church, however, insisted that people experiencing these thoughts needed to obey their spiritual advisors’ instructions without any hesitation, and that was the only thing people needed to do to recover. Obviously, we know now that the treatment of OCD is a lot more complex than mere obedience.

The Medical Community Steps In

Early Medical Treatments for OCD

It’s no secret that medical treatment back in the 17th century wasn’t anywhere near what it is today, and doctors used to use some wacky methods to treat patients with OCD that were harmful at worst and simply unhelpful at best.

Hannah Allen, an Englishwoman who published a famous autobiography about her experience with obsessions and compulsions, described a bizarre treatment that she went through to try to treat her affliction: the doctor drained her blood. Bloodletting was a common medical practice for thousands of years; the patient’s ailments were thought to be the imbalance of their four “humors”, and their blood was sometimes drained to cure them.

Other practices that were used to treat obsessive thinking at the time were laxatives, astrological readings, powerful sedatives such as bromides, and even opium or morphine.

We can guess now that none of these treatments worked, not for Ms. Allen or anyone else suffering from OCD at the time,

Psychiatry Comes Around In The 1800s

Thankfully, the field of psychiatry came around in the 1800s, which led to a newer understanding of obsessive thoughts and compulsions. In 1838, a French psychiatrist named Jean-Etienne Dominique Esquirol published a textbook that described this disorder of unwanted thoughts as a form of “monomania,” or partial insanity. Someone who suffered from monomania, it was thought at the time, were perfectly functional in their lives – except for the symptoms of their particular disorder.

Esquirol recognized that people with these obsessive thoughts were able to have some level of insight into the irrational nature of their thoughts, especially compared to people with psychotic disorders or delusions. This part of his theories feels accurate: so many people with OCD have a voice inside that tells them that their thoughts are not true, but the anxiety of the possibility of it being true makes not engaging in the compulsion seem nearly impossible.

The Classification Debate of the 1800s: What is OCD?

Eventually, French psychiatrists moved away from the idea of monomania altogether – but Esquirol had started the world of psychiatry on a quest to understand and help those who suffered from these types of thoughts. French and German psychiatrists started debating how to classify this disorder within their understandings of mental health at the time: was it a disorder of thought, a disorder of emotion, or a disorder of impulse control?

Some French psychiatrists tended toward classifying OCD as an impulse disorder. Henry Dagonet categorized OCD as folie impulsive, or impulsive insanity. He believed that people who struggled with OCD had problems with controlling their impulses; that they didn’t have a strong enough will to overpower their need to perform compulsions. Other French doctors theorized that OCD was an emotional disorder, especially considering the amount of anxiety involved.

Meanwhile, most German psychiatrists classified OCD as a disorder of thought, like paranoia. Carl Westphal, a German psychiatrist, made a huge difference in the study of the disorder. He was the first person to differentiate between OCD and things like phobias and classify it as an independent disorder; this is how we currently understand it in modern times.

By the end of the 19th century, some very important things had happened in the field of OCD (largely thanks to Westphal): obsessions were differentiated from delusions and compulsions from impulsions. This led to an understanding that people with symptoms of OCD weren’t suffering from any sort of psychosis, and had a great deal of insight into their condition. As exciting as that was, this was still a dark time for people living any kind of mental illness; they were often taken to “lunatic asylums” against their will and generally misunderstood and ostracized from society.

The Early 20th Century: The Arrival of Freud

Janet’s Les Obsessions et la Psychasthenie

In 1903, French psychologist Pierre Janet (who is considered by many to be one of the founding fathers of psychology) published a comprehensive work on his understanding of obsessions and compulsions. So much of what Janet contributed to the study of OCD helped us to understand OCD more deeply; for example, he was the first person to identify “psychasthenia”, which was a mental state characterized by obsessions, doubt, and unreasonable fear.

Freud’s Psychoanalytic Understanding of OCD

Freud, being Freud, interpreted all obsessive thoughts as symbols representing some repressed desire of the person’s subconscious. This was very much in line with how he interpreted symptoms of mental illness in general; for example, maybe someone’s obsession about cleanliness represents some sort of repressed sexual desire.

Speaking specifically of symptoms of OCD, Freud described obsessive thoughts and their accompanying compulsions as a result of unresolved conflicts in the subconscious part of people’s minds, otherwise known as the id. In 1909, Freud published a study on the case of “The Rat Man”, Dr. Ernest Lanzer, who had an obsessional fear of his family members being punished to death using rats. Freud analyzed Lanzer’s case and determined that the man’s obsession could be traced back to a “father complex”.

Although we know now that many of Freud’s interpretations of Lanzer’s symptoms are not rooted in scientific research, we can still appreciate him for the enormous contributions he made to the study of OCD as a disorder – and some modern studies have shown that some of his theories may not have been totally off-base.

Modern Developments in the Study Of OCD

Current Medical Classification of OCD

For a long time, OCD was categorized as an anxiety disorder in the Diagnostic Statistical Manual (DSM). This makes sense, as any person living with OCD can certainly tell you that the disorder causes an extremely distressing level of anxiety.

The 5th edition of the DSM, published in 2013, categorized OCD as a separate category of disorder: Obsessive-Compulsive and Related Disorders. Along with OCD, other disorders that are classified as a “related disorder” in the DSM-V are Body Dysmorphic Disorder, Hoarding Disorder, Skin Picking Disorder, and Trichotillomania. Although these disorders might seem unrelated at first glance, they all have something in common: repetitive behaviors, usually for the purpose of easing anxiety. Many people with OCD experience symptoms of these related disorders as well.

The Specific Causes of OCD Remain Unknown

Although we’ve come a long way in understanding OCD from the days when “blasphemous” obsessions were believed to be a religious problem, there are still lots of things we don’t know about it. We don’t know what exactly causes OCD in people, even though research shows that it’s probably a combination of a lot of things, including a person’s biology, genetics, and environment.

In the 20th and 21st centuries, modern scientific studies showed us that there is almost certainly a neurological component to OCD, as well as a genetic cause (although no specific genes have been identified yet). Traumatic events can increase the chances of someone developing OCD, especially if they’re already genetically predisposed. Learning theory also plays a part here, and it’s generally understood that people can learn obsessive and compulsive behaviors from the people around them.

ERP is Now the Most Effective Treatment for OCD

Here’s what might be the best development in OCD research of the 21st century: in the 1960s and 70s, Dr. Stanley Rachman developed a treatment method called Exposure and Response Prevention Therapy (ERP). ERP helps people with OCD gradually expose themselves to their scariest obsessive thoughts and get through the feelings of anxiety without engaging in compulsions. This allows them to desensitize to the fear that OCD thoughts bring and go about a healthy, fulfilling life without getting caught in the compulsion cycle.

Modern research shows us that ERP is, by far, the most effective treatment for OCD symptoms to date. It’s estimated to help up to 85% of people going through the treatment to recover from OCD. It’s a long way from bloodletting for obsessive thinking – and thank goodness for that!

Modern Psychopharmacology in the Treatment of OCD

Something else that has come along with modern times is the development of new psychopharmacological treatments for the symptoms of OCD; in layman’s terms, that’s medication. No longer are OCD sufferers being treated with laxatives and morphine, and we couldn’t be more relieved! One category of antidepressants, called SSRIs, is particularly effective in treating some of the symptoms associated with OCD.

There are four antidepressants that have been approved by the FDA for OCD: clomipramine, fluoxetine (more commonly known as Prozac), fluvoxamine, paroxetine, and sertraline (commonly known as Zoloft). Some other types of antidepressants have been shown to have hardly any effect whatsoever on OCD symptoms, though (even if they’re helpful for people experiencing depression or other mood disorders).

Other Modern Treatments for OCD

ERP isn’t the only treatment that has been developed for OCD. Acceptance and Commitment Therapy, mindfulness-based therapies, and other types of Cognitive Behavioral Therapy also have some promising research behind them.

Research is still being conducted every day, and we’re learning more and more about OCD as a disorder and how we can help people who suffer from it. The 20th and 21st centuries have brought with them an incredible jump forward in our understanding of OCD, and the treatments we have available to us today are more effective than they’ve ever been.

OCD Has a Long History

We are standing in the middle of an exciting time in OCD research. We don’t know what the future holds for the study of OCD, but we can say happily that we at Impulse Therapy are excited to be a part of it.