The history of treating Obsessive-Compulsive Disorder (OCD) reflects shifting theories, moving from spiritual interpretations to radical surgery, before ultimately landing on psychological science. OCD is characterized by intrusive, unwanted thoughts (obsessions) and repetitive mental or physical acts (compulsions). Though the condition has existed for centuries, its understanding has transformed dramatically, reflecting broader changes in how medicine has grappled with mental health.
Ancient and Early Interpretations
Symptoms recognizable as obsessions and compulsions were historically viewed as a moral or spiritual failing, not a medical issue. During the Middle Ages, repetitive acts or blasphemous thoughts were often attributed to demonic possession or temptation. Consequently, little formal “treatment” existed beyond religious rites intended to cleanse the soul or exorcisms aimed at driving out evil influences.
The concept of “scrupulosity” emerged, describing an excessive preoccupation with religious guilt that drove compulsive praying, confessing, and ritualistic penance. Physicians of the 17th and 18th centuries sometimes used humoral theory, suggesting an imbalance of bodily fluids might be the cause. Treatments were rudimentary and largely ineffective, sometimes including bloodletting in an attempt to adjust the body’s internal chemistry.
The Psychoanalytic Approach
The 20th century introduced the psychoanalytic model, reframing the condition, then called “obsessional neurosis,” as unconscious psychological conflict. Sigmund Freud theorized that OCD symptoms stemmed from a failure to resolve developmental conflicts, particularly those related to the anal stage. This failure was believed to cause the individual to regress and adopt defense mechanisms to manage anxiety.
Obsessions and compulsions were viewed as symbolic expressions of repressed sexual or aggressive impulses that had been pushed out of conscious awareness. The compulsion was thought to be a form of “undoing” an unacceptable thought or isolating it from its painful emotional component. Treatment was intensive and long-term, utilizing techniques like free association and dream analysis to help the patient gain insight into the buried childhood conflict. The goal was to uncover the root trauma, believing this realization would cause the symptoms to dissipate.
Physical and Radical Interventions
When psychological treatments failed to alleviate symptoms, practitioners sometimes resorted to drastic physical procedures, particularly from the 1940s to the 1960s. The most infamous was the prefrontal lobotomy, a psychosurgery that severed frontal lobe connections intended to calm the patient by reducing emotional intensity. Though generally harmful and often leading to severe personality changes, later, more targeted procedures like cingulotomy and limbic leucotomy were developed for treatment-resistant OCD.
Cingulotomy involves making precise lesions in the anterior cingulate gyrus, performed in the hope of disrupting neural circuits believed to be stuck in the OCD loop. Another dangerous intervention was Deep Sleep Therapy (DST), which used high doses of barbiturates to keep patients unconscious for days or weeks, believing continuous narcosis would reset the brain. These procedures, including early attempts at heavy sedation and ineffective drug regimens, were employed out of clinical desperation, carrying high risks and often leading to devastating side effects.
The Shift to Behavioral Understanding
A significant conceptual shift began in the mid-20th century, moving away from unconscious conflicts toward the principles of learned behavior. This perspective viewed compulsions not as symbolic acts, but as learned responses that temporarily reduced anxiety caused by an obsession. This temporary relief acted as negative reinforcement, ensuring the compulsive behavior would be repeated.
Early behavioral interventions applied conditioning theory to treat symptoms directly, rather than seeking a root cause. One technique was systematic desensitization, which involved teaching relaxation and gradually exposing the patient to fears in imagination or reality, moving up a “fear hierarchy.” Though limited in success for many OCD patients, this approach paved the way for Exposure and Response Prevention (ERP). In the late 1960s, researchers realized that simply facing the fear was insufficient; the patient also had to be prevented from engaging in the compulsive ritual, thus breaking the learned cycle of avoidance and reinforcement.