Obsessive-Compulsive Disorder (OCD) is a mental health condition marked by intrusive thoughts, images, or urges called obsessions, and repetitive behaviors or mental acts known as compulsions. These compulsions are performed to alleviate distress caused by obsessions or to prevent a dreaded event. The journey to define OCD as a distinct disorder spanned centuries, evolving from religious beliefs to a medical classification based on scientific observation. This progression highlights how behaviors now understood as OCD were disentangled from other conditions.
Early Accounts of Obsessive Behaviors
Behaviors resembling what is now known as OCD have been documented for centuries. In the 14th century, symptoms were described as “scrupulosity,” a term referring to an intense preoccupation with religious or moral purity. This involved obsessive fears of sinning or committing wrong, leading to repetitive confessions or religious devotions. Such behaviors were interpreted through a religious lens, seen as spiritual afflictions or moral failings, rather than a medical condition.
By the 17th century, religious leaders continued to describe similar patterns, sometimes labeling them “religious melancholies.” John Moore, the Bishop of Norwich, noted that some worshippers experienced intrusive “anti-Christian thoughts” during prayer. These historical accounts illustrate that intrusive thoughts and repetitive actions were present, even if attributed to spiritual or moral causes.
Pioneers of Psychiatric Classification
The formal recognition of OCD symptoms began in the 19th century. French psychiatrist Jean-Étienne Esquirol was among the first to describe OCD-like symptoms in 1838. He categorized these as “monomania,” a condition affecting a specific area of thought. Esquirol also introduced the term “obsessions” to describe persistent, unwanted thoughts.
Later in the century, German psychiatrist Karl Westphal significantly advanced the understanding of these symptoms. In 1877, he coined the term “Zwangsvorstellung” (compulsive idea) to describe obsessive thoughts, distinguishing them from delusions by noting that individuals recognized their irrationality. Westphal’s work shifted the focus from delusion to cognitive control and internal mental conflict.
French psychiatrist Pierre Janet, in the early 20th century, contributed “psychasthenia” in 1903. He viewed obsessions and compulsions as manifestations of reduced “psychological tension” or mental energy. Janet’s observations highlighted intrusive thoughts and ritualistic behaviors. Sigmund Freud developed “obsessional neurosis” in 1894, theorizing these symptoms arose from unconscious conflicts and viewing compulsions as defense mechanisms.
Standardizing the Diagnosis
The path to standardizing the diagnosis of Obsessive-Compulsive Disorder gained momentum with diagnostic manuals. The Diagnostic and Statistical Manual of Mental Disorders (DSM) played a central role in unifying criteria for mental health conditions. OCD criteria first appeared in the third edition of the DSM (DSM-III) in the 1980s, where it was classified under anxiety disorders. This classification reflected the understanding that anxiety was a prominent feature of the disorder.
In the DSM-IV, published in 1994, OCD remained categorized as an anxiety disorder. The diagnostic criteria specified the presence of obsessions, compulsions, or both, which were time-consuming or caused significant distress or impairment. A key criterion in DSM-IV was that the individual needed to recognize their obsessions and compulsions as unreasonable or excessive.
A significant reclassification occurred with the publication of the DSM-5 in 2013. OCD was moved from the anxiety disorders section into its own distinct chapter: “Obsessive-Compulsive and Related Disorders.” This change was based on growing evidence suggesting unique characteristics for OCD, differentiating it from other anxiety disorders. The DSM-5 also removed the requirement for individuals to recognize their obsessions as unreasonable, adding specifiers for different levels of insight. This evolution in diagnostic manuals has provided a more precise framework for understanding, researching, and treating OCD.