Handbook of Child and Adolescent Obsessive-Compulsive Disorder

Eric A. Storch, Gary R. Geffken, Tanya K. Murphy

• Publisher: Routledge
• Year: 2007
• ISBN:
  9781135593476
• Edition: 1
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Previously considered a rare condition among children and adolescents, recent research on obsessive-compulsive disorder (OCD) has indicated an increased prevalence among this age group, insofar as it is now considered one of the most common of all psychiatric illnesses affecting youth. Handbook of Child and Adolescent Obsessive-Compulsive Disorder

1

Obsessive-Compulsive Disorder: A Historical Overview

Pedro G. Alvarenga

Ana G. Hounie Marcos T. Mercadante

Euripedes C. Miguel

Maria Conceição do Rosario

University of São Paulo Medical School

Obsessions have an intriguing connection with human beings. They can develop from any thought, feeling, fear, or image and therefore can be present in our daily expressions of art, love, science and religion. Obsessive-compulsive disorder (OCD) is sometimes called the disease of doubt: Patients often doubt their thoughts, their senses, and their own beliefs (Rosario-Campos et al., 2001). Very frequently, they end up feeling trapped by the lack of certainty. OCD is also known as the disease of secrets (Rosario-Campos, et al., 2001). Patients hide their symptoms for shame or fear of being criticized. Some spend years looking for help, often without success.

In general, psychiatric concepts have changed over time. The same has happened with the definitions and knowledge related to OCD. For instance, once thought to be a rare disorder, we currently know that OCD affects 1% to 3% of the world population, independent of gender, religion or socioeconomic status (Karno & Golding, 1991; Kessler et al., 2005). The main objective of this chapter is to give an overview of the history of OCD.

Initial Descriptions of OCD

Ancient descriptions suggest that obsessive-compulsive (OC) symptoms have been a matter of concern throughout human history. For example, to-day what is called compulsive behavior could be represented by a metaphor based on the ancient myth of Sisyphus. As a punishment from the gods in the underworld, Sisyphus was compelled to roll a big stone up a steep hill; but before it reached the top of the hill the stone always rolled down, and Sisyphus had to begin all over again. This cycle continued on and on for eternity. In addition, OC symptom descriptions have been identified, quite consistently, since the 17th century. At that time, obsessions and compulsions were often described as symptoms of religious melancholy and sufferers were considered to be possessed by outside forces (Jenike et al., 1998; Salzman & Thaler, 1981). The Malleus Maleficarum (“The Witch Hammer”), first published in 1486 by the Dominicans, contains what has been considered the first description of OCD (Shapiro, Shapiro, Young, & Feinberg, 1988). The Malleus served as a guidebook during the Inquisition, helping the inquisitors in the identification, prosecution, and dispatching of Witches (Del Porto, 1994; Kramer & Sprenger, 1486/1991). In the 10th chapter of this guidebook, the authors described how men can be obsessed by the devil and compelled to act against their own thinking (Kramer & Sprenger, 1486/1991). In 1553, Inácio de Loyola described his own “scruples” that forced him to give exhaustive confessions (Loyola, 1991). In his 1691 sermon on religious melancholy, John Moore, Bishop of Norwich, England, described a phenomena he observed in people he referred to as obsessed individuals. He explained that these individuals experience “naughty, and sometimes blasphemous thoughts that start in their minds, while they are exercised in the worship of God, despite all their endeavors to stifle and suppress them” (Mora, 1969, pp. 163–174). Not surprisingly, the most popular treatment method at that time was exorcism, which sometimes reportedly resulted in therapeutic benefits (Krochmalik & Menzies, 2003).

Early Psychiatric Descriptions of OCD in European Psychiatry

By the first half of the 19th century, along with other changes in medical thinking, OCD shifted from the religious to the scientific field of enquiry. Modern concepts of OCD began to evolve in Europe, when psychiatry was strongly influenced by intellectual streams coursing through philosophy, physiology, chemistry and other biological sciences (Del Porto, 1994). OC symptoms were first considered to be a type of “insanity” or madness (Berrios, 1995, pp. 3–13). Obsessions in which insight was preserved were gradually distinguished from delusions, in which insight was not preserved. Compulsions were also distinguished from impulsions, which included a great number of paroxysmal and stereotyped behaviors (Del Porto, 1994). During that period of time, psychiatrists disagreed about whether the grounds of OCD lay in disorders of the will, the emotions, or the intellect (Berrios, 1995; Del Porto, 1994).

In 1838, Jean-Etienne Dominique Esquirol, the favorite student of Philippe Pinel at the Salpêtrière Hospital, first described a psychiatric disorder quite similar to the contemporary concept of OCD (the case report of “Mademoiselle F.”). He classified it as a form of monomania, a kind of partial insanity (Esquirol, 1838). Esquirol moved between defining OCD as a disorder of the intellect or the will (Esquirol, 1838). Pinel, along with his disciple, hypothesized that the origins of this mental illness resided in the “passions of the soul” and believed this “madness” did not fully and irremediably affect patient’s reasoning (Del Porto, 1994). Esquirol (1838) argued that, because his patients were aware that their obsessions were irresistible, they possessed a certain degree of insight, calling the obsessions “délire partiel” (partial delusions).

Across Europe, early medical descriptions, which correspond to contemporary definitions of OCD, focused on different aspects of the disorder. English psychiatrists emphasized the religious perspective and melancholic features, whereas the French school identified loss of will and anxiety as the principal symptoms of the disorder. Dagonet (1870, pp. 5–32, 215–259), for example, considered compulsions as a form of “folie impulsive” (impulsive insanity) in which violent and irresistible impulses overcame the subjects’ will and were manifested through obsessions and compulsions. Magnan (1893, pp. 109–426) described the “folie des dégénérés” (degenerative insanity), indicating cerebral pathology due to defective heredity.

The emergence of the “neurosis” concept was first introduced by Cullen in 1777, and further developed when Morel defined OCD as “délire émotif” (delusion of the emotions), which he believed to be originated from a pathology of the autonomic nervous system (Morel, 1866, pp. 385–402, 530–551). Morel was the first author to place OCD among disorders of emotion due to its anxiety component, reinforcing the “neurotic” aspects of the disorder. Towards the end of the 19th century, Legrand du Saulle, based on a clinical observational study, described OCD as “insanity with insight,” warning, however, that psychotic symptoms could be present sometimes (Legrand du Saulle, 1875). Moreover, other terms to define OCD throughout the 19th century were employed by French psychiatrists: “Manie sans délire” (mania without delusion); “folie raisonnante” (reasonable madness); “idée fixes” (unchangeable ideas); “idée irresistible” (irresistible ideas); “délire de toucher” (touching delusion); “délire avec conscience” (delusion with conscience); and “folie de doute” (doubt insanity; Berrios, 1989, pp. 283–295, 1995; Del Porto, 1994).

Whereas the emotive and volitional aspects of OCD were emphasized in France, German writers considered it, along with paranoia, as an intellectual disorder and deemed irrational thoughts as neurological events with cognitive representation. In 1868, Griesenger published three cases of “Grubelnsucht,” characterized as a ruminatory and questioning illness (Bergener, 1987). Westphal (1878, pp, 734–750) ascribed obsessions to a disordered intellectual function and used the term “Zwangsvorstellung” (compelled presentation or idea). In fact, Westphal was the first to describe OCD as it is currently defined in the classification manuals, including integrity of intelligence, absence of affective causal pathology, inability to suppress the intrusive thoughts, and recognition of the bizarreness of the representations. Interestingly, he also considered heritability as a prominent etiological factor. In England, the term “Zwangsvorstellung’ was translated as “obsession,” whereas in the United States it was translated as “compulsion.” The term obsessive-compulsive emerged as an agreement between the two definitions (Berrios, 1995; Del Porto, 1994).

Janet and the Psychasthenia Concept

In the last quarter of the 19th century, there was a shift towards a more psychological view of psychiatric disorders and the definition of OCD as “neurasthenia” emerged (Berrios, 1995; Laplanche & Pontallis, 2001). First coined by George Miller Beard in 1869, the “neurasthenia” concept included OC symptoms, as well as numerous other psychiatric symptoms such as fatigue, anxiety, headache, impotence, neuralgia, and depression, among others. It was explained as resulting from the exhaustion of the central nervous system’s storage of energy attributed to civilization (Beard, 1869). In the beginning of the 20th century, both Pierre Janet (1859–1947) and Sigmund Freud (1856–1939) isolated OC symptoms from neurasthenia. Influenced by Morel and Legrand du Saulle, Pierre Janet (1903) proposed that obsessional patients possessed an abnormal personality, with features such as anxiety, excessive worrying, lack of energy, and doubting. They described the successful treatment of compulsions and rituals with techniques consistent with the later development of behavior therapy (Pitman, 1987; Rachman & Hodgson, 1980).

Based on a study of 325 patients (with obsessions, compulsions, tics, and body dysmorphic features), Janet suggested that obsessions and compulsions were primitive psychological operations derived from diverted nervous energy (Janet, 1903). Thus, in his classical work, “Les Obsessions et la Psychasthenie,” Janet proposed that obsessions and compulsions arise in the third (final) stage of the psychasthenic illness and described the important role played in the psychasthenic mental state by symptoms defined as “forced agitations” separated into a mental group (obsessions), a motor group (tics) and an emotional group (dysmorphophobia; Janet, 1903). This symptomatology is very similar to the current descriptions of the obsessive-compulsive spectrum (Stein & Hollander, 1995). The first stage of psychastenia would correspond to what it is now called obsessive-compulsive personality disorder. The second stage (forced agitations) would be represented by some symptoms of the OC spectrum disorders. Despite the relevance of this contribution for the understanding of the psychopathology of OCD, 100 years later, “Les Obsessions et la Psychasthenie” has not been translated into English.

Freud and the Psychoanalytical Perspective

Sigmund Freud explored the human mind and developed his approach to psychology as a comprehensive method and a therapeutic technique to treat neurosis and other mental disorders. His idea that the mind works through unconscious processes and that the main cause of neurosis is the repression of painful memories sequestered from consciousness holds a central place in psychology today (Laplanche & Pontallis, 2001). Different from the descriptive work produced at his time, Freud was searching for ways of understanding the etiology of the disorders he observed, and how the symptoms evolved, in a similar way to the challenges faced by modern neuroscience.

In 1895, the term obsessive neurosis “Zwangsneurose”) was first mentioned in Freud’s paper about “anxiety neurosis” (Freud, 1895/1976, pp. 83–85). In his study, “Further Remarks on the Neuro-psychoses of Defense,” Freud proposed a revolutionary theory for the existence of obsessional thinking in which he defined obsessive ideas as “transformed self-reproaches that have re-emerged from repression and that always relate to some sexual act that was performed with pleasure in childhood” (Freud, 1896/1976, pp. 181–185). Freud developed a concept of obsessive neurosis that influenced and then drew on his ideas of mental structure, mental energies, and defense mechanisms. This concept included intellectualization and isolation (warding off the effects associated with the unacceptable ideas and impulses), undoing (carrying out compulsions to neutralize the offending ideas and impulses) and reaction formation (adopting character traits exactly opposite of the feared impulses; Laplanche & Pontallis, 2001).

A great proportion of Freud’s thinking about obsessive neurosis was formulated in 1909 with his famous description of the case of “The rat man,” in which Freud described the psychoanalytical treatment of a 29-year old man who developed certain impulses (Zwangshandlung) against aggressive and sexual obsessions since his early childhood. Later in his life, the patient came across a senior military officer who conveyed a particularly sadistic method of punishment that involved confining rats and placing them in the victim’s anus (Freud, 1909/1976). At this moment, Freud’s patient reportedly started obsessing that his dead father and a young lady he liked could have suffered this type of torture. Although the patient expressed horror as he mentioned it in his analysis, Freud interpreted it as one of “horror at pleasure of his own desires, of which he himself was unaware.” The precipitating cause of this man’s obsessions was never clearly identified by Freud or by the patient himself, but Freud correlated them to the patient’s ambivalent feelings (hate–love) about his father and his doubts concerning sexual orientation (Del Porto, 1994). Later, in “Totem and Taboo,” Freud illustrated OC symptoms from social and anthropological perspectives, in which compulsions, like primitive rituals, were assumed to be human efforts to magically modify the external world and to prevent catastrophes (Freud, 1913/1976).

In 1926, Freud reformulated his theories about the origin of OC symptoms. Thus, in the article “Inhibition, Symptom, and Anxiety,” Freud postulated that OC symptoms, as well as melancholia, derived from the ego’s fear of the superego punishment (Freud, 1926/1976). Thus, contrary to his previous publications, Freud considered that obsessive-compulsive neurosis existed as a syndrome separated from the “anal-e...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Foreword
• Preface
• About the Editors
• 1. Obsessive-Compulsive Disorder: A Historical Overview
• 2. Obsessive-Compulsive Disorder in Children and Adolescents: Diagnosis, Comorbidity, and Developmental Factors
• 3. Obsessive-Compulsive Spectrum Disorders
• 4. Assessment of Pediatric Obsessive-Compulsive Disorder
• 5. Psychological Theories of Obsessive-Compulsive Disorder
• 6. Neurobiology, Neuropsychology, and Neuroimaging of Child and Adolescent Obsessive-Compulsive Disorder
• 7. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections
• 8. Genetics of Obsessive-Compulsive Disorder: Evidence from Pediatric and Adult Studies
• 9. Cognitive-Behavioral Treatment of Pediatric Obsessive-Compulsive Disorder
• 10. Psychopharmacology of Pediatric Obsessive-Compulsive Disorder
• 11. Clinical Challenges in the Treatment of Pediatric OCD
• 12. Family-Based Treatment of Early Onset Obsessive-Compulsive Disorder
• 13. The Function of the Family in Childhood Obsessive-Compulsive Disorder: Family Interactions and Accommodation
• 14. School Issues in Children With Obsessive-Compulsive Disorder
• 15. Obsessive-Compulsive Disorder in the Primary Care Setting
• Author Index
• Subject Index