Early theories regarding the cause of this OCD-like condition stressed the role of distorted religious experience. English writers from the 18th and late 17th centuries attributed intrusive blasphemous images to the work of Satan. Even today, some patients with obsessions of “scrupulosity” still wonder about demonic possession and may seek exorcism.
The French 19th-century accounts of obsessions emphasized the central role of doubt and indecisiveness. In 1837, the French clinician Esquirol used the term “folie du doute,” or the doubting madness, to refer to this cluster of symptoms. Later French writers, including Pierre Janet in 1902, stressed the loss of will and low mental energy as underlying the formation of obsessive-compulsive symptoms.
The greater part of the 20th century was dominated by psychoanalytic theories of OCD. According to psychoanalytic theory, obsessions and compulsions reflect maladaptive responses to unresolved conflicts from early stages of psychological development. The symptoms of OCD symbolize the patient’s unconscious struggle for control over drives that are unacceptable at a conscious level.
Although often intuitively appealing, psychoanalytic theories of OCD lost favor in the last quarter of the 20th century. Psychoanalysis offers an elaborate metaphor for the mind, but it is not grounded in evidence based on studies of the brain. Psychoanalytic concepts may help explain the content of the patient’s obsessions, but they do little to improve understanding of the underlying processes and have not led to reliably effective treatments.
The psychoanalytic focus on the symbolic meaning of obsessions and compulsions has given way to an emphasis on the form of the symptoms: recurrent, distressing, and senseless forced thoughts and actions. The content of symptoms may reveal more about what is most important to or feared by an individual (e.g., moral rectitude, children in harm’s way) than why that particular individual developed OCD. Alternatively, the content (e.g., grooming and hoarding) may be related to the activation of fixed action patterns (i.e., innate complex behavioral subroutines) mediated by the brain areas involved in OCD.
In contrast to psychoanalysis, learning theory models of OCD have gained influence as a result of the success of behavior therapy. Behavior therapy does not concern itself with the psychological origins or meaning of obsessive-compulsive symptoms. The techniques of behavior therapy are built on the theory that obsessions and compulsions are the result of abnormal learned responses and actions. Obsessions are produced when a previously neutral object (e.g., chalk dust) is associated with a stimulus that produces fear (e.g., seeing a classmate have an epileptic fit). Chalk dust becomes connected with a fear of illness even though it played no causative role.
Compulsions (e.g., hand washing) are formed as the individual attempts to reduce the anxiety produced by the learned fearful stimulus (in this case, chalk dust). Avoidance of the object and performance of compulsions reinforces the fear and perpetuates the vicious cycle of OCD. The learned fears also begin to generalize to different stimuli. The fear of contamination with chalk dust may gradually spread to anything that can be found in a classroom, such as textbooks.