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History of OCD: from Medieval to Current Times

Obsessive Compulsive Disorder (OCD) can be grouped together with mental illness in general, as well as with specific sub-domains of mental illness.  However, OCD has unique characteristics that differentiate it from typical aspects of other mental illnesses, and have also, at times, given it the social conceptualization of personal idiosyncrasy and/or a problem with self-control.  The history of OCD is characterized by evolving notions of human nature, spirituality, medicine, and philosophy, and reflects themes experienced at the large social level.  A number of well-known individuals throughout the last few centuries, including Martin Luther (the leader of the Protestant Reformation in Europe), Charles Darwin (Evolution of the Species), Howard Hughes (whose life story was told in the movie The Aviator), and Katherine Hepburn, all are now considered to have suffered from OCD.   Additionally, the spectrum nature of OCD has led it to be classified at various times as a number of distinct, unrelated conditions.

In the pre-Renaissance world (prior to the 14th century) the belief was widely held that mental illnesses were caused by demons or supernatural forces.  “Scruples” was one term that was used to refer to the manifestations of OCD.  The ensuing treatment often involved the church, in which people sought the help and advice of clergy, and included things like exorcisms and other types of religious rituals.  During the European Renaissance (1300’s – 1500’s), society started to move away from these ideas.

During the Age of Enlightenment (starting in the 1600’s), clergy and other thinkers developed specific recommendations for the treatment of OCD, including not trying to suppress distressing thoughts, keeping oneself occupied with daily activities, and maintaining the company of others.  The beginnings of a type of behavioral therapy for OCD emerged around this time through autobiographical and self-help writings from current thinkers, including Richard Baxter.  The Roman Catholic Church also developed a system of recommendations that posited that OCD could only be treated by absolute adherence to the advice of one’s spiritual adviser.  Obedience became a dominant theme in the church’s recommendations for OCD treatment.

In the 1700’s, treatment of OCD shifted away from the church and became more medicalized, although physicians did not have many tools for treating OCD. This reflected a shift in societal consciousness towards rationalism and positivism and away from pure faith in the established spiritual systems.  Physicians used the same standard medical treatments that were applied to a broad array of medical conditions at the time, including bloodletting, laxatives and enemas to get rid of “bad thoughts”.  This time period was largely negative in the life experience of OCD sufferers, as medical practice was ill equipped to deal with psychological conditions and the era witnessed an increase in the institutionalization of OCD sufferers in insane asylums.  Institutionalization was a trend that continued with increasing prominence through the 1700’s, 1800’s, as OCD during this time period was conceived of as a type of insanity.  In the late 1800’s, a consensus was reached in the medical community that OCD was not a type of insanity, and it became less common to institutionalize OCD sufferers.

The growth of pharmaceutical treatment of OCD grew during the 1900’s, as the medical community and growing interest in psychological analysis debated the causes, nature, treatments, and outcomes of OCD.  Treatment with bromides, opium, and morphine became more common, although treatments during this time period were largely experimental and based on the hunches of individual physicians, who wrote about their experiences.  An emergent discussion about OCD as a neurological disease also began during this time period.

During the 1900’s, the emerging predominance of the psychoanalytic paradigm popularized by Freud came to view OCD symbolically, as representations of conflicts in primal urges experienced by patients.  Psychologists in the tradition popularized by Freud posited talk therapy as the appropriate treatment for OCD.  The psychoanalytic approach to OCD, and  the Freudian view of connection with basic primal conflicts, clashed with the ideas of the church, which maintained an emphasis on “scruples”.

Also during the latter part of the 1900’s, behavioral psychology began to take over as the dominant paradigms in the conceptualization, study, and treatment of OCD.  Behaviorists  moved away from talk therapy and came to view behavioral therapy as the appropriate treatment for OCD.  Exposure and Response Prevention (ERP), a treatment rooted in the behaviorist tradition, is still the dominant treatment used for OCD today.

Over the course of the history of OCD, understandings and treatment of OCD have largely stemmed from and reflected the state of societal consciousness, and philosophical and cultural developments at the social level.  As dominant views in society have shifted, so has the approach to psychological conditions such as OCD.  The history of OCD is reflective of the history of mental illness in general, as well as the evolving societal view about religion, medicine, rationalism, and the nature of human beings.

For more information, see http://www.ocdhistory.net/index.html

Stop the Stigma: Getting Real about Treatment for Mental Illness

Guest Post, by Anne

When I went in to a new doctor to refill my Sertraline (Zoloft) prescription, the doctor looked at me with a mix of condescension and pity and asked rhetorically, “you haven´t been able to stop the medication after all this time?”  Granted, this was a general practitioner MD, not a psychiatric specialist, as I had just moved and an appointment with a psychiatrist wasn´t available for several months.  But, this encounter left me wondering at this perception, even from a highly trained medical professional, that continued use of medication to treat depression was an indication of personal weakness.   The encounter left me feeling ashamed and embarrassed, like I had to explain my failure away.  But then I got angry.  A medical professional has a responsibility to be up to date on the current understandings of disease processes and conditions.   A person who is charged with caring for people at their most vulnerable, and who, of all people, should have been well versed in the complexity of the workings of neurotransmitters and their dysfunctions in the body, blamed me for a disease that is standard medical textbook, completely shutting down the possibility of trusting communication.  The inspiration for this article stems in part from this experience.

The reality is that he doctor´s attitude reflected a general stigma against mental illness we as a society still have, which perceives many mental illnesses as stemming from a character flaw, and failure to “get off the meds” as a personal failure rather than a medical one.   Many people who suffer from depression and other psychiatric conditions do not seek help for this very reason, and suffer needlessly, sometimes for entire lifetimes, when appropriate care and medication could have given them their lives back. People who say they, “don´t want to be dependent on any drug” are conflating the successful treatment of a physiological condition with substance dependency and abuse, or sometimes inferring that people who use psychiatric medication to treat their depression are gullible cash cows manipulated by the pharmaceutical industry.  While no medication is perfect and the pharmaceutical industry has its challenges, the reality is that, similar to other chronic conditions, depression and psychiatric illness are conditions that sometimes improve without medical treatment, and sometimes they don´t, much in the same way that some people´s diabetes can be controlled through dietary means alone, while other people must take insulin daily.  There is no real difference between the efficiency of mere will to make the disease get better for people with diabetes and people with depression.  It´s time we stopped shaming people who need to take medication over the long term for chronic depression and instead rejoiced that some people are helped by medication, as well as focused on the need to create medications that can help more people who are not responsive to the current treatments available.

This problem stems partly from the continued separation, in western allopathic thinking, of the body from the mind.  All mental workings are chemical processes.  When this system breaks down, illness can result.  The differences in physiology and chemistry between people with depression and those without can be temporary, caused by a transient disequilibrium brought about by some jarring incident or life event, or can be long lasting, often stemming from physiological causes.  Sometimes the pattern can be seen across generations.  For example,  my great grandmother had severe depression.  The stories passed down to me in our family indicate that, as the lonely wife of a minister who moved to a new parish every few years, she would leave her three daughters unattended while staring blankly out the living room window for hours at a time.  One time her father had to be called to come from across the country, summoned by a neighbor who told him “the girls are running wild.”  I remember her as the fragile but independent 97 year-old with a four-pronged cane, whose house smelled of vitamins and who had cat clocks and statues everywhere, but she suffered her whole life from what was often debilitating, bone crushing depression.

Despite her struggles, she managed to raise very successful daughters and lived to an old age.  Given the prevailing attitudes of the early 1900´s in terms of stigma against mental illness, she probably felt extremely guilty about her depression and chalked her inability to be free of it up to a deep character flaw.  However, based on her symptoms, it appears clear that she suffered from chronic major depression, and possibly OCD.  Though it seems to have skipped my grandmother, my mother was chronically depressed and had OCD.  In addition, I have chronic depression that only subsides with medical treatment and have had major episodes of major depression and OCD at various times throughout my life.

While I have started and stopped treatment with Sertraline various times throughout my experience with depression, the depression, for me, always comes back.  If I can one day find a way to be free of needing to take medication, I would welcome it gladly, as it would confer many liberating effects. I would appreciate not having the extra cost of the medication and doctor visits, as well as not having to ensure I have the proper amount of supply along with a doctor´s note when I travel internationally.  But I want to enjoy my life too.  I´m not willing to sacrifice the preciousness of each day that I don´t feel depressed, that I can work and enjoy spending time with others, that I can be productive, that I feel happy, in order to satisfy a false premise.  And I should not be looked at as less for that.

Promising Treatment for OCD and Depression

A significant number of people who suffer from Obsessive Compulsive Disorder (OCD) also suffer from depression.  While the exact mechanics are not fully understood, It is believed that OCD often increases depressive symptoms, sometimes leading to major depression, although OCD can exist in non-depressed individuals as well.  Similarly, depression can involve OCD components, as well as lead to their manifestation over time. When OCD and depression occur together, it can be more challenging to decide how to best treat the patient.  Seratonin-Reuptake Inhibitors (SRI´s) may or may not be totally effective at controlling both the OCD and the depression at a given dose, and, at the same time, it is often desirable to make the medication regimen as simple as possible.  The effects of some medications, when taken simultaneously, counteract or exacerbate the effects of another leading to undesired effects, and sometimes a single medication would be effective for both OCD and depression, but at different doses.  This presents a complex situation for assessing which treatment of combination of treatments will work best in a given patient´s situation. Continue reading Promising Treatment for OCD and Depression