Going beyond CBT to treat obsessive compulsive disorders (OCD)
This article is aiming at providing a hopefully useful framework for conceptualising an integrated theoretical and therapeutic approach to obsessive compulsive disorders that goes beyond the cognitive-behavioural model usually applied to treating obsessional compulsive disorders. It starts by introducing the classic psychoanalytic approach to obsessional neuroses as defined by Freud, as well as later developments as conceptualised by his daughter Anna Freud and contemporary psychoanalysts such as Leonard Saltzman. It continues by presenting more recent theoretical and clinical insights brought by innovations in neuroscience. And finally, it provides a critical account of the cognitive behavioural model applied to obsessional compulsive disorders.
Definitions of obsessive compulsive disorders
OCD is defined in DSM - 5 as the presence of the following:
A presence of obsessions, compulsions, or both.
Obsessions are defined by:
- Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
- The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralise them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined by:
- Repetitive behaviours (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
- The behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
Freud (1926) wrote that obsessional neurosis was ‘unquestionably the most interesting and repaying subject of analytic research’. Although the entity currently known as obsessive compulsive disorders (OCD) had been previously described by others, Freud coined the term ‘obsessional neurosis’ and provided some of the most detailed and vivid descriptions of the phenomenology of the disorder to date.
He also stressed that clients are able to conceal their illness, so that ‘many more people suffer from these forms of obsessional neurosis than therapists hear of’ (Freud, 1907). Freud’s important contribution to phenomenology was complemented by theoretical innovation as his psychoanalytic writing has provided a comprehensive description of the underlying psychic structures thought to be responsible for obsessive compulsive symptoms.
Indeed, psychoanalytic understanding of obsessional neurosis on the one hand, and of the hysteria on the other, can be seen as forming the clinical cornerstones on which Freud built his understanding of the unconscious and its role in psychopathology. Whereas the hysteric – often a woman – repressed ideas, the obsessive – often a man – repressed affect. Again and again, Freud returned to these two disorders, comparing and contrasting their manifestations and psychodynamics.
And yet, OCD has taken a back seat in modern psychoanalysis. Recent years have seen very few theoretical contributions to this topic. Moreover, it is not clear that psychoanalysis provides a useful and effective treatment for OCD. Indeed, when reviewing the psychoanalytic literature at hand, Esman (1989) concluded that there is little evidence that psychoanalysis provides an effective intervention for clients suffering from OCD.
What is perhaps intriguing is that, at the same time, we have witnessed a vast increase in knowledge about OCD. Recent developments in neuroscience have documented that OCD has specific mediating neurochemistry and neuroanatomy. Cognitive behavioural therapists have also documented the efficacy of some non – psychodynamic interventions in the treatment of OCD.
Psychoanalytic approaches to OCD
OCD has been very important to psychoanalytic thought and this disorder has been altered and revisited many times, following the development of psychoanalytic theory over time.
Freud has written several papers on this disorder, among which the most important ones are: ‘The Defence Neuro-Psychoses’ published in 1894, followed by the case study on ‘Rat Man’ in ‘Notes upon a case of obsessional neurosis’, published in 1909 and ‘Inhibitions, symptoms and anxiety’ published in 1926.
In his first paper, Freud draws a parallel between hysteria and obsessive compulsive neurosis and indicates that both disorders are caused by specific childhood sexual experiences that have resulted in a defensive mechanism to suppress certain negative dysfunctional thoughts.
However, he also distinguishes obsessional neurosis from hysteria, and he believes that the main difference between the two relies on the pleasure that has been taken by the child in some sexual experience in childhood. He thinks that obsessional neurosis is characterised by pleasure taken by the child during the childhood sexual experience, while in the case of hysteria, the childhood sexual experience has been ‘passive’. Thus, for Freud, the treatment involves ‘leading back the attention of patients…to the repressed sexual ideas in spite of all their protestations’ (Freud, 1894) in an effort to deal with the secondary defence of the ‘return of the repressed’.
Later on, Freud changes his mind about the origin of obsessional neurosis and discovers that clients’ memories are actually fantasies. It is interesting that lately there has been an explosion of research on child abuse, which may prompt us to view Freud’s first hydraulic of the mind’ in a new light. Childhood sexual abuse and physical trauma can frequently be found in clients with OCD, but there is still very little literature exploring this link.
In ‘Rat Man’, Freud’s most important paper on obsessional neurosis, he describes how pervasive the feelings of unconscious hatred and sadistic impulses are in this disorder: ‘in the cases of unconscious hatred, with which we are concerned, the sadistic components of love have been exceptionally strongly developed, and have consequently undergone a premature and all too thorough suppression, and … the neurotic phenomena…arise on the one hand from conscious feelings of affection…, and on the other hand from sadism persisting in the unconscious in the form of hatred’ (Freud, 1909, p. 202).
He also provides a very detailed and visionary account of the phenomenology of OCD. It is interesting that contemporary research has successfully explored the link between OCD and aggression, coming to the conclusion that many OCD patients have experienced childhood physical or sexual abuse.
For Freud, the main characteristics of the obsessional neurosis are the regressive return to the anal stage and the presence of sadistic libidinal drives. It is intriguing and interesting that contemporary theoretical constructs of OCD describe cognitions in OCD being closely related to dirt and fear of contamination, but at a more literal level.
By the time of his third major paper on obsessional neurosis ‘Inhibitions, symptoms and anxiety’, Freud had already updated his conceptual approach to the structural model of the mind. Hence, he talks about the major importance of the ego and the super-ego in the formation of obsessional neurosis, explaining that the ego regresses to the sadistic-anal stage, as a defence against the libidinal demands of the Oedipus complex: ‘the superego becomes exceptionally severe and unkind, and the ego, in obedience to the super-ego, produces strong reaction-formations in the shape of conscientiousness, pity and cleanliness’.
Karl Abraham’s 1921 paper ‘Contributions to the theory of the anal character’ draws closely on Freud’s concepts of anality, returning to the anal character triad of orderliness, parsimony and obstinancy (Freud, 1908). Like Freud, Abraham views the anal libidinal organization as underlying both symptom formation (obsessional neurosis) and character type (anal triad) – with the difference lying only in the fact that in the anal character there is no failure of repression and no return of the repressed (Freud, 1913).
Abraham hypothesises that when cleanliness or other tasks are demanded too soon by parents, a conflict may result between a conscious attitude of submissiveness and an unconscious desire for vengeance. These patients develop traits such as having to do everything themselves because no one else can do it as well, indexing and registering everything, giving gratifications in small and insufficient amounts and overemphasizing possession.
While Abraham’s argument that all these so-called anal traits have analogue sin the client’s attitude to faeces and defecation may be questioned, his description of these clients is another important contribution to the clinical phenomenology of the entity currently known as OCD.
Anna Freud writes an important paper in 1966 entitled ‘Obsessional Neurosis’, presented at the Twenty-Fourth International Psycho-Analytical Congress. She begins with her own view of obsessional neurosis, but her views are significantly following her father’s especially regarding the importance of the defence mechanisms and the id-driven behaviour.
What distinguishes Anna’s paper from her father’s works, are her hints to some limitations of the psychoanalytic framework regarding obsessional neurosis and the fact that she conveys a sense that other psychological models may become necessary for progress to be achieved in the treatment of this disorder. She also talks about the role of intellectualisation as a defence mechanism as well as interesting links between failed object-relations and heightened anality.
Anna Freud also points out a number of new foci, such as developments in ego psychology. She notes, for example, that the extension of defensive devices to include the ego’s ‘everyday functioning such as perceiving, thinking, abstracting, and conceptualising…represents an attempt to embrace the area of conflict as well as conflict-free area of secondary process functioning.’ (1966, p. 81). She also suggests a number of interesting hypotheses and formulas, for example noting that ‘in hysteria the body behaves as if on its own, the mind does the same in obsessional neurosis’ (1966, p. 83).
Peter Sifneos (1966) has argued that many clients respond to brief psychodynamic therapy. He also applies the same view to OCD, arguing that sometimes environmental factors, such as criticism from an authority, act as precipitant, resulting in the use of defense mechanisms that prove to be unsuccessful. He outlines several criteria for selecting clients for such short therapy, such as the absence of chronicity and the acute onset of OCD symptoms in a well-adjusted person facing an emotional crisis and a general fluidity of the defences used. His techniques for therapy include use of the positive transference, focusing on unresolved conflicts, avoidance of the development of transference neurosis, etc. It is an interesting perspective, especially because not much attention has been given to the phenomenon of acute OCD.
The psychoanalyst Leonard Salzman provides an important contribution to current therapeutic practice for the treatment of obsessional disorders in his book ‘Treatment of the obsessional personality’, published in 1968. In his book, he adds an important interpersonal aspect to Freud’s classical model and focus on issues of control.
His book is still relevant today to psychotherapeutic practice, as he talks in depth about difficulties encountered in working with OCD clients, who tend to be resistant to therapy: ‘the essential task in therapy with obsessive compulsive disorders is conveying insight .. without getting caught in the obsessional tug-of-war’ (Salzman, 1968, p.121), and how therapy can be become a ‘struggle for control and position’ with the OCD client war’ (Salzman, 1968, p.122). His advice to the therapist is to remain flexible while still holding firm boundaries, work in the here and now and be aware of his feelings of counter-transference, especially those around powerlessness and uncertainty.
Neuroscientific approaches to OCD
Although Freud already talks about some constitutional factors involved in the aetiology of OCD (1909, 1926) and ‘similar heredity’ (1895), it is only recently that progress in neuroscience has made the study of the human brain and neurotransmitters possible.
As early as 1938, Paul Schilder had reviewed some early evidence of the neurobiological factors involved in OCD, by noticing that some clients showed symptoms suggesting brain dysfunction. However, he remained a partisan of psychoanalysis and suggested that the cause may be either organic or psychogenic.
Later research by Stein, Hollander and Cohen (1994) revealed clear links between OCD and neuropsychiatric abnormalities. Steven Wise and Judith Rapoport led additional research evidence relating the functioning of the basal ganglia to the aetiology of OCD.
The work of Joseph Zohar and Thomas Insel (1987) further advanced the topic by providing insights into the neurochemistry of OCD and the role of the serotonin levels in the presentation of OCD symptoms. Later developments in brain imaging technologies such as PET (positron emission tomography) and SPECT (single photon emission computed tomography) have revealed activities specific regions of the brain.
Neuroscientific research has managed to provide fascinating insights into the aetiology of obsessive compulsive disorders and has had the effect of moving OCD away from its central position in psychoanalytic theory, where it was considered to shed light on the unconscious.
What neuroscientific approaches have also revealed are observations stressing the common phenomenology and psychobiology of related conditions such as Tourette’s syndrome, body dysmorphic disorders and hypochondriasis, which are equally characterised by intrusive thoughts and compulsions around rituals and neutralising behaviours.
Cognitive approaches to OCD
There have been a number of cognitive-behavioural approaches to emotional disorders in the past years and these approaches have started to form the basis for evidence-based psychological therapies for many presentations. The most popular one is Beck’s cognitive model (Beck, 1967) and it has been used extensively to provide treatment for anxiety and depression disorders.
However, although the cognitive model has provided useful information on the nature and treatment of depression and anxiety, it has so far failed in providing a convincing approach to understanding obsessional disorders. Beck (1976) attempts a cognitive explanation of obsessional-compulsive issues; however, his account is only based on the view that the content of obsessions is related to thoughts of danger in the form of doubt and warning.
His model fails to make the distinction between these thoughts and the typical thoughts of danger or risk shown to be specific to anxiety, although these disturbances have very different presentations. Beck’s model is not compelling enough as it does not provide a model that is differentiated enough from the generic anxiety models.
Yates (1993) has made a differently orientated attempt at a cognitive behavioural approach to obsessive compulsive disorder, with the aim of bridging the gap between cognitive behavioural and psychoanalytic theory. His approach is however lacking clarity and presents with too many problems stemming from the difficult enterprise of bridging such a big gap between two very different theoretical approaches. For example, there is a very heavy reliance on preconscious and unconscious cognitions, which, compared to the psychodynamic formulation, are presented as closer to the client’s awareness and being unacceptable ideas or feelings.
Despite the advances in our modern understanding of the neuroscience and cognitive behavioural therapy of OCD, there are important reasons to return to the classics. First, despite the dramatic advances made in neuroscience there are still many aspects of the disorder that require further investigation and the older psychonalytic framework may provide an important source of constructs and hypotheses.
Second, despite the success of cognitive behavioural therapy, there are still many cases where psychodynamic therapy plays an important role, either in encouraging clients to use these modalities, or as a supplement to them.
I believe that the question is perhaps not so much whether to return to Freud and other early authors, but rather how best to incorporate their findings.
- Abraham K. (1921). Contributions to the theory of the anal character. London. Hogarth Press.
- Freud S. (1894). The defence neuro-psychoses. Standard Edition 9: 167-76.
- Freud S. (1909). Notes upon a case of obsessional neurosis. Standard Edition 21: 188-22.
- Freud S. (1926). Inhibitions, symptoms, and anxiety. Standard Edition 20: 111-31.
- Freud A. (1966). Obsessional neuroses: a summary of psychoanalytic views as presented at the congress. International Psychoanalytic Journal 47: 116 -23.
- Freud A. (1966). Obsessional neuroses: a summary of psychoanalytic views as presented at the congress. International Psychoanalytic Journal 47: 116 -23.