From Ancient Times to Now: OCD Through the Years

Obsessive-Compulsive Disorder (OCD) is a mental health condition that affects an estimated 1-3% of the population worldwide. OCD is characterized by intrusive thoughts, images, or urges, known as obsessions, which cause significant anxiety or distress. To alleviate this distress, individuals engage in repetitive behaviors or mental acts, known as compulsions. These symptoms can be severe, consuming a significant portion of a person’s time and attention, and causing marked emotional distress and impaired functioning. 

Although modern psychiatry recognizes and classifies OCD as a distinct disorder, the roots of OCD run deep through history. The understanding and treatment of OCD have evolved significantly over the centuries, reflecting broader shifts in psychology, medicine, and societal views of mental illness but the road to this view has been full of twists and turns.

The Ancient Civilizations

Even before it was officially named, OCD has been recognized for thousands of years. Ancient civilizations, particularly the Romans and the Greeks, made references to obsessive behaviors in their writings that today, we would associate with OCD. 

Ancient Greeks and Romans were the first to recognize the relationship between mental and physical health, and physicians viewed mental illness as a medical condition, even though they didn’t understand it well. One of the earliest written descriptions of compulsive behavior can be found in the works of Aretaeus of Cappadocia (2nd century CE), a Greek physician. He wrote about individuals who were compelled to wash their hands excessively, describing behaviors that are strongly reminiscent of modern-day OCD symptoms. These writings hint at the existence of what we now recognize as compulsive behavior. However, at that time, these symptoms were not viewed in the context of a specific disorder but rather related to the individual’s temperament.

One of the earliest Roman accounts of OCD comes from the Roman historian Plutarch. He describes a Roman man whose behavior suggested issues with scrupulosity, guilt or anxiety over religious subjects that are commonly associated with OCD. Many ancient cultures, including some Greeks and Romans, attributed mental illnesses to religious causes, such as divine punishment or possession. Religion-focused treatment was not an uncommon practice. 

Medieval Perspectives 

During the Middle Ages, also known as the Dark Ages (5th to 15th centuries), much of Europe and the Middle East was dominated by religious influences on human behavior. Mental illnesses were often attributed to demonic possession or moral weakness. Ritualistic or obsessive behavior was often interpreted as a sign of possession or spiritual or moral failings, requiring religious interventions like exorcism or confession and repentance. 

Obsessive thoughts, particularly of a blasphemous or impure nature, were often viewed as temptations from the devil. In Catholicism, the phenomenon of "scrupulosity" was a religious form of OCD, in which individuals became consumed by fears of sin and guilt. They would obsess over minor or imagined transgressions and seek repeated forgiveness through confession. This form of obsessive religiosity was not seen as a psychological disorder but as a spiritual struggle. For some, it resulted in a life dominated by compulsion and fear of divine punishment. 

Writings of this time reflect the influence of religion and the phenomenon of scrupulosity, and what might today be considered OCD. German theologian Johannes Nider wrote about a nun, Kunegond, who worried excessively that her acts of confession were inadequate. Her constant fear and excessive fasting as penance resulted in questions about her sanity and her near-death.

Islamic scholars also documented forms of obsessive-compulsive behavior. In the 10th century, the Persian physician Avicenna (980–1037) wrote about a man who believed he was being persecuted by the devil and washed his hands excessively to purify himself. 

Beliefs about witchcraft were rampant in many parts of the world during the Middle Ages. Those with mental illness were thought to be bewitched or to be practicing witchcraft. Punishments could be extreme, and history is fraught with examples of these practices. In this period, religious and supernatural explanations for compulsions persisted, even as some scholars began to theorize about mental illness in more secular terms.

The Renaissance and Enlightenment

The Renaissance (14th to 17th centuries) marked a turning point in the understanding of mental illness. Philosophers and physicians began to embrace more humanistic and scientific perspectives. They began to challenge the prevailing religious explanations of mental disorders, moving toward theories grounded in observation and reason.

One prominent figure of this era was the French physician Jean-Étienne Dominique Esquirol. He was among the first to begin describing mental illnesses in more clinical terms. Esquirol recognized a category of patients who exhibited what he called "monomania," or “partial sanity”, characterized by an obsession with a single thought or action. While he didn’t identify OCD per se, he did recognize obsessive behavior as a distinct form of mental illness. 

The Enlightenment ushered in the age of reason and the scientific method. Mental health was increasingly being viewed through a medical/biological lens. Physicians and scientists like John Locke (1632–1704) and William Cullen (1710–1790) began to assert that mental illness could result from physical causes rather than moral or spiritual failings. However, while these shifts were significant, OCD remained largely misunderstood, often lumped together with other forms of "madness" or "hysteria." 

In the mid-1800’s, we start to see the formulation of the idea of an obsessive compulsive disorder. In 1877, Karl Westphal formulated the first precise definition of obsessive ideas and designated OCD as an independent disorder in its own right. Westphal used the term Zwangsvorstellung (compelled presentation or idea) to describe these thoughts. British physicians translated Zwangsvorstellung as "obsession," while in the United States it became "compulsion." The term "obsessive-compulsive” was born. 

While all these advancements were being made in understanding OCD and mental illness in general, it should be noted that treatment remained elusive. People who suffered from mental illness were often isolated, shunned, or institutionalized. Treatments were scarce at best, and dangerous at worst. 

19th-Century Advancements

The 19th century brought further understanding of mental health disorders, including OCD. French psychiatrist Pierre Janet was one of the first to describe obsessive-compulsive symptoms in detail. He observed patients who were plagued by intrusive thoughts and ritualistic behaviors. He began to view these symptoms as separate from other known mental illnesses. He believed that compulsions were an attempt to reduce the anxiety caused by obsessions. This belief would lay the foundation for today’s understanding of OCD. 

Sigmund Freud, the Father of Psychoanalysis, also made significant contributions to the study of OCD. Freud believed that OCD was rooted in unresolved conflicts in the unconscious mind. He viewed obsessive thoughts and compulsions as symbolic expressions of these conflicts, particularly related to sexual and aggressive impulses and defense mechanisms. While his theories were later replaced by more modern theories, his views on obsessions and compulsions  contributed to today’s understanding of OCD. 

The 20th Century: OCD Finds Its Place in Psychiatry

The early 20th century brought new diagnostic categories and treatments to psychiatry. In 1908, Swiss psychiatrist Eugen Bleuler (1857–1939) coined the term "obsessive-compulsive neurosis" to describe a specific type of neurotic disorder characterized by obsessions and compulsions. Around the same time, Emil Kraepelin (1856–1926), a German psychiatrist, began to classify mental disorders in a systematic way, giving way to the modern diagnostic manuals of today.

In the mid-20th century, the Diagnostic and Statistical Manual of Mental Disorders (DSM) became one of the first manuals of standardized diagnostic criteria, and OCD found its place. The first edition, published by the American Psychiatric Association in 1952, classified OCD as an anxiety disorder, emphasizing its connection to distress and fear. Today, the DSM is in its 5th edition and OCD is now included in a category of its own, OCD and Related Disorders.  

Treatment Advances

While doctors were trying to define OCD and other mental illnesses, others were trying to find viable treatments. History has not been kind to people living with mental illness and at various stages of history, sufferers were subjected to remedies from potions, prayers, penance to punishment for witchcraft to being institutionalized and more.

Throughout much of the 20th century, the primary treatments for OCD were psychoanalysis and, in severe cases, invasive procedures like lobotomies. However, the development of psychopharmacology and cognitive-behavioral therapy (CBT) in the mid-20th century revolutionized OCD treatment.

In the 1960s and 1970s, researchers discovered that medications like clomipramine, a tricyclic antidepressant, could significantly reduce OCD symptoms by affecting serotonin levels in the brain. This discovery led to the broader use of selective serotonin reuptake inhibitors (SSRIs) in the treatment of OCD, which remain one of the most effective pharmacological treatments to this day.

At the same time, CBT emerged as a highly effective psychological treatment for OCD. Specifically, a form of CBT called exposure and response prevention (ERP) was developed, which involves gradually exposing individuals to their obsessive fears and preventing them from engaging in their compulsive behaviors. ERP has become the gold standard for treating OCD. 

Today and Beyond

Today, OCD is recognized as a chronic but manageable condition, and research has continued to shed light on the neurological, genetic, and psychological factors that contribute to the disorder. Brain imaging studies have shown that OCD is associated with abnormal activity in certain regions of the brain, particularly the orbitofrontal cortex, anterior cingulate cortex, and basal ganglia.

Modern treatment approaches often combine medication and ERP, offering hope for those living with OCD. Research into OCD continues to evolve, with new therapeutic approaches, such as deep brain stimulation (DBS), showing promise for individuals with treatment-resistant OCD.

Conclusion

The history of OCD is a fascinating journey from ancient superstitions to modern scientific understanding. What was once seen as a manifestation of moral weakness or demonic possession is now recognized as a complex neurobiological condition that can be effectively treated. Although much has been learned about OCD over the centuries, ongoing research continues to deepen our understanding of the disorder and improve treatment options for those affected. Through these advances, people with OCD can now lead fulfilling lives, free from the fear and stigma that once surrounded their condition.

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