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Obsessive-Compulsive Disorder: Current ViewsDr. Aaron H. Esman M.D. a ba Weill Medical College of Cornell Universityb New York Psychoanalytic InstitutePublished online: 01 Jul 2008.

To cite this article: Dr. Aaron H. Esman M.D. (2001) Obsessive-Compulsive Disorder: Current Views, Psychoanalytic Inquiry: ATopical Journal for Mental Health Professionals, 21:2, 145-156, DOI: 10.1080/07351692109348929

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Obsessive-Compulsive Disorder:Current Views

A A R O N H. E S M A N, M.D.

145

Dr. Esman is Professor of Clinical Psychiatry, Emeritus, Weill Medical College

of Cornell University; Faculty, New York Psychoanalytic Institute.

Obsessive-compulsive disorder has been of central interest topsychoanalysis since Freud’s early papers, most particularly inthe “Rat Man” case. This early literature spelled out with greatclarity the presumed development, psychodynamics, andmeaning of obsessional and compulsive symptoms.Unfortunately, since Anna Freud’s 1969 review of the subject,virtually nothing has appeared in the psychoanalytic literaturethat has added to our understanding of the disorder or enhancedthe very limited therapeutic influence of psychoanalysis in suchcases. Meanwhile, there has been an avalanche of contributionsfrom biological psychiatry and behavioral psychology that havepropounded different theories of pathogenesis and have laidclaim to significant therapeutic effectiveness. If psychoanalysisis to have credibility in this field, it will have to enlist itself inmultidisciplinary research efforts directed toward enriching ourknowledge about the psychodynamics and the biologicalsubstrate of this illness (more common than once believed) andthe efficacy of our efforts to treat it.

N 1989, I PUBLISHED A PAPER (Esman, 1989) reviewing the history ofIpsychoanalytic views on obsessive-compulsive disorder (OCD) and

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the significance of recent nonanalytic investigations into this illness,considered by Freud (1926) to be “the most interesting and repayingobject of psychoanalytic research” (p. 113). In that essay I pointedout the poverty—indeed, the virtual absence—of psychoanalyticcontributions in the previous 2 decades, either to the understandingof the etiology and dynamics of the disorder or to its treatment.

Now, 12 years later, it would be pleasant to report a change in thissituation; unfortunately, such is not the case. During this period noother essay bearing directly on the topic has appeared in thepsychoanalytic literature. At the same time, over 1000 papers havebeen published in the general psychiatry and clinical psychologyliterature on OCD, of which at least 22 have been review articles. Aspecial number of “Psychiatric Clinics of North America” (Jenike,1992) contained a wide-ranging series of clinical and research reports;it is noteworthy that “psychoanalysis” does not appear in the indexof this monograph, nor is psychoanalysis or psychoanalyticpsychotherapy proposed as a treatment method in any of its essays.Indeed, Insel (1984) has stated, “In our series of 21 patients whowere collectively the recipients of more than one century ofpsychodynamic treatments, we had no reason to be . . . optimistic.. . . [Nowhere] in the literature on the psychodynamic treatment ofobsessional states are there clear and consistent data documentingthe frequency of positive responses to psychodynamic approaches”(p. 720).

It will be my purpose here to reassess the psychoanalytic literatureon OCD, both classical and recent, and to attempt to relate it to someof the more current studies from nonanalytic sources. In doing so, Ihope to be able to examine, if not explain, the decline inpsychoanalytic interest in what Freud considered the prototypicneurosis and to consider what role, if any, remains for psychoanalysisin the study and treatment of those who suffer from it.

Psychoanalytic Contributions1

The locus classicus for the formulation of the structure of obsessive-compulsive disorder is Freud’s (1909) Rat Man case. In the

1 The material in this section is a revised version of Esman (1989).

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remarkable case presentation (and the clinical footnotes), Freuddelineated some of the abiding notions about obsessional dynamics:the central role of ambivalence; the regression from unresolvedoedipal conflicts to anal-sadistic concerns with control; the salienceof the defenses of reaction formation, intellectualization, isolation,and undoing; and the critical importance of magical thinking. Hecarried these thoughts further in “The Disposition to ObsessionalNeurosis” (1913) in which he formulated the concept of the pregenitalorganization of the libido—determined, he suggested, primarily byconstitutional rather than experiential factors and crucial to theobsessional neurosis as the locus of regression when genital sexualorganization failed or had to be relinquished: “Hatred and analerotism,” he said, “have . . . taken over the representation of thegenital instincts” (p. 322) in such cases. Obsessional neurosis “usuallyshows its first symptoms in the second period of childhood (betweenthe ages of six and eight)” (p. 318); in such instances “the sexualorganization which contains the disposition to obsessional neurosis. . . is never afterwards completely surmounted” (p. 322). Freudcorrelated obsessional neurosis and obsessional character. In the latter,the “regression following repression . . . has occurred smoothly,”while “in the neurosis there are conflict, an effort to prevent regression. . . the reaction-formations against it and symptom-formationsproduced by compromises between the . . . opposing sides” (p. 324).Significant is a dissynchrony between ego development and libidinaldevelopment; precocity in the former encourages repression and thedevelopment of obsessional defenses.

Much of this is repeated in “Inhibitions, Symptom and Anxiety”(1926), but here Freud adds references to the “severe” and “unkind”character of the superego, determined also by the regression fromthe more mature superego characteristic of the genital organization.He defines the special role of the defenses of undoing and isolationin the obsessional and notes that, although obsessional ideas areconscious, they are disguised and distorted substitutes for theunconscious impulse that is being warded off.

Since Freud’s definition of the basic conflicts and defensivestructure of the obsessive-compulsive, subsequent contributions byothers have been little more than elaborations of or glosses on hisfundamental ideas. Abraham (1924) considered obsessive-compulsiveneurosis as a variant mode of the anal-sadistic organization of the

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libido, contrasting it with melancholia. In the former, the emphasisis, he suggested, on the retaining–controlling aspects; in the latter,the emphasis is on the more primitive-destructive aspects of this stageof development, fixation, or regression. Earlier, Ferenczi (1913) hadaddressed the omnipotent thinking of the obsessional, explaining itas a sign of regression to an early stage of the development of thesense of reality—the stage of “magic thoughts and magic words.”

Weissman (1954) addressed the characteristics of the superego inobsessional character and obsessive-compulsive neurosis—conforming to the common psychoanalytic view that the two areessentially identical in structure and that the latter develops out ofthe former by processes of regression and secondary defenseformation. Weissman elaborated on Freud’s distinction between thesevere primitive or, in Weissman’s terms, “archaic” superego of theobsessive-compulsive neurosis and the “mature” superego of thenormal person and the obsessive-compulsive character. Libidinalregression to anality in the face of the “archaic” superego leads toneurosis, while similar regression in the face of a “mature” superegoleads to obsessional character formation; at the same time the egoregression in obsessive-compulsive neurosis is greater than inobsessional character.

The principal reassessment of classical views on obsessive-compulsive neurosis can be found in Anna Freud’s (1966) summaryof the discussion at the 1965 Congress of the InternationalPsychoanalytical Association. She espoused prevalent views of thecontinuity between obsessional character and obsessive-compulsiveneurosis, of the primary role of impulses of the pregenital (i.e.,prephallic) anal-sadistic stage and the familiar catalog of defenses.She differentiated between obsessive-compulsive phenomena andboth the “pre-ego” repetitions of young children and mental defectivesand the “compelling” impulsive behaviors of addicts and delinquents.She underscored the central importance of the ambivalence (or lackof drive fusion). “Constitutional” factors, including inheritance, areimportant in determining not only the “intensity of the anal-sadistictendencies,” but also the “preference” for the characteristic defensemechanisms.

Miss Freud devalued efforts at finding determinants of obsessive-compulsive disorder in early infant development; events at this stagewere likely to be etiologically nonspecific as opposed to fixations

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related to anal phase development and to regression caused by phallic-oedipal conflicts. The interactions between drive and ego as theyrelate to regression and defense organization are, she said, complexand not fully understood. In the end, little was added by thediscussions at the Congress or by Miss Freud’s comprehensivesummary to well-established classical concepts.

The succeeding 2 decades, in their turn, added little more. Nagera(1978) addressed the subject in a book-length treatise that essentiallysummarized Freud’s views and those of later commentators, addinga “developmental approach” that remained rooted in libido theoryand familiar concepts of anal sadism and regression. In the“interpersonal” literature, Salzman (1985) and Mallinger (1984)emphasized the centrality of the obsessional’s need for “control” inall aspects of life. As Salzman put it, “The obsessive compulsivedynamism is a device for preventing any feeling or thought that mightproduce shame, loss of pride or status or a feeling of weakness ordeficiency whether such feelings are aggressive, sexual, or otherwise”(p. 13). These authors subscribed to the view that obsessionalcharacter and obsessive-compulsive neurosis are on a spectrum andthat the neurosis is the outcome of a breakdown of the adaptivedefenses leading to the mobilization of secondary pathological“security measures.” Developmentally, the basic need for control maybe the consequence of the child’s effort to cope with both“interpersonal dangers,” such as parental inconsistency andunreliability and “miscellaneous” external dangers (Mallinger, 1984).Most recently, Munich (1986) has described the eruption of frankobsessive-compulsive symptoms in the course of analysis of a patientwith an obsessional personality disorder. On each occasion thetransitory symptom formation was precipitated by the emergence ofmaterial related to issues of separation and loss, triggering regressionfrom oedipal to preoedipal longings and defense organization.

A special literature exists with regard to obsessive-compulsiveneurosis in childhood, where difficulties in application of classicaladult-derived categories complicate diagnosis and dynamicunderstanding. Despert (1955) defined the differences between severeobsessive-compulsive neurosis and “schizophrenia” in children,relying primarily on the intactness of reality testing and the ego-alien quality of the symptom to support the former diagnosis. In herview, obsessive-compulsive neurosis is “not so rare as noted in the

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literature” (p. 240), and its onset may “be considerably earlier (5 or6 years level) than generally reported” (p. 252). In her discussion ofDespert’s paper, Mahler (1955) emphasized the “pivotal” importanceof the retention of object relations. “If this can be objectively orclinically ascertained, the case in question cannot be called psychotic”(p. 286).

Sandler and Joffe (1965) described obsessive-compulsive neurosesin children, differentiating them from obsessive symptoms that arisein the course of anal-phase development and persist. These, they say,are not, strictly speaking, neurotic “because they occur during thecourse of progressive development rather than as a consequence ofregression” (p. 428). Wulff (1951) takes a similar position, statingthat “preoedipal” obsessive-compulsive symptoms are reactive toexternal influences, rather than the outcome of intrapsychic conflict.Like others, these authors distinguish both these and truly neuroticobsessive-compulsive symptoms from symptoms that serve to dealwith threats of annihilation and disintegration in borderline andpsychotic children and from repetitive behaviors in post-traumaticdisorders. The emphasis of their discussion is on the role of regressionin the ego, in particular, its defensive organization, in addition to thedrive regression emphasized in earlier writings.

More recently, the very existence of obsessive-compulsive neurosisin children has been questioned by Yorke and Burgner (1980) whocontend that “we [should] speak only of obsessional tendencies andobsessional phenomena in children” (p. 42). In their view, thedevelopmental line from primary bodily discharge to mentalizationand the development of signal anxiety has not been sufficientlytraversed by children (prior, presumably, to adolescence) to permitthe formation of a true obsessional neurotic structure. Theirconception of the dynamics of the “phenomena” they do observe doesnot differ significantly from the traditional one.

This view conflicts sharply, however, with the findings of Swedo,Leonard and Rapoport (1992), who studied 70 children andadolescents with clearly defined (DSM III) OCD; onset occurred asearly as age 5. Earlier, Judd (1965) in a review of 405 child patientsfound five clear cases of obsessive-compulsive disorder. Theiraverage age of onset was 7½, conforming with Freud’s figures.Though all showed typical features of superego rigidity, ambivalence,and guilt reactions, their histories indicate no special difficulties withtoilet training. Hollingsworth et al. (1980) reported 17 cases

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conforming to strict diagnostic criteria in a large child guidance clinicover a span of 16 years. Average age of onset was 9.6 years, and 82percent of parents suffered from severe psychopathology, not furtherspecified. These authors concluded that the obsessive-compulsivesymptoms in their cases represent efforts at defense against realitystresses in the family, encouraged by identification with the verbal/obsessive cognitive style of the parents. Symptoms tended to persiston long-term follow-up.

Obsessive-Compulsive Disorder and Obsessive-CompulsivePersonality: The New Nomenclature

As noted earlier, it has been a commonplace of psychoanalytic thoughton the subject that obsessive-compulsive disorder (or obsessive-compulsive neurosis) is developmentally and structurally allied toobsessive-compulsive personality. The emergence of the neuroticsyndrome represents, in this view, a breakdown and regressivereintegration of the underlying personality structure. Recent reports,however, cast doubt on this supposed relation. Insel (1984), forexample, states explicitly that obsessive-compulsive disorder is nota severe form of obsessive-compulsive personality. Between 16percent and 36 percent of patients with the neurosis do not havepremorbid obsessive traits. In fact, he states, obsessive-compulsivepersonality tends to decompensate, not into the neurosis, but intodepression. The premorbid personality of the patient with obsessive-compulsive disorder is likely to be “cautious and introverted” ratherthan showing the classical anal triad of orderliness, obstinacy, andparsimony. Flament and Rapoport (1984) concur with respect tochildren; they found that few, if any, of their patients were clean,orderly, or ruminative, nor did they manifest the classical “anal triad.”Rather, they tended to be shy and nonaggressive. The obsessive-compulsive children showed no more “normal developmental rituals”than did controls, and on followup “there were more compulsivepersonality diagnoses than at baseline,” suggesting that the lattermight be a consequence of the neurotic disorder rather than apredisposing factor (Rapoport, personal communication).

This view is adumbrated by Weintraub (1981), who says, “Mostcompulsive characters do not develop neurotic symptoms and manycompulsive neurotics do not have compulsive character traits”(p. 165). In their intensive study of 44 well-defined cases of obsessive-

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compulsive disorder, Rasmussen and Tsuang (1986) found that allhad compulsive traits premorbidly. Nonetheless, they, too, concludedthat “there is no direct relationship between the compulsivepersonality disorder and obsessive-compulsive disorder in general”(p. 325). They also found a high incidence of depressed mood (80percent) and of diagnosable major depressive illness (30 percent) intheir subjects.

Biological Factors

Stimulated by the empirical observation that certain chemicalcompounds (initially chlomipramine, then the specific serotonin-reuptake inhibitors (SSRI’s)) are clinically effective in alleviating,if not curing, OCD symptoms, an explosion of neurobiological studieshas occurred over the last 2 decades. The specificity of this clinicalresponse strongly suggests the special role for serotonin in thepathophysiology of OCD. As Insel and Winslow (1992) state, “Theprecise mechanism remains unclear, but some decrease inresponsiveness to endogenous serotonin seems likely followingchronic administration of potent serotonin uptake inhibitors” (p. 814).Studies of the metabolism and biodynamics of serotonin have thusfar been inconclusive, although, as these authors put it, “The absenceof positive replicated findings may be more a reflection of ourprimitive tools for studying this monoamine than convincing evidencefor normal functioning” (p. 816). Rauch and Jenike (1993) conclude,however, that “although antiobsessional agents may well havetherapeutic effects via the 5HT system, there is little unequivocalevidence to suggest an underlying abnormality in the 5HT system”(p. 20).

The most impressive neurobiological findings have emerged fromthe new brain imaging studies, particularly PET-scanning. Baxter(1992) reports “evidence for symptom-related abnormalities in theorbital prefrontal cortex in OCD. The caudate nucleus, although lessconsistently implicated, also has been found in several studies todemonstrate pre-treatment abnormalities” (p. 882). Insel and Winslow(1992) however, caution that, even though “pharmacologic andbehavioral treatments of OCD that effectively decrease the symptomsalso normalize the functional imaging results, . . . these PET andSPECT findings are associated with OCD symptoms but probably

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do not localize a neurological cause for OCD” (p. 820). Indeed, Rauchand Jenike note repeatedly that it is not clear whether many of theobserved neurobiological deviations are primary or secondary, thatis whether they can be considered as the cause or the consequence ofthe disorder. In any case, they argue against simplistic models,contending that “a comprehensive neurobiological model of OCDmust acknowledge the interrelationship between multiple transmittersystems and integrate anatomical and neuropharmacologicalconcepts” (p. 20).

Behavioral Approaches

Behaviorists address OCD, as they do other disorders, withoutconcern for etiology, whether psychodynamic or biological, but ratherwith the aim of modifying maladaptive behaviors of whatever origin.In their exposition of their mode of treatment, Dar and Greist (1992)contend that “behavior therapy . . . with exposure and responseprevention is effective in reducing obsessions and rituals in at leasthalf of those suffering this disabling disorder” (p. 893). Similartreatment of children with OCD is probably as effective, thoughsystematic studies are lacking. The use of parents as co-therapists isoften necessary in order to help the child to carry out the homeexercises that make up the essential elements of this treatmentapproach. Such “OCD spectrum” disorders as trichotillomania(Swedo and Leonard, 1992) are also reportedly responsive tobehavioral interventions, particularly in synergy with (SSRI)medication.

Implications for Psychoanalysis

There is no avoiding the fact that the weight of clinical and researchevidence on OCD is not favorable to psychoanalysis as a therapeuticinstrument. Psychoanalysis has clearly delineated the dynamics ofthe obsessive-compulsive’s struggles for control, the torture of hisunresolvable ambivalence, and the catalogue of his defensiveoperations. But it appears increasingly that it has been overtaken inits understanding of the etiology and pathogenesis of the disorderand outmatched in the effectiveness of its therapeutic efforts. Is there,then, any longer a place for psychoanalysis at the OCD table?

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There seems little reason to doubt that the sorts of conflictual issuesascribed to—or discovered in—the obsessive compulsive by decadesof analytic investigation are real and significant. The desperatedefensive struggles against murderous wishes and the restitutive aimof the compulsive act were, after all, clear to Shakespeare; the anxietyabout contamination from masturbatory acts or fantasies requires onlyminimal interpretive inference. Understanding of content, that is, ofobsessions and compulsions yields readily enough to psychoanalyticinterpretation.

But the conflicts illuminated by such interpretive efforts are notexclusive to the obsessive-compulsive. They can be seen in thosewho suffer from a variety of neurotic disorders; they are indeed thestuff that dreams are made on; they are the driving elements of literarytragedy. The special form they assume in OCD appears to bedetermined by a specific biological susceptibility, whetherneuroanatomical or neurochemical or both. We are concerned herewith Freud’s question about “choice of neurosis,” and the“complemental series” of which he spoke appears to be weightedheavily on the side of constitution. It would seem that, onceestablished, obsessive-compulsive symptoms, or rather the neuralnetworks that subserve them, are relatively immune to purelyinterpretive influence, however “exact” or accurate this may be. It isfor this reason that psychoanalysis has had virtually nothing to sayabout the disorder for the past 3 decades.

The discoveries of the neurobiologists and the therapeutic claimsof the behaviorists are based on laboratory studies and controlledexperiments—the kinds of extraclinical and systematic investigationsthat Grünbaum (1984) has proposed as the indispensable requirementfor validation of psychoanalytic hypotheses. To date, psychoanalystshave been largely unsuccessful in devising such studies, and appealsto “clinical experience” are no longer sufficient. If psychoanalystshope to remain in the picture, they are going to have to offercontributions of the same level of rigor and scientific sophisticationas those provided by the neurobiologists and the behavioralpsychologists. To do this will entail a major shift in the training ofpsychoanalytic researchers and a redesign of curricula in psycho-analytic institutes, whether they are autonomous or university based.

In short, the problem of OCD brings into sharp focus some of themajor issues confronting psychoanalysis as it faces its second century.

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New investigative technologies and new therapeutic methods presentpowerful challenges in both the clinical and theoretic realms. In theera of “managed care” and “cost-effectiveness,” psychoanalysis mustcompete with treatment methods that have demonstrated greaterefficacy at lower cost than analysts can claim, at least with OCD.Does psychoanalysis have a role to play in the ongoing study of thisillness? Perhaps it does, but it must rise to the challenge and developnew ways of investigating and treating those who suffer from thedisorder. The game will surely not be won by the efforts oftraditionally isolated psychoanalytic practitioners, but rather throughcollaborative, interdisciplinary research.

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