Intrusive thoughts and repetitive behaviors are a part of everyday life. We double-check that we locked the door, replay awkward conversations in our heads, or feel weary using a fork that briefly touched the floor. These instances reflect the brain’s natural way of managing uncertainty and risk.
However, for people with obsessive-compulsive disorder (OCD), these thoughts and behaviors are not just occasional worries or habits. This disorder has been recognized in various forms throughout history, from early religious interpretations to modern neuroscience. Understanding the history of OCD not only shows how far we’ve come but also helps us progress forward in how we treat patients struggling with this serious mental health condition.
The first descriptions of OCD were tied to religion and morality, not medicine. Before people understood mental health, intrusive thoughts and compulsive behaviors were seen as spiritual struggles.
One of the earliest forms of OCD-like behavior was called scrupulosity, which is an extreme fear of sinning or doing something morally wrong. People with scrupulosity felt intense guilt over their thoughts or actions and would try to soothe their anxiety through compulsive behaviors like excessive praying, confession, or strict rituals. At this time, this was considered a type of religious melancholy.
Since mental illness wasn’t well understood, many people suffering from OCD were seen as morally weak, overly anxious, or under the influence of supernatural forces. Instead of receiving medical help, they would often turn to priests or religious figures for guidance.
In the 15th-17th centuries, obsessive thoughts and compulsions were blamed on the devil. During this time, many people believed that unwanted, blasphemous, or disturbing thoughts were a sign of partial demonic possession, while more extreme cases involving hallucinations were thought to be full possession. This belief led to harsh treatments, like exorcisms.
One well-known book from the 1400’s, the Malleus Maleficarum (The Hammer of Witches), described a priest who experienced compulsive thoughts and actions:
“[w]hen he passed any church, and genuflected in honour of the Glorious virgin, the devil made him thrust his tongue far out of his mouth when he tried to engage in prayer, [the devil] attacked him more violently.”
Today, we recognize this as a possible case of intrusive thoughts and compulsive behaviors, but at the time, it was seen as something supernatural.
Famous literature from this era also reflected OCD-like behaviors. Shakespeare’s character Lady Macbeth shows classic signs of OCD-related compulsions in her obsessive hand-washing caused by guilt:
“[…] it is an accustomed action with her, to seem thus washing her hands. I have known her continue with this a quarter of an hour.” (Macbeth, Act V, Scene i)
Though Shakespeare wasn’t diagnosing Lady Macbeth, this passage shows the repetitive nature of compulsions. Her behavior mirrors the way OCD can make people feel the need to perform rituals over and over, even when they logically know it isn’t necessary.
By the 19th century, doctors had started to categorize mental illnesses more formally, but OCD was still not recognized as its own condition. Instead, it was grouped under other psychiatric terms.
French psychiatrist Jean-Étienne Dominique Esquirol classified OCD in his 1838 psychiatric textbook as a form of monomania, or partial insanity. This was where a person:
At the time, there were conflicting ideas about treatment as doctors couldn’t agree on whether OCD was a disorder of thinking or self-control.
Then, in 1875, French psychiatrist Henri Legrand du Saulle described a disorder that sounds very similar to modern OCD. He called it “la folie du doute avec délire du toucher,” and he used this term to describe an anxiety order he observed in some of his patients. They experienced:
By the late 19th century, Sigmund Freud introduced new ideas about mental health that were more focused on psychology. Freud believed that OCD, then called “obsessional neurosis,” was caused by repressed thoughts and hidden emotional conflicts. He theorized that people with OCD used defense mechanisms to cope with distressing thoughts including:
For example, if someone had an unwanted thought, they might develop a ritualistic behavior like handwashing, counting, or checking to control their anxiety.
Freud also believed childhood experiences influenced OCD. He suggested that anxiety from childhood trauma could become buried in the unconscious mind and later resurface as obsessive thoughts or compulsions.
For much of history, OCD was widely misunderstood. In fact, until the 1980’s, many patients with OCD were misdiagnosed with schizophrenia. This was because both disorders could involve:
As research improved, doctors realized that OCD and schizophrenia were separate conditions. This led to OCD being recognized as its own disorder rather than being grouped under other illnesses.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard reference for diagnosing mental health conditions. OCD was first included in the DSM-III in the 1980’s and was classified as an anxiety disorder, grouped with phobias and panic disorders. In 2013, it was updated in the DSM-5 and moved to a new category called “Obsessive-Compulsive and Related Disorders.”
The new OCD-related disorders category now includes:
Additionally, the DSM-5 added new OCD specifiers, including degree of insight (based on how aware patients are of their compulsions) and tic-related OCD (a subtype where OCD and tics co-occur). These updates over time helped to refine how OCD is diagnosed and treated, giving patients a better chance of receiving appropriate care.
Modern behavioral therapy began in the 1950’s with the work of B.F. Skinner and Joseph Wolpe, who introduced techniques that are still used today. Wolpe developed systematic desensitization, which helps patients gradually face their fears. This involved:
On the other hand, Skinner coined operant conditioning. Operant conditioning is based on the idea that behaviors are learned through reinforcement. If an action is followed by a reward, it is more likely to be repeated, while behaviors followed by negative consequences are less likely to continue.
For OCD, compulsions become reinforced behaviors because they provide short-term relief from anxiety. An example could be when a person with contamination OCD washes their hands excessively. This behavior is reinforced because it reduces anxiety in the moment, making it more likely to be repeated.
The principles of operant conditioning directly influenced exposure and response prevention (ERP), which is the most effective and most commonly used behavioral therapy for OCD. ERP works by:
The first medication used for OCD was clomipramine, a tricyclic antidepressant that showed to be effective in the early 1980’s. However, it had strong side effects, making it a less ideal long-term treatment.
In 1989, studies found that fluvoxamine, the first selective serotonin reuptake inhibitor (SSRI) for OCD, was highly effective. Since then, SSRIs have become the first-line medication for OCD because they:
Common SSRIs used for OCD today include:
While SSRIs don’t cure OCD, they help manage symptoms and improve quality of life for many patients.
Research continues to improve our understanding of OCD and its treatment, with new studies exploring the neurological basis of the disorder. Advances in neuroimaging have identified brain regions that are responsible for OCD-related symptoms, which allows for more targeted treatments. Scientists are investigating and learning about other interventions as well, including:
As research evolves, more effective and personalized treatments are on the horizon. If you or a loved one is struggling with OCD, Cura Behavioral Health can help with our evidence-based therapies, including outpatient care and TMS. Reach out today to explore your treatment options.
Scrupulosity – Journal of Affective Disorders
Drawing the Line Between Obsessive-Compulsive Disorder and Schizophrenia – Cureus
[Classification of obsessive compulsive disorder: evolution in the DSM-V] – La Revue du Praticien
Behavioral Therapy _ Encyclopedia .com
Pharmacological treatment of obsessive-compulsive disorder – Psychiatric Clinics of North America
Episode 119: Obsessive Compulsive Disorder (OCD) – Psychiatry & Psychotherapy Podcast
Study opens doors for more effective OCD treatment based on individual brain profiles – TranSpread
Determining if TMS therapy suits your mental health journey should involve consultation with a qualified professional. At Cura Behavioral Health, we provide comprehensive assessments to help you make informed treatment decisions.
Don’t let a mental health condition hold you back any longer. Schedule a consultation with Cura Behavioral Health today. Our experienced team is ready to answer your questions and create a personalized treatment plan tailored to your unique needs.
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Dr. Kevin Simonson, an esteemed Medical Director at Cura Behavioral Health, brings over 15 years of experience in psychiatry. A graduate from a top medical school, he specializes in the treatment of mood disorders and anxiety, employing a patient-centered approach. His dedication to evidence-based care and his commitment to advancing mental health practices have made him a respected figure in the field. Dr. Simonson’s leadership ensures the highest standard of care for the community at Cura Behavioral Health.
