286 Am J Psychiatry 138:3, March 1981

Obsessive-Compulsive Disorders: A Review of the Literature

BY LEON SALZMAN, M.D., AND FRANK H. THALER, M.D.

Freud defined obsessive-compulsive symptoms in

The authors reviewed the studies on obsessive-
terms of compelling impulses of the unconscious and
compulsive disorders publishedfrom 1953 to 1978.
defensive psychological responses to them. Until
They report on various theories ofthe etiology of the
Freud’s psychoanalytic theories were applied to the
disorders andprovide an overview ofthe studies based
obsessional disorders, treatment was essentially di-
on these theories. The treatment modalities covered
rected toward liberating or exorcising the agents that
include behavioral modification drug therapy, ,

possessed a disordered individual. Since the disorder

psychotherapy surgery
, and experimental
, therapies.
involved behavior and thinking that were beyond
The authors conclude that, although the obsessive-
one’s conscious or willful choice, the concept of the
compulsive disorders are widely present, there is a
paucity ofnew data concerning their treatment. The
unconscious was uniquely applicable to the under-
standing of these irrational and incomprehensible be-
evidence to date, however, suggests that
haviors. The psychoanalytic method, designed to
psychotherapy is an essential ingredient in the
elucidate hidden motivating forces, seemed appropri-
treatment process . They recommend that further
ate; however, the difficulties in altering or terminating
clinical studies be done to elucidate the etiology and
obsessional thinking or compulsive behavior through
treatment ofthese disorders.
psychoanalytic treatment has required newer ap-
proaches and a fresh look at the etiology and theoreti-
cal conceptions of these disorders.
T he history and development of the theory and ther-
Freud described the main defenses of obsessive-
apy of obsessive-compulsive states are character-
compulsive states as isolation, displacement, reaction
ized by the sparsity of theories proposed and the abun- formation, and undoing. His theories explained the
dance of therapeutic approaches developed. In this
roles of these ego defenses and elucidated the symp-
overview we will examine the contributions of the lit- toms on the basis of a regressive movement to a pre-
erature published from 1953 to 1978 on the theoretical oedipal, anal-sadistic era of psychosexual develop-
conception and therapeutic handling of the obsessive- ment. The earlier literature on these characterological
compulsive disorders.
and neurotic developments was composed of clinical
The earliest theories concerning these disorders in-
studies in which the theories were confirmed, reaf-
volved the notion of possession by outside forces that
firmed, and verified by many clinical examples and
necessitated a ritual of exorcism by witch doctors, claims of resolution or alteration of the symptoms. Al-
mystics, or religious leaders to force out the undesir- though there were remarkably few challenges to
able invaders. The first dynamic and rational hypothe- Freud’s concepts until the behavioral modification the-
ses were developed by Freud, who explained Janet’s
orists emerged in the last three decades, a survey of
theories and conceptualized obsessive-compulsive the literature from 1953 to 1978 documents the current
symptomatology in terms of the unconscious, tracing therapeutic interest in behavioral modification ap-
its development from psychosexual roots in the libido
proaches to eliminate both the behavioral and cogni-
theory. Janet viewed the symptoms as arising from tive elements of obsessive-compulsive states.
psychic fatigue and the diminution of available mental
Later theorists (Sandor Rado, for example) empha-
energy, which prevented an individual from con-
sized particular elements such as repressed rage; es-
trolling his thoughts and actions and brought on obses-
sentially, however, the idea ofthe control ofhostile or
sional thoughts and compulsive acts. unacceptable sexual impulses dominated these theo-
retical contributions. The ego psychoanalysts (Horn-
ey, Sullivan, and, later, the existential analytic theo-
Written at the invitation of the Editor. Received June 4, 1979;
revised Oct. 30, 1979; accepted Feb. 8. 1980. rists) focused on security and helplessness, but the es-
From the Department of Psychiatry, Georgetown University sential psychodynamic interpretation remained. The
Medical School. Washington. D.C. therapy that followed these theories suggested an in-
Address reprint requests to Dr. Salzman, 1800 R St. , NW., tensive psychoanalytic experience in order to remove
Washington, DC 20009.
Copyright © 1981 American Psychiatric Association 0002-953X/ the regressive fixation and to liberate the rigid super-
81/03/0286/1 l/$00.50. ego.
A,n J Psychiatry 138:3, March 1981 LEON SALZMAN AND FRANK H. THALER 287

FREUD’S CONCEPT OF OBSESSIONALISM their moral requirements but have great impatience
and intolerance of anxiety. The presence of magical
thinking, or the omnipotent expectation of magical ca-
The term ‘obsessive-compulsive
‘ neurosis’ refers ‘

pacity to control or influence others by their thinking,

to a wide variety of phenomena that may be manifest-
is a regular feature. Under conditions of stress or ex-
ed at any time in a person’s life. It refers to thoughts,
feelings, ideas, and impulses that an individual cannot treme demands, these personality characteristics may
congeal into symptomatic behavior that will then be-
dispel in spite of an inner desire to do so. The com-
pelling nature of the activity-despite the fact that it come ritualized.
Fortunately, all of the symptoms of obsessions are
may be illogical, undesirable, and unnecessary-is the
rarely present in one patient; however, the range is
central issue. Generally, such thoughts or feelings are
consistent and universal.
alien to the individual’s usual attitudes and are experi-
enced as being somewhat strange, even outrageous Compulsions
and embarrassing, sometimes disgusting, at times
A compulsion is a persistent, ritualized behavior
frightening-but always distressing.
It is an intriguing development in view of current
pattern-sometimes bizarre , irrational, and beyond
choice or decision to terminate. Extreme and bizarre
notions of free will and freedom of choice that in spite
behaviors are very noticeable, but lesser compulsive
ofall the wishes, desires, and active opposition of the
rituals involving meticulous, rigid, organized, and
obsessive individual, he is forced by some internal
well-controlled activities are almost always present.
pressure to concern himself with a variety of experi-
The compulsive individual exerts severe control
ences that may be distasteful or frightening to him.
over his emotions, thereby producing a pseudoplacid,
Several elements are invariably present in obses-
unaffected, flattened emotional state. The behavior is
sive-compulsive states and constitute the inherent dy-
inflexible, unspontaneous, obstinate, stubborn, routi-
namism of the disorder. These include 1) behavior or
nized, and ritualized beyond necessity. A need for cer-
thoughts that persist beyond the need for and/or in
tainty, guarantees, and absolute perfection in the be-
spite of voluntary action, 2) the presence of anxiety
havior is a fixed feature.
and/or somatic distress because of the ego-alien nature
We should note at this point that there has been a
of such thoughts, and 3) insight into the illogical and
renewed and extensive interest in the phobias in recent
unreasonable nature of the thought or action, which
years. Although some authors consider phobias a cate-
nonetheless fails to alter the behavior.
gory within the obsessional disorders, others view
them as a distinct and separate entity. In either case,
the extensive literature relative to phobias will not be
DYNAMICS OF OBSESSIVE AND COMPULSIVE
included in this overview, as it merits a separate article
DISORDERS in itself.
Obsessions

The obsession is a persistent, ritualized thought pat- THE MEANING OF OBSESSIVE-COMPULSIVE

tern that can be identified in the personality structure BEHAVIOR
before the presence of noticeable ritualized behavior.
Obsessional symptoms refer to the intrusion of It was evident to many people long before Freud
thoughts, images, words, or presumed desires into that the bizarre behavior of the obsessive-compulsive
one’s awareness, against one’s will and choice, and individual had great meaning to the person afflicted. In
beyond one’s conscious capacity to terminate. In addi- recent years the adaptive value of such behavior has
tion, the phenomena of doubting, procrastination, and come to be recognized more clearly: the insistent, pre-
indecision can be included in this category because the occupying thoughts of an obsessive-compulsive mdi-
individual seems incapable of closure in the consid- vidual so fill his attention that it is scarcely possible for
eration of an issue or train of thought. any other thought processes to take place. The sudden
Obsessive personality character structures were de- appearance of a highly repugnant thought is so bizarre
scribed by Freud as orderly, stubborn, and parsi- and so alien to the person’s manifest personality that it
monious; others have described them as obstinate, immediately distracts him from anything else that
perfectionistic, punctual, meticulous, frugal, and in- might be going on at the time. In this way, the obses-
dined to intellectualism. Janet described obsessive sive thought serves the purpose of directing attention
personalities as rigid, inflexible, lacking in adapt- away from a more significant and possibly more dis-
ability, overly conscientious, and persistent even in tressing thought. This is more easily understood when
the face of undue obstacles. Obsessive individuals the obsessive thought is a pointless rumination or an
generally appreciate order and discipline, are depend- endless speculation about philosophical or religious
able and reliable, and have high standards and ethical matters. The distracting or controlling function of such
values. They are practical, precise, and scrupulous in a thought is comparatively more difficult to recognize
288 OBSESSIVE-COMPULSIVE DISORDERS Am J Psychiatr 138:3, March 1981

when the thought itself is extremely upsetting and dis- the distress ofthe indecisiveness, procrastination, and
turbing. noncommunicative behavior that their defenses dic-
The occurrence of such fantastic intrusions has pro- tate.
vided considerable support for the concept of an un-
conscious and for the notion that ideas and feelings
which are outside the immediate awareness can never- THEORIES OF ETIOLOGY
theless influence behavior substantially For instance, .
intrusive thoughts that involve screaming obscene Although there is no single issue involved in the ulti-
words at inappropriate times or places suggest may mate development of obsessional personalities, sever-
that the individual wants to become the focus of public al theories have been advanced. These theories can be
attention-a contradiction of the belief that an obses- divided roughly into two categories: the biological or
sive thought is designed to shelter the individual from genetic theories and the psychodynamic theories,
public notice and crucial concerns. However, the which range from classical descriptions of Freud’s the-
same basic process is operative when, regardless of ones to the ego psychoanalytic theories.
how extreme or revolting an obsessive thought might
be, it is still much less distressing than the idea it is Genetic Theories
covering up. Freud called this process ‘ ‘dis-
Several recent studies by both American and foreign
placement.” practitioners suggest the possibility of genetic factors
Ruminations about death, philosophical
moral and
in obsessional disorders. More specifically, the studies
issues, or hypochondriacal preoccupations are at-
suggest some constitutional predisposition toward ob-
tempts to control one’s destiny and to guarantee one’s
sessional symptoms.
future. They often represent the very essence of a per-
Although these theories are interesting and at times
son’s concerns. Yet it seems to us that the need for
illuminating, we believe that genetic theories offer few
total control more accurately describes the entire
therapeutic guides; therefore, we will not deal with
range of obsessive activity.
them in this article.
Although greater emphasis has been placed recently
on the genetic and constitutional factors involved in Psychodynamic Theories
obsessive-compulsive disorders, the therapeutic ap-
proaches have remained essentially psychodynamic. The psychodynamic theories basically center
Except for reaffirmations and confirmations in the ex- around two issues: 1) aggression and rage and 2) the
tensive psychiatric literature on this subject, there battle for autonomy between the growing child and the
have been remarkably few additions to the original for- mother. These issues focus on the inevitable inter-
mulations postulated. relationship of the child to the nurturing and accultur-
Efforts in the past 25 years have moved away from ating agent (i.e., mother), who demands restraints and
the concept of obsessions and compulsions as charac- expects performances that may or may not be within
terological or defensive disorders. The flood of data the capacity of the child.
in the past quarter of a century from conditioning Psychoanalytic Theories Emphasizing Psychosexual
theorists and practitioners of behavioral modification Genesis
has led toward the concept of obsessions and compul-
sions as conditioned avoidance responses producing The earliest theory emphasizing a psychosexual
thoughts and behavior in an attempt to minimize anx- genesis (1896) was abandoned by Freud when he al-
iety. These studies (mainly research and therapeutic tered his views on the role of sexual trauma. This theo-
efforts by conditioning theorists and practitioners of ry held that obsessions were caused by an active gen-
behavioral modification) all deal with specific behav- ital experience during childhood in which the child
ioral distortions such as phobias, rituals, or obsessive both participated and found pleasure.
thinking and use a variety of conditioning techniques, By 1913 the concept of anality and anal sadism had
including implosion, thought-stopping, flooding, mod- evolved, producing the idea that obsessive-compulsive
eling, paradoxical intention, and exposure in vivo. Al- disorders involve hostile impulses against the parents.
though some traits such as procrastination, indecisive- These impulses were consequently dealt with, in theo-
ness, and perfectionism are acknowledged as relevant ry, by the elaborate obsessional defenses; hence, the
issues, they are viewed as secondary. notions of hatred and sadism remain key issues in psy-
In an attempt to elucidate obsessional phenomena, it choanalytic conceptualizations.
is crucial to acknowledge their presence in a variety of In this theory it would appear that the occurrence of
manifestations: from obsessional traits, which may be obsessional symptoms is a defensive regression to an
constructive and adaptive, to obsessive-compulsive anal-sadistic phase, with the ego, superego, and id
neuroses, in which the behavior is maladaptive and de- functioning in a manner appropriate to that phase. The
structive. In between are individuals with obsessive ego defenses of isolation, displacement, reaction for-
personalities who may or may not be suffering from mation, and undoing predominate in this theory.
Am J Psychiatry 138:3, March 1981 LEON SALZMAN AND FRANK H. THALER 289

Ego and Instinct Theories truth to be the entire truth, excluding the achieve-
ments of all other approaches.
Ego and instinct theories view behavior as intra-
It is our view that choosing a therapy on the basis of
psychic and interpersonal. Thus they involve anality
time and expediency alone cannot be the foundation
but postulate an environmental situation imposing un-
for a heuristic science of human behavior. Although
due interference with the anal phase.
time and expediency are relevant and important fac-
Neo-Freudian Theory tors in reducing distress and in encouraging adaptive
living, the treatment modalities must be viewed as fa-
Neo-Freudian theories go beyond libidinal concepts cilitators or adjuncts rather than as empirical or theo-
of anality and refer to the more generalized accultur- retical facts. They can be viewed as stepping stones to
ating process ofthe individual. Thus in this theory it is an ultimate, encompassing theory ofthe etiology of the
not anality but enraged defiance that alternates with obsessional states.
guilty fear: the struggle between mother and child. It seems to us important to take into consideration
Rage was emphasized by Rado, but other theorists the enormous body of knowledge that has already
(e.g., Sullivan, Homey, Dai, and Salzman) postulated been carefully evaluated and that is consistent with
that the child’s need for acceptance and recognition theory in any ultimate integration of all our research
requires activities on the part of the child that are ex- efforts. Of interest is the fact that of the 177 articles
cessive and extreme. These theorists view the problem listed in Index Medicus from 1953 through 1978 per-
as an overdemanding and controlling emphasis on the taming to the various therapies of obsessive-com-
child’s development that leads to obsessional symp- pulsive neuroses, 66 (37.3%) were studies of behavior-
toms. The focus is away from rage and defiance to the al treatments and 49 (27.7%) were studies ofdrug ther-
extreme need for acceptance and for being loved that apies. Twenty-nine (16.3%) were studies of psycho-
lies at the ultimate base of this disorder. therapy, 14 (8%) were of surgery, 13 (7.4%) were of
In addition, one of us (L.S.) has focused on the experimental therapies, and 6 (3.3%) were combina-
child’s need for control of his tender impulses rather tion studies. (There were also 1 19 untranslated foreign
than rage as more crucial to the ultimate development articles listed in Index Medicus.)
of obsessive and compulsive symptoms. We reviewed 93 of the 177 articles: 37 (39.8%) on
Learning Theory behavioral treatments, 13 (14%) on drug therapies, 27
(29%) on psychotherapy, 8 (8.6%) on surgery, 5 (5.4%)
According to learning theory, obsessions and com- on experimental therapies, and 3 (3.2%) on combina-
pulsions are conditioned responses to anxiety-pro- tion studies.’
yoking events. Anxiety is dealt with either by associa-
tion with neutral events, producing obsessional pre-
occupation, or by reducing the anxiety, producing PSYCHOTHERAPY
compulsive behavior.
Theoretical Model
There have been few additions to the theoretical for-
mulations regarding obsessional disorders in the 25 The prevailing psychodynamic view maintains that
years studied. The publications that are reviewed here among obsessive-compulsive individuals there is a de-
were, to an overwhelming degree, based on simple be- fensive regression of the intrapsychic structures from
havioral models that offer few insights into the psycho- the oedipal to the preoedipal, anal-sadistic phase of
dynamic understanding of this disorder. development. This regression is dealt with by the de-
fenses of undoing, isolation, and displacement.
Recent publications have
stressed the issues of de-
REVIEW OF THE LITERATURE fiance versus compliance without relating their pres-
ence to any zonal or libidinal struggle. These formula-
In reviewing the literature we found that the treat- tions also emphasize the cognitive deficits and learning
ment of obsessive-compulsive disorders can be di- difficulties relative to cultural requirements.
vided into five distinct treatment modalities: psycho- The insight or dynamic approach to obsessive-corn-
therapy, behavioral approaches, drug therapy, sur- pulsive disorders contends that the observed behav-
gery, and experimental treatments. All of the ap- iors are merely symptoms reflecting deeper, uncon-
proaches have their advocates, and success is often scious difficulties.
retroactively rationalized to fit into a preconceived
Treatment
theoretical model. Some approaches have few theo-
retical grounds to support their validity,
while others Many authors believe that great emphasis should be
make no attempt to elucidate a conceptual
framework. placed on the here and now while at the same time
It is also of note that some of the behavioral approach-
es, which have had limited success in modifying ‘An extensive annotated bibliography is available from the au-
crippling symptoms, tend to expand their corner of the thors on request.
 290 OBSESSIVE-COMPULSIVE DISORDERS Am J Psychiatry 138:3, March 1981

unraveling the detailed and widespread defensive tech- the therapist and accept the inevitable difficulties in
niques that affect every part ofan obsessional person’s the therapeutic process. Thus the patient must be ca-
life. pable of tolerating some anxiety and be able to express
Noonan (1) wrote that in-depth treatment of ob- his feelings. He must have stable areas in his living,
sessive-compulsive reactions perhaps inadvertently such as work, some interpersonal success, intelli-
strengthens those reactions and that the searching, in- gence, some flexibility, and the capacity for intro-
terpretive, in-depth approach in many instances facili- spection.
tates an introspective obsessive stance. One of us Nemiah (6) also wrote that it is possible to effect a
(L.S.) (2) also suggested that the search for ultimate complete disappearance of compulsive behavior in
causes in the form of early traumatic experience can some patients by the simple device of informing them
encourage even greater obsessionalisms by fitting into that the physician will assume complete responsibility
the individual’s neurotic patterns. for anything that may happen as a result of their not
Because of the tendency on the part of obsessional carrying out their impulses. Unfortunately, the im-
patients to ramble and to be easily distracted, one of us provement usually lasts for only a matter of hours.
(L.S.) suggested that the free association process can In these reports there appears to be a greatly hoped-
defeat the very purposes of therapy. Consequently, he for symptom alteration rather than a demand for total
believes that the therapist must be active and energetic resolution of the disorder. This approach permits the
and must intervene when the communication becomes integration of psychodynamic theories with behavioral
too confusing or too filled with unrelated details. In modification techniques and enables an individual to
addition, the past is so shrouded in amnesia, falsified, function more effectively during the therapy, which fo-
or distorted that depending exclusively on such recon- cuses on exposing the underlying issues (2).
structions can strengthen the obsessional defenses. Gutheil (7) wrote that it is advisable in the therapy of
Because of this, the most effective therapeutic ap- obsessive-compulsive neurosis at times to follow the
proach lies in the examination of recent events and patient’s own neurotic strategems and at other times to
particularly in the transference phenomenon. counteract them. He stated that the general aims of
Barnett (3) wrote that the therapist must ‘try to un- ‘ therapy are general improvement of the ego inte-
dercut the cognitive mechanisms which maintain the gration; strengthening of the ego-id boundary cathexis
obscurity, vagueness, and confusion.” He further (the patient should be encouraged to verbalize and
stated that therapists spend too much time pursuing work through aggressions that were generated but nev-
the matter of feelings, while neglecting the analysis of er discharged toward the proper subjects), and im-
important thinking processes. The therapist must aid provement of the superego functions.
in unraveling the dysfunctional thought processes that Gutheil also questioned the rationality of psycho-
interfere with meaningful living. therapy for obsessive-compulsive disorders. Obses-
One of us (L.S.) (4) wrote that insight therapy alone sive-compulsive neurosis, despite all the suffering and
can rarely be sufficient in treating obsessive-corn- privation it causes the patient, also represents a source
pulsive disorders -the patient needs encouragement, of tremendous narcissistic inflation of his ego and
support, pressure, guidance, and often drugs
to aid makes him master over the destinies of man, his own
him in changing. In an earlier article (5) he stated
that included. Gutheil made a number of tactical sugges-
the possibility of involvement and participation by the tions that are similar to the therapeutic techniques of
therapist can stimulate the patient to commit himself one ofus (L.S.). Gutheil suggested that therapy cannot
to the therapeutic relationship and risk changes in his follow traditional psychoanalytic lines and that each
living. He outlined the goals and treatment for obses- tactic and defense must be rooted out, examined, ex-
sional states as follows: 1) to discover and elucidate plored, and assisted toward change.
the basis for the excessive feelings of insecurity that James Suess (8) wrote about the difficulty and im-
require absolute guarantees before action is pursued portance of establishing a trusting relationship with
and 2) to demonstrate by repeated interpretation and obsessive-compulsive patients. One technique he sug-
encouragement to action that such guarantees are not gested involves ‘letting‘ the patient borrow the thera-
necessary but, rather, that they interfere with living. pist’s superego,” establishing in the patient a “self-
The foregoing is possible only when the patient can criticizing identity more compatible with guilt-free liv-
acknowledge that anxiety is universal and omnipresent ing.” In striving to adaptively respond to his feelings,
and can never be permanently eliminated from life. the physician can often facilitate the therapeutic pro-
Thus treatment must differ from the classical psycho- cess by reducing the patient’s abnormal guilt from an
analytic model. overpowering superego.

Nemiah (6) offered a synthesis of the classical psy- The obsessional patient’s experience with the thera-
choanalytic model with more current formulations. He pist can later be generalized into his daily life by work-
stated that the criteria for selecting patients for insight ing through the same process with other people. He
psychotherapy depend on factors other than symp- learns in therapy that other people feel happiness or
toms. These factors all involve the ability to relate to anger or fear, and at times even disgust or hate for
Am J Psychiatry 138:3, March 1981 LEON SALZMAN AND FRANK H. THALER 291

themselves, but can accept the appropriate use of their studies recommended a revision of the psychoanalytic
emotions without danger, self-doubt, or vulnerability. techniques that encompass the ego psychodynamic ap-
It is the patient’s fear ofhis omnipotence and the over- proaches-revisions including more direct involve-
powering strength of his feelings that make him cau- ment and confrontation, a focus on the here and now,
tious. His thoughts and feelings control him, rather an avoidance of excessive interpretations of the past,
than being used in his service (8). and a requirement for commitment to action in the
Friedmann and Silvers (9) discussed the case of an present.
18-year-old boy with severe obsessive-compulsive The focus on aggression, anger, hostility, and simi-
neurosis treated in an inpatient setting with a combina- lar elements in the essential dynamics of this disorder
tion of insight-oriented, group, family, and behavioral has not yielded the therapeutic alteration to justify a
therapies. On discharge, the patient’s anxiety was at a continued attachment to their validity as etiological
higher level than on admission, but obsessional factors. However, the issues ofcontrol and rigidity are
thoughts and depression were markedly improved. supported in the recent publications, and the cognitive
Noonan (1) described the case of a 35-year-old male and rational elements of the disorder are focused on
student treated by induced anxiety. The patient’s corn- more effectively than in the earlier theories.
plaints centered around an extreme fear of authority
and a growing number of meaningless rituals. In seven
sessions the patient’s anxiety was induced by synthe- BEHAVIORAL MODIFICATION
sizing insight-oriented and behavioral approaches,
Theoretical Model
which elicited a significant abreaction in a brief period
of time. The origins of theory concerning behavioral modifi-
Psychoanalytically oriented short-term therapy for cation are based on learning principles that have been
obsessional disorders was discussed by Sifneos (10). experimentally derived from work done in animal re-
The criteria he suggested for selecting patients for search laboratories. During 1953 to 1978 the learning
short-term analysis are the following: 1) an acute onset theories that have evolved have been extensively ap-
of symptoms in a fairly well-adjusted patient, 2) anx- plied to various clinical psychopathologies, including
iety, 3) motivation, 4) above-average intelligence, 5) the obsessive-compulsive disorders.
history of at least one meaningful relationship, and 6) There is general agreement that learning can be de-
ability to interact well with the psychiatrist. fined as the modification of a behavioral tendency by
Sifneos suggested the following techniques for such experiences as exposure or conditioning. Learn-
short-term analysis of obsessive-compulsive patients: ing theory maintains that if one voluntarily performs
1) early use of positive transference, 2) concentration and maintains a certain act, that behavior becomes
in areas of unresolved conflicts, 3) avoidance of the self-selecting. In order for learning to take place, rein-
development of a transference neurosis, and 4) early forcement (defined as any event contingent on the re-
termination of treatment. In patients whom Sifneos sponse of the organism that alters the future likelihood
treated, attitudes toward symptoms changed more of that response) must occur.
substantially than the actual symptoms themselves, Learning theory, as it concerns obsessive-corn-
but the patients appeared to be happier. pulsive disorders, indicates that an obsessional
Schwartz (1 1) preferred the use of psychoanalytic thought produces anxiety because it is paired with an
group treatment of obsessive disorders because the unconditioned, anxiety-provoking stimulus. Likewise,
therapy is more ego-oriented, realistic, and less pene- compulsions are established when the individual dis-
trating of unconscious processes (7). The patient is covers that the compulsive act reduces the anxiety at-
given the chance to observe behavior in vivo and is tendant to an obsessional thought. Eventually the re-
encouraged to give up some controls. duction in anxiety serves to reinforce the compulsive
act. Behavioral therapists using classic learning theory
Summary
concentrate solely on observable behavior, largely ig-
A limited number of articles has been published on noting inner conflicts as causes of behavior.
the various psychotherapies of obsessive-compulsive Although this theory may supply a rationale for a
disorders. Pessimistic views on the benefits of psycho- treatment aimed at symptom removal, it appears to be
therapy for these disorders have been expressed by a gross oversimplification of the data.
several authors, and further contributions by dynamic
Treatment
theorists and therapists have been, at best, sparse and
unimaginative. Many of the articles that we reviewed More than 30% of the reports we reviewed on be-
were mere replications of the original formulations. havioral modification treatment concerned the therapy
Some of the recent studies have suggested that the of patients with phobias and obsessions. Generally,
traditional psychoanalytic approaches require drastic treatment proceeds only after a detailed analysis of the
revision because they have added nothing to the corn- patient’s behavior has been completed. Thereafter,
prehension or resolution of these disorders. Other multiple techniques are used to alter the patient’s re-
 292 OBSESSIVE-COMPULSIVE DISORDERS Am J Psychiatry 138:3, March 1981

sponses to the presumed stimuli, especially fear- by in vivo exposure only and a combination of imag-
evoked behavior. Overall, with few important ex- med and in vivo exposure. According to Beech and
ceptions, effective techniques to reduce fear involve Vaughan the success rate was 52%.
exposing the patient to distressing situations until he The techniques ofexposure can be viewed as a spec-
adapts to the situation. Desensitization, flooding, im- trum from flooding (sudden confrontation with the pro-
plosion, paradoxical intention, operant shaping, and vocative stimulus designed to elicit the greatest emo-
cognitive rehearsal can all be viewed as variations of tional reaction over a prolonged period) to desensi-
the technique of exposure. tization (a slow, brief exposure to the provocative
Systematic desensitization. Developed by Wolpe stimulus until minimal tension is attained). Either
(12) in 1958 for the treatment of phobias, systematic method can include aversive stimulus, in vivo ex-
desensitization has been applied to the treatment of posure, graded exposure, or exposure combined with
obsessive-compulsive disorders. Briefly, the theory is modeling.
that the anxiety experienced by the obsessional patient Although much experimental work has been done,
is a response to stimuli in the environment and that the the field is plagued by the dearth of controlled experi-
rituals reduce the experienced anxiety and thus serve ments and, perhaps even more importantly, by the in-
as an avoidance response. Whatever the patient as- congruity and disagreements over definitions used by
signs his anxiety to is most often the cause of it, and various investigators.
treatment is aimed at alleviating that anxiety. For ex- Although the technique of systematic desensiti-
ample, a patient who experiences anxiety on seeing or zation has proven useful with regard to phobic pa-
touching something considered dirty reduces his anx- tients, it has generally not been helpful with the obses-
iety by repeatedly washing his hands. sive-compulsive states. There are no published reports
The aim of desensitization is to eliminate the anx- of controlled studies of desensitization in the litera-
iety, thereby eliminating the compulsive ritual. The es- ture.
sentials of the treatment are 1) to establish a hierarchy Modeling, flooding , and response prevention There .
of anxiety-provoking stimuli, 2) to train the patient in have been no adequate explanations for the partial ef-
relaxation techniques, and 3) to present the hierarchy fectiveness of these techniques. The theoretical model
in the presence of the incompatible relaxed state (re- for modeling, flooding, and response prevention main-

ciprocal inhibition) induced by drugs or imagery. Rit- tains that the obsessional patient, in an effort to reduce
uals are not dealt with directly, on the basis ofthe as- anxiety, will either avoid the feared stimuli or perform
sumption that as the patient’s anxiety is reduced the rituals to undo his thoughts or rid him of his con-
rituals will no longer be necessary. tamination.
Walton (13) reported the case of a patient who corn- Although the efficacy of desensitization for corn-
pulsively kicked all stones or cleared away all paper in pulsions is questionable, two related forms of treat-
his path, fearing that someone would trip over the ment for compulsions have been developed within the
stones or paper and injure himself. A hierarchy of situ- past 18 years (one by Levy and Meyer and the other by
ations was constructed for this patient, beginning with Marks and associates), both of which seem to be
a clean corridor in the hospital to increasingly littered promising.
pathways. The patient was given chlorpromazine be- Levy and Meyer (16) exposed 15 patients to stimuli
fore each session and walked with the therapist with- that triggered their compulsive rituals. The patients
out kicking stones or picking up paper. Although some were then interrupted or prevented from acting out
inadvertent modeling was present in this experience, it their rituals. Levy and Meyer’s procedure is called
is fairly typical of the treatment by desensitization. ‘‘apotrepic therapy’ ‘ from the Greek ‘to ‘ turn away,

Beech and Vaughan (14) reported on a case by deter, or dissuade. “ Ten of the 15 patients were much
Worsley concerning a patient who cleaned her house improved.
excessively. The patient was trained in relaxation and Marks and associates (17), in contrast to Levy and
then desensitized in imagination to a hierarchy of Meyer, considered response prevention to be a neces-
scenes in which she would not remove dust for in- sary but relatively minor condition in treatment and
creasing periods of time. stated that the method of presentation of the stimulus
Wolpe (15) reported the use of imagined and in vivo is the major determinant. Patients with contamination
stimuli with a man who would spend two hours wash- fears and washing rituals seem to have the best prog-
ing after ruminating about his feelings ofbeing contam- nosis. In a controlled study of 20 patients these au-
mated by his own urine. thors found that exposure in vivo and response pre-
Beech and Vaughan (14) reviewed a total of 21 cas- vention with or without modeling was helpful. The re-
es, which constituted the greater proportion ofall pub- sults of the series indicated that there was no
lished material on desensitization by 1978. In all but 2 significant difference between flooding and modeling
cases a sedative or muscle relaxant was used to inhibit and that both were significantly superior to relaxation
anxiety. Half of the cases involved desensitization in control treatment.
imagination only, and the rest were roughly divided Boulougouris and Bassiakos (18) reported a favor-
Am J Psychiatry 138:3, March 1981 LEON SALZMAN AND FRANK H. THALER 293

able outcome for 3 severely incapacitated obsessive- Satiation training and thought-stopping. These
compulsive patients in an uncontrolled trial. Treat- techniques have been evolved principally to deal with
ment consisted of fantasy sessions during which pa- obsessional thoughts. Almost all other behavioral
tients were exposed to stimuli that were known to trig- techniques deal with overt measurable behavior, but
ger discomfort and rituals and then prevented from these techniques are aimed at thoughts.
performing their rituals. Rachman (21) used the term “satiation” to connote
The effect of response prevention was evaluated by the instructions given to patients to hold the obses-
Mills and associates (19) in an in-depth study of 5 pa- sion, even though useless and alien, in their minds for
tients. They found a dramatic and lasting decline in periods oftime up to 15 minutes or more. With succes-
compulsive rituals after a period of response pre- sive trials the patients have increasing difficulty in
vention. holding the thought.
The results of all the studies demonstrate that mod- Rachman observed that many obsessional thoughts
eling, flooding, and response prevention are effective are followed by putting-right procedures (Freud’s ‘un- ‘

for the majority of patients with rituals. Approximate- doing’ ‘). The patient’s ruminations are exposed to the
ly 75% of the patients showed some improvement, al- ‘‘provoking trigger’ (i.e. the disturbing‘ thought,
, im-
though only 9 patients reported on in the literature age, or impulse) and then the patient is instructed to
were found to be totally free from rituals at the end of refrain from carrying out the checking ritual. This
treatment. technique should be substantially more effective than
Paradoxical intention. Viktor Frankl (20), who de- thought-stopping and slightly more effective than the
veloped the concept of paradoxical intention as a ther- satiation treatment alone.
apeutic tactic in the obsessional states, arrived at his The treatment program is to initially subject the
orientation through existential, philosophical thinking. most troublesome obsessions to satiation treatment.
Frankl’s theory rests on the assumption that the obses- After satiation treatment is in effect, the response pre-
sional individual is responsible not so much for his ob- vention procedures are introduced.
sessive ideas as for his attitudes toward them. Thought-stopping is another technique developed to
Paradoxical intention can be defined as the process deal with obsessional thoughts. Basically, the tech-
whereby the patient is encouraged to do or to wish to nique involves the patient’s communicating to the
happen the very thing that he fears the most, exagger- therapist that he is having an obsessional thought. Ini-
ating it in a deliberate evocation of humor. This delib- tially the therapist will interrupt the rumination by
erate evocation of humor is an important element in shouting, ‘ ‘Stop,’ ‘ or, perhaps, using some form of
Frankl’ 5 approach. aversive stimuli to stop the thought. Control of the
Frankl and others believe that the tendency to fight stimulus to stop is quickly transferred from the thera-
against a compulsion only intensifies it. The vicious pist to the patient.
cycle, according to this technique, can be broken by Gullick and Blanchard (22), in a paper illustrating
encouraging the individual to pursue the compulsion the advantages of combining behavioral therapy with
rather than fight it. By exaggeration, the symptom be- insight-oriented psychotherapy described a 33-year-
,

comes ludicrous and humorous and stimulates the pa- old man with the recurring thought that he had bIas-
tient’s humaneness, detachment, and self-transcen- pherned God. The technique of thought-stopping was
dence. Contrary to
avoidance, paradoxical intention introduced, consisting first of having the therapist
encourages confrontation and is similar to flooding and shout, ‘Stop,”
‘ in the middle of one of the patient’s
implosion in induced anxiety in the behavioral modifi- ruminations and then having the patient shout,
cation procedures. ‘ ‘Stop,’ himself,
‘ first aloud and then to himself, as a
Many authors believe that the technique of para- way of disrupting the ruminative chain.
doxical intention could supplement dynamic therapy Emmelkamp and Kwee (23) compared the effects of
but not replace it. In a psychoanalytic framework thought-stopping and the effects of prolonged ex-
paradoxical intention can be viewed as gratifying the posure in imagination with 5 patients whose major
id impulse, making the superego an ally of the ego and problem was obsessional ruminations but who did not
helping the ego gain strength and become less restrict- suffer from compulsive rituals. No clear differences
ive. It can also be viewed as making conscious the un- were found between the effect of thought-stopping and
conscious motivation, which may terminate the corn- the effect of exposure in imagination. These authors
pulsive action. concluded that ‘a method ‘ of treatment which has a
Paradoxical intention is philosophically and strategi- positive effect in almost all types ofobsessions is still a
cally useful, but it is our contention that it succeeds far-off goal.”
because it changes the obsessive thoughts or corn- Aversive therapy. Simply put, the theory of this
pulsive behavior into concise and deliberate activities therapy is that an activity or object that is repeatedly
which the patient controls. Once the actions are within associated with an aversive experience tends to be
the patient’s control, they can be terminated. Frankl avoided. The aversive experiences used have included
claimed a 46% resolution with this treatment. pharmacological drugs that induce nausea and vomit-
294 OBSESSIVE-COMPULSIVE DISORDERS Amn J Psychiatry 138:3, March 1981

ing, electrical shocks, and symbols that induce dis- Anxiolytics, in many cases, appear to relieve the
gust, fright, or any other response aversive to the pa- anxiety that coexists with obsessive-compulsive dis-
tient. This treatment has been used in treating sexual orders, and antidepressants often serve to relieve the
deviance (i.e. transvestisrn
, and fetishism), alcohol- secondary depression. In addition, indications that
ism, and other addictions and ruminations. haloperidol and chlorirniprarnine have antiobsessive
Goorney (24) reported the successful treatment of a effects have been reported, although this is yet to be
compulsive gambler by electrical aversion. Shocks proven in controlled studies.
were given at random during the time the patient went
through his reading and selecting of horses to bet on Treatment
until the time he would hear the results of the race on
the radio. Our review of several representative articles pub-
Barker and Miller (25) reported on three compulsive lished between 1953 and 1978 indicates that a wide ar-
gamblers. The successful treatment consisted of ap- ray of drug therapies has been employed in the treat-
plying random shocks while the patient was gambling ment of obsessive-compulsive disorders. These drugs
with a one-armed bandit. One patient received 672 have included trifluoperazine, doxepin, phenelzine,
shocks over the 12 hours of gambling treatment, the LSD, brornazepam, chlomiprarnine, oral phencycli-
second patient received 700 shocks over 6 hours, and a dine, chlordiazepoxide, insulin, iproniazid, irnipra-
third patient received 450 shocks over 5 hours. mine , irninodibenzyl, and L-tryptophan.
An article by Wyndowe and associates (26) dis-
Summary cussed the study of 15 obsessive-compulsive patients
treated with chlorirnipramine: the results indicated a
No unifying principle adequately explains the ef-
definite antiobsessional effect of the drug. A study by
fects of behavioral therapy on obsessive-compulsive
Trethowan and Scott (27) involving 59 patients demon-
individuals. Some techniques have obviously helped,
strated a converse result: there was little relief of ob-
but definitive treatment remains elusive.
sessive-cornpulsive symptoms, but anxiety, tension,
Behavioral modification seems to be an effective
aggressive urges, and hypochondriacal ideas were re-
technique for treatment when ritualistic compulsions
duced.
are crippling. Techniques applicable to a well-circurn-
Capstick (28) also claimed satisfactory results in the
scribed compulsion seem to work best.
treatment of 4 patients with chlomipramine. A study
Systematic desensitization has a well-developed
of 21 patients conducted by De Silva (29) from 1969
theoretical basis, but there have been no controlled
to 1975 showed chlomipramine to be effective as an
studies concerning the treatment of obsessive-corn-
antidepressant as well as an antiobsessional drug. A
pulsive states. Modeling, flooding, and response pre-
pilot study by Yaryura-Tobias and Neziroglu (30) also
vention have a generally inadequate theoretical base,
demonstrated the antidepressive and antiobsessive
but they have had encouraging results. However, be-
properties of chlorimipramine.
havior modification has been by no means established
An article by Burrell and associates (31) reported on
as the treatment of choice.
the use ofbrornazeparn in obsessional, phobic, and re-
In their informative review, Beech and Vaughan (14)
lated states. Two hundred twenty patients in whom
summarized the state ofaffairs as follows: “In the light
obsessionality was a prominent underlying cause of
of our review of treatment evidence, we must reluc-
disturbance were treated with satisfactory results. The
tantly conclude that there is no conclusive evidence
authors stated that the benzodiazepine series of corn-
that behavioral modification offers a viable approach
pounds has been the most encouraging group of agents
to the modification of abnormal thoughts in obsession-
so far in the treatment of obsessional states due to the
als. For the motor components, . . . however, the pic- fact that their principal site of action is on the limbic
ture appears to be a little brighter. . . . Finally, we are system of the brain, which is implicated in obsessive
in no doubt that much of the definitive work in this
thinking.
area remains to be done.”
A report by Annesley (32) discussed the case history
of a patient with an obsessive-compulsive disorder
treated effectively with phenelzine. An evaluation of
DRUG THERAPY
the therapeutic effects of doxepin hydrochloride in ob-
Theoretical Model sessive-compulsive neurosis (33) showed the drug to
be beneficial.
Pharmacological approaches to the treatment of ob- An article by Yaryura-Tobias and Bhagavan (34) on
sessive-compulsive disorders have included anx- treatment with L-tryptophan and nicotinic acid supple-
iolytic, antiobsessive, and antidepressant agents. The ments indicated that 7 obsessive-compulsive patients
rationale for employing these approaches is varied. responded successfully to the drugs; all of them
Most of the relevant studies have thus far been uncon- showed considerable improvement after one month of
trolled. therapy. An article by Brandrup and Vanggaard (35)
Am J Psychiatry 138:3, March 1981 LEON SALZMAN AND FRANK H. THALER 295

explored the possibilities of treatment through admin- EXPERIMENTAL APPROACHES

istration of LSD.
Theoretical Model
Summary The theoretical rationale for experimental approach-
es has not been spelled out by the researchers, who
Although the drug studies, particularly those with unanimously accept an organic etiological basis for ob-
chlorimipramine and bromazepam, appear to be favor-
sessive-compulsive disorders.
able and report good results, there are too few studies
and inadequate follow-up or comparison with other Treatment
forms of treatment, including placebo controls. More
A review of experimental approaches from 1953 to
drug studies are needed before optimistic or positive
1978 includes reports of treatment with chemical (36)
recommendations can be made for their use.
and electrical (37) convulsions, prolonged sleep (an
untranslated Russian article). hypnosis (38), electro-
narcosis (39), and prefrontal procaine injection (40)-
SURGICAL TREATMENT
the latter reported in only one case.
Carbon dioxide (36) was used in three obsessive-
Theoretical Model
compulsive patients (three to five treatments per week
Therationale for surgery involves the cutting of for a year) to the point ofunconsciousness but not con-
tracts the cortex
from to the thalamus on the presump- vulsions. Improvement was not seen until more than
tion that obsessions and compulsions are caused by 100 treatments had been given; all three patients were
reverberating circuits that need to be interrupted. It reported to be substantially improved.
has been suggested that the reduction of anxiety from Gruber (37) reported on possible mechanisms of ac-
lobotomizing procedures reduces the affect but leaves tion of a new technique of ECT application in obses-
the obsessional practices intact. sive-compulsive disorders. His article suggested ex-
cellent results with just a single treatment.
Treatment Saul (38) reported on the treatment of a severe ob-
sessive-compulsive and phobic patient with hypnosis
Stereotactic bilateral operations seem to be the cur-
after failure with group and individual therapy. The pa-
rent surgical treatment of choice for obsessive-corn-
tient had nine hypnotherapy sessions in total, which
pulsive individuals. operation The
is performed with a
the therapist used predominantly to examine ego and
thin probe by the frontal
undercutting lobes, especially
superego issues. One-year follow-up showed good ad-
the orbital surface and various limbic structures.
justment; the crippling phobias and obsessions were
The original surgical approach was leucotomy (bilat-
eliminated.
eral prefrontal lobotomy), but smaller and smaller op-
erations were performed because of disabling person- Summary
ality changes. With stereotactic surgery there is less
Overall, there seems to be a paucity of innovative
tissue damage between cortex and lesion.
therapies for the obsessive-compulsive individual, and
Most of the reports we reviewed showed a better
there is no discernible evidence that these approaches
than 60% improvement in a variety of obsessional and
offer any hope for progress if such approaches are
compulsive features. This percentage has not changed
more extensively or intensively applied.
since the original work in 1935 by Moniz, who found
that approximately one-third of his patients were not
improved following injections of alcohol into the white
CONCLUSIONS
matter of the prefrontal region.

Summary Our review of the literature published from 1953 to

1978 reveals a paucity ofinformation in all areas, phys-
Uncontrolled studies abound; many report good re- iological as well as psychological. Even the most pro-
sults but involve very little long-term follow-up. Most lific and optimistic area-behavioral modification-
patients reported on were referred to surgery only af- has been universally disappointing. Beyond the altera-
ter other treatments had failed. Leucotomy patients tion, amelioration, and termination of some rituals,
did significantly better than control subjects through- there is no conclusive evidence that the behavioral
out follow-up with respect to obsessions and anxiety, modification approach offers a viable or lasting solu-
but most leucotomy patients were not cured and went tion.
from severe to moderate impairment. Maximum im- With regard to drugs, surgery, and other experimen-
provement of general anxiety and obsessions occurred tal and physiological therapies, there is neither con-
within one to three months and was maintained vincing nor suggestive evidence that more can be ac-
through eight-year follow-ups. The outcomes seemed complished than the relief of some anxiety-at a cost
unrelated to the premorbid personality. that often outweighs the potential benefits. The psy-
296 OBSESSIVE-COMPULSIVE DISORDERS Am J Psychiatry 138:3, March 1981

chotherapeutic approaches, including intensive, brief, States. New York, John Wiley & Sons. 1978, pp 35-50
15. Wolpe J: Behavior therapy in complex neurotic states. Br J Psy-
group, and combined approaches, have unfortunately
chiatry I 10:28-34, 1964
added little to our previous formulations on the psy- 16. Levy R, Meyer V: Ritual prevention in obsessional patients.
chodynamics of this disorder. Proc R Soc Med 64:1115-1118, 1971
Obsessive-compulsive disorders are widely present 17. Marks IM, Hodgson R. Rachman 5: Treatment of chronic ob-
sessive-compulsive neurosis by in-vivo exposure: a two-year
in the population at large and in the patient population follow-up and issues in treatment. Br J Psychiatry 127:349-364.
in particular. There is, therefore, a critical need for 1975
further studies of the epidemiological and etiological 18. Boulougouris JC, Bassiakos L: Prolonged flooding in cases with
obsessive-compulsive neurosis. Behav Res Ther 1 1 :227-23 1.
factors involved. In addition, much needs to be done
1973
in the field ofgenetics, as it is clear that certain factors 19. Mills HL, Agras WS, Barlow DH, et al: Compulsive rituals
render an individual more susceptible to obsessional treated by response prevention: an experimental analysis. Arch
influences in the family structure. We still need to Gen Psychiatry 28:524-529, 1973
20. Frankl VE: The Unheard Cry for Meaning. New York, Simon &
know how, when, and where obsessive-compulsive Schuster, 1978, pp 114-183
symptoms move to the extremes of normalcy and be- 21. Rachman S: The modification ofobsessions: a new formulation.
come antithetical to productive and creative efforts. Behav Res Ther 14:437-443. 1976
It is not pessimistic to conclude that few significant 22. Gullick EL, Blanchard EB: The use of psychotherapy and be-
havior therapy in the treatment of an obsessional disorder: an
changes in our views and treatment of this disorder experimental case study. J Nerv Ment Dis 156:427-431. 1973
have been made. A reaffirmation of the continuing 23. Emmelkamp PM, Kwee KG: Obsessional ruminations: a com-
needs for research and clinical studies to critically re- parison between thought-stopping and prolonged exposure in
imagination. Behav Res Ther 15:441-444, 1977
vise our theories and treatment tactics is, however,
24. Goorney AB: Treatment ofa compulsive horse race gambler by
evident. aversion therapy. Br J Psychiatry 114:329-333. 1968
25. Barker JC, Miller M: Aversion therapy for compulsive gam-
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