Eva Surawy Stepney discusses how OCD has been understood in relation to fear, anxiety and guilt
Contemporary psychiatry is beginning to recognise guilt as the central affect experienced by those with a diagnosis of Obsessive-Compulsive Disorder (OCD). In fact, an increasing number of publications identify ‘deontological guilt’, ‘guilt-sensitivity’ and an ‘inflated sense of responsibility’ as they key factors underpinning the development and maintenance of OCD-related obsessive thinking.1 This emphasis on guilt, however, represents a distinct departure from mainstream conceptions of OCD which, over the last fifty years, have placed anxiety and fear as central to its aetiology and treatment. Diagnostic manuals consistently place OCD in the ‘anxiety disorders’ category.2 In popular culture ‘obsessions’ are often equated with ‘phobias’, with a fear (e.g. of germs or open spaces) characterising depictions of the symptom(s).
In this brief blog post I will illustrate how the prior neglect of guilt in clinical discussions of ‘obsessions’ – in favour of a narrow focus on anxiety and fear – can be traced back to the incorporation of psychoanalysis into inter-war British psychiatry. Due to a reliance on evolutionary frameworks, as well a culture of social conservatism, the psychoanalytic category of obsessional neurosis entered British psychiatry without the guilty conflicts of the Freudian unconscious. Instead, the diagnosis was explained with reference to a simple fear-response. The focus on fear, as well as the resulting merging of obsessions and phobias, had profound implications for conceptualisations of ‘obsessions’ throughout the twentieth-century, as well as their identification and treatment in clinical practice today.
Between 1894 and 1896, the psychoanalyst Sigmund Freud developed a distinct diagnostic category with persistent thoughts at its core: obsessional neurosis. Within this category, Freud defined a ‘true obsession’ as ‘an idea that forces itself upon a patient, accompanied by an associated emotional state.’3 Like his prior work on hysteria, the psychoanalyst located the origin of these ‘true obsessions’ in a distressing sexual event taking place in childhood. However, unlike hysteria, where such an event was received ‘passively’, in cases of obsessional neurosis, it involved a degree of ‘active’ pleasure.4 This led to an overwhelming sense of guilt and consequently, the repression of the original experience. The memory was substituted by disturbing and recurrent thoughts, which arose with an associated state of self-reproach.
In the early twentieth-century, Freud’s original explanation of ‘true obsessions’ was abandoned – along with the entirety of his preceding theoretical framework. In Notes upon a Case of Obsessional Neurosis (1909), obsessions were not a response to a guilt-laden memory, which had taken place in the external world, but the result of internal psychic conflict.5 Freud argued that pre-social impulses (id) developed prior to the regulating forces of the self (ego) and society (super-ego); when societal expectations began to exert their influence, certain individuals felt intense guilt and profound psychic conflict. Attempts to repress primitive thoughts/impulses (libidinal wishes) resulted in their pathological persistence. Excessive guilt and an overvaluation of the power of one’s thoughts remained central.
Freud in Britain
In the interwar period there was a sudden and notable appearance of obsessional neurosis in British psychiatric discourse – where the category began to be included alongside hysteria, ‘shell-shock’, and the anxiety neuroses in textbook and journal entries. However, there were a number of significant modifications to the Freudian category, which have had profound implications for subsequent definitions of ‘obsessions’.
Freud maintained that ‘obsessions’ were different from ‘phobias’ because of their central emotion: phobias relied on anxiety, whilst obsessions were accompanied with guilt, doubt, or self-reproach.6 Despite this clear differentiation, which was central to the psychoanalytic category, in British publications the role of guilt was not acknowledged. Instead, ‘obsessions’ and ‘phobias’ were conflated, with both characterised in terms of anxiety and fear.
Fear in Context
The role of fear in discussions of ‘obsessions’ can be understood with reference to the context in which psychoanalysis entered mainstream British psychiatry: namely, through the shell-shock ‘epidemic’.7 Historian Tracy Loughran has argued that central to British psychiatry’s conception of shell-shock was a merging of psychoanalytic concepts (‘repression’, ‘trauma’) with existing evolutionary doctrines.8 Anthropologist Alan Young has similarly shown how the psychiatrist W.H.R Rivers, a key figure in treating shell-shocked soldiers, adopted an evolutionary-grounded Freudian model.9 Whilst drawing on Freud’s concepts of conflict and the unconscious, Rivers dismissed the reduction of ‘instinct’ to a libidinal energy and instead drew upon the evolutionary narrative of English biologist, Herbert Spencer. He argued that the unconscious contained a ‘fight-flight-freeze response’ which re-enacted an ‘ancestral reaction to danger stimuli via a simple emotional pathway (fear)’.10 In combining the concepts of Spencer and Freud, Rivers suggested that in shell-shocked officers, a conflict emerged between an instinctual (unconscious) ‘fear’ and a social (conscious) duty to fight. This conflict led to ‘conversion’ (or substituted) symptoms such as paralysis, mutism and anxiety states.
Focussing upon evolutionary grounded theories (already well established in British psychiatry) to explain psychic distress, enabled a more acceptable and ‘scientific’ psychoanalysis to enter Britain. This version was rooted in existing conceptions of the mind as a hierarchy of evolutionary instincts, and was considered distinct from the realm of unsavoury Freudian phantasy. An emphasis on fight-flight conflict (in relation to fear) – rather than repressed sexual desires – shaped discussions of other Freudian categories, including obsessional neurosis.
The integration of Freudian ‘obsessions’ in this modified form is evident in Thomas Walker Mitchell’s Problems in Psychopathology (1927). The British physician noted that obsessional neurosis was characterised by obsessive thoughts and fears which resulted from a ‘displacement of affect’ (psychoanalytic notion).11 However, rather than the displaced affect being guilt or self-reproach, he emphasised anxiety: ‘it is noteworthy that when the unconscious wish threatens to enter into consciousness it always gives rise to anxiety.’12 Mitchell stressed that the formation of an ‘obsession’ is thus a ‘mechanism of defence against the occurrence of anxiety’. In ‘symptom formation it looks as if the ego were trying to escape or defend itself against something which it fears’. Here Mitchell uses the psychoanalytic-evolutionary hybrid reminiscent of Rivers: ‘obsessions’ are conceptualised as a psychic-defence mechanism which responds to a conflict between the ego and its desire to ‘escape’ (flight) or ‘defend’ (fight) against that which it fears. This was distinct from Freud’s notion of ‘obsessions’ as substituting a repressed libidinal wish, and the accompanying guilt and self-reproach.
The focus on fear in inter-war discussions of psychic conflict facilitated the conflation of ‘obsessions’ and ‘phobias’. In the Lancet in 1922, the medical doctor and lecturer in ‘psychoneuroses’, Milais Culpin, wrote that ‘phobias are a form of obsessional neuroses’.13 Culpin noted that a ‘fear of knives and bridges’ is a phobia which, ‘when viewed from another aspect, may prove to be a suicidal obsession’. This is followed by a quote from Lady Macbeth, addressing her husband:
“Art thou afeard / To be the same in thine own act and valour / As thou art in desire?”
Culpin suggests that if we can picture Macbeth as having ‘repressed his murderous desire and successfully denying himself that it ever existed, the fear affect attached to the now unconscious desire might arise into consciousness and we should find an obsession with knives’.14
Although Culpin’s example relies on a distinctly psychoanalytic concept of repressed instinctive desire, the ‘affect’ attached to Macbeth’s unconscious murderous drive is fear, rather than guilt. The transformation of a primitive wish into an obsession with knives also relied on the Freudian mechanism of phobias. As with Culpin’s example of Macbeth, Freud outlined how in phobias, an internal fear was transformed into an external act. The example of an agoraphobic patient who is ‘afraid of feelings of temptation that were aroused in him by meeting people in the street’ is used to explain the resulting desire to avoid going outside.15 In including ‘obsessions’ and ‘phobias’ within the same framework, Culpin enabled fear to be utilised in explanations of both.
Examples of obsessions/phobias in British psychiatric textbooks ranged from ‘fears of blushing’ to ‘fears of heights’- which differed substantially from the ‘obsessions’ (e.g. of violating family members) contained in Freud’s writings. Whilst the psychoanalytic category was utilized and ‘obsessions’ were seen to arise in the mind (rather than the nervous system), there was no reference to the complex mechanisms of guilt which were fundamental to Freud’s distinction between ‘true obsessions’ and ‘phobias’. The complexity of psychoanalytic interpretations was reduced to a simplistic theory of common fear-responses.
The consequence of privileging fear in the explanation of obsessions, as well as their conflation with phobias, has had long lasting implications for conceptions and treatment of the symptom. After the Second World War there was a steady replacement of psychoanalysis in the treatment of obsessional neurosis in favour of psychosurgical interventions – which were justified on the basis of disrupting ‘chronic tension’ (a bodily response to fear). When obsessional disorders were repackaged by behavioural psychologists in the 1970s, repetitive thoughts were described as sustained by ‘anxiety-reducing’ behaviours. Within this framework, techniques for treatment centred on the reduction of fear. Whilst concepts such as ‘inflated responsibility’ were introduced via cognitive psychology in the late 1980s (arguably drawing on early Freudian principles), the role of anxiety continues to dominate first-line screening and treatment procedures for OCD today. This leaves many, with obsessions shrouded in guilt and shame, to fall through the net.
Eva Surawy Stepney is a PhD candidate in the School of History at the University of Sheffield. Her work explores the history of Obsessive-Compulsive Disorder (OCD) and ideas of evidence-based practice in British clinical psychology. She has lived experience of OCD and has written for Rethink Mental Illness. Twitter @EvaSurawy.
1 E.g. Giacomantonio, M., Salvatic, M., Mancini, F., ‘Am I guilty of not? Deontological guilt, uncertainty and checking behaviour’, Applied Cognitive Psychology 33.6 (2019); Melli, G. et al, ‘The role of guilt sensitivity in OCD symptom dimensions’, Clinical Psychology and Psychotherapy 24.5 (2017).
2 Up until the most recent American Diagnostic and Statistical Manual (DSM-5), OCD was a subcategory of ‘Anxiety Disorders’. It now falls under ‘Obsessive-Compulsive and Related Disorders’.
3 Freud, S., Obsessions and Phobias (1895). Read Books Ltd. (2013), p.3.
4 Nagera, H., Obsessional Neuroses: Developmental Psychopathology (New York, 1926), p.29.
5 Freud, S., ‘Two Case Histories: Little Hans and The Rat Man (1909)’ in Strachey, J., (ed.) The Standard Edition of the Complete Psychological Works of Sigmund Freud: Volume X, (London, 1955).
6 Freud, Obsessions and Phobias, p.6.
7 Loughran, T., ‘A Crisis of Masculinity? Re-writing the History of Shell-shock and Gender in First World War Britain’, History Compass 11.19 (2013).
8 Loughran, T., ‘Evolution, regression and shell-shock: emotion and instinct in theories of the war neurosis etc., c. 1914-1918,’ Manchester Papers in Economic and Social History 58 (2007).
9 Young, A., ‘W. H.R. Rivers and the War Neuroses’, Journal of the History of the Behavioural Sciences 35.4 (1999).
10 Ibid, p.364.
11 Mitchell, T. W., Problems in Psychopathology (London, 1927), p.47.
12 Ibid, p.48.
13 Culpin, M., ‘Phobias with the History of a Typical Case’, The Lancet 200.5169 (Sept, 1922), p.680.
14 Ibid, p.681.
15 Freud, S. New Introductory Lectures on Psychoanalysis, first published 1915. (London, 1974), p. 84.