Obsessive-Compulsive Disorder: Psychoanalytic Theory

Learning Theory

A model based on the psychological concept of conditioning has also been used to understand the development of obsessions and

compulsions. Compulsions, whether mental or observable, usu-ally decrease the anxiety engendered by obsessional thoughts. Thus, if a person is preoccupied with fears of contamination from germs, repetitive handwashing usually decreases the anxiety caused by these fears. The compulsion becomes a conditioned response to anxiety. Because of the tension-reducing aspect of the compulsion, this learned behavior becomes reinforced and eventually fixed. Compulsions, in turn, actually reinforce anxi-ety because they prevent habituation from occurring; that is, by performing a compulsion, contact with the fear-evoking stimu-lus (e.g., dirt) is not maintained, and habituation (a decrease in fear associated with the stimulus) does not occur. Thus, the vicious circle linking obsessions and compulsions is maintained (Figure 51.4). This learning theory model of OCD has had a major influence on the way behavioral therapy is used in its treatment.

Psychoanalytic Theory

Much of the psychoanalytic literature on OCD does not distin-guish between the phenomena observed in OCD (obsessions and compulsions) and the traits of OCPD. This distinction has rel-evance because of treatment implications. Although the clinical observations of earlier psychoanalysts, such as Freud’s famous Ratman case (Freud, 1963), reflect current clinical presentations of Axis I OCD, understanding symptoms from the psychoana-lytic perspective have not yielded improvement in this disorder’s symptoms. Conversely, characterologic problems such as perfec-tionism, indecisiveness and rigidity, seen in OCPD, may benefit from a psychoanalytic orientation that focuses on the meaning of these symptoms or traits; such traits have typically not responded well to medications alone, although further investigation of this question is needed.

Recent theory has attempted to integrate the biology of OCD with psychological models by proposing a phylogenetic model based on systems theory. In this model, behavioral in-hibition and harm-assessment systems, which develop early in human phylogeny, are disrupted. This disruption can occur at a hierarchically primary level of biological organization, result-ing in neurobiologic disturbance, or at a hierarchically higher level of organization, leading to psychological disturbances. Such a model can help to explain the diversity of symptoms seen in OCD, from the more primitive biologically based be-haviors based on fight/flight and risk to more psychologically sophisticated behaviors involving morality and guilt. This model might also explain why neither biological or psycho-logical treatments alone always lead to complete remission of symptoms (Cohen et al., 1997).