A psychoneurotic reaction characterized by a persistent impulse to think certain thoughts (obsessions) or carry out certain actions (compulsions). Obsessions and compulsions are usually found in the same patient, but one type of reaction may be more prominent than the other. The individual usually realizes that his behavior is unreasonable but is powerless to control it.Obsessive-compulsive reactions are gross exaggerations of the common tendency to dwell on the same idea, such as a haunting melody, a single phrase or sentence, or to perform the same act, such as scratching one’s head or touching every picket in a fence. In the neurotic form, however, these ideas or actions obtrude themselves with overpowering insistence, monopolize the mind, restrict the personality and interfere with everyday activities. Moreover, they are frequently more pointless, absurd, or repugnant than the usual preoccupations. Some individuals ruminate for days on end about infinity or creation or why a chair has four legs. Others have recurrent fantasies about killing a beloved member of the family or shouting blasphemous words in church, and no matter how hard they try, they cannot get rid of these ideas. Fortunately they rarely carry out unethical or violent acts, although they may become extremely apprehensive about doing so.Obsessive-compulsive reactions of one kind or another are among the most common psychoneurotic disorders, constituting an estimated 20 to 30 per cent of the total number of cases.Obsessions vie with phobias in number and variety. Some obsessive thoughts are disturbing only because they waste so much time—for example, counting to seven seventy-seven times, or occupying one’s self with an insoluble scientific problem such as perpetual motion. Other obsessions may be a source of torment to the individual—for instance, preoccupation with thoughts about death and disease, or the feeling that one is going insane. One particularly distressing variety of obsession is “folie du doute” (madness of doubt), a persistent vacillation and indecision even about the simplest matters such as whether to make a telephone call or cross a street. Feelings of doubt are often accompanied by compulsive acts, such as checking the front door lock a dozen times, even to the point of getting up in the middle of the night.Compulsions are usually stereotyped, repetitive acts ranging from simple behavior, such as crossing one’s t’s in a certain way or snapping one’s fingers a certain number of times, to complex rituals such as placing one’s clothes in a certain order and saying a nonsensical rhyme every night before going to bed. The performance of these actions brings a feeling of relief and satisfaction; if they are neglected or resisted, the individual is filled with uneasiness and tension. During periods of stress, compulsions become particularly irresistible and multiply to a point where they dominate the entire waking life. These activities may be annoying but they are rarely harmful to others. Compulsive stealing (kleptomania) and fire- setting (pyromania) are the most important exceptions. See these topics.Cameron (1947) classifies compulsive behavior into six major but not mutually exclusive categories: compulsive repetition of acts, as in checking again and again to see whether the door has been locked; serial compulsions: carrying out sequences of acts or adhering rigidly to a certain order of behavior, as in dressing; compulsive restraint or coercion: the irresistible need to hold one’s self or others in check by demanding devotion to routine or detail; compulsive orderliness: overconcem with simple everyday arrangements, with unbearable anxiety if there is any variation; compulsive magic: putting faith in signs, rituals, incantations and stereotyped actions, such as touching every third picket in a fence; and antisocial compulsions: the irresistible need to perform criminal acts, such as setting fires, stealing, committing murder or suicide.The same underlying factors apply to both obsessions and compulsions, since they are aspects of a single type of neurotic reaction. In general they are both defenses against anxiety, but any one of several different mechanisms may be employed. First, substitution. Some individuals screen out disturbing ideas or threatening impulses by substituting meaningless thoughts and activities. The man who is failing in business may become preoccupied with trivial problems in accounting; the woman who feels guilty about her sexual impulses may endlessly arrange and rearrange the furniture in her home. In a case cited by Freud a patient blocked off a fear of insanity by continually brooding over the question “Why must I breathe?” In rare instances the individual may apply himself compulsively to social issues or scientific questions and thus may solve other problems even if he cannot solve his own.A second pattern is the isolation of impulses from their emotional origins (“isolation of affect”). An individual with obsessive fantasies of aggression may feel they are forced upon him against his will and therefore are no fault of his own. In this way he denies that he actually harbors dangerous impulses. In one case, a man was obsessed with “horrible thoughts” of hitting his son over the head with a hammer. He could not explain his obsession, but analysis revealed that his wife had suffered so much pain during the birth of the child that she refused him sexual relations from then on. In addition she lavished most of her attention on the boy. In this case the man’s obsession was the combined result of repressed hostility toward the son and an unconscious desire to get him out of the way in order to regain his former marital happiness. Both motives had been successfully cut off from recognition, and in this way the man was freed from responsibility for his violent thoughts.A guilty reaction resulting from forbidden impulses or acts frequently gives rise to obsessions and compulsions. The man who hates and wants to harm his wife may feel compelled to pray for her a hundred times a day. The boy who has engaged in sexual play may wash his hands a hundred times a day or daub himself with mercurochrome until he looks like an Indian war dancer —yet if he is asked why he does these things, he will maintain that he simply has a special sensitivity to germs. An obsessive fear of contaminating others may also arise from feelings of guilt, and the individual may feel compelled to wear gloves constantly or refrain from bodily contact of any kind. These are all methods of counteracting, expiating, or atoning for dangerous impulses. The technical term for this reaction is undoing.Two other patterns are particularly noteworthy. Some people deny their underlying wishes by going to the opposite extreme—the mechanism of reaction formation. An individual with strong unconscious homosexual desires may devote himself completely to organizations dealing with the problem of homosexuality. Similarly, Masserman (1961) relates the case of the successful executive who hated the responsibility of marriage and being a father. This man was in the habit of calling his children’s school three times a day to see if they were safe and sound, and he never came home without bringing presents to his entire family. Through these compulsive activities he was hiding his true feelings from himself as well as from others.Finally, many individuals defend themselves against anxiety by organizing every aspect of their lives in a meticulous and rigid manner. They usually have an obsession for schedules, budgets, and invariable routines. These preoccupations give them a sense of security, but they also serve to screen out dangerous impulses since there just isn’t time or place for them. The price they pay, however, is a high one, for they inevitably lead narrow, predictable, unimaginative lives.Although obsessive-compulsives do not all fall into a single personality pattern, they do tend to be restricted, methodical, obstinate, and overcontrolled individuals. They lack spontaneity and verve, and live by rules and regulations. Many of them are overconscientious, submissive, and conventional, and have unhealthy attitudes toward sex. Frequently their parents have had the same perfectionistic drives and the same intolerance of disorder, and have tried to push their children ahead too fast.Like other neurotics, obsessive-compulsives have strong feelings of inadequacy and are excessively susceptible to guilt feelings. To them the world as a whole is a dangerous place, and they are caught between threatening impulses from within themselves and threatening situations from outside. Their obsessive thoughts and rigid routines may be interpreted as attempts to appease fate and block off anxiety. Their rituals have a semimagic quality that recalls the rites and incantations of primitive tribes.The whole psychic economy of these individuals is precarious, and to maintain peace of mind they must constantly readjust its shaky balance by thinking of things they do not want to think about or performing actions they do not want to carry out. It is not surprising, then, that the acutely obsessive individual finds it difficult to live with himself, and others find it next to impossible to live with him.Obsessive-compulsive reactions frequently present difficult problems of diagnosis. Normal defensive traits shade so gradually into neurotic behavior that it is necessary to ask how seriously the life of the individual is disturbed and whether his obsessive behavior is gathering force. Obsessive thinking and compulsive rituals may be confused with the ruminations and mannerisms of the early schizophrenic. A schizophrenic, however, shows less tension and fails to see how absurd his compulsions are. He is also likely to believe that external influences are forcing him to think and act as he does. As Bleuler has put it, the neurotic struggles against his obsession, and the delusional patient struggles with it. Manic-depressive patients are frequently afflicted with obsessional ideas in the depressive phase, but investigation will disclose that the depression preceded the obsessive ideas. The depression is therefore the basic reaction.Obsessive compulsive patients are frequently more resistant to treatment than other psychoneurotics because of the rigidity of their personalities. Most cases require long-term psychotherapy with the double aim of revealing the sources of the compulsive character traits and the unconscious meaning and purpose of the rituals and obsessive thoughts. Feelings of guilt and tendencies to over conscientiousness and perfectionism can sometimes be explored in short-term therapy, and re-educational techniques may also be effective in helping the patient modify his extreme reactions. During this process the therapist usually encourages him to discover and cultivate latent interests in order to reduce preoccupation with meaningless and repetitious activities, and to promote the kind of personality growth he most needs.Illustrative Case:“. . . This boy’s excessive cleanliness first showed itself at the age of thirteen, when it was noticed that he washed his hands many times during the day. Later he began to bathe frequently. Frequently he stayed two or three hours in the bathtub. On a number of occasions he daubed iodine on his hands and face. He told his parents that he had scratched himself and wanted to prevent infection. In addition to iodine, he had bought mercurochrome and other antiseptics for use in ‘emergencies.’ He also used a boric acid solution to wash his eyes every evening. The parents stated that he refused to play ordinary games with other children because he did not want to soil his hands. When asked to explain his concern regarding cleanliness, he stated that he realized that he washed more than other boys, but that in his case there were real reasons. He believed that his skin was of such a texture that it retained dirt and germs, and he therefore was forced to wash and scrub himself.“No amount of persuasion was successful in deterring the boy from this until his original conflicts began to be solved. He stated that he had been greatly worried about his guilt regarding his previous activities with other boys. His parents discovered that he took part in sex play and punished him. They had frequently lectured him on the evils of ‘immoral’ behavior and on one occasion, when he was nine, made him sign a pledge never to smoke or drink even beer. They also told him how some terrible diseases result from masturbation. ... He stated that he had ‘sworn ofF masturbating on many occasions, and after each time he masturbated he felt thoroughly ashamed of himself. He also believed that he was deficient in character and will power because he could not stop. He stated, ‘I know it’s a dirty habit and if anyone finds me out they will think terrible things about me.’ After many interviews and much discussion, he began to change his attitude regarding the immorality of his past behavior and the possible consequences of his supposed moral transgressions. His excessive cleanliness gradually decreased and he was able to take part in the activities of other boys without feelings of unpleasantness from soiling his hands and clothes.” (Sherman, 1938).