G L E N O. G A B B A R D, M.D.

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 Dr. Gabbard is Bessie Walker Callaway Distinguished Professor of Psycho-

analysis, Karl Menninger School of Psychiatry, Menninger Clinic; Director and Training and Supervising Analyst, Topeka Institute for Psychoanalysis.

As neuroscience research has uncovered the genetic/biological basis of obsessive-compulsive disorder (OCD), a broad consensus has been reached that behavior therapy and a selective serotonin reuptake inhibitor are the treatments of choice for the c o n d i t i o n . N e v e r t h e l e s s , p s y c h o a n a l y t i c a l l y i n f o r m e d approaches still have much to offer in an overall treatment plan. The biologically determined symptoms have unconscious meanings to the patient that may lead the patient to be highly invested in maintaining the symptoms. Also, psychodynamic factors may be involved in triggering an exacerbation of the symptoms. Moreover, the compulsions and obsessional thoughts almost always have interpersonal meanings that need to be addressed. Family members and others, including treaters, may feel compelled to accommodate themselves to the illness as a response to coercive behaviors by the patient. Finally, the characteriological features of individuals with OCD tend to undermine treatment efforts in many cases and may require psychoanalytically informed therapy to deal with them.

W O C L I N I C A L E N T I T I E S , hysterical neurosis and obsessive-Tcompulsive neurosis, have historically been considered the model conditions for psychoanalytic treatment. While psychoanalysis was born out of experiences with hysteria, Freud’s classic 1909 paper on the “Rat Man” brought obsessive-compulsive neurosis into the psychoanalytic literature with a rich and compelling psychodynamic formulation of the symptoms. Since that time, the classical formulation, widely accepted in analytic circles, was that the anxiety provoked by the oedipal situation led the obsessive-compulsive neurotic to regress to an anal-phase constellation of defenses, including reaction formation, doing and undoing, and isolation of affect. This regression was often viewed as more likely because of the longstanding presence of anal fixations resulting from disturb- ances during the phase of toilet training (Nemiah, 1988).

Despite the longstanding tradition of treating obsessive-compulsive neurosis with psychoanalysis, reports of symptomatic cures with psychoanalytic treatment are virtually nonexistent (Zetzel, 1970; Malan, 1979; Jenike, Baer, and Minichiello, 1986; Nemiah, 1988; Perse, 1988).

Parallel with the realization that psychoanalysis does not alter the obsessive-compulsive symptoms, there has been a growing tendency within psychiatry to view the disorder as one that has a largely biologically based etiology. Indeed, the change in nomenclature in D S M – I I I f r o m o b s e s s i v e – c o m p u l s i v e n e u r o s i s t o o b s e s s i v e – compulsive disorder (OCD) reflects a widely held view that neurotic mechanisms as traditionally defined by psychoanalytic theory are not particularly germane to the etiology of OCD.

The evidence for biological components to the etiology is convincing. OCD patients exhibit increased metabolism (as compared with normal control subjects) in the orbitofrontal cortex, the anterior cingulate cortex, and the caudate nuclei (Baxter et al., 1987; Swedo et al., 1989). Other lines of evidence include a higher rate of concordance for OCD in monozygotic and dizygotic twins, an increased prevalence in patients with Tourette’s Syndrome (and in their families), and a dramatic response in some patients to psychosurgery (Elkins, Rapopart, and Libsky, 1980; Lieberman, 1984; Turner, Bieder, and Nathan, 1985). In addition, Luxenberg et al. (1988) demonstrated with the use of computed tomography that the caudate nucleus volume is significantly less in OCD patients as

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compared to healthy controls. Patients with OCD also show significantly more signs of central nervous system dysfunction than controls (Hollander et al., 1990). One of the most striking recent findings about OCD patients that also suggests a biological component to the etiology is the fact that there is virtually no placebo response (Mavissakalian, Jones, and Olson, 1990). This finding is in stark contrast to conditions such as panic disorder that may have as much as a 25–40 percent placebo response (Gabbard, 1992).

Animal models for OCD are now emerging that suggest that serotonin abnormalities are significantly involved in the pathogenesis of OCD (Greist and Jefferson, 1995). Many of these, such as canine acral lick, a grooming behavior in large dogs that is remarkably similar to obsessive-compulsive behavior in humans, appears to respond to potent serotonin reuptake inhibitors (Rapoport, Ryland, and Kriete, 1992). In addition, potent serotonin reuptake inhibitors are also effective in the treatment of OCD in humans (Greist and Jefferson, 1995).

Part of the difficulty in the field stems from the disentangling of obsessive-compulsive personality disorder (OCPD), which is eminently responsive to psychoanalysis, and OCD. Although there has been a historical tendency to see the two conditions as part of the same continuum of illness, the evidence is now substantial that the two are rather distinct entities (Pitman and Jenike, 1989; Baer et al., 1990; Stein and Hollander, 1993). In fact, only about 6 percent of OCD patients also have obsessive-compulsive personality disorder. In general, OCD patients view their symptoms more egodystonically and therefore have greater suffering as a result. The traits of OCPD patients are often egosyntonic and may cause more distress in significant others than in the patient. This distinction does have certain limitations, and clinicians should keep in mind that some OCD patients also experience their symptoms as somewhat egosyntonic (Rasmussen and Eisen, 1989; McCullough and Maltsberger, 1995). In this paper I shall focus specifically on psychoanalytically informed approaches to OCD rather than OCPD.

In an era in which behavior therapy and serotonin reuptake inhibitors have become the widely accepted treatments of choice for OCD patients (Greist and Jefferson, 1995), we now are at risk for relegating psychoanalytically informed approaches to history and thereby shortchanging many of our patients from a necessary and

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valuable component to the therapeutic armamentarium brought to bear with OCD patients. Despite the impressive research in the neurosciences about the biological underpinnings of OCD, the psychoanalytically informed clinician still has much to contribute to a comprehensive treatment plan for such patients.

The treatment strategies for OCD that I shall articulate fall broadly in the category of psychodynamic psychiatry (as opposed to psycho- dynamic psychotherapy). Previously, I have defined psychodynamic psychiatry as follows: “an approach to diagnosis and treatment characterized by a way of thinking about both patient and clinician that includes unconscious conflict, deficits and distortions of intrapsychic structures, and internal object relations” (Gabbard, 1994b, pp. 4–5). As implied by this definition, the psychodynamic clinician is always thinking in terms of unconscious meaning, transference, countertransference, and resistance, even when not involved in formal psychoanalytic psychotherapy or psychoanalysis. For example, a psychodynamic clinician may be prescribing a serotonin reuptake inhibitor for a patient with OCD but thinking about the interactions with the patient from a psychodynamic perspective. This psychoanalytically informed approach implies a particular conceptual model for understanding the illness of OCD.

Stress Diathesis Model of OCD

Increasing evidence suggests that many of the major psychiatric disorders can best be understood based on a stress diathesis model (Gabbard, 1992, 1994a). While there are clearly genetic processes at work in the etiology and pathogenesis of OCD, psychosocial stressors appear to be important as well. Clinicians have long observed that increased stress or the recurrence of original precipitating problems can worsen symptoms of OCD while reduction in tension can improve them (Black, 1974). Some provocative research suggests that OCD symptoms may be significantly influenced by issues involving childcare and pregnancy. For example, Buttolph and Holland (1990) found that 69 percent of patients with OCD could relate the exacerbation or onset of their symptoms to parental care of their children, pregnancy, or childbirth. In a study of 106 female patients suffering from OCD, Neziroglu, Anemone, and Yaryura-Tobias (1992) noted that pregnancy was associated with the onset of OCD symptoms

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more than any other life event. In fact, 39 percent of those patients with children first experienced symptom onset during pregnancy. Five women in the study had had an abortion or a miscarriage, and four of those five noted exacerbation or onset of OCD symptoms while they were pregnant.

In my own clinical experience with OCD patients who are young mothers or who are pregnant, I have often noted a link between increased intensity of the OCD symptoms and a rise in unconscious or barely conscious aggression toward the child. For example, one OCD patient who was a new mother of a 6-month-old said that she immediately turned off the television whenever a news story or talk show featured a discussion of child abuse by parents. In the course of psychotherapy, she recognized the extent to which she struggled with overwhelming murderous wishes toward her child. While the form the obsessional thoughts took often suggested that a disaster from the outside would strike down the child, dynamic exploration helped the patient understand that the threat she feared really came from within rather than from external sources.

Part of this conceptual model is that symptoms, no matter how biologically influenced, nevertheless have meanings, conscious or unconscious, to the patient. As I noted in a previous communication (Gabbard, 1992), psychodynamic conflicts frequently appropriate the biochemical forces within the brain and use them as a vehicle of their expression. In that communication I described a young man who had completely controlled his mother’s life to the point where she quit her job to stay home with him and cater to his every need. Meanwhile, the father was forced by the young man to stay in a separate room in the house so that the father would not contaminate his son with “germs” from the outside world. In this regard, the OCD symptoms served as a way of facilitating an unconscious oedipal triumph in which the young man had his mother all to himself while his father was out of the picture.

Of great significance in this case was the patient’s resistance to any kind of psychiatric treatment. He had refused to go to psychiatrists and had refused medications with some proven efficacy for OCD. Only when his resistance could be addressed and understood was the patient capable of collaborating in an overall treatment program. Hence, the discovery of his intense dependency on his mother and his wish to continue in his conflictual oedipal triumph had to be taken

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up with him through psychodynamic understanding before he finally agreed to take clomipramine.

Treatment Implications

In considering treatment implications for OCD, the foregoing case vignette underscores an extraordinarily crucial point—namely, that many OCD patients tenaciously hang on to their symptoms because of their special meanings and because of the interpersonal control they exert on others. They thus may be uninterested in doing the work of behavior therapy or complying with medication regimens. Indeed, many controlled trials exclude such problematic patients because of their poor motivation or refusal to comply, and therefore empirical research on OCD may not adequately address this subgroup of patients.

Even when OCD patients are compliant with standard treatment regimens, the results are less than ideal. For example, in the c o m p r e h e n s i v e m u l t i c e n t e r p r o j e c t t o s t u d y t h e e ff i c a c y o f clomipramine, after 10 weeks of treatment the mean reduction of symptoms was only 38–44 percent (Clomipramine Collaborative S t u d y G r o u p , 1 9 9 1 ) . M o r e o v e r, m a n y p a t i e n t s r e l a p s e o n clomipramine or other serotonin reuptake inhibitors if they do not have associated behavior therapy (Zetin and Kramer, 1992). Behavior modification involving in vivo exposure combined with response prevention appears to have the best results (Barlow and Beck 1984), but a high relapse rate also occurs with this modality, which requires extensive cooperation from the patient (Marks, 1981).

Patients with OCD often have considerable difficulties in interpersonal relationships, both with family members and with those at work or in social settings. The diagnosis of OCD is associated with a high risk of separation or divorce (Zetin and Kramer, 1992). Psychodynamic approaches are extremely useful to help clarify and address the relationship problems encountered by the illness. Identification of the stressors and their particular meanings to patients may also help both the patient and family members to be aware of precipitating events and try to reduce their impact or avoid them as much as possible.

The neurobiological substrate of OCD leads to certain kinds of unconscious patterns in relationships that ultimately become

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internalized as the patient’s characteristic object relationships. These are then reexternalized in familial and extrafamilial relationships to create a host of problems. The advantage of a psychodynamic orientation in treatment is that the transference–countertransference developments can be systematically examined as a way of helping patients understand their relationship problems in other contexts.

Mr. A was a 26-year-old single man who was admitted to a psychiatric hospital unit because his symptoms had become virtually d i s a b l i n g a n d b e c a u s e h e h a d r e f u s e d t o c o o p e r a t e w i t h pharmacotherapy and behavior therapy approaches. He was preoccupied with the possibility that his mother and father had stepped on the AIDS virus on their way home from their respective jobs and was convinced that the house needed to be sprayed with disinfectants thoroughly to prevent his coming into contact with the virus. His parents had colluded with his insistence that every item of furniture in the house needed to be sprayed and scrubbed down. Each evening they would systematically go through the ritual of spraying and wiping off much of the household under the direction of the patient.

When Mr. A came into the hospital unit, he asked his primary nurse for details about the previous occupant of his room. The nurse explained that such information was confidential and could not be shared with him. Nevertheless, he persisted in asking questions, particularly regarding the previous occupant’s masturbatory habits. He became obsessed with the notion that there might be semen stains in his room that could transmit HIV infection to him. In my daily interviews with him, much of the time of our discussions was consumed with this possibility. Despite the absurdity of his fear, his insistence that we discuss the possibility of HIV contamination was powerfully coercive to the point that I found myself engaging in extensive efforts to argue from a rational, logical standpoint that his fears were essentially irrational. Mr. A’s demand that I participate with him in a dialogue about HIV had an obligatory quality associated with it. I felt invaded by it and “bullied” into a kind of folie à deux in which nothing else was important to the two of us. In short, I had become an extension of Mr. A.

On one morning, while making rounds, I walked into his room to find Mr. A’s primary nurse with disinfectant spray in one hand and a paper towel in the other, “decontaminating” the furniture in Mr. A’s room. The nurse appeared rather ashamed that he had been caught colluding with the patient’s fear of contamination.

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When I met with the nurse later, I explained to him that I could empathize with his dilemma—namely, that Mr. A’s need to discuss his obsession and to engage in rituals to assure himself that the room was decontaminated was so powerfully compelling that one could easily get drawn into colluding with it. I pointed out to the nurse, that via projective identification, he had become tyrannized by the patient in the same way that the patient’s parents had been tyrannized by Mr. A at home. I shared with the nurse the time-honored view of the psychoanalytic hospital as a place where a patient recreates his family situation (more precisely, his internal object world) in the milieu of the hospital with various staff members (Gabbard, 1988).

When the nurse refused to engage in such collusion following that incident, Mr. A became highly indignant. The extent of his entitlement was truly remarkable. He clearly had the expectation that others in his environment should behave as narcissistic extensions of himself. He massively denied the autonomy and subjectivity of anyone else in his life. They existed only to respond to his needs, and his omnipotent control was highly dehumanizing.

I spent a good deal of time in my meetings with him pointing out his pattern of object relatedness, both in his relationship with the nurse and with me on the unit and with his parents at home. I clarified with him that his sense of urgency about the catastrophic nature of his thoughts regarding contamination by HIV caused others to feel that they must do his bidding or there would be dire consequences. While this approach did not directly reduce his obsessive-compulsive symptoms, it was of extraordinary value in helping him develop greater empathy for others and to view them as subjects rather than objects under his omnipotent control. In the social worker’s sessions with the parents and Mr. A, a great deal of progress was made in h e l p i n g t h e p a r e n t s s e e t h a t c o l l u d i n g w i t h h i s n e e d s f o r “decontamination” were not in his best interests in the long run. The parents felt extraordinary relief in gaining permission from the social worker, and eventually from Mr. A, to act out of their own needs rather than to subject themselves to Mr. A’s controlling behavior.

Another cogent reason to incorporate psychodynamic strategies w i t h O C D p a t i e n t s i s t h e f a c t t h a t m a n y h a v e s i g n i f i c a n t characterological issues that serve as powerful resistances to forms of treatment such as behavior therapy or pharmacotherapy. In fact, Baer et al. (1990) found that the presence of schizotypal, borderline, and avoidant personality disorders predicted poor treatment outcome

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in patients with OCD treated by clomipramine. Moreover, even when patients fall short of meeting DSM-IV criteria for a personality disorder, they still may have prominent characterological features that interfere with the implementation of a comprehensive treatment program.

In another study (Aubuschon and Malatesta, 1994), 31 patients with OCD who were comorbid for a personality disorder were treated with comprehensive behavior therapy. Their outcomes were compared with a group of OCD patients without comorbid personality disorders. Those patients with personality disorders were rated as more difficult to treat, were more likely to terminate behavior therapy prematurely, and required more psychiatric hospitalizations than the OCD patients without personality disorders.

Mr. B was a 38-year-old divorced man who had been successful in a management position until he became unable to function effectively at work because of obsessional thoughts and compulsive rituals. Although he had a longstanding paranoid personality disorder and some mild symptoms of OCD, his functioning had never been impaired until his father’s illness and death 2 years prior to seeking t r e a t m e n t w i t h m e . H i s o b s e s s i o n s a n d r i t u a l i s t i c b e h a v i o r dramatically worsened at the time of his father’s death, to the point where he found he could not function effectively at work.

The patient had been angry at his father the last time he saw him before his death and felt extraordinarily guilty about the fact that their last meeting had been an angry one. The day preceding the father’s funeral, Mr. B had strained his back playing baseball, and during the funeral he experienced such severe low back pain that he needed to take narcotic medication. Although he stopped the narcotics after several days, his back pain continued in conjunction with his worsening obsessional thoughts. The content of these thoughts was primarily focused on his potential to hurt others. For example, he was afraid that if he went to work, he would open the door to the men’s room and seriously injure someone who was coming out as he walked in by hitting him with the swinging door.

As a child, Mr. B had attempted to undo his anger toward his parents with various forms of ritualistic behavior. His gradually worsening rituals since his father’s death reflected his unconscious conviction that he had caused his father ’s death because of the intensity of his anger. A variety of rituals, including driving to work

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and back as many as eight or ten times, were designed to undo the death by increasingly escalating the rituals.

He had seen two previous clinicians prior to coming for help from me. He had initially tried cognitive-behavior therapy that focused exclusively on his symptoms. He finally quit because he felt the cognitive-behavior therapist was not helping. He told me that he had repeatedly explained to this therapist that he was aware of how ridiculous the cognitive distortions were, but the awareness of their irrational nature did not help him change the thoughts.

He next went to a psychiatrist who offered to prescribe him clomipramine. He read every piece of material he could get his hands on regarding the medication but consistently refused to take it. Because of his basic paranoid orientation toward the world, he was convinced that the medication would somehow destroy him or at the very least cause unmanageable side effects.

When he finally came to see me, I spent a good deal of time working with him about his resistance to taking medication. I observed that he seemed to be terribly concerned that his anger had damaged his father. In response to that observation, he would repeatedly assert that he was not, in fact, an angry person. His anger would often escalate as he insisted on the notion that he had transcended any problem with anger. Finally, after a good deal of work on his paranoid character features, he agreed to take the clomipramine. He took it for about 1 year at maximal therapeutic doses but experienced no change whatsoever.

He then went through a period of months obsessing about whether it would be advisable for him to try fluoxetine. He again read extensively about fluoxetine and worked with me around his paranoid ideas involving side effects. After a few months of discussing it, he tried taking fluoxetine but felt that he was getting progressively worse on it after 2 months and discontinued it.

Despite his lack of success with pharmacotherapy and cognitive- behavior therapy, he did persist in his individual psychodynamic therapy and gradually made gains in many areas of his life. While his symptoms were manageable, they did not disappear. On the other hand, his paranoid personality improved in a number of significant ways. He became much less rigid and more open to entertaining ideas that he had previously rejected. He became able to form a reasonably trusting therapeutic alliance with me and, in association with that

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trust, became much less hostile. He was also able to have a mutually gratifying and meaningful sexual relationship with a woman, which had previously been virtually unthinkable because of his paranoia. He became much less isolated and formed other relationships as well. He even began to return to work part time as his anxiety about his OCD symptoms became less bothersome to him. In short, he had made an adaptation to his symptoms that greatly enriched the quality of his life.

Conclusions

These brief clinical illustrations point out the continued role of psychoanalytically informed treatment with patients suffering from obsessive-compulsive disorder. Regardless of the presence of biological determinants that may generate OCD symptoms, these symptoms nevertheless are rich in unconscious meaning that may cause patients to be highly invested in maintaining their symptoms. Psychodynamic understanding of the meaning of those symptoms may be of enormous assistance in improving compliance with pharmacotherapy or behavior therapy treatment programs.

OCD is an illness that fluctuates in its severity, and a dynamic understanding of psychosocial triggers may assist in managing the patient with OCD. For example, in the case of Mr. B, it became clear that the onset of his symptoms was closely linked to concerns about aggression toward others. In other patients, anxieties about injuring children or babies may be contributory. In still others, sexual anxieties may serve as a trigger.

The symptoms of OCD almost always have interpersonal meanings that must be addressed. Biologically determined symptoms may serve as the ideal vehicle to express psychodynamically based conflicts. Hence, family members and others in significant relationships with the patient may find themselves controlled and coerced into behaviors that are highly dysfunctional. The transference–countertransference dimensions of the treatment relationship with OCD patients may provide a window into these recurring patterns that can be fruitfully addressed as part of treatment.

The characterological features of individuals with OCD tend to undermine treatment efforts in many cases. Confronting and interpreting the characterological dimensions of the patient may have

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a significant impact on the overall management of the patient. Moreover, personality features of individuals with OCD may respond dramatically to dynamic psychotherapy so that these patients can lead much more gratifying lives. The case of Mr. B demonstrates an instance in which the patient’s adjustment to life improved greatly despite the fact that the OCD symptoms persisted.

Finally, we must be mindful that a certain percentage of patients will respond to neither pharmacotherapy nor behavior therapy. A psychodynamic treatment approach may be necessary to deal with a treatment-refractory situation, even though the clinician must have modest goals for the improvement of the symptoms per se. OCD serves as a model illness to demonstrate the value of an integrated a p p r o a c h t o t h e t r e a t m e n t o f m a j o r p s y c h i a t r i c d i s o r d e r s . Psychodynamic strategies will continue to have a major role in psychiatry as illustrated by the many ways in which psychodynamic thinking is applicable to conditions such as OCD.

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