Obsessive-Compulsive Disorder: Its Conceptual

History in France During the 19th Century

GE. Berrios

Until the 1850s. obsessive-compulsive phenomena were considered to be a variant of the old
notion of insanity. Around this time they became a separate disease: first, as a member of the old
class of the neuroses; then, briefly, as a variant of the newly formed notion of psychosis; and finally,
as a neurosis proper (in the post-1880s sense). These changes reflected theoretical shifts in the
definition of the grand psychiatric categories. After 1860, organic causal hypotheses for OCD
included dysfunctions of the autonomic nervous system and cortical blood supply. Psychological
hypotheses suggested the OCD might result from volitional, intellectual, or emotional impairment,
the last of which predominated after 1890. Issues relating OCD to personality types and
hereditability were dealt with in terms of the degeneration theory. By the late 188Os, OCD achieved
full clinical and nosological definition.
0 1989 by W.8. Saunders Company.

0
BESSIVE COMPULSIVE DISORDER (OCD) includes interloping and
iterative thoughts and/or actions that may interfere with or paralyze
behavior. OCD may be accompanied by declarations of distress, characterized by
resistance, interference, and the presence of insight. In spite of revived interest in
OCD,‘.’ its nosological status, natural history, and classification remain unclear.
Assuming that OCD-like behavior phenomena existed before the 19th century,* it
is plausible to expect that words and concepts were marshalled to define them.9 If so,
the history of the words (historical semantics) and concepts (conceptual history)
require separate analysis. They were affected differently by the epistemological
break that changed the psychiatric discourse during the early 19th century.”
The concepts involved in the current definition of OCD were tooled during the
19th century. This review focuses on the French psychiatrists responsible for its
formation. German and British work is comparatively less important, and has been
dealt with elsewhere.8~9*1’

HISTORY OF THE WORDS

Since the Medieval period, latin terms such as obsessio, compulsio, impulsio, and
scrupulus were adopted by the European medical community to deal with OCD-like
phenomena. A number of vernacular terms served a similar function in ordinary
language.*
As part of the 19th-century drive for description, French psychiatrists coined the
following noun and adjectival phrases to name clinical phenomena, which included
OCD: manie sans dblire, I2 folie raisonnante, l3 monomanie raisonnante,14
kleptomanie, ” id&es fixes, I6 idt?e irresistible,” dilire aver conscience and d6lire
sans dglire. ‘* id&es restrictives or mobiles,‘g pseudomonomanie,20 folie lucide,=’
folie or monomanie avec conscience, ” dilire de toucher,23 folie de doute,24 dklire

From the Department of Psychiatry, University of Cambridge, England. Address reprint requests to
G.E. Berries. M.A.. M.D.. F.R.C.Psych. Department of Psychiatry, University of Cambridge, Adden-
brooke’s Hospital (Level 4), Hills Rd., Cambridge CB2 2QQ. U.K.
0 1989 by W.B. Saunders Company.
00i0-440X/89/3003-0002$03.00/0

Comprehensive Psychiatry, Vol. 30. No. 4 (July/August), 1989: pp 283-295 283

284 G.E. BERRIOS

emotif,25 obsessions pathologiques,26 folie des htrkditaires dtg&?res,27 and crainte

de souillure.2a
These categories also referred to clinical phenomena other than OCD. Since
Pinel, manie sans dklire and folie raisonnante described forms of insanity
unaccompanied by delusions (i.e., that escaped the conventional intellectual
definition of insanity).29 Prichard’s concept of moral insanity was but an anglicized
version of this category.30
The inclusion of OCD underfolie raisonnante proved unsuccessful. This category
had no conceptual machinery to explain the presence of thoughts which, although
persistent and disturbing, did not qualify as delusions (clinical observations
demonstrated that some sort of insight seemed to be present).3’
After the 185Os, OCD was redefined within a new category, “folie avec
conscience” (insanity with insight). The transfer was dealt with in a famous debate
in the SociCtt Mtdico-Psychologique.32 By temporarily surrendering the lack-
of-insight criterion (central to the concept of delusion), psychiatrists supporting this
category allowed a number of disorders such as OCD, agoraphobia and panic
disorder, and hypochondriacal and homicidal monomanias to be classified as
insanities. Folie avec conscience disintegrated by the end of the century under the
pressure of the advancing (and narrower) Kraepelinian view of psychosis33; by then,
OCD was also given an alternative clinical and etiological interpretation.

HISTORY OF THE CONCEPT

The First Halfof the 19th Century: Esquirol(1772-1840)

Esquirol14 opened a new clinical space for OCD when he classified the disease of
Mlle. F as a form of volitional monomania (dklire partiel). He defined this category
as “involuntary, irresistible, and instinctive activity”; the patient is “chained to
actions that neither his reason or emotion have originated, that his conscience
rejects and his will cannot suppress.” Esquirol noticed that Mlle. F described her
thoughts as irresistible and hence seemed to have insight. He concluded that such
irresistibility reflected a weakness in the volitional faculty. Diseases of the will
remained a popular subject in French psychiatry until the end of the century.34.35
The view that the OCD was a partial insanity or monomania did not last long. The
concept of monomania, never very popular, declined in the 1850~.~~Critics claimed
the following faults (1) it had resulted from a mechanical application of Faculty
Psychology3’; (2) it encompassed too many clinical states and hence had little or
nothing to say about individual phenomenology3*; (3) it was based on cross-sectional
observation and had no conceptual machinery to handle longitudinal symptom-
change$‘; (4) it handled subjective symptomatology poorly which, since the 1840s
had become an important aspect of the definition of mental disorder29; and (5) it
created legal difficulties.@ The category was sounded its death knel14i at the
1853-1854 debate of the Socitte Medico-Psychologique in Paris. Its disappearance
set the category of OCD asunder.

The Second Halfof the Century: Morel (1809-1873)

Morel” described OCD as a member of a category he called dklire emotif, and
which he considered not as “an insanity but as a neurosis, that is, a disease of the
emotions.“25 He wrote: “what I call ‘delire emotif’ corresponds to a particular type
OBSESSIONS IN THE IQTH CENTURY 285

of fixed idea and abnormal act whose existence, however, does not entail an
involvement of intellectual faculties.” For example, the drive leading to the
compulsion resulted from a heightened affective state. Morel’s use of the word dkfire
was unconventional in that it allowed for the presence of insight.42
Analysis of his seven cases confirms the broad nature of the category that also
included vasomotor and digestive symptomatology, phobias, dysphoria, unmoti-
vated fears, fixed ideas, and impulsions, as long as there was no cognitive
impairment. Janet’s concept of psychasthenia43*” followed this grouping very
closely.
Three reasons explain the success of d&Ike emot$ first, the towering reputation
of Morel; second, it provided an alternative to the German view that OCD was a
thinking disorder similar to paranoia4’; and third, it allowed for the classification of
a variety of anxiety-equivalents.46 Luys4’ suggested that since ideas, emotions, and
actions had separate cortical localization, nervous excitation might give rise to
bizarre ideas, involuntary emotions, or compulsive acts. Luys disagreed with
Morel’s view that all vegetative functions were localized in the ganglionar system.47
Reclassification of the OCDs as a form of neuroses reopened the possibility that
they might result from nervous involvement of areas of the brain related to
cognition, emotions, or volition. Once again, it must be remembered that in 1866 the
word “neurosis” was only half-way through its long development.48
Morel’s view has been echoed in the history of psychiatry, particularly in the
1960s by Beech and Perigault,3 and later by DSM-III-R,49 where OCD is classified
as an emotional disorder. However, neither of these efforts has solved the objection
raised at the time against Morel’s view: why the so-called insanities with insight, in
spite of their common origin, are so clinically dissimilar. The belief that there was no
need for a generic name for such a heterogeneous group of disorders won the day
and the concept of fulie cfvec conscience faded way.

Dagonet (1823-1902) and the Concept of Impulsion

While obsessions were defined vis-a-vis the concept of delusion, compulsions
required separation from impulsions, a class of symptoms including all manner of
paroxysmal, stereotyped, and (apparently) involuntary actions.
The explanatory force of the term “impulsion,” (imported from the science of
Mechanics),” resulted from its analogical use that alluded to vestigial behaviors,
drives, cravings, and appetites. This helped psychiatrists to explain apparently
unmotivated seizural and episodic behavioral phenomena. In addition to OCD,
impulsive insanity also included phobias, homicidal and suicidal tendencies, manic
behavior, hypochondriacal preoccupations, and even epileptic seizures.‘i3’*
The concept of impulse was ambiguously poised in two different dimensions. In
one, it was used both as a description and as an explanation; in the other, it was
considered as either reactive or endogenous. From a historical viewpoint, the earliest
view was that it was of inner origin.52q53
Versions of impulsive or instinctive insanity, based on Faculty Psychology,30 were
in circulation in European psychiatry as early as 1810. According to Faculty
Psychology, the will was a separate mental function, and hence susceptible to
independent impairment. 3o Pinel” and Georgets4 included cases with impetuositi
de penchans in this category of manie sans dglire or non delirante. Esquirol’s’4*55
286 G.E. BERRIOS

notion of monomania56 brought the disorders of the will into the mainstream of
psychiatry.
After the decline of the notion of monomania, the monomanic impulsive
syndromes were included in the category of impulsive insanity, thus named by
Marc& and Foville.52 Dagonet offered a clinical and taxonomic analysis and
concluded that any patient suffering from insanity might display “impulsions
violentes, irresistibles.” The latter could be primary or secondary to delusion,
pathological affect, or hallucinations. They could be of short duration or chronic.52
They “resulted from a failure of the will.” Dagonet included in this category clinical
phenomena in which “the more one tries to discard an idea, the more it becomes
imposed upon the mind, the more one tries to get rid of an emotion or tendency, the
more energetic it becomes.”
Legrand du Saulle (1830-1886)
Consolidation of the clinical description of the OCDs was achieved in the work of
Legrand du Saulle, 57 who reported 27 cases (11 his own) in 1875. He recognized
that OCD patients were admitted to the hospital only when severely ill or
complicated by psychotic symptoms or depression. He was aware of OCD’s
fluctuating course, insidious onset, and tendency to symptom-change with time. He
classified OCD as one of the varieties of insanity with insight, reporting that it had
early onset, occurred more frequently in women, affected individuals from higher
social classes, and occurred more frequently in fastidious and rigid personalities.
A believer in longitudinal analysis, he identified three stages in OCD. In the first
there were “involuntary, spontaneous and irresistible thoughts on various subjects
without illusions or hallucinations”; with a “feeling of doubt, of brooding,” and
occasionally, “mental representations and images” of the repetitive thoughts. These
symptoms engendered fears and anxieties and led to the establishment of rituals.
In the second the condition was characterized by unexpected revelations made to
relatives or friends of the presence of symptoms often kept secret for years.
Depression, anxiety, agitation, and suicidal ideas might also appear together with
suicidal brooding, but rarely led to self-harm. Patients could also develop animal
phobias, somatic (e.g., vasomotor) symptoms, rituals, fear of touching objects,
abnormal cleanliness, hand washing, and eccentric behaviour. Insight was not lost
and doubt became less bothersome. Symptoms followed a fluctuating pattern with a
course punctuated by attenuations and remissions.
The third stage included major compromise of psychosocial competence, rituals,
and obsessional paralysis. On follow-up, (often longer than 20 years), some patients
had become house-bound and maintained only a semblance of insight; they showed
a typical “double book-keeping” type of behavior and examination revealed a
darker, almost psychotic side. There was no evolution towards dementia.
Although his work transits the old and new concepts of insanity, some confusion
may be caused by Legrand du Saulle’s quaint usage of the terms neuroses (in its
pre-Morel meaning), and dtlire, (one of whose renditions is delusion), to refer to
obsessions.42 Legrand du Saulle wrote this book 9 years after Morel’s paper,25 and
he accepted the latter’s view that OCD was primarily a problem of emotions. But,
his great clinical acumen, applied to the analysis of 27 cases (the largest series
published up to that period), led him to identify forms of behavior that went beyond
what was considered acceptable for the neuroses of his time. So, although paying lip
OBSESSIONS IN THE 19TH CENTURY 287

service to the neurosis theory, the book suggests something that has since become an
important issue, i.e., the presence of psychotic symptoms in OCD.
There is yet another point that may confuse the reader; it relates to his inclusion
of animal phobias, agoraphobia, vasomotor phenomena and other somatic symp-
toms, panic disorder, and probably some cases of partial epilepsy with complex
seizures. With regard to this, remember that Legrand du Saulle was writing in
1875, that these clinical states had not yet been separated from the nosological
viewpoint, and that during this period somatic symptoms were freely included as
part of the definition of mental disease.
This attitude vis-a-vis somatic symptoms changed when Freud’s theories became
available. Psychiatrists then felt unable to include somatic symptoms among the
primary symptoms of psychosis (e.g., the vasomotor changes of catatonia), and
either ignored them or regarded them as secondary and accidental. Those who have
studied Janet’s work44 have realized that he maintained the boundaries for OCD
exactly where Legrand du Saulle had drawn them 30 years earlier, i.e., including
phobias and epileptic states in OCD.

Ball (1834-I 893)

Ba115s suggested eight operational criteria for OCD: insight; sudden onset
(patients may remember the very day the disease started); paroxysmal nature
(severity increases in certain periods, and winter is a period of calm); fluctuating
course (there are long periods of remission); no cognitive impairment; release of
tension after the compulsion has been carried out; high frequency of somatic and
anxiety symptoms; and family history, although acquired obsessions are common.
Ball classified OCD according to the following states: minor (obsession only),
moderate (additional presence of anxiety and major hesitations), and major
(compulsions also). As precipitants he listed tiredness and fatigue, major life events,
puberty, sexual problems, pregnancy, puerperium, and menopause. Ball’s view was
that OCD resulted from impaired brain circulation, but strongly advised against the
use of morphine. Ball’s criteria became popular.

Magnan (1835-I 916)

Magnanz7 classified mental disorders into organic, psychosis proper, and states of
mental retardation. The second group he subdivided into mania, melancholia,
chronic delusional state, intermittent psychosis, and psychosis of degeneration
(&lie des d6g&ztr&s). OCD was included in the latter category together with
phobias, agoraphobia, sexual perversions, and hypochondriacal states. OCD and its
variants, onomatomanie (repeating obsession)59 and erythromanie Cfacilit6 ex-
treme ii rougir, i.e., blushing),@ together with the other disorders, were assumed to
result from cerebrospinal pathology. They were also assumed to “develop only in
subjects affected by degeneration . . . and merit to be considered as the psychologi-
cal stigmata of degeneration psychosis. . . .” Following the same model, Ameline61
suggested cerebral entropy as an explanation for the disorder.
Ladame13 summarized Magnan’s contribution well:

“The majority of authors, following Morel, have considered heredity as an important factor in
obsessions. None of them had, however, considered the symptoms themselves as a direct sign of
pathological heredity. This is what, with great success, has been done by Magnan. The various
288 G.E. BERRIOS

clinical presentations of obsessions and impulsions are for this distinguished alienist episodic
syndromes of the psychosis of degeneration. They are true psychological stigmata. . .”

ETIOLOGICAL DISPUTES
As mentioned previously, there were three psychological hypotheses that ac-
counted for OCD. The emotive and volitional views were more popular in France
while the intellectual view predominated in Germany,62 where Westpha163 sug-
gested that Zwangworstelfungen (obsessional presentations) resulted from a pri-
mary dysfunction of intellect.* However, his operational definition of obsessions
differed from that of the French; he refused to give up the lack-of-insight criterion
for delusions (Wahn).8 Instead, he asserted that obsessions were an ego-dystonic
variant of fixed ideas. Westphal’s intellectual view received varying degrees of
support from Tuke, Magnan, Cramer, Wernicke, Ziehen, and Darnbluth.
The emotive view remained popular among the French, and toward the end of the
century began to spread. (It was supported by Aschaffenburg, Kraepelin, Freud,
Hartenberg, Bleuler, and Stocker.)
The volitional theory, started by Esquirol and Billod, decreased in popularity
during the third quarter of the century, only to undergo limited revival in the work of
Ribot, Arnaud, and Legrain. Thus, Arnaud64 suggested that aboulia, a severe
volitional deficit, was the primary impairment in OCD:

“Amongstbbsessives, whatever their severity, aboulia is always present and always precedes the
disease; its permanence explains the obsessional state. . . emotional accompaniments, and ideas play
an important role but are secondary in the pathogenesis of obsessions. . .”

He stated that the error of the intellectual view resulted from the belief that ideas
were primary ingredients in any form of behavior.29 Legrain, a follower of the
physiological views of LuYs,~~,~~.~’also proposed a version of the volitional
hypothesis.
On the other hand, Haskovec, 68 better known for his description of pre-
neuroleptic akatisia, considered the emotional aspects of OCD to be secondary and
argued in favor of a version of the intellectual view. He believed that the emotive
view resulted from the analysis of samples that had been contaminated by phobic
and anxious patients. He proved his point by analyzing a sample of OCD patients
(n = 100) that contained such confusing symptoms,6’ concluding that
“sometimes the visual image of the phobic object triggers the obsessional idea, and this, in turn,
heightens the emotion; the patient may, for example, see an axe, and this will trigger the obsession of
killing a loved one.“68

Among psychiatrists writing in French, Haskovec was the exception. By the turn
of the century, when Janet was collecting both cases and hypotheses to write his
book L’Obsession et la Psychasthenie,43 practically everyone supported the emotive
hypothesis.

CONSOLIDATION OF THE EMOTIVE VIEW

The emotive view proved popular not only in relation to OCD, but also to clinical
states such as abulia69 which, during the first half of the century, had been
considered as a form of volitional disorder. Anxiety-based explanations became
acceptable not only because great men were espousing them, but because the second
OBSESSIONS IN THE t 9TH CENTURY 289

half of the century was a period of revival for all the aspects of affectivity and
emotion, and their relationship to the autonomic nervous system.2g*70
This shift was encouraged not only by the internal logic of research in psychology
and psychiatry, but also by the fact that the non-emotive explanations were found
lacking. In addition, there was the Zeitgeist factor: in France this was a period of
heightened social anxiety. Zeldin71 suggested that anxiety increased
‘1 . in the sense that traditional supports of behaviour were weakened, that people were left
facing a larger world and a vastly greater range of problems, with far less certainty as to how they
should treat them, and often with sharper sensibilities.”

In turn, this seems to have put a great deal of clinical pressure on physicians, as the
type of complaints brought to them fell well outside the range of traditional insanity
concepts. Related explanatory concepts such as neurasthenia, psychasthenia,
surmenage, and phosphate deficiency thus became very popular.
Therefore, research by psychologists (who were often philosophers, also) took
place against a background of emotivitk and was encouraged by changing
philosophical winds blowing in favor of the emotive view.72 Conditions in which
affective symptoms featured prominently were a natural target for this change.
From the methodological viewpoint, the following belief started during this period:
The best way to learn about normal function was to study it during disease.
Towering among researchers during this period were Luys, Ribot, F&t. and the
other members of the School of Paris (Paulhan, Janet, and Binet).73
There soon developed a philosophical reaction against the materialism and
intellectualism propounded by psychiatrists such as Baillarger and Morel. This
reaction, in a country that, despite Pasteur and Bernard, never ceased to worry
about its spiritual needs, was strong, and the emotive hypothesis rode high on this
yearning. The reaction was led by Lemoine and Janet (1823-1899) in particular. It
began in 1867 with the publication of the latter’s Le Cerveau et la Pens.5e.72 Janet,
who greatly influenced the work of his nephew, Pierre,74 was the standard-bearer of
the emotive tradition in French philosophical psychology, started by Maine de
Biran,73 and kept alive by illustrious philosophers such as Royer-Collard (whose
brother was a psychiatrist), Cousin, Jouffroy, and Ravaisson.74 In his popular Paris
lectures,75 Janet insisted that feelings and emotions were at the center of psycholog-
ical organization.

ISSUES OF CLASSIFICATION
The clinical phenomena covered by the French categories d6fire emotif and folie
avec conscience were the same as those presently covered by the sections “Anxiety
Disorders” (or “Anxiety and Phobic Neuroses”) and “Impulse Control Disorders
Not Otherwise Specified” in DSM-III-R,4g except that they also included vasomo-
tor phenomena (e.g., Reynaud’s disease). After the 186Os, these two categories
absorbed most of the clinical states included under folie raisonnante, which was
consequently narrowed down until it reached its final definition in the work of
Serieux and Capgras.76*77
After 1900, the gradual teasing out of folie avec conscience into OCD, panic
disorder, anxiety disorder, phobic anxiety, and vasomotor phenomena, took place in
France under the influence of historical factors such as the narrowing and
psychologization of the neuroses (a la Freud),48V78and relentless clinical research.
290 G.E. BERRIOS

The analysis of the process of disintegration of folie avec conscience is beyond the
scope of this review, but can be followed in the work of Brissaud, Souques, Devaux,
Logree, Guede, Claude, and Levy-Valensi.79-84

PSYCHOLOGICAL BACKGROUND

Ribot (1839-l 916). Fkrt. and Paulhan

Of the French psychologists of the second half of the 19th century, Thiodule
Ribot is probably the best known and certainly the most influential.85386With regard
to OCD he wrote:
“The mental state called ‘insanity of doubt’ or ruminative mania is to the irresolute character,
what abulia is to the apathetic character. It consists in hesitation over futile issues, and incapacity to
make decisions. The hesitation affects the intellectual sphere and the patient faces endless
self-questioning . . If ‘psychological rumination’ (as Legrand du Saulle states) was all that there is,
we should have nothing else to say; but the perturbation of intellect translates itself into acts. The
patient dares not do anything without taking endless precautions. If he writes a letter, he reads it
many times, egged on by the fear of having forgotten or misspelt a word . . . This is a disease of the
will resulting from weakness of character and accompanied by pathology of the intellect. In a way, it
is to be expected that obsessional ideas will become translated into empty acts, not adapted to
reality; in this process, however, individual factors play a role; and we have found a decrease in
vitality (‘abaissement du ton vital’). Evidence for this factor is to be found in the nature of the
diseases which may cause it (hereditary neuropathies, debilitating illnesses), and in the fainting that
may follow efforts to overcome the problem etc. . . ‘.“35

In his La Pathologie des Emotions,*’ written under the influence of Ribot,

Charles F&t (1852-1907) undertook the description of all clinical phenomena
related to morbid affectivity, including OCD. His list was large, as he believed that
“there existed no mental activity unaccompanied by sentiment of some kind.”
However, he used the term “emotion” in a general sense to name all affective
states.** His central claim was that, generally, intellectual and volitional symptoma-
tology were secondary to primary morbid affect.
He offered a fourfold classification of clinical phenomena falling within the
category of morbid emotivity, according to whether or not arousal and emotivity
were diffuse or systematic (focused on a particular trigger or area), and whether or
not the functions were increased or decreased.*’ In the first group (diffuse and
increased), he included all general or free-floating anxiety states; in the second
(diffuse and decreased), the stupors; in the third (systematic and increased), specific
phobias and OCD; and in the fourth (systematic and decreased), sexual deficits. He
reported a number of cases that demonstrated frequent overlapping of symptomatol-
ogy. He parried the obvious criticism that his systematic and increased group was
resurrecting the affective monomanias by claiming that patients in this category
always present intellectual pathology, i.e., abnormal mental contents acting as
triggers for the emotional response. This was not the case for the monomanias.
Frederic Paulhan’s main work includes an analysis of the concept of character”
(on which Ribot based the chapter on the same topic in his book on emotions), and of
the emotions.” On the latter, like Ribot, he espoused an epiphenomenic view and
conceived of the emotions as psychophysiological phenomena subject to the laws of
evolution. ” As Hoffding 91showed, Paulhan’s” hyp othesis that elementary feelings
can be combined into composite ones, could also be used to account for the
phenomenon of doubt. For example, when hope and fear are present in equal
OBSESSIONS IN THE 19TH CENTURY 291

strength, he believed that “doubt results, whose central feature is anxious

restlessness that may lead to rash decisions to stop the anxiety caused by the
hestiation. . . .”
FCrC and Paulhan, with their enthusiastic support for the psychological and
physiological analysis of the emotions, spoke a language that psychiatrists could
understand. They made sure that the emotive view of OCD reigned supreme.

Pitres (I 848-l 928) and Rkgis (1855-l 918)

Pitres and RBgisp2defined obsessions as

“a morbid syndrome characterised by the anxious experiencing of parasitical thoughts and

feelings which force themselves upon the self and lead to a form of psychical dissociation whose final
stage is a splitting of the conscious personality . . . we do not hesitate to consider emotions as the
primitive and fundamental element of the obsession.”

They defended the emotive view at the Twelfth International Congress of Medicine
in Moscow in 1897, but rejected the Freudian sexual hypothesis.
In their book, which deals with obsessions, impulsions, phobias, and panic
disorder, Pitres and Regis rejected the view that panic disorder (&rose dbngoisse)
was a separate entity; instead, they considered it as a syndrome that could become
grafted upon OCD, anxiety disorder, or depression. They reported 110 cases (the
largest series until then) in which 63% had clear emotional precipitants, and 80%
had relatives suffering from some form of mental disorder. Age of onset was before
30 years, and the disease, more common in women, was divided in ideational and
compulsive varieties.

The Aftermath: Janet (1859-1947)

Janet owes much to the work of his predecessors, including Pitres and RCgis. His
contribution, as his coworker Raymondp3 once said,p4 must be considered to be more
theoretical than clinical. For Janet, OCD resulted from a dislocation of function;
they were an engourdissement of the mind that required no anatomical substratum.p5
Obsessions were but the experiential or subjective concomitant of a feeling of
incompletion that resulted from a defect in the “function of the real.” This amounts
to no more than a metaphorical redescription of how patients often respond in
relation to their inability to bring tasks to completion. Janet carved out psychasthe-
nia from the already inflated category of neurasthenia.p6~p7
Psychasthenia, itself an over-inclusive category, soon became the new giant of
neuropathology. Pa In I’Automatisme Psychologique,” Janet considered obsession
as an id&e _fixe which, together with hallucinations, constituted “simple and
rudimentary forms of mental activity.“43 Psychasthenia was essentially an etiologi-
cal term and hence could not have clear-cut descriptive clinical boundaries.‘00
Rather, it relied on theoretical mechanisms such as a reduction of psychological
tension”’ and incompletion (inachLvement).74*‘02 Schwartzlo was right in referring
to it as “a cluster of symptoms artificially demarcated to which the predominance of
a ‘typical (causal) mechanism’ conferred a particular aspect.”
Indeed, analysis of the 236 cases reported by Janet shows that psychasthenia
included, in addition to OCD, panic, phobic and tic disorders, hypochondriacal and
confusional states, and some forms of epilepsy. Janet’s psychological approach
firmly placed OCD in the territory of the neuroses, which also included at the time
292 G.E. BERRIOS

neurasthenia, hysteria, and psychasthenia. 96-98This was to be reinforced by

Freud.‘04*‘05 (See references 10 and 103 for a history of the psychodynamic
hypothesis with regard to OCD.)

SUMMARY AND CONCLUSIONS

In conclusion, this review has demonstrated the following:
1. Between the 1830s and 1900, OCD was successively classified as insanity
(monomania), neurosis (old definition), psychosis (new definition), and, finally, as a
member of the newly formed class of neuroses.
2. The component symptoms of OCD also went through changes. Obsession had
to be separated from delusion (&5&e), and both of them from their common
ancestor, idiefixe. This process was completed by the 1870s. However, it must be
remembered that the French word dklire means more than the English term
“delusion.” Compulsion, in turn, had to be separated from the term “impulsion,”
i.e., the name for a parent class constituted by all forms of paroxysmal, episodic,
stereotyped, and irresistible behavior. This second process took longer to be
completed.
3. Three theories accounted for the psychogenesis of OCD: volitional, emotive,
and intellectual. The former two were more popular in France, and eventually the
emotive hypothesis predominated. By considering OCD to be a form of pathological
or distorted emotion, it was possible to retain it as a functional disorder, at the same
time maintaining its relationship to the autonomic nervous system. Very impor-
tantly, it was also possible to satisfy the ongoing fashion (which also influenced
Freud) of interpreting most mental disorders as an impairment of emotional
mechanisms.
4. The natural history of OCD, with its episodic course and varied symptomatol-
ogy, was fully worked out before the turn of the century. Janet confirmed rather
than created these findings.
5. The concept of degeneration played an important role in the formation of
OCD. It provided a basis for the claim that a form of pathological personality might
underlie OCD. It also provided a mechanism for the biological transmission of the
disease. In the work of Magnan, OCD even became a psychological stigma of
degeneration.
6. OCD, agoraphobia, panic disorder, and other anxiety disorders were traveling
companions up to the end of the century. Their final teasing out was made more on
theoretical (etiological) than clinical or epidemiological grounds.
7. The historical problem posed by OCD seems to have been that, although
recognized since the 1830s as a sui generis cluster of symptoms, it did not elicit an
imaginative response from psychiatrists; most tried to pigeonhole it into one of the
ongoing clinical categories. This Occamian attitude might have encouraged great
economy of thought, but has probably done little to increase the understanding of
this fascinating and elusive condition.

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