OCD: History and Discovery

The experiences we now call obsessive-compulsive disorder are very old, but the idea of OCD is surprisingly young. For centuries, unwanted, repugnant, intrusive thoughts and the rituals people performed to quiet them were understood through the language of religion — as scrupulosity, a tormenting doubt about sin and salvation. Only in the nineteenth century did French and German physicians begin to describe these same phenomena as a medical condition, coining the terms monomania, folie du doute (“the doubting madness”), obsession, and compulsion. The twentieth century brought competing explanations — psychoanalytic, then behavioral and biological — and, with them, the first treatments that genuinely worked: Exposure and Response Prevention (Victor Meyer, 1966) and the serotonergic medications clomipramine and the SSRIs. This page traces that journey from the confessional to the clinic, taking care to mark where the history is well documented and where it rests on interpretation.

Table of Contents

  1. Scrupulosity: The Religious Era of the Doubting Disease
  2. Esquirol, Monomania, and the First Medical Descriptions (1838)
  3. Folie du Doute: The French Alienists
  4. Westphal 1877 and the Birth of “Obsession” and “Compulsion”
  5. Janet’s Psychasthenia and Freud’s Obsessional Neurosis
  6. Victor Meyer and the Behavioral Revolution (1966)
  7. Clomipramine, Serotonin, and the SSRIs
  8. From Anxiety Disorder to Its Own DSM-5 Chapter (2013)
  9. What the History Means Today
  10. Research Papers and References
  11. Connections

Scrupulosity: The Religious Era of the Doubting Disease

For most of recorded Western history, the symptoms we now call OCD had no medical name. People tormented by blasphemous, violent, or sexually repugnant thoughts they did not want — and driven to repeat prayers, confessions, or washings to undo them — were understood through religion, not medicine. The relevant term was scrupulosity (from the Latin scrupulus, a small sharp stone in the shoe): a pathological, paralyzing doubt about whether one had sinned, confessed adequately, or remained worthy of salvation. This is widely regarded as the earliest documented framing of obsessive-compulsive phenomena, and the parallels to modern intrusive thoughts and compulsive checking are striking.

Several historical figures left first-person accounts that later writers have read as scrupulosity, including the Reformation theologian Martin Luther, the founder of the Jesuits Ignatius of Loyola, the English preacher and author John Bunyan, and the scholar Robert Burton (author of The Anatomy of Melancholy, 1621). One of the clearest medical-adjacent descriptions came in a 1691 sermon by Bishop John Moore of Norwich, who described otherwise devout men and women plagued during worship by “naughty, and sometimes Blasphemous Thoughts” that “start in their Minds” against their will — thoughts the sufferers found horrifying precisely because they were so contrary to their values. Moore called this affliction “religious melancholy.” Clergy of the era also noted parishioners returning to confession many times a day to repeat the same sins.

It is important to be precise about what this evidence does and does not show. These are retrospective interpretations: we cannot diagnose long-dead people, and the religious framework genuinely shaped how sufferers experienced and reported their distress. What the historical record establishes is not that “OCD existed in 1500” as a recognized illness, but that the phenomenology — ego-dystonic intrusive thoughts paired with anxiety-driven, repetitive neutralizing rituals — is recognizable across centuries, long before any medical theory existed to explain it. The scrupulosity literature is the prehistory of OCD, not its diagnosis.

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Esquirol, Monomania, and the First Medical Descriptions (1838)

The shift from a religious to a medical understanding began in earnest in nineteenth-century France. The French alienist Jean-Étienne Dominique Esquirol (1772–1840), a pupil of Philippe Pinel and one of the founders of modern psychiatry, is usually credited with one of the first detailed clinical descriptions of obsessive-compulsive symptoms. In his influential 1838 treatise Des maladies mentales, Esquirol described a patient — a young woman tormented by an irresistible fear that she might have taken or stolen something, who checked her hands and clothing compulsively — and classified her condition as a form of monomania, his term for a “partial insanity” in which one circumscribed area of thought is disordered while the rest of the mind functions normally.

Esquirol specifically used the phrase monomanie raisonnante (“reasoning monomania”) for cases like this, and he wrestled with a question that still defines OCD today: was this a disease of the intellect (a false belief) or of the will (an inability to resist an act one knows to be senseless)? He noticed that these patients retained insight — they recognized their fears as excessive or absurd — which set them apart from patients with delusions. That observation, that the obsession is experienced as alien and unwanted (what modern clinicians call ego-dystonic), is one of the most durable contributions of this early work, and it remains a defining feature of OCD.

A note on attribution is warranted, because secondary sources sometimes blur the timeline. Esquirol’s 1838 contribution was the careful clinical description and its placement under monomania; the famous phrase folie du doute belongs to the generation of French physicians who came after him, discussed in the next section. Esquirol’s original works are named here as historical primary texts rather than as modern citations.

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Folie du Doute: The French Alienists

Over the middle and later nineteenth century, French alienists refined Esquirol’s observations into a distinct clinical picture they named folie du doute — literally “the madness (or insanity) of doubt,” often rendered in English as “the doubting disease.” The phrase captures the core experience of many people with OCD: not a fixed false belief, but an endless, corrosive uncertainty — Did I lock the door? Did I cause harm? Am I contaminated? Did I really mean that thought? — that no amount of checking or reassurance can permanently resolve.

The term is generally associated with Jean-Pierre Falret (1794–1870), who is credited with using “folie du doute” around mid-century, and most famously with Henri Legrand du Saulle (1830–1886), whose 1875 monograph La folie du doute (avec délire du toucher) — “the madness of doubt, with delusion (or delirium) of touch” — gave the syndrome its most enduring nineteenth-century description and tied the pathological doubting to the compulsive touching, checking, and avoidance behaviors it provoked. Bénédict Augustin Morel, another French clinician of the period, grouped such cases under délire émotif (“emotional delusion”), proposing that they sprang from a disorder of the emotions rooted in the nervous system rather than from faulty reasoning.

This French tradition matters because it reframed the problem decisively. By naming the disorder for doubt rather than for sin or for false belief, the alienists located the pathology in the patient’s relationship to uncertainty itself — an insight that anticipates the modern cognitive understanding of OCD as a disorder of inflated responsibility, intolerance of uncertainty, and the futile pursuit of absolute certainty. The religious patient had asked “Am I damned?”; the nineteenth-century patient asked “Can I ever be sure?” The question had moved from the soul to the mind.

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Westphal 1877 and the Birth of “Obsession” and “Compulsion”

While French physicians were mapping the doubting disease, German psychiatry supplied the vocabulary we still use. In 1877, the Berlin neuropsychiatrist Carl (Karl) Friedrich Otto Westphal (1833–1890) published an influential paper offering one of the first precise definitions of obsessive ideas and arguing that they constituted a disorder in their own right. His key term was Zwangsvorstellung — a compound usually translated as “compelled (or forced) presentation/idea.” Westphal emphasized that these intrusive ideas arose against the patient’s will, could not be banished by reasoning, and — crucially — occurred in an otherwise intact intellect, free of the broader disorganization seen in psychosis.

A revealing accident of translation followed. The German Zwang (compulsion, coercion, force) and Vorstellung (idea, presentation) did not map neatly onto any single English or French word, and the concept embraced both the intrusive mental event and the compelled action. As Westphal’s work spread, British physicians rendered Zwang as “obsession,” emphasizing the unwanted thought, while American usage leaned toward “compulsion,” emphasizing the driven act. Rather than choose between them, the field eventually fused the two into the compromise label we still use: obsessive-compulsive. Our modern diagnostic name is, in a real sense, a translation settlement.

Westphal’s framing was foundational. By insisting that obsessions occur in a clear, reasoning mind and reflect a specific disturbance — not a moral failing, not a delusion, and not general insanity — he laid much of the groundwork for the phenomenology, definition, and classification of OCD that would eventually be codified in the twentieth-century diagnostic manuals. Together with Daniel Hack Tuke in Britain and others across Europe, the late-nineteenth-century clinicians established obsessions and compulsions as a legitimate, bounded object of medical study.

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Janet’s Psychasthenia and Freud’s Obsessional Neurosis

As the twentieth century opened, two towering figures pulled obsessive-compulsive phenomena out of older catch-all categories such as “neurasthenia” and gave them rival theoretical homes. The French psychologist Pierre Janet (1859–1947) published his vast two-volume work Les Obsessions et la Psychasthénie in 1903, coining psychasthenia to describe a condition marked by obsessions, compulsions, doubts, phobias, indecision, and a pervasive sense of incompleteness and “mental weakness.” Janet proposed that obsessions arose from a lowering of “psychological tension” that impaired a person’s grip on present reality. Remarkably, his clinical recommendations — graded encouragement to confront feared situations and to resist the rituals — foreshadow modern behavioral treatment by more than sixty years.

The other great theory came from Sigmund Freud (1856–1939), whose 1909 case study Notes upon a Case of Obsessional Neurosis — the famous “Rat Man” case, concerning a patient later identified as Ernst Lanzer — became the defining psychoanalytic account of OCD. Freud framed obsessional neurosis as the product of unconscious conflict, typically between forbidden aggressive or sexual impulses and the defenses erected against them. He described mechanisms such as isolation (separating a thought from its feeling), undoing (a ritual that magically cancels a forbidden wish), and reaction formation that remain part of the descriptive vocabulary of OCD even among clinicians who reject the underlying theory.

For roughly the first half of the twentieth century, Freud’s model dominated, and OCD was understood and treated as obsessional neurosis. This is a crucial caveat for the history: the psychoanalytic era produced rich description but, by later evidence-based standards, no reliably effective treatment. Long-term analysis aimed at uncovering unconscious conflict rarely relieved the rituals, and OCD acquired a grim reputation as a chronic, treatment-resistant condition. That pessimism is exactly what the behavioral and pharmacological breakthroughs of the 1960s onward would overturn.

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Victor Meyer and the Behavioral Revolution (1966)

The single most important turning point in the treatment of OCD came in 1966, when the British psychologist Victor Meyer, working at the Middlesex Hospital in London, reported the outcomes of two patients with severe washing and checking rituals whom he treated with a then-novel and deliberately demanding method. He exposed the patients to the very situations that triggered their obsessive fears (touching “contaminated” objects) and then prevented the compulsive response — the washing — for prolonged periods, with continuous staff supervision. The approach became known as Exposure and Response Prevention (ERP).

Meyer’s reasoning drew on experimental psychology, particularly O. H. Mowrer’s two-factor theory of how fear is learned and maintained, and on the observation that frightened animals stop being frightened if they are kept in the feared situation long enough without escape. He grasped two things that proved decisive: first, that refraining from a compulsion does not produce the unbearable, never-ending anxiety patients expect — the anxiety rises and then falls on its own (habituation); and second, that the feared “disastrous consequences” (illness, catastrophe, divine punishment) simply do not occur. The ritual, in other words, was not protecting the patient from anything; it was feeding the fear.

The results were dramatic compared with anything that had come before, and over the following two decades ERP was systematized and tested — most influentially by Stanley Rachman, Isaac Marks, and colleagues in the United Kingdom — into the evidence-based, first-line psychological treatment for OCD that it remains today, now usually delivered within a broader cognitive-behavioral therapy (CBT) framework. Meyer’s 1966 paper is rightly regarded as the origin of effective psychological treatment for OCD: it converted a disorder long thought intractable into one that responds, often substantially, to a specific and learnable procedure.

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Clomipramine, Serotonin, and the SSRIs

The second great treatment breakthrough was pharmacological, and it arrived along a winding path. Clomipramine (Anafranil), a tricyclic compound, was developed by the Swiss firm Ciba-Geigy and first synthesized in the early 1960s. Beginning in 1967, the Spanish psychiatrist Juan José López-Ibor and others reported that clomipramine produced striking improvement in obsessive-compulsive symptoms — not merely in mood — a finding confirmed over the 1970s and 1980s in increasingly rigorous trials. After controlled studies established its efficacy, clomipramine became the first medication approved by the U.S. FDA specifically for OCD, in 1989.

Clomipramine’s success carried a major scientific clue. Among the tricyclics, clomipramine is a particularly potent inhibitor of the reuptake of serotonin, and its effectiveness in OCD — where other, equally good antidepressants that lacked strong serotonergic action did not help — gave rise to the serotonin hypothesis of OCD: the idea that the disorder involves dysregulation of serotonergic neurotransmission. This is best described as a well-supported but still-incomplete hypothesis, not a settled mechanism: serotonin clearly matters to treatment response, but it does not fully explain the disorder, and modern accounts also implicate cortico-striato-thalamo-cortical brain circuits, glutamate signaling, and genetic factors.

The serotonin clue was quickly exploited. Through the late 1980s and 1990s, the selective serotonin reuptake inhibitors (SSRIs) were tested and approved for OCD — fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox, the first SSRI marketed specifically for OCD), and paroxetine (Paxil) — offering efficacy comparable to clomipramine with far fewer side effects. Two practical lessons emerged that still guide care: OCD typically requires higher doses and a longer trial (often 8–12 weeks) than depression to respond. The arrival of ERP and the serotonergic medications together shifted OCD’s center of gravity away from the psychoanalytic couch and toward a behavioral and biological understanding — and, for the first time in its long history, gave most patients a realistic expectation of meaningful relief.

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From Anxiety Disorder to Its Own DSM-5 Chapter (2013)

As OCD entered the American diagnostic manuals, it was filed among the anxiety disorders. OCD first appeared as a named entity in the DSM (the second edition, DSM-II, 1968, still used the older “obsessive compulsive neurosis”), and from DSM-III (1980) onward it was classified as an anxiety disorder — a reasonable placement given how central fear and anxiety are to the obsessional experience. For decades, that is where clinicians, researchers, and insurers found it.

That changed with the fifth edition. When the American Psychiatric Association published DSM-5 in 2013, it removed OCD from the anxiety disorders and created a new, dedicated chapter: “Obsessive-Compulsive and Related Disorders.” This grouped OCD with conditions that share its repetitive, compulsive structure — body dysmorphic disorder, hoarding disorder (newly recognized), trichotillomania (hair-pulling), and excoriation (skin-picking) disorder — several of which had previously been scattered across other parts of the manual. The World Health Organization’s ICD-11 later adopted a similar grouping.

The reclassification was not a mere bureaucratic rearrangement; it reflected accumulated evidence from genetics, neuroimaging, and treatment response suggesting that OCD has more in common with this family of compulsive disorders than with phobias and panic. In a sense, the 2013 decision completed a long arc that began with Esquirol and Westphal: the recognition that obsessive-compulsive phenomena form a distinct category with their own boundaries — not a variety of melancholy, not a neurosis, and not simply a kind of anxiety, but a disorder, and a family of disorders, in its own right.

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What the History Means Today

Read as a whole, the history of OCD is a story of reframing — of the same human suffering being seen, in turn, as a spiritual crisis, a partial insanity, a doubting disease, a neurosis, and finally a treatable brain-and-behavior condition. Each era kept something true. The religious writers correctly saw that the thoughts were unwanted and abhorrent to the sufferer. The French alienists correctly identified doubt and the craving for certainty at the disorder’s core. Westphal correctly insisted the mind was otherwise intact. Janet and the behaviorists correctly intuited that confronting the fear and dropping the ritual is the way out. And the pharmacologists correctly read serotonin as a clue, even if not the whole answer.

This history also carries an explicitly non-stigmatizing lesson, which matters because real people with OCD read pages like this one. OCD is not a character flaw, a lack of willpower, or evidence of a person’s hidden wishes; the entire historical record — from Bishop Moore’s devout parishioners to Esquirol’s insightful patients — testifies that obsessions are ego-dystonic, experienced as intrusive and contrary to the sufferer’s true values. People with violent or blasphemous intrusive thoughts are not dangerous or sinful; they are, almost by definition, people horrified by such thoughts. Naming the disorder accurately, and separating the medical condition from the centuries of moral and religious judgment heaped upon it, is itself part of the treatment.

Most importantly, the modern chapter of this history is genuinely hopeful. A condition that the psychoanalytic era considered nearly intractable is now, for the majority of patients, substantially treatable with Exposure and Response Prevention, with serotonergic medication, or with both together. The arc from the 1691 confessional to the 2013 diagnostic manual is, at bottom, the arc from helpless suffering to effective help — which is the best reason to understand where the idea of OCD came from. For the clinical picture, diagnosis, and current treatment in depth, see the main Obsessive-Compulsive Disorder page.

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Research Papers and References

The references below combine peer-reviewed historical scholarship on OCD with curated PubMed topic-search links into the relevant literature. Historical primary texts — Esquirol’s Des maladies mentales (1838), Legrand du Saulle’s La folie du doute (1875), Westphal’s 1877 paper, Janet’s Les Obsessions et la Psychasthénie (1903), Freud’s “Rat Man” case (1909), and Bishop John Moore’s 1691 sermon — are named in the article as historical sources rather than as modern citations. Each link opens at PubMed (U.S. National Library of Medicine) or the cited journal in a new tab.

  1. Berrios GE. Obsessive-compulsive disorder: its conceptual history in France during the 19th century. Comprehensive Psychiatry. 1989;30(4):283-295. — doi:10.1016/0010-440X(89)90052-7
  2. Pitman RK. Pierre Janet on obsessive-compulsive disorder (1903): review and commentary. Archives of General Psychiatry. 1987;44(3):226-232. — doi:10.1001/archpsyc.1987.01800150038005
  3. Krochmalik A, Menzies RG. The classification and diagnosis of obsessive-compulsive disorder — historical overview. (Topic search) — PubMed: OCD history and nosology (Westphal, Janet)
  4. Fornaro M, Gabrielli F, Albano C, et al. Obsessive-compulsive disorder and related disorders: a comprehensive survey. Annals of General Psychiatry. 2009;8:13. — doi:10.1186/1744-859X-8-13
  5. Meyer V. Modification of expectations in cases with obsessional rituals. Behaviour Research and Therapy. 1966;4(4):273-280. — doi:10.1016/0005-7967(66)90083-0
  6. Abramowitz JS, Taylor S, McKay D. Obsessive-compulsive disorder. The Lancet. 2009;374(9688):491-499. — doi:10.1016/S0140-6736(09)60240-3
  7. Stein DJ, Costa DLC, Lochner C, et al. Obsessive-compulsive disorder. Nature Reviews Disease Primers. 2019;5(1):52. — doi:10.1038/s41572-019-0102-3
  8. López-Ibor JJ and the early clomipramine reports in OCD (topic search) — PubMed: clomipramine, OCD, and the serotonin hypothesis
  9. Fineberg NA, Brown A, Reghunandanan S, Pampaloni I. Evidence-based pharmacotherapy of obsessive-compulsive disorder. International Journal of Neuropsychopharmacology. 2012;15(8):1173-1191. — doi:10.1017/S1461145711001829
  10. Religious scrupulosity, “the doubting disease,” and OCD in historical context (topic search) — PubMed: scrupulosity and OCD in historical context
  11. DSM-5 obsessive-compulsive and related disorders — reclassification and rationale (topic search) — PubMed: DSM-5 obsessive-compulsive and related disorders
  12. Exposure and response prevention for OCD — development and efficacy (topic search) — PubMed: exposure and response prevention for OCD
  13. Freud’s “Rat Man” and the psychoanalytic concept of obsessional neurosis (topic search) — PubMed: Freud, Rat Man, and obsessional neurosis

External Authoritative Resources

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Connections

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