Maudsley Hospital in London
Maudsley Hospital in London |
Aubrey Lewis, clinical director of Maudsley Hospital, was a leading figure in British psychiatry. His 1957 lecture on obsessional illness provides a window into where OCD research stood in the 1950s.
This [obsessional illness] may seem an unprofitable subject to review at the present time. There has been no marked increase in our knowledge of it in recent years, and indeed much of what can be found on the subject in current textbooks had already been fully stated and closely discussed in the first two decades of the century−a period in which Janet's monumental work on Obsessions and Psychasthenia appeared, as well as the detailed studies by Friedmann, Löwenfeld, and Bumke: Freud, Abraham and Jones also put forward at that time their views of the varieties and mechanisms of obsessional neurosis. The clinical phenomena have been well recognized and described for over half a century, and little new information has accumulated in recent years regarding the treatment and course of the illness.
Some aspects of the problem are, however, worth looking at again, in the light of recent evidence....
The essence of an obsession is the fruitless struggle against a disturbance that seems isolated from the rest of mental activity.... The indispensable subjective component of an obsession lies in the consciousness of the patient: to him it is an act of will, which he cannot help making, to try and suppress or destroy the unwelcome intruder upon his mental integrity; but the effort is always in vain. It does not matter whether the intruder is a thought, an idea, or an image, or an impulse, accompanied by appropriate affect....
Obsession can conveniently be divided into primary and secondary. An example would be first the insistent feeling that one is dirty−that is the primary phenomenon: and then there is the impulse to wash−the secondary phenomenon, developed in order to obtain relief from the primary disturbance. The second phenomenon can be regarded as defensive and aimed at preventing or relieving tension....
I shall abstain from considering the present psycho-analytic standpoint on obsessional character, though from reading I take it to be complicated, more so than when Ernest Jones and Abraham wrote their essays on anal-erotic character traits. For rather similar reasons I shall not speak of von Gebsattel's existentialist analysis of the obsessional's world, in which the sufferer is forever in action against his tireless energy, a world in which pseudo-magical forces of unsubstantial ruin and decay seem to threaten him, with no prospect of truce or, for him, of victory....
It is sometimes forgotten that distempers of this nature, so severe as to cause profound psychological upheaval or to affect permanently the course of a man's life, can nevertheless consort with great practical abilities and a faith that moves mountains. The anankast [a little-used term for OCD sufferer] who regards his neurosis as a sufficient reason, or it may be excuse, for leading an empty inept life, punctuated by visits to his psychotherapist, has as a social creature nothing in common with the scrupulous−I suppose we should now say over-scrupulous−man of affairs, or creative worker, who, as the cliché puts it, has learnt to live with his obsessional symptoms. We know little about those who struggle without our help and make much of their lives; there are some famous men, however, who point the moral in giant letters. I would mention two of these [goes on to discuss John Bunyan and Martin Luther].
The obsessional patient is often pitiably unhappy: he needs whatever help we can give him. But in seeking to give that help we have to recognize the uncertainties that attend our treatment of the condition, making all the stronger our obligation not to do harm in one great department of the patient's life while we are helping, or hoping to help, him in another. Whether treatment is psychological or surgical, by drugs or by regime, bold or prolonged, there are dangers, not always faced and avoided, which are as serious as those ensuing upon medical neglect and apathy towards the disorder. In no condition is it more essential than in this to study the patient closely, to diagnose his illness with caution, to understand his values and possibilities, and to define limited objectives before embarking upon treatment.