When one Hannah Allen, an Englishwoman known for her 1683 autobiography, described people beset by melancholy as “exceedingly fearful . . . beyond what there is cause for,” she noted, “Every thing which they hear or see, is ready to increase their fears. . . . Their thoughts are most upon themselves, like the millstones that grind on themselves when they have no grist; so one thought begets another. Their thoughts are taken up about their thoughts”—the very definition of the anxiety that underlies, and can only be vanquished by, compulsive behavior. Hannah herself was treated for her insistently anxious thoughts with phlebotomy, another indication that the malady was considered physical and not supernatural. She later sought help from Richard Baxter (1615–1691), a leader of the English Puritan church, who became known far and wide for his healing ability.
Sickness, Not Satan
What makes Baxter notable in the history of compulsions is that he firmly rejected the demonic possession explanation for compulsive behaviors, ascribing them instead to “the involuntary effects of sickness.” Someone beset by “doubts and fears and depraving thoughts, and blasphemous temptations” was like one “in a fever,” suffering “unavoidable infirmities.” Friends and family of someone so suffering, Baxter advised, should “divert them from the thoughts which are their trouble; keep them on some other talk or business; break in upon them, and interrupt their musings. . . . If other means will not do, neglect not physick [medicine] . . . tho’ they will be averse to it, as believing that the disease is only in the mind.”
Anglican bishop John Moore (1646–1714) preached about the “disorder of mind” that brings unwanted “naughty, and sometimes blasphemous thoughts,” especially during worship services. Although such sufferers may “charge themselves with the sin against the Holy Ghost,” he said, in fact the compulsion arises from a “disorder and indisposition of the body,” a mark of the growing recognition that such travails reflected something physical, not supernatural. The solution? “Neither violently struggle with [the compulsions],” Moore advised, “since experience doth teach that they increase and swell by vehement opposition; but dissipate and waste away, & come to nothing when they are neglected”—to which one might respond, easier said than done.
By the eighteenth century more physicians were taking note of patients besieged by mental compulsions that did not necessarily have a religious component. Dr. John Woodward (1665–1728) described one Mrs. Holmes, who in 1716, at the age of twenty-six and pregnant, chanced to look out a window and catch sight of a large porpoise in the river Thames “and was much delighted with the viewing of it.” Two weeks later, she was suddenly “invaded” by a “strong perplexing thought of the porpoise; and a fright, lest that should mark her child.” Taking to her bed as her child’s birth grew near, Mrs. Holmes “had thoughts of the devil, as tempting and vehemently urging of her to ill; particularly to fling her child into the fire, beat its brains out, and the like.” Woodward prescribed “an oily draught; and . . . purge . . . to be taken next morning.” He reported that its laxative effects were quite apparent—it produced “at least a dozen stools”—and by the next day her thoughts became less “unruly.”
In the Directorium Asceticum, or Guide to the Spiritual Life, published in 1754, Jesuit theologian Giovanni Battista Scaramelli (1687–1752) offers one of the earliest accounts of behavioral compulsions, “exterior acts,” including people shaking their heads, pressing their hands to their chests, rolling their eyes, praying, and repeatedly confessing. Foreshadowing twentieth-century research, Scaramelli concluded that the cause of compulsions was an “anxious character” and observed that giving in to compulsions reinforced rather than vanquished the anxiety propelling them: “The more the thoughts are driven away the more they return to the mind,” he warned. Compulsive prayer, in particular, is particularly self-defeating: “Some persons are greatly distressed in reciting vocal prayers, fancying they have omitted portions, or not pronounced the words plainly, so that they repeat again and again the same words.”
The end of the seventeenth century brought a tectonic change in how scholars viewed madness, grounding mental illnesses in the nervous system. One dramatic case of physicians recognizing that behavior reflected something going on in the nerves and the brain came in 1787, when two dozen girls working in a Lancashire cotton mill were swept up in an episode of mass hysteria. It began when one slipped a mouse down the dress of another, who, terrified, had what observers called “a fit” and shook with violent convulsions for twenty-four hours. The next day, three more girls—though mouseless—came down with convulsions, as did six more the following day, and more throughout the week. Girls living or working miles away from the mill were also seized by the hysteria. They “were infected entirely from report, not having seen the other patients,” as an account from the time put it, reporting with some astonishment that the girls experienced “anxiety, strangulation, and very strong convulsions” so violent as to “require four or five persons to prevent the patients from tearing their hair and dashing their heads against the floor or walls.”
A Dr. St. Clare was summoned from a neighboring town. Rejecting any notions of demonic possession, he had just the thing: a device that generated electric shocks. Cranking it up, he administered this treatment to one girl after another. “The patients were universally relieved without exception,” we are told. “As soon as the patients and country were assured that the complaint was merely nervous, easily cured,” the epidemic vanished. While the episode stands out as an excellent example of the placebo effect, more significant is what it reveals about the paradigm shift in the understanding of mad behavior: the cause lay not in the devil but in “nerves,” and the cure lay in the physical world, not the spiritual.
A second leap forward occurred at about this time. Earlier, the only recognized forms of madness were “lunacy,” in which the sufferer has parted ways with reality and which today is called psychosis; “melancholy” (irrationality, not depression); and “idiocy,” or mental retardation. These conditions were permanent and all-encompassing; anything that did not wholly engulf the mental faculties was not deemed mental illness, so even severe washing or checking compulsions didn’t make the cut. But starting in the eighteenth century, doctors recognized that mental disorders could be partial and temporary, not all-encompassing and permanent—making odd behaviors now fair game for neurologists (who preceded “alienists”—psychiatrists—as the designated experts on all matters of the brain). Previously, having a mild, partial, occasional mental disorder had had almost a cachet, even a certain charm. That comes through in an episode of what, had it occurred in a different social stratum and been more isolated, would surely be diagnosed as a behavioral compulsion: the mania for collecting.
Wunderkammers
For two centuries starting in the 1600s, European royalty, scholars, and apothecaries began to create “cabinets of curiosities,” hodgepodge collections of the exotic, beautiful, or rare, collected from the grounds of one’s estate or from sojourns to the ends of the earth. In 2013 the Grolier Club, a gem of a museum in Manhattan, presented an exhibit of these collections displayed in drawers and on shelves in Wunderkammers, the German term for “rooms of wonder,” or cabinets of curiosities. The drive and tenacity—yes, compulsion—it took to collect and assemble, catalogue and display the Wunderkammers was as obvious as their contents were marvelously bizarre. The cabinets housed dried, exotic plant specimens as well as tiny animal skeletons; shells and pieces of coral; hardened arteries and kidney stones; antique coins and medals; fossils and rocks; scientific instruments and even a stuffed crocodile, and more, all documented in elaborate ledgers.
The mania for cabinets of curiosities waned, as all manias eventually do, with many of the collections seeding some of Europe’s and America’s great museums of natural history (as well as not-so-great freak shows and traveling circuses). But while they lasted Wunderkammers were a socially approved compulsion. The line between disease and cultural activity was already as b
lurry as the writing on those centuries-old ledgers, but wherever it lay the stigma of lunacy was replaced by the notion of madness as the inheritance of the more sensitive, refined, educated classes—something absent in “the poorer and less civilized inhabitants of modern Europe,” as Thomas Arnold wrote in his 1782 Observations on the Nature, Kinds, Causes and Prevention of Insanity, Lunacy or Madness. Madness including compulsive behavior—mild, tempered, well-behaved—was now a marker of civilization, breeding, and intelligence. In the eighteenth century, obsessions and compulsions “move to the fore, to signify a very human essence, and to be a characteristic of genius, good birth, and good character,” Lennard Davis of the University of Illinois wrote in his 2009 book Obsession: A History.
French psychiatrist Jean-Étienne-Dominique Esquirol (1782–1840) introduced the term “monomania” around 1810, meaning mental imbalance caused by a single train of thought or object of attention. Monomaniacs could think, reason, and behave normally in every regard other than the focus of their mania. Hardly had Esquirol invented the term than monomania became one of the most common diagnoses of patients entering France’s asylums. This view found its way not only into how people behaved and regarded others, but also into fiction. In the 1886 novel The Man of Feeling, author Henry Mackenzie had his main character visit Bedlam (Bethlem Royal Hospital), England’s first psychiatric hospital, finding a mathematician who felt compelled to calculate the paths of comets and a famous schoolmaster compelled to determine the precise pronunciation of ancient Greek verbs. An unstoppable compulsion to collect or create, to calculate astronomical trajectories or plumb the mysteries of an extinct tongue, made this mild form of madness—if madness it was—fashionable, a sign of a sharp mind and a tenacious spirit. To be madly compelled was a mark of intellectual accomplishment.
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By the late eighteenth century, case reports of people compelled to think certain thoughts or perform certain actions were more likely to describe nonreligious rather than religious ones. That’s not to say scrupulosity had vanished. But as secular institutions and ways of thinking began to compete with the Church, there were many more ways to be compulsive than to compulsively think blasphemous thoughts or confess one’s sins. In fact, people in secular cultures tend to have fewer religious OCD symptoms than do those in highly religious cultures; it is the rare atheist, after all, who feels heart-pounding anxiety if she does not light Shabbas candles. A 2004 study by researchers at the Federal University of Rio de Janeiro compared adults with OCD at the university clinic in Rio with those in other parts of the world. A predominance of religious obsessions was found only in the Middle East, suggesting—the authors wrote in the Journal of Psychiatric Research—that “cultural factors may play a significant role” in the compulsions that people engage in.
There was another reason for the shift from predominantly religious compulsions to washing, checking, and the like: as medicine became a profession, people besieged by compulsions tended to seek help from doctors, not priests. It thus became the former—eventually joined by psychiatrists—who wrote down their case histories, and patients figured they could reveal compulsions other than scrupulosity.
One such account came down to us because its subject was Samuel Johnson (1709–1784), the essayist, poet, literary critic, biographer, and lexicographer. James Boswell’s Life of Samuel Johnson, published in 1791, described how Johnson would walk down the street “and repeatedly touch posts. . . . Upon every post as he passed along, I could observe he deliberately laid his hand; but missing one of them, when he had got at some distance, he seemed suddenly to recollect himself, and immediately returning back, carefully performed the accustomed ceremony, and resuming his former course, not omitting one till he gained the crossing.”
Boswell also noted Johnson’s “anxious care to go out or in at a door or passage, by a certain number of steps from a certain point, or at least so as that either his right or left foot, (I am not certain which,) should constantly make the first actual movement. . . . I have, upon innumerable occasions, observed him suddenly stop, and then seem to count his steps with a deep earnestness; and when he had neglected or gone wrong in this sort of magical movement, I have seen him go back again, [and] put himself in a proper posture to begin the ceremony.”
Frances Reynolds, artist and youngest sister of the eighteenth-century English portrait painter Sir Joshua Reynolds, described Johnson’s “extraordinary gestures or antics with his hands and feet, particularly when passing over the threshold of a Door, or rather before he would venture to pass through any doorway. On entering Sir Joshua’s house with poor Mrs Williams, a blind lady who lived with him, he would quit her hand, or else whirl her about on the steps as he whirled and twisted about to perform his gesticulations.”
Scholars as well as ordinary people regarded these behaviors as eccentric, peculiar or curious, not evidence of insanity. In his Life of Samuel Johnson, Macaulay argues that Johnson’s genius was intimately tied to his “eccentricities,” a diagnosis that the good citizens of London apparently agreed with. Seeing the great man touch every lamppost as he walked down the street, they “thought it was eccentric but without further consequence,” wrote Lennard Davis. “No one called an exorcist.”
Medicine Takes Center Stage
In the nineteenth century, the medical establishment finally came into its own, and claimed compulsions (and much else that had previously been left to the clergy) as its purview. Physicians in France became the first to recognize compulsions as a medical disorder unconnected to religion, and accounts of compulsive behavior bloomed like crocuses in March. Physicians were just starting to parse the idea of insanity, debating whether compulsions were a disorder of the will, the intellect, or the emotions. With only a few exceptions, French physicians during the eighteenth and nineteenth centuries saw compulsions as disorders of the emotions, while the Germans saw them as diseases of the intellect and will.
The first medical account of compulsive checking comes from Jean-Étienne-Dominique Esquirol—the psychiatrist who coined the term “monomania.” Combining clinical acumen with rudimentary epidemiology, he described mental illnesses and estimated their prevalence more accurately than anyone before him. As physician-in-chief at the Salpêtrière Hospital in Paris (originally the Hospice de la Salpêtrière), Esquirol was known for his efforts to bring more humane treatment to the mentally ill, and his Des maladies mentales, considérées sous les rapports médical, hygiénique, et médico-légal (1838) is considered the first modern text on clinical psychiatry.
One of his patients, the blue-eyed Mademoiselle F., thirty-four, suffered from what today we would call compulsive checking. “She spends much time in completing the accounts and invoices, being apprehensive of committing some error; of substituting one figure for another; and consequently, of wronging purchasers,” Esquirol wrote. Nothing that screams stark raving mad, but enough for him to consider her mentally ill and an “interesting case.” Mlle F., who sought treatment in 1834, had contamination-related compulsions as well: “her toilet usually occupies her an hour and a half, and more than three hours” when her symptoms are at their worst, Esquirol wrote. “Before leaving her bed, she rubs her feet for ten minutes, in order to remove whatever may have insinuated itself between the toes or beneath the nails. She afterwards turns and re-turns her slippers, shakes them, and hands them to her chamber-maid, in order that she, after having carefully examined them, may assure her that they conceal nothing of value. The comb is passed through the hair a great number of times, with the same intent. Every article of her apparel is examined successively, a great number of times, inspected in every way, in all the folds and wrinkles, and rigorously shaken. . . . If, from any cause, these precautions are not taken, she is restless during the whole day.” Like today’s OCD patients, Mlle F. was “aware of her condition; perceives the ridiculous nature of her apprehensions, and the absurdity of her precautions,” Esquirol wrote. He diagnosed an “involuntary, irresistible, and instincti
ve activity” that had “chained” the poor woman to “actions that neither reason or emotion have originated, that . . . will cannot suppress.”
By this time the most common compulsions related to cleaning and checking, for which we can blame the emergence of the germ theory of disease. Similarly, the expectation of being safe in one’s own home was a prerequisite for compulsive checking, which was further egged on by the widespread adoption of conveniences such as stoves that came with built-in threats. “Worrying itself, as indicated by the use of the word ‘worry’ in the modern sense, came into the English language in the nineteenth century,” Lennard Davis wrote.
French physician Henri Legrand du Saulle (1830–1886) christened it “la folie du doute avec délire de toucher” (the title of his 1875 book). Contrary to Esquirol’s view that compulsions arose from disorders of the intellect and volition, du Saulle saw them as disorders of emotion, which is closer to the twenty-first-century view that they are born in anxiety. What du Saulle termed “the morbid drama” began with the “grip of unceasing anxieties” about contamination, bringing about a “neurosis” marked by “fear of touching certain objects along with a grossly abnormal preoccupation with cleanliness and repeated washing.” Sufferers are “aware at every moment of the bizarreness of the behavior,” du Saulle wrote, in early recognition of the ego-dystonic nature of what became known as OCD.
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