Is a Psychodynamic Perspective Relevant

to the Clinical Management of Obsessive-

Compulsive Disorder?

SUSAN CHLEBOWSKI, M.D.

ROBERT J. GREGORY, M.D.*
Obsessive-compulsive disorder (OCD) can be a severe and disabling condi-
tion with considerable variability in clinical presentation, course, and treat-
ment response. Based upon demonstrated efficacy in clinical trials, selective
serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy
(CBT) have become the treatments of choice for patients with OCD. By
contrast, psychodynamic formulations and treatments are often considered
irrelevant or contraindicated. In the present paper, the authors present five
clinical cases of OCD where psychodynamic understanding and/or treatment
was essential for optimizing outcome. The authors suggest that a careful
psychosocial history and dynamic formulation can enrich understanding in
patients with OCD and may sometimes point to alternative or supplementary
treatments. Psychodynamic interventions may be considered for two sub-
groups of patients: those with late-onset OCD that coincides with interper-
sonal stressors, and those having borderline personality disorder, for whom
specialized forms of treatment, such as dynamic deconstructive psychother-
apy, may be indicated.
KEYWORDS: obsessive-compulsive disorder; borderline personality
disorder; psychodynamic, dynamic deconstructive psychotherapy

INTRODUCTION
Obsessive-compulsive disorder (OCD) is a distressing and disabling
condition. It is characterized by recurrent thoughts, impulses or images,
and/or compulsive behaviors or mental acts that impair role performance
and social functioning (American Psychiatric Association, 2000). The
lifetime prevalence is currently estimated to be 2% to 3% worldwide

Department of Psychiatry, SUNY Upstate Medical University, Syracuse. NY. Mailing address:
"Department of Psychiatry, SUNY Upstate Medical University 750 East Adams Street, Syracuse, NY
13210. e-mail: [email protected]
A M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol. 6 3 , No. 3, 2009

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(Szeszko et al., 2004; Zetin & Kramer, 1992). Obsessive-compulsive

disorder is more common in males, and less common among first-born
children (Pollard, Wiener, Merkel, & Enseley, 1990). Functional im-
aging of patients with OCD demonstrates abnormal brain activity
within the anterior/lateral orbitofrontal cortex, cingulate gyrus, striatal
cortex, and caudate nucleus (Linden, 2006; Rauch, Shin, & Wright,
2003).
The onset of OCD is often gradual, beginning in early adulthood;
however, childhood onset is not uncommon (Piacentini & Langley, 2004;
Wilhelm, Tolin, & Steketee, 2004). Family and twin studies support a
genetic component (Van Grootheest, Cath, Beekman, & Boomsma, 2007).
However, OCD is also frequently precipitated by stressors, including
sexual and/or marital difficulties, pregnancy, and illness of a significant
person or the death of a close relative. The symptoms typically wax and
wane with life stress; though some patients exhibit a steady progression of
their symptoms (Zetin & Kramer, 1992).
The most prominent hypothesis regarding pathophysiology has been
that OCD is a manifestation of a serotonin imbalance (Zohar, Kennedy,
Hollander, & Koran, 2004). Despite this association between serotonin
and OCD, 40% to 60 % of OCD patients do not respond adequately to
treatment with selective serotonin reuptake inhibitors (SSRIs) or to clo-
mipramine (Kaplan & Hollander, 2003).
Other neurotransmitters have also been implicated in OCD. For
example, symptoms appear to increase with high doses of dopamine
agonists, possibly indicating the role of midbrain dopamine in OCD
pathophysiology (Alevizos, Lykouras, Zervas, & Christodoulou, 2002;
Denys, Zohar, & Westenberg, 2004). There is data to support the roles of
the inhibitory neurotransmitter GABA (Zai et al., 2005) and of sex
hormones (Breandes, Spoares, & Cohen, 2004) in OCD. In addition,
partial antagonism of the NMDA receptor reduces glutaminergic activity,
which may contribute to OCD symptoms (Greenberg et al., 2009; Rolls,
Loh, & Deco, 2008). Thesefindingssuggest either the pathophysiology is
much more complex than a serotonin imbalance or there is heterogeneity
of pathophysiological mechanisms.
In support of heterogeneity, data suggest that variations in the under-
lying genetics of OCD are associated with different phenotypal subtypes.
For example, studies of first-degree relatives of patients with OCD
indicate that some genes may be associated with the obsessions of clean-
liness and cleaning while other genetic variations may be associated with
hoarding (Pittenger, Kelmendi, Bloch, Krystal, & Coric, 2005). Linkage
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studies also support genetic variability by implicating multiple genes and

chromosome locations that may contribute to the development of OCD
(Grados & Wilcox, 2007).
Several discreet subtypes of OCD have been identified clinically based
upon types of compulsions (Fontenelle, Mendlowicz, & Versiani, 2005) or
types of dysfunctional beliefs (Calamari et al., 2005, Abramowitz, Khand-
ler, Nelson, Deacon, & Rygwall, 2005). Clinical subtypes are stable over
time, and different subtypes respond differently to treatment (Besiroglu et
al., 2007). Neurotransmitter, genetic, and clinical variability suggest that
OCD is a heterogeneous disorder (Mataix-Cols, Conceicau do Rosario
Campos, & Leckman, 2005; Nestadt et al., 2003).
Modern psychosocial paradigms of OCD have focused on strategies to
relieve anxiety and include Cognitive Behavioral Therapy (CBT), which,
for OCD, includes both Cognitive Therapy (CT) and Behavior Therapy
(BT). Approximately 63% to 90% of patients with OCD will respond to
individual CT, with the results reduced for group CT (Wilhelm et al.,
2006; Cottraux et al., 2001). The response rates for BT, typically expo-
sure—response prevention, have been reported to vary from 60% to 80%.
However, the rate decreases to 50% to 60% once dropouts are included
(Bjorgvinsson, Hart, & Heffelfinger, 2007).
Following a course of CBT, the OCD symptoms continue to persist
to a mild to a moderate degree in most patients (Eddy, Dutra, Bradley,
& Westen, 2004). Despite these limitations, most clinicians still con-
sider CBT to the best psychotherapeutic treatment for patients with
OCD, given that it is the best studied in randomized controlled trials.
Psychoanalytic formulations and treatments of OCD have fallen out of
favor and are seldom used in modern clinical practice. Some analysts have
expressed the opinion that psychodynamic psychotherapy is contraindi-
cated for this condition since there is little in the literature to support its
efficacy (Gabbard, 2004; Gibbons, Crits-Christoph, & Hearon, 2008).
The present paper addresses the question of whether psychoanalytic
paradigms are still relevant for the evaluation and treatment of persons
with OCD. Can a psychoanalytic perspective enrich our understanding of
individuals with OCD beyond current biological and cognitive formula-
tions? Is there a subgroup of persons with OCD who may benefit from
psychodynamic psychotherapy? The following cases present instances
where exploration of patient dynamics enriched our understanding of the
clinical presentation and helped to optimize treatment.

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CLINICAL CASES
Case I
Ms. S. was a 40-year-old married mother of two children, ages 5 and
7 years. Her primary-care physician referred her for a psychiatric consul-
tation. The patient's chief complaint, intrusive thoughts of committing
violent acts towards her children, had been occurring during the past 2
years, usually just before her bedtime. The thoughts were extremely
distressing and she recognized them as being irrational since she deeply
cared for her children. She would see various objects around the home,
such as knives and gloves, and feared she might use them to hurt her
children. To avoid these thoughts, she hid such objects in drawers. She had
no other clear compulsions or obsessions, other than lifelong hypochon-
driacal worry about having a heart attack or stroke. There was no evidence
of any comorbid Axis I or I I disorder.
When asked about relational issues, the patient reluctantly admitted to
increased marital difficulties. She complained that her husband had be-
come more controlling over the past two years, even of taking charge of
theirfinances.Because of this, she felt she has no control over her life. Ms.
S. came to a realization during the course of the evaluation that she was
angry and resentful towards her husband and that she had never acknowl-
edged these feelings. The lack of control she felt in her present situation
reflected the feelings she had experienced as a child while taking care of
her sick mother. No other clear stressors or précipitants coincided with the
onset of her obsessions.
During the same initial evaluation, the consultant made Ms. S. aware of
the link between emotions in the past and present, and provided an
interpretation that perhaps the patient was redirecting some of the anger
she felt towards her husband to her children. The consultant then made a
referral to CBT and initiated a trial of sertraline, with follow up in one
week.
At the follow-up visit, Ms. S. stated that she not started taking the
sertraline, nor followed through on the referral to CBT because her
obsessions were mostly resolved (only one obsessive episode in the past
week). Her obsessions continued to improve at 1 month follow up and
were completely resolved by the 6-month follow-up visit. She reported
she felt "something had changed inside me" after realizing that she had
been harboring anger towards her husband, and she also started to become
more assertive in the marital relationship. At the final visit she stated, " I am
not afraid to be around my kids anymore!"
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Case II
Ms. J. was a 30-year-old married female when she started weekly
psychodynamic psychotherapy. Throughout her adult life, she had expe-
rienced distressing obsessions and compulsions that centered on fears her
house would burn down. She repeatedly checked stoves and electrical
appliances to make sure they were turned off, and when leaving the house,
she would repetitively return to check them. The patient met criteria for
multiple conditions, including bipolar disorder, anorexia nervosa (binge -
ing/purging type), alcohol dependence, and borderline personality disor-
der (BPD). Medications prescribed for Ms. J. included valproate and
risperidone for several years prior to the current therapy, and these were
continued. She also received multiple trials of antidepressants in the past,
including fluoxetine, sertraline, and doxepin. Despite adequate dose and
duration, these had provided no benefit.
The psychodynamic approach taken with this patient, labeled dynamic
deconstructive psychotherapy (DDP), was developed specifically for BPD
and shown effective in a randomized controlled trial (Gregory et al., 2008).
A premise of DDP is that the symptoms of BPD, and common comorbid
Axis I disorders, are secondary to aberrant processing of emotional
experiences (Gregory & Remen, 2008; www.upstate.edu/ddp). The ther-
apist discerned that Ms. J.'s OCD symptoms represented a projective
displacement of the patient's anger and destructive wishes onto objects in
her house. However, DDP does not involve interpreting symptoms as
defenses, but rather aims to remediate aberrant processing of emotions by
fostering verbalization of recent interpersonal episodes and helping pa-
tients to identify, label, and acknowledge their emotions. In addition,
therapists practicing DDP assist the patient to explore alternative or
opposite attributions towards self and other and provide the patient with
novel experiences in the patient-therapist relationship that deconstruct
distorted attributions and promote individuation and differentiation.
Improvement in OCD symptoms was gradual but steady. By 6 months,
the obsessions and compulsions were much diminished and no longer
interfered significantly with functioning. By 1 year, the OCD had com-
pletely resolved and did not re-emerge over 5 years of follow up.
Case III
Ms. S. was a 22-year-old single female just released from a psychiatric
hospital following a suicide attempt. The year prior to the hospitalization,
she had received treatment for refractory OCD, including multiple trials of
the SSRIs fluvoxamine, fluoxetine, and sertraline at maximum recom-
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mended dosages, as well as a short-term trial cognitive behavior therapy,

which included exposure response prevention. Trials of adjunctive medi-
cations were also attempted, including bupropion, alprazolam, clonaz-
epam, and olanzapine. Symptoms of OCD included obsessions of contam-
ination and cleansing compulsions, such as multiple daily showers and
hand washing approximately every 30 minutes. In addition, the patient met
DSM-IV criteria for anorexia nervosa (bingeing/purging type), alcohol
dependence, and BPD.
The clinician formulated her cleansing rituals as representing an at-
tempt to undo displaced feelings of shame. Ms. S. began a course of DDP,
according to the principles outlined in the case above. Antidepressants
were discontinued and lamotrigine, titrated to 100 mg, twice a day was
prescribed. Symptomatic improvement was marked, and by 6 months of
treatment, her obsessions and compulsions were mostly resolved and no
longer interfered significantly with functioning. At that time, she com-
pleted her graduate studies and left the area to pursue her career.
Case IV
Ms. K. was a 29-year-old married female referred by her therapist for
medication consultation for refractory OCD. The nature of her obsessions
was unusual and included the idea that there were "bloody tampons" lying
about the house. Compulsions included searching the house for the
tampons and washing laundry repeatedly to rid them of blood contami-
nation. The patient fully realized that these beliefs and behaviors were
irrational, there was no evidence of other Axis I or Axis I I conditions, and
had never been prescribed psychotropic medications. The patient was
treated unsuccessfully during the past year with a psychotherapy approach
that combined elements of cognitive behavior therapy, including exposure
response prevention, with supportive psychotherapy.
Ms. K. stated that the symptoms began two years ago, which the
psychiatric consultant noted to himself coincided with Ms. K's marriage.
The patient, however, denied problems in the relationship and stated that
her husband was very supportive. When asked about their sexual relation-
ship, the patient reluctantly admitted they had never had successful
intercourse due to her dyspareunia. The consultant thought that the
bloody tampons might have symbolic meaning as a threatening penis,
serving to displace the patient's fears of sexuality. He did not share this
with the patient, but instead recommended that the patient begin a trial of
sertraline. He also recommended that the patient and her husband begin
couples therapy to improve their sexual activity. The patient became
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irritated and dismissed this suggestion as irrelevant. The consultant then

pointed out the coincidence in timing of Ms. K.'s the marriage and the
onset of symptoms and suggested that the two might be related. Ms. K.
became irate and stormed out of the office, stating that she would seek
more professional help elsewhere. Ms. K.'s therapist later called the
consultant and acknowledged that she had not obtained a sexual history
and that the dyspareunia might be relevant. The consultant had no further
contact with the patient.
Case V
Mr. S. was a 20-year-old single college student who presented to the
outpatient clinic for treatment of OCD, which had worsened since moving
away from home to attend college. In the past, he had been treated with
SSRIs and a brief trial of CBT, which included exposure response pre-
vention, but these treatments had not been helpful in relieving his condi-
tion. His symptoms began at age 11 years and included a recurring
obsession of leaving various body parts (i.e. limbs, eyes) in his wake,
causing him to check constantly for missing body parts. He also had
obsessions regarding numbers, bottles, and staples. He was unable to use
a stapler, fearing he would staple his eye to the paper. He was unable to
step on "white lines" for fear of being absorbed into them. He had to open
any closed, half-filled bottle or jar because he saw/felt a part of him
trapped within the container. The patient was pathologically enmeshed
with his mother, who was his sole support. He became suicidal when
separation or any perturbation threatened their relationship.
After the first two visits, the patient reported improvement with his
"stapler obsessions" because of a new relationship, and he noted that
having girlfriends consistently improved his symptoms and self-esteem.
Because of the bizarre aspects of his obsessions, the clinician requested
psychological testing to assess for underlying psychosis. A Minnesota
Multiphasic Personality Inventory-2 was administered and the results
indicated a "fake bad" profile, which suggested an exaggerated component
to his illness consistent with a diagnosis of factitious disorder. A Rorschach
test indicated severely impaired reality testing and psychotic thought
processes. The clinician did not discuss the "fake bad" profile at the time
in deference to the developing therapeutic relationship.
Even though some of the patient's symptoms were exaggerated, the
clinician felt that Mr. S. was fragile, had shallow, unfulfilling interpersonal
relationships, and low self-esteem. The OCD symptoms served partly as a
justification for engaging in therapy, and partly as identification with the
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sick role to defend against annihilation anxiety or a psychotic break.

Psychotherapy sessions exploring the dynamics of his relationships and the
meaning of his symptoms resulted in the patient acknowledging that his
OCD symptoms were exaggerated, but had become a way of life. He stated
that he felt empty and dead inside and that the illness provided meaning
to his existence.
The patient met with the clinician for 12 sessions. During the course of
treatment, the patient began to focus less on his symptoms of OCD and
more on relational issues. He acknowledged that he lived in a magical
dream world, and he began to question his relationships, especially those
with his mother. However, as he questioned the idealization of his mother
over the course of what would be his last 3 sessions, the patient became
more anxious, decided to drop out of treatment, and returned to live with
his mother. When he left treatment, he reported that he no longer was
experiencing symptoms of OCD.
DISCUSSION
In contrast to CBT, psychoanalytic paradigms for OCD have focused
on adaptive aspects of symptoms as a way to resolve intrapsychic conflict.
The psychoanalytic literature describes several theories for the develop-
ment of OCD and often employs the term, obsessional neurosis. Some
older psychodynamic theories postulate that OCD arises from unresolved
fixations at the anal stage of development, where aggressive and sexual
impulses conflict with a rigid superego and certain ego defenses that
attempt to keep the impulses out of consciousness. These defenses include
denial, doubting, indecision, intellectualization, isolation, magical think-
ing, rationalization, reaction formation, repression, and undoing. For
example, a patient with a self-described "dirty mind" may magically undo
"forbidden" impulses by obsessing about cleanliness or engaging in com-
pulsive cleaning rituals (Fenichel, 1945). Within this conceptualization, the
cause of excessive sexual or aggressive impulses may be due to genetic
influences or traumatic events occurring during the anal phase (Freud,
1966). Treatment aims to help patients identify and acknowledge their
forbidden impulses and ego defenses. Therapy is successful when the
patient's ego strength or self-esteem reaches a level that allows for
relinquishing obsessions or compulsions and attaining the ability to sup-
port existence without the use of the defenses (Lang, 1997).
Recent psychoanalytic theories of OCD derive from object relations
theory and focus on the development of a fragmented or ambivalent self.
For example, according to one theory, the anal stage is important for
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learning what is within the body and what is outside the self/body.
Through this experience, the individual learns to differentiate between self
and nonself (Rice, 2004). Other theorists emphasize a lack of fusion or
synthesis between good and bad attributions of self and other (Kempke &
Luyten, 2007). The patient feels threatened by thoughts that he or she is
bad, imperfect, unreliable, uncontrollable, or immoral, and he or she is
unable to integrate these attributions into a coherent self-image. These
psychoanalytic formulations overlap with recent cognitive-behavioral for-
mulations of OCD, which emphasize contradictory and poorly integrated
attributions of self and other (Guidano & Liotti, 1983; Bhar & Kyrios,
2007). With both the object relations and modified cbt approaches,
treatment involves exploration and integration of good and bad attribu-
tions of self and other and a therapist with an accepting attitude.
The five cases presented in this paper illustrate how a psychodynamic
perspective may enrich clinical understanding and optimize treatment. In
Case I , the patient's obsessions of harming her children appeared to be a
displacement of aggression towards her husband. Making this connection
conscious to the patient through an interpretation resulted in a sudden and
dramatic remission of her OCD.
Cases I I and I I I were lower functioning patients, and their obsessions
and compulsions were secondary to BPD. Obsessive-compulsive disorder
occurs in about 25% of inpatients with BPD and co-occurrence is
associated with a diminished response to treatments for OCD (Baer et al.,
1992; Hansen, Vogel, Stiles, & Gotestam, 2007). An empirically supported
psychodynamic therapy for BPD, which focused on remediating aberrant
emotion processing, rather than interpretation, resulted in marked im-
provement in OCD symptoms. These cases suggest that specific psychody-
namic therapies may sometimes be helpful for OCD occurring in the
context of BPD, even after serotonergic agents have produced a subopti¬
mal response.
Cases IV and V illustrate how a detailed history and a dynamic
formulation enhance understanding of OCD symptoms and generate a
more successful treatment plan. In Case IV, the patient's symptoms were
refractory to a one-year trial of CBT. However, the previous therapist did
not know the patient had dyspareunia, did not identify that the onset of
OCD coincided with the patient's marriage, and did not recognize the
possible symbolic significance of the obsession. These factors may have
contributed to the patient's poor response to CBT. Supplementing CBT
with couples therapy may have produced better results. This case, how-
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ever, also illustrates the risk of early interpretations before an alliance is

fully formed.
In Case V, the clinician used a detailed interpersonal history and
psychological testing to postulate that the patient's OCD was partly
factitious and was serving to justify the sick role and contain psychotic
tendencies. This formulation prevented the therapist from initiation of
treatments that had a low potential of benefit and facilitated exploration of
the patient's conflicted relationship with his mother.
CONCLUSION
The etiology of OCD is often assumed to be entirely due to an inherited
malfunction of the serotonin system, leading to abnormal cognitions and
behaviors that are exacerbated by psychosocial stressors. Randomized
controlled trials show serotonergic agents and CBT are efficacious and
therefore, should be considered as first-line treatments for most cases of
OCD. However, responses to these treatments vary and are suboptimal for
many patients. Moreover, there is evidence for heterogeneity in the
pathophysiology of this disorder and individual variability in clinical
presentation. This suggests that there may be distinct subgroups within the
population with OCD who may benefit from different conceptualizations
and treatments. As the cases in this paper demonstrate, some patients have
complex adaptations and interpersonal factors contributing to their symp-
toms. A careful psychosocial history and dynamic formulation can enrich
understanding of OCD and suggest alternative or supplementary treat-
ments so as to optimize outcomes. Psychodynamic interventions may be
considered for two subgroups of patients:
1. Those who have co-occurring BPD. Such patients may respond to
non-interpretive psychodynamic approaches that focus on process-
ing emotional experiences.
2. Those whose OCD starts in adulthood coinciding with the onset of
interpersonal stressors and whose symptoms may have symbolic
significance. In the context of a stable therapeutic alliance, such
patients may sometimes respond to interpretations that link their
symptoms to specific stressors.

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