What is the Obsessive-Compulsive Spectrum?


The obsessive-compulsive spectrum is a model of medical classification where various psychiatric, neurological and/or medical conditions are described as existing on a spectrum of conditions related to obsessive-compulsive disorder (OCD).

Refer to An Overview of the Biology of Obsessive-Compulsive Disorder.

“The disorders are thought to lie on a spectrum from impulsive to compulsive where impulsivity is said to persist due to deficits in the ability to inhibit repetitive behavior with known negative consequences, while compulsivity persists as a consequence of deficits in recognizing completion of tasks.”

OCD is a mental disorder characterised by obsessions and/or compulsions. An obsession is defined as “a recurring thought, image, or urge that the individual cannot control”. Compulsion can be described as a “ritualistic behaviour that the person feels compelled to perform”. The model suggests that many conditions overlap with OCD in symptomatic profile, demographics, family history, neurobiology, comorbidity, clinical course and response to various pharmacotherapies. Conditions described as being on the spectrum are sometimes referred to as obsessive-compulsive spectrum disorders.


The following conditions have been hypothesized by various researchers as existing on the spectrum:

However, recently there is a growing support for proposals to narrow down this spectrum to only include body dysmorphic disorder, hypochondriasis, tic disorders, and trichotillomania.

Body Dysmorphic Disorder

Refer to Body Dysmorphic Disorder.

Body dysmorphic disorder is defined by an obsession with an imagined defect in physical appearance, and compulsive rituals in an attempt to conceal the perceived defect. Typical complaints include perceived facial flaws, perceived deformities of body parts and body size abnormalities. Some compulsive behaviours observed include mirror checking, ritualised application of makeup to hide the perceived flaw, excessive hair combing or cutting, excessive physician visits and plastic surgery. Body dysmorphic disorder is not gender specific and onset usually occurs in teens and young adults.


Hypochondriasis is excessive preoccupancy or worry about having a serious illness. These thoughts cause a person a great deal of anxiety and stress. The prevalence of this disorder is the same for men and women. Hypochondriasis is normally recognised in early adult age. Those that suffer with hypochondriasis are constantly thinking of their body functions, minor bumps and bruises as well as body images. Hypochondriacs go to numerous outpatient facilities for confirmation of their own diagnosis. Hypochondriasis is the belief that something is wrong but it is not known to be a delusion.

Tic Disorders

Tourette’s syndrome is a neurological disorder characterised by recurrent involuntary movements (motor tics) and involuntary noises (vocal tics). The reason Tourette’s syndrome and other tic disorders are being considered for placement in the obsessive compulsive spectrum is because of the phenomenology and co-morbidity of the disorders with obsessive compulsive disorder. Within the population of patients with OCD up to 40% have a history of a tic disorder and 60% of people with Tourette’s syndrome have obsessions and/or compulsions. Plus 30% of people with Tourette’s syndrome have clinically diagnosable OCD. Course of illness is another factor that suggests correlation because it has been found that tics displayed in childhood are a predictor of obsessive and compulsive symptoms in late adolescence and early adulthood. However, the association of Tourette’s and tic disorders with OCD is challenged by neuropsychology and pharmaceutical treatment. Whereas OCD is treated with SSRI, tics are treated with dopamine blockers and alpha-2 agonists.


Refer to Trichotillomania.

Trichotillomania is an impulse control disorder which causes an individual to pull out their hair from various parts of their body without a purpose. The cause for trichotillomania remains unknown. Like OCD, trichotillomania isn’t a nervous condition but stress can trigger this habit. For some people pulling their hair out of boredom is normal, but that isn’t the case for someone that is dealing with trichotillomania. Emotions do not affect the behaviour but these behaviours are more prevalent in those that suffer with depression. Review articles recommend behavioural interventions such as habit reversal training and decoupling.

What is Psychical Inertia?


Psychical inertia is a term introduced by Carl Jung to describe the psyche’s resistance to development and change.

He considered it one of the main reason for the neurotic opposing, or shrinking from, his or her age-appropriate tasks in life.

Refer to Repetition Compulsion.

Freudian and Other Developments

Freud argued that such psychic inertia played a part in the lives of the normal, as well as of the neurotic, and saw its origins in fixation between early instincts and their first impressions of significant objects. As late as Civilization and its Discontents (his 1930 book), he considered as a major obstacle to cultural development “the inertia of the libido, its disinclination to give up an old position for a new one”.

Later Jungians have seen psychic inertia as a force of nature reflecting both internal and outer determinants; while others have seen it as a product of social pressures, especially in relation to ageing.

What is Repetition Compulsion?


Repetition compulsion is a psychological phenomenon in which a person repeats an event or its circumstances over and over again.

This includes re-enacting the event or putting oneself in situations where the event is likely to happen again. This “re-living” can also take the form of dreams in which memories and feelings of what happened are repeated, and even hallucinated.

Repetition compulsion can also be used to cover the repetition of behaviour or life patterns more broadly: a “key component in Freud’s understanding of mental life, ‘repetition compulsion’ … describes the pattern whereby people endlessly repeat patterns of behaviour which were difficult or distressing in earlier life”.

Refer to Psychical Inertia.


Sigmund Freud‘s use of the concept of “repetition compulsion” (German: Wiederholungszwang) was first defined in the article of 1914, Erinnern, Wiederholen und Durcharbeiten (“Remembering, Repeating and Working-Through”). Here he noted how “the patient does not remember anything of what he has forgotten and repressed, he acts it out, without, of course, knowing that he is repeating it … For instance, the patient does not say that he remembers that he used to be defiant and critical toward his parents’ authority; instead, he behaves in that way to the doctor”.

He explored the repetition compulsion further in his 1920 essay Beyond the Pleasure Principle, describing four aspects of repetitive behaviour, all of which seemed odd to him from the point of view of the mind’s quest for pleasure/avoidance of unpleasure.

The first was the way “dreams occurring in traumatic neuroses have the characteristic of repeatedly bringing the patient back into the situation of his accident” rather than, for example, “show[ing] the patient pictures from his healthy past”.

The second came from children’s play. Freud reported observing a child throw his favourite toy from his crib, become upset at the loss, then reel the toy back in, only to repeat this action. Freud theorised that the child was attempting to master the sensation of loss “in allowing his mother to go away without protesting”, but asked in puzzlement “How then does his repetition of this distressing experience as a game fit in with the pleasure principle?”.

The third was the way (noted in 1914) that the patient, exploring in therapy a repressed past, “is obliged to repeat the repressed material as a contemporary experience instead of … remembering it as something belonging to the past … the compulsion to repeat the events of his childhood in the transference evidently disregards the pleasure principle in every way”.

The fourth was the so-called “destiny neurosis”, manifested in “the life-histories of men and women … [as] an essential character-trait which remains always the same and which is compelled to find expression in a repetition of the same experience”.

All such activities appeared to Freud to contradict the organism’s search for pleasure, and therefore “to justify the hypothesis of a compulsion to repeat—something that seems more primitive, more elementary, more instinctual than the pleasure principle which it over-rides”: “a daemonic current/trait”, “a daemonic character”, a “daemonic compulsion”, likely alluding to the Latin motto errare humanum est, perseverare autem diabolicum (“to err is human, to persist [in committing such errors] is of the devil”). Following this line of thought, he would come to stress that “an instinct is an urge inherent in organic life to restore an earlier state of things” (an explanation that some scholars have labelled as “metaphysical biology”), so to arrive eventually at his concept of the death drive.

Along the way, however, Freud had in addition considered a variety of more purely psychological explanations for the phenomena of the repetition compulsion which he had observed. Traumatic repetitions could be seen as the result of an attempt to retrospectively “master” the original trauma, a child’s play as an attempt to turn passivity into activity: “At the outset he was in a passive situation … but by repeating it, unpleasurable though it was, as a game, he took on an active part”.

At the same time, the repetition of unpleasant experiences in analysis could be considered “unpleasure for one system [the ego] and simultaneously satisfaction for the other [the id]. In the second edition of 1921, he extended the point, stating explicitly that transference repetitions “are of course the activities of instincts intended to lead to satisfaction; but no lesson has been learnt from the old experience of these activities having led only to unpleasure”.

Five years later, in Inhibition, Symptom and Anxiety, he would quietly revise his earlier definition – “There is no need to be discouraged by these emendations … so long as they enrich rather than invalidate our earlier views” – in his new formula on “the power of the compulsion to repeat—the attraction exerted by the unconscious prototypes upon the repressed instinctual process”.

Later Psychoanalytic Developments

It was in the later, psychological form that the concept of the repetition compulsion passed into the psychoanalytic mainstream. Otto Fenichel in his “second generation” compendium The Psychoanalytic Theory of Neurosis stressed two main kinds of neurotic repetition.

On the one hand, there were “Repetitions of traumatic events for the purpose of achieving a belated mastery … seen first and most clearly in children’s games”, although the “same pattern occurs in the repetitive dreams and symptoms of traumatic neurotics and in many similar little actions of normal persons who … repeat upsetting experiences a number of times before these experiences are mastered”. Such traumatic repetitions could themselves appear in active or passive forms. In a passive form, one chooses his or her most familiar experiences consistently as a means to deal with problems of the past, believing that new experiences will be more painful than their present situation or too new and untested to imagine. In the active, participatory form, a person actively engages in behaviour that mimics an earlier stressor, either deliberately or unconsciously, so that in particular events that are terrifying in childhood become sources of attraction in adulthood. For instance, a person who was spanked as a child may incorporate this into their adult sexual practices; or a victim of sexual abuse may attempt to seduce another person of authority in his or her life (such as their boss or therapist): an attempt at mastery of their feelings and experience, in the sense that they unconsciously want to go through the same situation but that it not result negatively as it did in the past.

On the other hand, there were “Repetitions due to the tendency of the repressed to find an outlet”. Here the drive of the repressed impulse to find gratification brought with it a renewal of the original defence: “the anxiety that first brought about the repression is mobilized again and creates, together with the repetition of the impulse, a repetition of the anti-instinctual measures”. Fenichel considered that “Neurotic repetitions of this kind contain no metaphysical element”, and “even the repetition of the most painful failure of the Oedipus complex in the transference during a psychoanalytic cure is not ‘beyond the pleasure principle'”.

Later writers would take very similar views. Eric Berne saw as central to his work “the repetition compulsion which drives men to their doom, the power of death, according to Freud … [who] places it in some mysterious biological sphere, when after all it is only the voice of seduction” – the seduction of the repressed and unconscious id.

Erik Erikson saw the destiny neurosis – the way “that some people make the same mistakes over and over” – in the same light: “the individual unconsciously arranges for variations of an original theme which he has not learned either to overcome or to live with”. Ego psychology would subsequently take for granted “how rigidly determined our lives are—how predictable and repetitive … the same mistake over and over again”.

Object relations theory, stressing the way “the transference is a live relationship … in the here-and-now of the analysis, repeating the way that the patient has used his objects from early in life” considered that “this newer conception reveals a purpose … [in] the repetition compulsion”: thus “unconscious hope may be found in repetition compulsion, when unresolved conflicts continue to generate attempts at solutions which do not really work … [until] a genuine solution is found”.

Later Formulations

By the close of the twentieth century, the psychoanalytic view of repetition compulsion had come into increasing dialogue with a variety of other discourses, ranging from attachment theory through brief psychodynamic therapy to cognitive behavioural therapy.

Attachment theory saw early developmental experiences leading to “schemas or mental representations of relationship … [which] become organized, encoded experiential and cognitive data … that led to self-confirmation”.

The core conflictual relationship theme – “core wishes that the individual has in relation to others” – was seen in brief psychodynamic therapy as linked to the way in “a repetition compulsion, the client will behave in ways that engender particular responses from others that conform with previous experiences in interpersonal relationships”.

Psychological schemas – described in cognitive psychology, social psychology, and schema therapy – are “an enduring symbolic framework that organises constellations of thought, feeling, memory, and expectation about self and others”. In some cases psychological schemas may be seen as analogous to the role in psychoanalytic theory of early unconscious fixations in fuelling the repetition compulsion.

What is Acting Out?


In the psychology of defence mechanisms and self-control, acting out is the performance of an action considered bad or anti-social. In general usage, the action performed is destructive to self or to others.

The term is used in this way in sexual addiction treatment, psychotherapy, criminology and parenting. In contrast, the opposite attitude or behaviour of bearing and managing the impulse to perform one’s impulse is called acting in.

The performed action may follow impulses of an addiction (e.g. drinking, drug taking or shoplifting). It may also be a means designed (often unconsciously or semi-consciously) to garner attention (e.g. throwing a tantrum or behaving promiscuously). Acting out may inhibit the development of more constructive responses to the feelings in question.

In Analysis

Sigmund Freud considered that patients in analysis tended to act out their conflicts in preference to remembering them – repetition compulsion. The analytic task was then to help “the patient who does not remember anything of what he has forgotten and repressed, but acts it out” to replace present activity by past memory.

Otto Fenichel added that acting out in an analytic setting potentially offered valuable insights to the therapist; but was nonetheless a psychological resistance in as much as it deals only with the present at the expense of concealing the underlying influence of the past. Lacan also spoke of “the corrective value of acting out”, though others qualified this with the proviso that such acting out must be limited in the extent of its destructive/self-destructiveness.

Annie Reich pointed out that the analyst may use the patient by acting out in an indirect countertransference, for example to win the approval of a supervisor.


The interpretation of a person’s acting out and an observer’s response varies considerably, with context and subject usually setting audience expectations.

In Parenting

Early years, temper tantrums can be understood as episodes of acting out. As young children will not have developed the means to communicate their feelings of distress, tantrums prove an effective and achievable method of alerting parents to their needs and requesting attention.

As children develop they often learn to replace these attention-gathering strategies with more socially acceptable and constructive communications. In adolescent years, acting out in the form of rebellious behaviours such as smoking, shoplifting and drug use can be understood as “a cry for help.” Such pre-delinquent behaviour may be a search for containment from parents or other parental figures. The young person may seem to be disruptive – and may well be disruptive – but this behaviour is often underpinned by an inability to regulate emotions in some other way.

In Addiction

In behavioural or substance addiction, acting out can give the addict the illusion of being in control. Many people who suffer with addiction, either refuse to admit they struggle with it, or some do not even realise they have an addiction. For most people, when their addiction is addressed, they become defensive and act out. This can be a result of multiple emotions including shame, fear of judgement, or anger. It is important to be patient and understanding towards those who suffer with addiction, and to realise that most people want to break free from the symptoms and baggage that come with addiction, but do not know how or where to start. Thankfully, there are many preventative measures and programs than can help those who personally struggle with addiction, or for those who have a friend or family member that suffers with addiction.

In Criminology

Criminologists debate whether juvenile delinquency is a form of acting out, or rather reflects wider conflicts involved in the process of socialisation. Deviant behaviour is commonly associated with crime and social deviance. Many of those who are involved in crime, usually grew up in broken homes, or had no authority figure in their life. For some, a life of crime is all they have ever known. This could be a reason as to why there is a debate over whether or not juvenile delinquency is a form of acting out.


Acting out painful feelings may be contrasted with expressing them in ways more helpful to the sufferer, e.g. by talking out, expressive therapy, psychodrama or mindful awareness of the feelings. Developing the ability to express one’s conflicts safely and constructively is an important part of impulse control, personal development and self-care.