Management of Rumination and Obsessions in Primary Care.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Prim Care Companion CNS Disord 2024;26(3):23f03653. Author affiliations are listed at the end of this article.

Effects of acceptance-based strategies on psychological responses to disorder-relevant stimuli in inpatients with obsessive-compulsive disorder: An experimental study.

BACKGROUND AND OBJECTIVES: Preliminary findings suggest that acceptance and commitment therapy-informed exposure therapy may be an effective treatment for obsessive-compulsive disorder (OCD). However, there is a lack of experimental studies that have examined immediate effects of acceptance-based strategies during exposure to disorder-relevant stimuli in persons with OCD. METHODS: Fifty-three inpatients (64% female) with OCD participated in an experimental study during which they were exposed to obsessive-compulsive washing-relevant pictures and were instructed to either passively view these pictures for 5 s (neutral condition), to accept their feelings (acceptance condition) or to intensify their feelings (exposure condition) for 90 s each. RESULTS: The acceptance condition led to higher acceptance and lower unpleasantness of patients' current feelings compared to the neutral condition and to lower strength of obsessions and urge to perform compulsions but only when compared to the exposure condition. Higher self-reported OCD symptom severity related to higher unpleasantness and strength of obsessions, particularly in the neutral condition. LIMITATIONS: Future studies need to test whether the current findings translate to other stimuli and other forms of obsessions and compulsions. Due to the short duration, the exposure condition might have only mimicked the early phase of exposure and response prevention. CONCLUSIONS: Acceptance-based strategies during cue exposure immediately increase acceptance of and reduce unpleasant feelings. In line with the rationale of acceptance-based treatment approaches, which do not aim at immediate disorder-specific symptom reductions, effects on obsessions and compulsions may be more delayed or require repeated training sessions.

Patient specific intracranial neural signatures of obsessions and compulsions in the ventral striatum.

Objective. Deep brain stimulation is a treatment option for patients with refractory obsessive-compulsive disorder. A new generation of stimulators hold promise for closed loop stimulation, with adaptive stimulation in response to biologic signals. Here we aimed to discover a suitable biomarker in the ventral striatum in patients with obsessive compulsive disorder using local field potentials.Approach.We induced obsessions and compulsions in 11 patients undergoing deep brain stimulation treatment using a symptom provocation task. Then we trained machine learning models to predict symptoms using the recorded intracranial signal from the deep brain stimulation electrodes.Main results.Average areas under the receiver operating characteristics curve were 62.1% for obsessions and 78.2% for compulsions for patient specific models. For obsessions it reached over 85% in one patient, whereas performance was near chance level when the model was trained across patients. Optimal performances for obsessions and compulsions was obtained at different recording sites.Significance. The results from this study suggest that closed loop stimulation may be a viable option for obsessive-compulsive disorder, but that intracranial biomarkers are patient and not disorder specific.Clinical Trial:Netherlands trial registry NL7486.

Manipulating visual perspective for obsessional imagery and its impact on obsessive-compulsive symptoms in an analogue sample.

Visual perspective may have an important role in the phenomenology of intrusive images relevant to psychological disorders such as obsessive-compulsive disorder (OCD). The aim of the current study was to examine the subjective and behavioural effects of manipulating visual perspective, to either field or observer, on intrusive images related to doubting and contamination concerns. One hundred and twelve undergraduate participants with high levels OCD symptoms were asked to identify and imagine an intrusive image related to either doubting or contamination concerns. We then randomly assigned them to re-visualise their image from either a field (first-person) or observer (third-person) visual perspective. Participants shifted towards using an observer perspective demonstrated a greater decrease on ratings of subjective measures of image-related distress, prospective likelihood of the image occurring, and urges to suppress the image, relative to those shifted to a field perspective. In addition, those in the observer perspective evidenced a greater decrease on behavioural indices relevant to OCD, such as reduced frequency of the intrusive image and decreased efforts to neutralise the image. We discuss implications for imagery in OCD.

A Psychoanalytical Approach to Diogenes Syndrome.

This article is an attempt at a psychoanalytic understanding of Diogenes syndrome, or hoarding disorder syndrome, by way of a clinical case. This syndrome is characterized by a failure to attend to proper housing habits, including the hoarding of rubbish that may, in fact, create unsuitable, even dangerous, living conditions. The clinical case used suggests that Diogenes syndrome or hoarding disorder reflects or indicates an extreme form of obsessive neurosis involving libidinal regressions to anal fixations designed, paradoxically, to satisfy both a passion for dirty and for order. However, this pathological hoarding may also function to protect the subject against fears associated with meeting people, thereby avoiding any possible intimacy and promoting self-exclusion in an anti-object aim. Finally, the case under discussion helps us to understand the particular psychological aspects or relevance that the actual items and rubbish accumulated have in this syndrome.

Acute effects of aerobic exercise on negative affect and obsessions and compulsions in individuals with obsessive-compulsive disorder.

BACKGROUND: The acute effects of aerobic exercise on improved mood and anxiety reduction have been demonstrated across clinical and nonclinical populations. Limited work has evaluated the acute effects of aerobic exercise on negative affect, obsessions, and compulsions in patients with Obsessive Compulsive Disorder (OCD). METHOD: Fifty-five patients (64% female) with treatment-resistant OCD were randomized to either 12 weeks of aerobic exercise (AE) or health education contact (HEC) control. Participants rated negative affect (i.e., mood and anxiety), obsessions and compulsions before and after each weekly AE or HEC session. Multilevel models were constructed to evaluate the effect of intervention condition, treatment week (time), and their interaction in terms of acute change in affect, obsession, and compulsions. RESULTS: Results reflected a main effect of condition, such that AE resulted in significantly larger increases in positive mood, and reductions in anxiety and compulsions, as compared to HEC. There was also a main effect of time in predicting acute anxiety reduction, such that linear reductions in anxiety over the course of treatment were observed. No significant effects were observed for acute changes in obsessions. LIMITATIONS: The sample was small and was limited in demographic heterogeneity. Bouts of aerobic exercise were not standardized in terms of duration and mode, which could impact affective response to exercise, and acute affective OCD effects were exclusively self-reported. DISCUSSION: The current findings may help elucidate potential mechanisms of action of exercise on OCD outcomes. In addition, these results point toward the potential of designing exercise interventions that can teach patients to utilize individual bouts of physical activity, "in-the-moment" to improve mood and reduce anxiety and compulsions.

What Drives OCD Symptom Change During CBT Treatment? Temporal Relationships Among Obsessions and Compulsions.

Cognitive behavior therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD). However, less is known about how obsessions and compulsions change during treatment, either in tandem, sequentially, or independently. The current study used latent difference score analysis to show path-analytic dynamic modeling of OCD symptom change during CBT. Four competing models of the temporal relationship between obsessions and compulsions were examined: no coupling (obsessions and compulsions are not dynamically related), goal directed (obsessions lead to subsequent changes in compulsions), habit driven (compulsions lead to subsequent changes in obsessions), and reciprocal. Treatment seeking participants (N = 84) with a principal diagnosis of OCD completed 12 weeks of CBT group therapy and completed measures assessing obsession and compulsion severity at pretreatment, Sessions 4 and 8, and end of treatment. Bivariate results supported the goal directed traditional CBT model, where obsession scores are temporally associated with subsequent changes in compulsion scores. These results have implications for theoretical and treatment modelling of obsessions and compulsions in OCD treatment.

Scrupulosity, Religious Affiliation and Symptom Presentation in Obsessive Compulsive Disorder.

BACKGROUND: Scrupulosity is a common yet understudied presentation of obsessive compulsive disorder (OCD) that is characterized by obsessions and compulsions focused on religion. Despite the clinical relevance of scrupulosity to some presentations of OCD, little is known about the association between scrupulosity and symptom severity across religious groups. AIMS: The present study examined the relationship between (a) religious affiliation and OCD symptoms, (b) religious affiliation and scrupulosity, and (c) scrupulosity and OCD symptoms across religious affiliations. METHOD: One-way ANOVAs, Pearson correlations and regression-based moderation analyses were conducted to evaluate these relationships in 180 treatment-seeking adults with OCD who completed measures of scrupulosity and OCD symptom severity. RESULTS: Scrupulosity, but not OCD symptoms in general, differed across religious affiliations. Individuals who identified as Catholic reported the highest level of scrupulosity relative to individuals who identified as Protestant, Jewish or having no religion. Scrupulosity was associated with OCD symptom severity globally and across symptom dimensions, and the magnitude of these relationships differed by religious affiliation. CONCLUSIONS: Findings are discussed in terms of the dimensionality of scrupulosity, need for further assessment instruments, implications for assessment and intervention, and the consideration of religious identity in treatment.

Treatment of obsessive morbid jealousy with cognitive analytic therapy: An adjudicated hermeneutic single-case efficacy design evaluation.

OBJECTIVE: The evidence base for the treatment of morbid jealousy with integrative therapies is thin. This study explored the efficacy of cognitive analytic therapy (CAT). DESIGN: An adjudicated hermeneutic single-case efficacy design evaluated the cognitive analytic treatment of a patient meeting diagnostic criteria for obsessive morbid jealousy. METHOD: A rich case record was developed using a matrix of nomothetic and ideographic quantitative and qualitative outcomes. This record was then debated by sceptic and affirmative research teams. Experienced psychotherapy researchers acted as judges, assessed the original case record, and heard the affirmative-versus-sceptic debate. Judges pronounced an opinion regarding the efficacy of the therapy. RESULTS: The efficacy of CAT was supported by all three judges. Each ruled that change had occurred due to the action of the therapy, beyond any level of reasonable doubt. CONCLUSIONS: This research demonstrates the potential usefulness of CAT in treating morbid jealousy and suggests that CAT is conceptually well suited. Suggestions for future clinical and research directions are provided. PRACTITIONER POINTS: The relational approach of CAT makes it a suitable therapy for morbid jealousy. The narrative reformulation component of CAT appears to facilitate early change in chronic jealousy patterns. It is helpful for therapists during sessions to use CAT theory to diagrammatically spell out the patterns maintaining jealousy.

Association splitting of the sexual orientation-OCD-relevant semantic network.

There is little research on treating symptoms of sexual orientation-obsessive-compulsive disorder (SO-OCD). Semantic networks represent a new cognitive approach for understanding cognitive mechanisms of SO-OCD. Specifically, we tested whether the self-help cognitive technique of association splitting (AS) developed from this approach would be efficacious in reducing SO-OCD symptoms and thought suppression. One hundred and twenty heterosexual undergraduates (82 females, 38 males) were randomly assigned to either the AS or waitlist control group. At baseline and four weeks later, participants completed items assessing SO-OCD symptoms, measures of sexual obsessions and thought suppression, and an association task in which they generated associations to different cue words. Generated associations were coded based on SO-OCD relevance and emotional valence. Results indicated reductions in SO-OCD-relevant associations across levels of emotional valence and SO-OCD-irrelevant negative associations, and increases in SO-OCD-irrelevant positive and neutral associations, only in the AS group. Furthermore, there were reductions in SO-OCD symptoms, sexual obsessions, and thought suppression only in the AS group. Importantly, these findings were obtained with overall large effect sizes. AS appears to be an efficacious self-help technique in reducing SO-OCD symptoms, sexual obsessions, and thought suppression. Clinical implications, limitations, and suggestions for future research are discussed.

Longitudinal effects of an intervention on perfectionism in adolescents / Efectos a largo plazo de una intervención sobre el perfeccionismo en adolescentes

Perfectionism is a personality disposition characterized by a person´s striving for flawlessness and the setting of excessively high performance standards. This trait has been associated with a broad range of psychopathological conditions. Consequently, prevention of its harmful effects must start early. Objective: To investigate if one group session to manage perfectionism has the effect of reducing the levels of this trait, two and six months later. Method: A community-based sample of 978 Portuguese adolescents from three different high schools completed a self-reporting questionnaire including the Child and Adolescent Perfectionism Scale, before and after one skill session. Three groups were formed: the intervention group received a skill session aimed at reducing perfectionism; control group 1 received a skill session aimed at healthy habits, and control group 2 received no intervention. Results: At baseline, no significant mean differences were found by gender or by school in Total Perfectionism or its dimensions. After one session to manage Perfectionism, the intervention group showed significant reduction in self-oriented perfectionism (SOP) scores, two months (p = .001) and six months later (p = .02). No significant reductions were observed in the control groups. Discussion: Our findings suggest that adolescents are sensitive to short interventions aimed at reducing perfectionism (AU)

Perfeccionismo es un rasgo de la personalidad caracterizado por la lucha por la perfección y la fijación de normas de rendimiento excesivamente altas. Se ha asociado con una amplia gama de condiciones psicopatológicas. En consecuencia, la prevención de sus efectos nocivos debe comenzar temprano. Objetivo: investigar si una sesión para manejar el perfeccionismo puede reducir los niveles de este rasgo, dos y seis meses más tarde. Método: una muestra comunitaria de 978 adolescentes, de tres secundarias, respondió a un cuestionario de auto-reporte incluyendo la Escala de Perfeccionismo Infantil y Adolescente antes y después de una sesión. El grupo de Intervención recibió una sesión orientada a reducir el perfeccionismo. El grupo control 1 una sesión sobre hábitos saludables y el grupo control 2 no recibió intervención. Resultados: al inicio, no se encontraron diferencias significativas de medias por género y por escuela. Después de una sesión para manejar el Perfeccionismo, el grupo de intervención mostró una reducción significativa en las puntuaciones del perfeccionismo auto-orientado, dos meses (p = .001) y seis meses después (p = .02). Sin reducciones significativas en los controles. Discusión:nuestros hallazgos sugieren que los adolescentes son sensibles a intervenciones cortas para reducir el perfeccionismo (AU)

Psychiatric comorbidities in autism spectrum disorder: A comparative study between DSM-IV-TR and DSM-5 diagnosis / Comorbilidades psiquiátricas en los trastornos del espectro autista: estudio comparativo entre los criterios DSM-IV-TR y DSM-5

Background/Objective: The heterogeneous clinical presentations of individuals with Autism Spectrum Disorders (ASD) pose a significant challenge for sample characterization. Therefore the main goal of DSM-5 must be to identify subgroups of ASD, including comorbidity disorders and severity. The main goal of this study is to explore the psychiatric comorbidities and the severity of symptoms that could be relevant for the phenotype characterization in ASD and also to compare these results according to the different classification criteria between the DSM-IV-TR and the DSM-5. Method: A comparative study of severity and psychiatric comorbidities was carried out between a sample of participants that only met criteria for Pervasive Developmental Disorder (PDD) according to the DSM-IV-TR and a sample of participants that also met ASD criteria according to DSM-5 classification. The recruitment of children was via educational (N=123). The psychiatric symptoms, comorbid disorders and severity of symptoms were assessed through The Nisonger Child Behavior Rating Form, clinical interview and The Inventory of Autism Spectrum Disorder, respectively. The psychiatric comorbidities considered were: anxiety, eating behavioural problems, self-aggressiveness, hetero-aggressiveness, self-harm, obsessive compulsive disorder and attention deficit and hyperactivity disorder. Results: Statistically significant differences between both groups were found regarding obsessive compulsive disorder, eating behavioural problems and severity. Conclusions: The results support the hypothesis that patients who meet the DSM-5 criteria have more severe symptoms, not only regarding the core autistic symptoms but also in relation with psychiatric comorbidities (AU)

Antecedentes/Objetivo: Los Trastornos del Espectro Autista (TEA) incluyen un grupo heterogéneo en cuanto a su presentación clínica, que supone un desafío a nivel de caracterización diagnóstica. Por consiguiente, el objetivo principal de la clasificación DSM-5 debería de ser identificar subgrupos de TEA incluyendo severidad y comorbilidades psiquiátricas. El objetivo principal de este estudio es explorar las comorbilidades diagnósticas que pueden ser relevantes como descriptores de fenotipos autistas así como la severidad de los síntomas de autismo y comparar los resultados de las diferentes criterios de clasificación entre el DSM-IV-TR y el DSM-5. Método: Se realiza un estudio comparativo de severidad y comorbilidades psiquiátricas entre una muestra con diagnóstico de Trastorno Generalizado del Desarrollo, según criterios DSM-IV-TR, y una muestra que cumplía también criterios para TEA según la clasificación DSM-5. La muestra fue obtenida en centros educativos (N=123). Las comorbilidades psiquiátricas y la severidad de los síntomas se evaluaron a través del The Nisonger Child Behavior Rating Form, entrevista clínica y el Inventario de Trastorno del Espectro Autista, respectivamente. Las comorbilidades estudiadas fueron ansiedad, alteraciones de la conducta alimentaria, auto-agresividad, hetero-agresividad, autolesiones, trastorno obsesivo-compulsivo y déficit de atención e hiperactividad. Resultados: Se encontraron diferencias estadísticamente significativas entre ambos grupos para trastorno obsesivo-compulsivo, alteraciones de la conducta alimentaria y severidad. Conclusiones: Se apoya la hipótesis de que los individuos que cumplen criterios diagnósticos según DSM-5 tienen mayor severidad sintomática, no sólo con respecto a los síntomas autistas centrales, sino también en relación con comorbilidades psiquiátricas (AU)

Obsessionality: Modulating the Encounter with Emotional Truth and the Aesthetic Object.

Experiences with autistic and primitive mental states have significant implications for our understanding of obsessionality. Consequently, obsessionality is seen as an attempt at a massive simplification of experience, in order to deal with the pain inherent in the encounter with intense emotional experience and with the separateness of an enigmatic object that eludes one's omnipotent control. Moreover, early loss and a precocious awareness of separateness often play roles in the withdrawal to obsessional thinking and verbosity, and to an illusion of omnipotent control of the object. Interpretations focusing on conflicting desires, or linking repressed and displaced parts of the personality with the defenses against them, do not reach these patients in a way that facilitates psychic change. An alternative approach, it is suggested, is to work at primitive, nonsymbolic levels of mental functioning, where experience cannot be verbally communicated and dynamically interpreted, but must first be lived in the here and now of the analysis. This is illustrated through the analysis of a person trying to cope with the experience of early loss by deadening emotion and finding shelter in obsessionality.

A 9-year-old girl with persistent obsessive and compulsive behaviors in a primary care pediatric practice.

CASE: Chloe is a 9-year-old gal whose mother made an initial visit to a new pediatrician for concerns about her behavior. Chloe is apprehensive about the visit and frequently hides behind her mother.Her parents first noticed Chloe becoming angry and more emotional 3 years ago, which her parents did not initially understand. However, over the past year, she has started to have more worries and unusual behavior.Chloe and her mother report that when she walks through doorways, she will almost always go back and walks through again. At home, she will walk through doorways multiple times and at school, she will pretend she forgot something so her friends do not notice. She often will not walk downstairs and occasionally her mother has to carry her. Clothes are problematic for Chloe. If her father touches something of a specific color and then touches Chloe, she will have to change her clothes or take a shower. Sometimes, she will never be able to wear those clothes again. She had a recent episode where she could not stop tapping a red paper, because if she stopped, she said it would burst into flame. During the 2 weeks before the pediatric visit, symptoms increased to the point that she is now refusing to go to school. When she stays home, she lays in 1 place all day.Chloe is a fourth grade student. The family does not report academic concerns. She has friends. She denies any appetite or sleep problems. She endorses periods of sadness, lack of energy, and decreased interest in social activities, mostly because she worries and is embarrassed. She kept her behaviors hidden from her 5 siblings for the past year, and she talked only to her mother about them. She is worried her friends might discover her behaviors.The family history is notable for multiple paternal family members with anxiety and bipolar disorder and depression on mother's side. A few months ago, Chloe's family adopted a 7-year-old child with special needs from China.Her growth, vital signs, and physical examination are unremarkable. Her mother filled out the Short Mood and Feelings Questionnaire and the Screen for Child Anxiety-Related Emotional Disorders, which both had elevated scores.

Development and evaluation of a computerized intervention for low distress tolerance and its effect on performance on a neutralization task.

BACKGROUND AND OBJECTIVES: A growing body of research has linked high distress intolerance (DI) to obsessions, but not other OCD symptom domains. However, existing research is correlational. Experimental studies are needed, but brief methods for reducing DI are lacking. To address these gaps in the literature, a brief, computerized intervention aimed at reducing DI was developed to determine if changing DI affected obsessional phenomena. METHODS: Individuals reporting high DI were randomized to a treatment or waitlist control group (N = 53). Individuals in the treatment group received the DI treatment (i.e., a 2 h computerized intervention) over two weeks, and then underwent a post-assessment in which DI and obsession-relevant phenomena were measured. Individuals in the control group only received the post-assessment. RESULTS: Analyses revealed a greater reduction in self-reported DI on one measure and smaller decreases in behavioral DI in the intervention condition relative to the waitlist condition, as well as lower in-vivo urges to neutralize an intrusive thought; however, anxious reactivity to the intrusion and neutralization behavior were not affected. Further, bootstrapping analyses revealed that reductions in DI mediated the effect of the intervention on neutralization urges. LIMITATIONS: A clinical sample and placebo control condition were not used. CONCLUSIONS: These results provide experimental evidence for the role of DI in obsessional phenomena, specifically in affecting urges to neutralize intrusions, findings consistent with negative reinforcement models of DI. Further, results revealed that DI can be reduced with a brief, computerized intervention, which has important implications for future experimental research and treatment development.

Testing the Mediating Effects of Obsessive Beliefs in Internet-Based Cognitive Behaviour Therapy for Obsessive-Compulsive Disorder: Results from a Randomized Controlled Trial.

UNLABELLED: Although cognitive interventions for obsessive-compulsive disorder (OCD) have been tested in randomized trials, there are few trials that have tested the specific mechanisms of cognitive interventions, i.e. how they achieve their effects. In this study, we aimed to investigate the mediating effects of a short cognitive intervention in the treatment of OCD and used data from a recently conducted randomized controlled trial where 101 participants were allocated to either Internet-based CBT (ICBT) or to a control condition. Obsessive beliefs were measured at pre-treatment, at the time they had received the cognitive intervention, and also at post-treatment. Weekly OCD symptoms were measured throughout the 10 weeks of treatment. We hypothesized that (1) the ICBT group would have greater reductions in obsessive beliefs (controlling for change in OCD symptoms) after completing the cognitive intervention, and that (2) this reduction would, in turn, predict greater OCD symptom reduction throughout the rest of the treatment period. Contrary to our expectations, the longitudinal mediation analysis indicated that (1) being randomized to ICBT actually increased the degree of obsessive beliefs after receiving the cognitive intervention at weeks 1-3, and (2) increase in obsessive beliefs predicted better outcome later in treatment. However, when repeating the analysis using cross-sectional data at post-treatment, the results were in line with the initial hypotheses. Results were replicated when the control condition received ICBT. We conclude that, although obsessive beliefs were significantly reduced at post-treatment for the ICBT group, early increase rather than decrease in obsessive beliefs predicted favourable outcome. KEY PRACTITIONER MESSAGE: This study investigated the impact of cognitive interventions on obsessive beliefs for patients with obsessive-compulsive disorder. Results showed that a sudden increase in obsessive beliefs is not an indicator of worse treatment response. On the contrary, it is more likely that the patient is better off when having this sudden increase. Clinicians should not be alarmed if the patient has a sudden increase in obsessive beliefs, but we do recommend the clinician to investigate the reasons for this further.

Musical obsessions: a comprehensive review of neglected clinical phenomena.

Intrusive musical imagery (IMI) consists of involuntarily recalled, short, looping fragments of melodies. Musical obsessions are distressing, impairing forms of IMI that merit investigation in their own right and, more generally, research into these phenomena may broaden our understanding of obsessive-compulsive disorder (OCD), which is phenomenologically and etiologically heterogeneous. We present the first comprehensive review of musical obsessions, based on the largest set of case descriptions ever assembled (N=96). Characteristics of musical obsessions are described and compared with normal IMI, musical hallucinations, and visual obsessional imagery. Assessment, differential diagnosis, comorbidity, etiologic hypotheses, and treatments are described. Musical obsessions may be under-diagnosed because they are not adequately assessed by current measures of OCD. Musical obsessions have been misdiagnosed as psychotic phenomena, which has led to ineffective treatment. Accurate diagnosis is important for appropriate treatment. Musical obsessions may respond to treatments that are not recommended for prototypic OCD symptoms.

Converting a Freudian analysis into a Jungian one: obsession, addiction, and an answer from Job.

In his analyses of obsessional patients, Sigmund Freud suggested that they suffered from intrusive cognitions and compulsive activities. Early psychoanalysts delineated the phenomenology of obsessionality, but did not differentiate what is currently termed obsessive-compulsive disorder from obsessional personality. However, it was widely recognized that the success of psychoanalysis with obsessional patients was limited due to rigid characterological defences and transference resistances. The present paper examines the case of a middle-aged obsessional academic who had been treated for nearly twenty years in a 'classical' Freudian psychoanalysis prior to entering Jungian analysis. It examines how persistent focus on Oedipal conflicts undesirably reinforced the transference resistance in this obsessional man, and suggests that focusing instead on diminishing the harshness of the super-ego via the therapeutic alliance, and fostering faith in the salutary aspects of unconscious processing has led to salutary results in this case. The biblical book of Job is adopted as ancient instruction in how to address the scrupulosity and addictive mental structuring of obsessionality in analysis.