Psychological theories of OCD have encompassed psychoanalytic as well as more general non-psychodynamic aetiological approaches, focusing alternatively on volitional, intellectual, and/or emotional impairment. Freud's famous patient, the Rat Man, has been seen as a paradigm of a psychologically determined illness, illustrating the central role of anal sadistic concerns with control, ambivalence, magical thinking, and the salience of defences such as reaction formation, intellectualization, isolation, and undoing.(31) Freud went on to formulate a theory of pregenital organization of the libido, determined by constitutional rather than experimental factors, and crucial to the obsessional neurosis. He also provided fascinating speculations on the similarity between obsessive-compulsive phenomena, children's games, and religious rites. Later, Anna Freud(32) stated that: 'obsessional outcomes are promoted by a constitutional increase in the intensity of the anal-sadistic tendencies probably as the result of inheritance combined with parental handling'. However, despite the beautifully described dynamics of obsessional symptoms, most illustrative of unconscious processes, the psychoanalysts have also pointed out the extreme difficulty in treating severe OCD with classical analytic treatment.
Even though psychological factors are insufficient to cause Tourette's disorder, tic behaviours have long been identified as stress-sensitive conditions, and an intimate association has been noted between the content and timing of tics and dynamically important events in the lives of children.
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