Obsessive Psychosis

OBSESSIVE PSYCHOSIS. - In the most modern classifications it is included in the group of the psychoneuroses; it takes its name from the typical symptomatic complex: compulsive or obsessive ideas, represented by a series of individual words or numbers, of representations and of impulses that insinuate themselves into the field of consciousness with a mechanism that is not always identifiable, endowed with elementary and irresistible force.

Obsessive psychoneurosis is characterized by the relation of the conscious "ego" to such ideas; the patient, in fact, contrary to what happens in delusional and demented forms, perceives the absurdity of such manifestations and criticizes them, though he does not succeed in freeing himself from them. We are, therefore, faced with a content of consciousness foreign to the will (parasitic psychism) and with a psychic reaction of defense that attempts to drive it away (defensive psychism). In the past the obsessive idea was not distinguished from the delusional idea of the paranoiac (v. PARANOIA); it acquired a nosographic value of its own through the work of Griesinger and of Westphal (1887), who defines it as "compulsive idea," and of Donath (1897), who introduces the term "anancasm" (from the Greek ἀνάγειη = necessity, fatality). At first, opinions differed regarding the emotional or intellectual origin of compulsive ideas; at present the possibility is accepted that the obsessive idea may appear as a primitive intrusion (parasitic psychism) into the intellectual sphere, without necessarily being accompanied by an affective reaction. Janet spoke of "psychasthenia," attributing the obsessive disorder to a particular psychic lability. German authors place the group of compulsive ideas in the chapter of constitutional nervousness or nervous asthenia (Schultze), thus admitting a hereditary factor in the mechanism of origin of the disorders; this factor is, in turn, interpreted in different ways: Kraepelin and others assert that it is a matter of a specific heredity, other authors discern hereditary relationships with dysphoric personalities, with manic-depressive psychosis (v.), with schizophrenia (v.) (Bleuler) and also (Fuchs) with epilepsy (v.).

At the basis of the obsessive personality one notes the accentuation of a psychological property that normally constitutes an important component of the psyche: the "tendency to persist and become fixed" of mental acts; an accentuation that determines habits of excessive scrupulousness, tenacity, pedantry, characteristics that constitute the

"perseverative type." This type in itself is nothing but a particular psychological figure, foreign to pathology; naturally, if the aforementioned characteristics are at the service of a normal intellectual activity they can be transformed into socially useful qualities; otherwise, in intellectually poorly endowed individuals, the tendency to persevere gives rise to pedantic and sterile manifestations. At times the characteristics of the "perseverative type" are so accentuated as to assume the appearance of compulsions and gradually shade into the true "anancastic personality" (v. below). According to a purely neurological conception the mechanism of compulsion and of iteration is brought close to that of stuttering and of tics, "spasm of thought" (Stern).

The followers of the psychogenetic theory, which in recent years has made the greatest contribution to the understanding of compulsive disorders, hold instead that it is a matter of a defect of integration of the instinctive tendency to persist and become fixed of mental acts; this tendency, failing to adapt and harmonize itself in a more mature and complex psychological reality, remains isolated and ends by fixing itself upon different psychic contents, thus producing the obsessive picture. In the proponents of this latter tendency the effort directed toward the symbolic interpretation of the anancastic content is constant, through an analysis conducted with the methods of Freudian psychodynamics. Again, on the part of psychoanalytic authors, the mechanism of the emergence of the compulsive idea is explained as a desire to avoid unpleasant thoughts; to achieve this, patients would think continuously of something different, until this persistent polarization of thought would assume the character of compulsion.

A separate physiognomy appears in the group of phobias: in them the feeling of repugnance and terror that subjects display toward certain objects or animals or toward particular situations has the character of a strong emotional reaction, such as to bring the content of the phobia back to consciousness continuously, in an obsessive manner.

From the point of view of symptomatology, obsessive ideas must be considered according to their intrinsic qualities and the behavior of the patient.

With respect to intrinsic qualities, a distinction is made between: 1) compulsive images, iterative repetitions especially of optical or auditory representations (verses, musical passages, scenes with sexual content, of massacres, etc.). 2) Compulsive ideas. - a) devoid of real affective charge, e.g., the compulsion to perform useless calculations continuously, to enumerate historical dates, to ask oneself absurd and puerile questions that cannot have an answer (why does man have two legs?, why are trees green?, etc.); b) which bear a more or less accentuated affective charge, e.g., the doubt of having left the gas tap open, of having forgotten the key in the lock, of not having fully repaid a sum, of not having made an exhaustive confession, etc. 3) Compulsive impulses. - a) "primary" if they appear independently of an idea, e.g., touching objects repeatedly, performing complicated and purposeless rituals (frequently observed in psychopathic children); b) "secondary" if they follow the appearance of a primitive compulsive idea, e.g., impulses to blaspheme or to perform improper acts in environments in which such acts contrast vividly, as in church or in society; impulses to kill a loved one, to commit suicide, etc. In some cases the compulsive action has the evident task of putting an end to the anguished state aroused by the obsessive idea. Thus, for example, in the case of a patient of Westphal, who, assailed by the doubt of having signed every piece of paper he saw and immediately associating with this the fear that someone might abuse his signature, resolved the state of anguish that assailed him only by tearing up all the sheets of paper around him, though being perfectly conscious of the absurdity of his behavior.

As for the behavior of the subject, it varies in relation to the defensive psychism and to the affective reactions that may be present: 1) The patient passively accepts the compulsion with a fatalistic resignation, adapting himself to the disorder; the criticism that he manifests often has the appearance of a purely formal acknowledgment; the patient, in other words, does not try to resist the compulsion, and this does not provoke any reaction of anxiety; he performs the ceremonials, repeats gestures and words, considering this inevitable. The result is frequently an asocial and egoistic behavior, in that everything is subordinated to the execution of the compulsions; the patient minimizes his manifestations, never turns to the doctor, but is brought to him by family members, who are often forced to take part in the strangest ceremonials in order to satisfy the obsessive impulses of their relative. One then speaks of an "anancastic personality," which some authors classify among the psychoses, and in fact the symptomatology often suggests that of a schizophrenic "defect." 2) The patient has a lively and intimate defense psychism and is profoundly conscious of the disorder; he suffers anxiously from the parasitic ideas that beset him, which absorb his psychic energies, thus excluding more vital and real interests. The anxiety derives above all from the sensation of impotence in controlling the compulsive idea and from the possible doubt of yielding to the obsessive impulse. At times, as has been seen, the obsessive ideas have a reprehensible content that can, in itself, frighten the patient; in such cases the anxiety may appear, at first, not so much linked to the parasitic character of the compulsion as to what it represents and to the fear of being able to carry out the blameworthy impulse. This category of patients, unlike the preceding one, often requires the help of the psychiatrist.

With regard to course, obsessive psychosis generally begins at a young age and evolves rather rapidly; it is not rare to find in the anamnesis an external event that precedes the obsessive disorder and acts toward it as a triggering factor. The course, apart from therapy, varies according to the severity of the symptoms; there exist mild forms lasting a few months and more severe forms in which the morbid episodes follow one another as in the true "anancastic personality," without hope of remission or of arrest of the symptomatology.

From the standpoint of diagnosis, the disease must be differentiated above all from certain forms of schizophrenia; there also exist compulsive episodes of periodic recurrence, with a strong depressive component, which must be considered as distinctive forms (Bonhoeffer; v. PSICOSI MANIACO DEPRESSIVE). The presence of obsessive disturbances in the multiform picture of neurasthenia is frequent. From the compulsive idea, finally, the "dominant idea" must be distinguished, always accompanied by a strong charge of primary anxiety.

As curative treatment, psychotherapy is to be applied according to the different etiopathogenetic theories. In some very severe cases, electro-shock therapy may be attempted, with the method of "annihilation" (Bini-Bazzi); in general the symptom disappears only temporarily. Psycho-surgery (prefrontal leucotomy), because of the uncertainty of the results and the frequent deterioration of the personality to which it can give rise, is to be advised against from the medical standpoint and in general appears doubtfully licit from the moral aspect.

Mannuccio Mannucci

MORAL IMPUTABILITY

The patient with obsessive psychosis cannot be considered a mentally ill person in the strict sense of the word, being normally endowed with sound understanding, normal critical faculty, and the capacity for freely willed acts. Nevertheless, in the particular moments when he is dominated by the obsessive idea and by the compulsive impulse, he cannot be considered capable of deliberate consent, in relation to the irresistible determining power of the idea charged with affective tone, persistently embedded in the course of thought, and because of the natural tendency that every idea has to turn into action (A. Eymieu, op. cit., in bibl.). In relation to this, his moral and juridical responsibility is usually greatly diminished, often totally abolished; on this point, more than a general criterion of judgment, what counts is the study of the individual case in relation to the intensity, the persistence, and the chronicity of the disorder (v. PSICOPATICHE PERSONALITÀ). As a general rule, it is advisable to reassure the subject regarding the imputability of his obsessive thoughts and his compulsive impulses, without however completely and generically absolving him of responsibility for everything that passes through his mind or is done by him.

Giuseppe de Nismo