PSYCHOSIS OBSESSIVA. – In the most modern classifications it is included in the group of psychoneuroses, and takes its name from the typical symptomatic complex: compulsive or obsessive ideas, represented by a series of individual words or numbers, images and impulses that insinuate themselves into the field of consciousness through a mechanism not always identifiable, endowed with elemental and irresistible force.
Obsessive psychoneurosis is characterized by the relationship of the ego or conscious mind to such ideas; the patient, in fact, unlike what happens in delirious and demential forms, is aware of the absurdity of these manifestations and criticizes them, yet is unable to free himself from them. We are thus faced with a content of consciousness that is alien to the will (parasitic psychic activity) and with a psychic reaction of defense that tends to drive it away (defensive psychic activity). In the past, the obsessive idea was not distinguished from the delusional idea of the paranoiac (v. PARANOIA); it acquires a nosographic value of its own through the work of Griesinger and Westphal (1887), who define it as “compulsive idea,” and of Donath (1897), who introduces the term “anancasm” (from the Greek ἀναγνώσκω = necessity, fatality). At first, various opinions were held regarding the emotional or intellectual origin of compulsive ideas; currently, it is accepted that the obsessive idea may appear as a primitive intrusion (parasitic psychic activity) into the intellectual sphere, without necessarily being accompanied by an affective reaction. Janet spoke of “psychasthenia,” attributing the obsessive disturbance to a particular psychic lability. German authors place the group of compulsive ideas in the chapter on nervousness or constitutional nervous asthenia (Schultze), thus admitting a hereditary factor in the origin of the disturbances; this factor, in turn, is interpreted in various ways: Kraepelin and others affirm that it is a matter of specific heredity, while other authors see hereditary connections with dysphoric personalities, with manic-depressive psychosis (v.), with schizophrenia (v.) (Bleuler), and even (Fuchs) with epilepsy (v.).
At the root of the obsessive personality, one notes the accentuation of a psychological property, which normally constitutes an important component of the psyche: the tendency to persist and fix mental acts; this accentuation determines habits of excessive scrupulousness, tenacity, pedantry—characteristics that constitute the “persecutory type.” This type in itself is nothing more than a particular psychological figure, alien to pathology; naturally, if the aforementioned characteristics serve a normal intellectual activity, they can be transformed into socially useful qualities; otherwise, in individuals of limited intellectual endowment, the tendency to perseverate gives rise to pedantic and sterile manifestations. Sometimes the characteristics of the “persecutory type” are so accentuated as to assume the aspect of compulsions and gradually fade into the true “anancastic personality” (v. below). According to a purely neuro-logical conception, the mechanism of compulsion and iteration is likened to that of balbuties and tics, “spasms of thought” (Stern).
The followers of the psychogenetic theory, which in recent years has made the greatest contribution to the understanding of compulsive disturbances, instead believe these to be a defect in the integration of the instinctive tendency to persist and fix mental acts; this tendency, failing to adapt and harmonize within a more mature and complex psychological reality, remains isolated and ends up fixing itself to different psychic contents, thus producing the obsessive picture. Among the proponents of this latter trend, there is a constant effort directed toward the symbolic interpretation of the anancastic content, through an analysis conducted with the methods of Freudian psychodynamics. Even among psychoanalytic authors, the mechanism of the onset of the compulsive idea is explained as a desire to avoid spiritual thoughts; to achieve this, patients continually think of something else, until this persistent polarization of thought assumes the character of compulsion.
A distinct physiognomy appears in the group of phobias: in these, the feeling of repugnance and terror that subjects experience toward certain objects or animals or particular situations has the character of a strong emotional reaction, such as to continually bring the content of the phobia back to consciousness in an obsessive manner.
From the point of view of symptomatology, obsessive ideas should be considered according to their intrinsic qualities and the patient’s behavior.
With regard to intrinsic qualities, they are distinguished as: 1) compulsive images, repetitive iterations especially of optical or auditory representations (verses, musical passages, scenes with sexual content, massacres, etc.). 2) Compulsive ideas. – a) devoid of real affective charge, e.g., compulsion to count steps, adopt childish mannerisms that cannot be justified (why does man have two legs? why are trees green? etc.); b) those that carry a more or less pronounced affective charge, e.g., doubt about having left the gas tap open, having forgotten the key in the lock, not having returned a sum of money in full, not having made a full confession, etc.
Compulsive impulses. – a) “primary” if they appear independently of an idea, e.g., repeatedly touching objects, performing complicated and purposeless rituals (frequently observed in psychopathic children); b) “secondary” if they follow the appearance of a primary compulsive idea, e.g., impulses to blaspheme or perform improper acts in environments where such acts are strongly inappropriate, such 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 purpose of putting an end to the anguished state aroused by the obsessive idea. Thus, for example, in the case of a patient described by 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, could only relieve the anguish that assailed him by tearing up all the sheets of paper around him, even though he was perfectly aware of the absurdity of his behavior.
As for the patient’s behavior, it varies in relation to the defensive psychic activity and any affective reactions that may be present: 1) The patient passively accepts the compulsion with a fatalistic resignation, adapting to the disturbance; the criticism he manifests often has the appearance of a purely formal acknowledgment; the
The patient, in other words, does not attempt to resist the compulsion, and this does not provoke any reaction of distress; he performs the rituals, repeats gestures and words, considering it inevitable. This frequently results in asocial and selfish behaviour, since everything is subordinated to the execution of the compulsions; the patient minimizes his manifestations, never consults a doctor himself, but is brought by his family, who are often forced to take part in the most bizarre rituals to satisfy the obsessive impulses of the relative. This is then referred to as a “personalistic anarchistic” personality, which some authors classify among the psychoses, and indeed the symptomatology often suggests that of a “defective” schizophrenic. 2) The patient possesses a lively and intimate psychic defence mechanism and is deeply conscious of the disturbance; he suffers anguishfully from the parasitic ideas that harass him, which absorb his psychic energies, thus excluding more vital and real interests. The anguish derives above all from the sensation of impotence to control the obsessive idea and from the possible doubt of yielding to the obsessive impulse. Sometimes, as has been seen, the obsessive ideas have a reprehensible content that may, in itself, frighten the patient; in such cases, the anguish may at first appear not so much linked to the parasitic nature of the compulsion as to what it represents and to the fear of being able to carry out the harmful impulse. This category of patients, unlike the previous one, often requires the help of the psychiatrist.
As regards the course, p. o. generally begins at a young age and evolves rather rapidly; it is not rare to find in the anamnesis an external event preceding the obsessive disturbance and acting as a triggering factor. The course, apart from therapy, varies according to the severity of the symptoms; there are mild forms lasting a few months and more severe forms in which the morbid episodes succeed one another as in the true “personalistic anarchistic” personality, without hope of remission or arrest of the symptomatology.
From the point of view of diagnosis, the disease must be distinguished above all from certain forms of schizophrenia; there are also compulsive episodes with periodic recurrence, with a strong depressive component, which must be considered as dysthymic forms (Bonhoeffer; V. PSICOSI MANIACO-DEPRESSIVA). Frequent is the presence of obsessive disturbances in the multifarious picture of neurasthenia. Finally, the “dominant idea,” always accompanied by a strong charge of primary anxiety, must be distinguished from the obsessive idea.
As for curative treatment, psychotherapy must be applied according to the various aetiopathogenetic theories. In some very serious cases, electro-shock therapy may be attempted, with the “annihilation” method (Bini-Bazzi); generally, 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 may give rise, is to be discouraged from the medical point of view and, in general, appears dubiously licit from the moral point of view.
Manuccio Mannucci
MORAL IMPUTABILITY. — The sufferer from p. o. cannot be considered a mentally ill person in the strict sense of the word, since he is normally endowed with correct 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 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 by the natural tendency that every idea has to turn into action (A. Eymieu, op. cit., in bibl.). In relation to this, his moral and legal responsibility is usually greatly diminished, often totally abolished; on this point, more than a general criterion of judgment, the study of the individual case in relation to the intensity, persistence, and chronicity of the disturbance is valid (v. PSICOPATICHE PERSONALITÀ). In general, it is advisable to reassure the subject regarding the imputability of his obsessive thoughts and compulsive impulses, without however completely and generically absolving him of responsibility for everything that passes through his mind or is done by him.