OBSESSIVE PSYCHOSIS. — In the more modern classifications, it is included in the group of psychoneuroses; it takes its name from the typical symptom complex: compulsive or obsessive ideas, represented by a series of individual words or figures, representations, and impulses that insinuate themselves into the field of consciousness through a mechanism that is not always identifiable, endowed with elementary and irresistible force.
Obsessive psychoneurosis is characterized by the relationship of the conscious «ego» to such ideas; the patient, in fact, unlike what occurs in delusional and demential forms, perceives the absurdity of these manifestations and criticizes them, although he is unable to free himself from them. We are therefore confronted with a content of consciousness foreign to the will (parasitic psychism) and with a psychic defensive reaction 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 Westphal (1887), who defined it as a «compulsive idea», and of Donath (1897), who introduced the term «anancasm» (from the Greek ἀνάγειη = necessity, fatality). At first, opinions differed concerning the emotional or intellectual origin of compulsive ideas; it is currently 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 obsessive disorder to a particular psychic lability. German authors place the group of compulsive ideas in the chapter on nervousness or constitutional nervous asthenia (Schultze), thereby admitting a hereditary factor in the mechanism underlying the origin of the disorders; this factor, in turn, is interpreted in various ways: Kraepelin and others maintain that it involves a specific heredity, while other authors discern hereditary relationships with dysphoric personalities, manic-depressive psychosis (v.), schizophrenia (v.) (Bleuler), and also (Fuchs) 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 of mental acts to persist and become fixed»; an accentuation that produces habits of excessive scrupulousness, tenacity, and pedantry, characteristics that constitute the
«perseverative type». This type in itself is merely a particular psychological configuration, unrelated to pathology; naturally, if the aforementioned characteristics serve a normal intellectual activity, they may 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 that they assume the appearance of compulsions and gradually shade into the true «anancastic personality» (v. below). According to a strictly neurological conception, the mechanism of compulsion and iteration is brought close to that of stammering and tics, a «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, instead consider the condition to involve a defect in the integration of the instinctive tendency of mental acts to persist and become fixed; unable to adapt and harmonize itself within a more mature and complex psychological reality, this tendency remains isolated and ultimately becomes fixed upon different psychic contents, thereby producing the obsessive picture. Among the proponents of this latter tendency, there is a constant effort to interpret the anancastic content symbolically, through an analysis conducted using the methods of Freudian psychodynamics. Psychoanalytic authors likewise explain the mechanism underlying the emergence of the compulsive idea as a desire to avoid unpleasant thoughts; in order to achieve this, patients would think continuously about something else, until this persistent polarization of thought assumed the character of compulsion.
A distinct configuration appears in the group of phobias: in them, the feeling of repugnance and terror that subjects experience toward certain objects or animals, or in particular situations, has the character of a strong emotional reaction, such as to bring the content of the phobia continually back into consciousness in an obsessive manner.
From the standpoint of symptomatology, obsessive ideas must be considered according to their intrinsic qualities and the patient’s behavior.
With regard to their intrinsic qualities, the following are distinguished: 1) compulsive images, iterative repetitions, especially of visual or auditory representations (verses, musical passages, scenes with sexual content, scenes of massacres, etc.). 2) Compulsive ideas. — a) lacking any real affective charge, e.g., the compulsion to perform useless calculations continuously, to enumerate historical dates, to ask absurd and childish questions that cannot be answered (why does man have two legs?, why are trees green?, etc.); b) bearing a more or less pronounced affective charge, e.g., the doubt that one has left the gas tap open, forgotten the key in the lock, failed to return a sum in full, failed to make a sufficiently exhaustive confession, etc. 3) Compulsive impulses. — a) «primary» when they appear independently of an idea, e.g., repeatedly touching objects, performing complicated and purposeless rituals (frequently observed in psychopathic children); b) «secondary» when they follow the appearance of a primitive compulsive idea, e.g., impulses to blaspheme or to perform improper acts in environments where such acts would strongly conflict with the setting, such as in church or in company; impulses to kill a loved one, to commit suicide, etc. In some cases, the compulsive action clearly serves to put an end to the anguished state aroused by the obsessive idea. Thus, for example, in the case of a patient of Westphal’s, who, assailed by the doubt that he had signed every piece of paper he saw and immediately associating with this the fear that someone might misuse his signature, resolved the state of anguish that overcame him only by tearing up all the sheets of paper around him, while being perfectly conscious of the absurdity of his behavior.
As for the subject’s behavior, it varies in relation to the defensive psychism and to any affective reactions that may be present: 1) The patient passively accepts the compulsion with fatalistic resignation, adapting himself to the disorder; the criticism he expresses often has the appearance of a purely formal acknowledgment; the
The patient, in other words, does not seek to resist the compulsion, and this provokes no reaction of anxiety; he performs the ceremonials, repeats gestures and words, considering this inevitable. This frequently results in asocial and egotistical behavior, since everything is subordinated to the performance of the compulsions; the patient minimizes his manifestations and never consults a physician, but is brought to one by his family, who are often compelled 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 possesses a lively and intimate defensive psychism and is profoundly conscious of the disorder; he suffers agonizingly from the parasitic ideas that torment him and absorb his psychic energies, thereby excluding more vital and real interests. The anxiety derives above all from the feeling of helplessness in controlling the compulsive idea and from the possible doubt that he may yield to the obsessive impulse. Sometimes, as has been seen, obsessive ideas have a reprehensible content that may, in itself, frighten the patient; in such cases the anxiety may at first appear to be linked not so much 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 a psychiatrist.
With regard to its course, p. o. generally begins at a young age and progresses rather rapidly; it is not uncommon to find in the anamnesis an external event that precedes the obsessive disorder and acts toward it as a triggering factor. The course, irrespective of therapy, varies according to the severity of the symptoms; there are mild forms lasting a few months and more severe forms in which morbid episodes follow one another, as in the true “anancastic personality,” without hope of remission or arrest of the symptomatology.
From the diagnostic standpoint, the illness must be differentiated above all from certain forms of schizophrenia; there are also compulsive episodes recurring periodically, with a strong depressive component, which must be regarded as distinct forms (Bonhoeffer; V. PSICOSI MANIACO DEPRESSIVE). The presence of obsessive disorders is frequent in the multiform picture of neurasthenia. Finally, the compulsive idea must be distinguished from the “dominant idea,” which is always accompanied by a strong charge of primary anxiety.
As curative treatment, psychotherapy is to be applied according to the various etiopathogenetic theories. In some very severe cases, electroshock therapy may be attempted, using the method of “annihilation” (Bini-Bazzi); generally, the symptom disappears only temporarily. Psychosurgery (prefrontal leucotomy), because of the uncertainty of its results and the frequent deterioration of the personality to which it may give rise, should be discouraged from the medical standpoint and, in general, appears dubiously licit from the moral standpoint.
Mannuccio Mannucci
MORAL IMPUTABILITY. — The patient suffering from o. p. cannot be considered mentally ill in the strict sense of the word, since he is normally endowed with sound understanding, normal critical capacity, and the ability to perform 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, given the irresistible determining power of the idea charged with affective colouring, persistently embedded in the course of thought, and because of the natural tendency of every idea to turn into action (A. Eymieu, op. cit., in the bibliography). In this regard, his moral and legal responsibility is usually greatly diminished, and often entirely abolished; on this point, rather than a general criterion of judgment, what matters is the study of the individual case in relation to the intensity, persistence, and chronicity of the disorder (v. PSICOPATICHE PERSONALITÀ). In general, it is advisable to reassure the subject concerning his imputability for his obsessive thoughts and compulsive impulses, without, however, completely and indiscriminately relieving him of responsibility for everything that passes through his mind or is done by him.