Obsessions and phobias their psychical mechanism and their aetiology 1 страница

(1895)

I shall begin by challenging two assertions which are often found repeated in regard to the syndromes ‘obsessions’ and ‘phobias’. It must be said, first, that they cannot be included under neurasthenia proper, since the patients afflicted with these symptoms are no more often neurasthenics than not; and secondly, that we are not justified in regarding them as the effect of mental degeneracy, because they are found in persons no more degenerate than the majority of neurotics in general, because they sometimes improve, and sometimes, indeed, we even succeed in curing them.¹

Obsessions and phobias are separate neuroses, with a special mechanism and aetiology which I have succeeded in demonstrating in a certain number of cases, and which, I hope, will prove similar in a good number of fresh cases.

As regards classification of the subject, I propose in the first place to exclude a group of intense obsessions which are nothing but memories, unaltered images of important events. As an example, I may cite Pascal’s obsession: he always thought he saw an abyss on his left hand ‘after he had nearly been thrown into the Seine in his coach’. Such obsessions and phobias, which might be called traumatic, are allied to the symptoms of hysteria.

Apart from this group we must distinguish: (a) true obsessions; (b) phobias. The essential difference between them is the following:

Two constituents are found in every obsession: (1) an idea that forces itself upon the patient; (2) an associated emotional state. Now in the group of phobias this emotional state is always one of ‘anxiety’, while in true obsessions other emotional states, such as doubt, remorse, or anger, may occur just as well as anxiety. I will first attempt to explain the really remarkable psychological mechanism of true obsessions, a mechanism quite different from that of the phobias.

¹ I am very glad to find that the authors of the most recent work on this subject express opinions very similar to mine. Cf. Gélineau (1894), and Hack Tuke (1894).

I

In many true obsessions it is quite plain that the emotional state is the principal thing, since that state persists unchanged while the idea associated with it varies. The girl in Case 1 quoted below, for example, felt remorse in some degree for all sorts of reasons - for having stolen, for having ill-treated her sisters, for having made counterfeit money, etc. People who doubt have many doubts at the same time or in succession. It is the emotional state which remains constant in them; the idea changes. In other cases the idea, too, seems fixated, as in Case 4, of the girl who pursued the servants in the house with an incomprehensible hatred, though constantly changing the individual object.

Now a careful psychological analysis of these cases shows that the emotional state, as such, is always justified. The girl in Case 1, who suffered from remorse, had good reasons for it; the women in Case 3 who doubted their powers of resistance to temptation knew very well why. The girl in Case 4, who detested servants, had good reasons for complaining, etc. Only, and it is in these two characteristics that the pathological mark lies, (1) the emotional state persists indefinitely, and, (2) the associated idea is no longer the appropriate original one, related to the aetiology of the obsession, but is one which replaces it, a substitute for it.

The proof of this is the fact that we can always find in the previous history of the patient, at the beginning of the obsession, the original idea that has been replaced. The replaced ideas all have common attributes; they correspond to really distressing experiences in the subject’s sexual life which he is striving to forget. He succeeds merely in replacing the incompatible idea by another ill-adapted for being associated with the emotional state, which for its part remains unchanged. It is this mésalliance between the emotional state and the associated idea that accounts for the absurdity so characteristic of obsessions.

I will now bring forward my observations and conclude with an attempt at a theoretical explanation.

Case 1. A girl reproached herself for things which she knew were absurd: for having stolen, for having made counterfeit money, for being involved in a conspiracy, etc., according to what she happened to have been reading during the day.

Reinstatement of the replaced idea: She reproached herself with the masturbation she had been practising in secret without being able to renounce it. She was cured by careful surveillance which prevented her from masturbating.

Case 2. A young man, a medical student, suffered from an analogous obsession. He reproached himself for all sorts of immoral acts: for having killed his cousin, for having violated his sister, for having set fire to a house, etc. He got to the point of having to turn round in the street to see whether he had not killed the last passer-by.

Reinstatement: He had been much affected by reading in a quasi-medical book that masturbation, to which he was addicted, destroyed one’s morale.

Case 3. Several women complained of an obsessional impulse to throw themselves out of the window, to stab their children with knives, scissors, etc.

Reinstatement: Obsessions based on typical temptations. These were women who, not being at all satisfied in marriage, had to struggle against the desires and voluptuous ideas that constantly troubled them at the sight of other men.

Case 4. A girl who was perfectly sane and very intelligent displayed an uncontrollable hatred against the servants in the house. It had been started in connection with an impertinent servant, and had been transferred from servant to servant, to an extent that made housekeeping impossible. The feeling was a mixture of hate and disgust. She gave as a reason for it that the coarseness of these girls spoilt her idea of love.

Reinstatement: This girl had been an involuntary witness of a love-scene in which her mother had taken part. She had hidden her face, had stopped up her ears, and had done her utmost to forget it, as it disgusted her and would have made it impossible for her to remain with her mother, whom she loved tenderly. She succeeded in her efforts; but her anger at her idea of love having been defiled persisted within her, and this emotional state soon linked itself to the idea of a person who could take her mother’s place.

Case 5. A girl had become almost completely isolated on account of an obsessional fear of incontinence of urine. She could no longer leave her room or receive visitors without having urinated a number of times. When she was at home or entirely alone the fear did not trouble her.

Reinstatement: It was an obsession based on temptation or mistrust. She did not mistrust her bladder, but her resistance to erotic impulses. The origin of the obsession shows this clearly. Once, at the theatre, on seeing a man who attracted her, she had felt an erotic desire, accompanied (as spontaneous pollutions in women always are) by a desire to urinate. She was obliged to leave the theatre, and from that moment on she was a prey to the fear of having the same sensation, but the desire to urinate had replaced the erotic one. She was completely cured.

Although the cases I have enumerated show varying degrees of complexity, they have this in common: the original (incompatible) idea has been replaced by another idea, the substituted idea. In the cases which I now append, the original idea has been replaced, but not by another idea; it has been replaced by acts or impulses which originally served as measures of relief or as protective procedures, and are now grotesquely associated with an emotional state which does not fit them, but which has persisted unchanged, and which has remained as justifiable as it was at its origin.

Case 6. Obsessional arithmomania. - A woman found herself obliged to count the boards in the floor, the steps in the stair case, etc. - acts which she performed in a ridiculous state of anxiety.

Reinstatement: She had begun the counting in order to distract her mind from obsessional ideas (of temptation). She had succeeded in doing so, but the impulse to count had replaced the original obsession.

Case 7.Obsessional brooding and speculating. - A woman suffered from attacks of this obsession which ceased only when she was ill, and then gave place to hypochondriacal fears. The theme of her worry was always a part or function of her body; for example, respiration: ‘Why must I breathe? Suppose I didn’t want to breathe?’ etc.

Reinstatement: At the very beginning she had suffered from the fear of becoming insane, a hypochondriacal phobia common enough among women who are not satisfied by their husbands, as she was not. To assure herself that she was not going mad, that she was still in possession of her mental faculties, she had begun to ask herself questions and concern herself with serious problems. This calmed her at first, but with time the habit of speculation replaced the phobia. For more than fifteen years, periods of fear (pathophobia) and of obsessive speculating had alternated in her.

Case 8. Folie du doute. - Several cases showed the typical symptoms of this obsession but were explained very simply. These persons had suffered or were still suffering from various obsessions, and the knowledge that the obsessions had disturbed all their acts and had many times interrupted their train of thought provoked a legitimate doubt about the reliability of their memory. The confidence of each one of us is shaken, and we all of us have to re-read a letter or repeat a calculation if our attention has been distracted several times during the performance of the act. Doubt is a quite logical result when obsessions are present.

Case 9. Folie du doute (Hesitation). - The girl in Case 4 had become extremely slow in the performance of all her everyday actions, particularly in her toilet. She took hours to tie her shoe laces or to clean her finger-nails. By way of explanation she said she could not make her toilet while the obsessional ideas were occupying her, nor immediately afterwards. As a result, she had become accustomed to wait a definite length of time after each return of the obsessional idea.

Case 10. Folie du doute. (Fear of scraps of paper.) - A young woman had suffered from scruples after having written a letter; at the same time she collected all the pieces of paper she saw. She explained this by confessing to a love which she had formerly refused to admit. As a result of constantly repeating her lover’s name, she was seized with a fear that the name might have slipped off the end of her pen, that she might have written it upon some scrap of paper in a pensive moment.¹

Case 11. Mysophobia. - A woman kept washing her hands constantly and touched door-handles only with her elbow.

Reinstatement: It was the case of Lady Macbeth. The washing was symbolic, designed to replace by physical purity the moral purity which she regretted having lost. She tormented herself with remorse for conjugal infidelity, the memory of which she had resolved to banish from her mind. In addition, she used to wash her genitals.

As regards the theory of this process of substitution, I will content myself with answering three questions that arise here.

(1) How can the substitution come about?

It seems to be the expression of a special inherited mental disposition. At any rate, ‘similar heredity’ is often enough found in obsessional cases, and in hysteria. Thus the patient in Case 2 told me that his father had suffered from similar symptoms. He once introduced me to a first cousin who had obsessions and a tic convulsif; and to his sister’s daughter, aged eleven, who already gave evidence of obsessions (probably of remorse).

(2) What is the motive for the substitution?

I think it may be regarded as an act of defence (Abwehr) of the ego against the incompatible idea. Among my patients there are some who remember a deliberate effort to banish the distressing idea or recollection from the field of consciousness. (See Cases 3, 4, 11.) In other cases the expulsion of the incompatible idea is brought about which has left no trace in the patient’s memory.

(3) Why does the emotional state that is associated with the obsessional idea persist indefinitely instead of vanishing like other states of our ego?

This question may be answered by reference to the theory of the genesis of hysterical symptoms developed by Breuer and myself.¹ Here I will only remark that, by the very fact of the substitution, the disappearance of the emotional state is rendered impossible.

¹ Cf. the German popular song:

Auf jedes weisse Blatt Papier möcht’ ich es schreiben:

Dein ist mein Herz und soll es ewig, ewig bleiben.II

In addition to these two groups of true obsessions there is the class of ‘phobias’, which must now be considered. I have already mentioned the great difference between obsessions and phobias: that in the latter the emotion is always one of anxiety, fear. I might add that obsessions are varied and more specialized, phobias are more monotonous and typical. But this distinction is not of capital importance.

Among the phobias, also, two groups may be differentiated, according to the nature of the object feared: (1) common phobias, an exaggerated fear of things that everyone detests or fears to some extent: such as night, solitude, death, illnesses, dangers in general, snakes, etc.; (2) contingent phobias, the fear of special conditions that inspire no fear in the normal man; for example, agoraphobia and the other phobias of locomotion. It is interesting to note that these phobias have not the obsessive feature that characterizes true obsessions and the common phobias. The emotional state appears in their instance only under special conditions which the patient carefully avoids.

The mechanism of phobias is entirely different from that of obsessions. Substitution is no longer the predominant feature in the former; psychological analysis reveals no incompatible, replaced idea in them. Nothing is ever found but the emotional state of anxiety which, by a kind of selective process, brings up all the ideas adapted to become the subject of a phobia. In the case of agoraphobia, etc., we often find the recollection of an anxiety attack; and what the patient actually fears is the occurrence of such an attack under the special conditions in which he believes he cannot escape it.

¹ ‘On the Psychical Mechanism of Hysterical Phenomena’ (1893a)

The anxiety belonging to this emotional state, which underlies all phobias, is not derived from any memory; we may well wonder what the source of this powerful condition of the nervous system can be.

I hope to be able to demonstrate, on another occasion, that there is reason to distinguish a special neurosis, the ‘anxiety neurosis’, of which the chief symptom is this emotional state. I shall then enumerate its various symptoms and insist on the necessity for differentiating this neurosis from neurasthenia, with which it is now confused. Phobias, then, are part of the anxiety neurosis, and are almost always accompanied by other symptoms of the same group.

The anxiety neurosis, too, has a sexual origin as far as I can see, but it does not attach itself to ideas taken from sexual life; properly speaking, it has no psychical mechanism. Its specific cause is the accumulation of sexual tension, produced by abstinence or by unconsummated sexual excitation (using the term as a general formula for the effects of, of relative impotence in the husband, of excitation without satisfaction in engaged couples, of enforced abstinence, etc.).

It is under such conditions, extremely frequent in modern society, especially among women, that anxiety neurosis (of which phobias are a psychical manifestation) develops.

In conclusion I may point out that combinations of a phobia and an obsession proper may co-exist, and that indeed this is a very frequent occurrence. We may find that a phobia had developed at the beginning of the disease as a symptom of anxiety neurosis. The idea which constitutes the phobia and which is associated with the state of fear may be replaced by another idea or rather by the protective procedure that seemed to relieve the fear. Case 7 (obsessive speculating) presents a neat example of this group: a phobia along with a true substitutive obsession.

ON THE GROUNDS FOR DETACHING A PARTICULAR SYNDROME FROM NEURASTHENIA UNDER THE DESCRIPTION ‘ANXIETY NEUROSIS’(1895)

It is difficult to make any statement of general validity about neurasthenia, so long as we use that name to cover all the things which Beard has included under it. In my opinion, it can be nothing but a gain to neuropathology if we make an attempt to separate from neurasthenia proper all those neurotic disturbances in which, on the one hand, the symptoms are more firmly linked to one another than to the typical symptoms of neurasthenia (such as intracranial pressure, spinal irritation, and dyspepsia with flatulence and constipation); and which, on the other hand, exhibit essential differences in their aetiology and mechanism from the typical neurasthenic neurosis. If we accept this plan, we shall soon obtain a fairly uniform picture of neurasthenia. We shall then be in a position to differentiate from genuine neurasthenia more sharply than has hitherto been possible various pseudo-neurasthenias (such as the clinical picture of the organically determined nasal reflex neurosis, the nervous disorders of the cachexias and arterio-sclerosis, the preliminary stages of general paralysis of the insane, and of some psychoses). Further, it will be possible - as Möbius has proposed - to eliminate some of the status nervosi of hereditarily degenerate individuals; and we shall also discover reasons why a number of neuroses which are to-day described as neurasthenia - in particular, neuroses of an intermittent or periodical nature - ought rather to be included under melancholia. But the most marked change of all will be introduced if we decide to detach from neurasthenia the syndrome which I propose to describe in the following pages and which satisfies especially fully the conditions set out above. The symptoms of this syndrome are clinically much more closely related to one another than to those of genuine neurasthenia (that is, they frequently appear together and they replace one another in the course of the illness); and both the aetiology and the mechanism of this neurosis are fundamentally different from the aetiology and mechanism of genuine neurasthenia as it will be left after this separation has been effected.

I call this syndrome ‘anxiety neurosis’, because all its components can be grouped round the chief symptom of anxiety, because each one of them has a definite relationship to anxiety. I thought that this view of the symptoms of anxiety neurosis had originated with me, until an interesting paper by E. Hecker (1893) came into my hands, in which I found the same interpretation expounded with all the clarity and completeness that could be desired.¹ Nevertheless, although Hecker recognizes certain symptoms as equivalents or rudiments of an anxiety attack, he does not separate them from the domain of neurasthenia, as I propose to do. But this is evidently due to his not having taken into account the difference between the aetiological determinants in the two cases. When this latter difference is recognized there is no longer any necessity for designating anxiety symptoms by the same name as genuine neurasthenic ones; for the principal purpose of giving what is otherwise an arbitrary name is to make it easier to lay down general statements.

¹ Anxiety is actually brought forward as one of the principal symptoms of neurasthenia in a work by Kaan (1893).

ITHE CLINICAL SYMPTOMATOLOGY OF ANXIETY NEUROSIS

What I call ‘anxiety neurosis’ may be observed in a completely developed form or in a rudimentary one, in isolation or combined with other neuroses. It is of course the cases which are in some degree complete and at the same time isolated which give particular support to the impression that anxiety neurosis is a clinical entity. In other cases, where the syndrome corresponds to a ‘mixed neurosis’, we are faced with the task of picking out and separating those symptoms which belong, not to neurasthenia or hysteria, and so on, but to anxiety neurosis.

The clinical picture of anxiety neurosis comprises the following symptoms:

(1) General irritability. This is a common nervous symptom and as such belongs to many status nervosi. I mention it here because it invariably appears in anxiety neurosis and is important theoretically. Increased irritability always points to an accumulation of excitation or an inability to tolerate such an accumulation - that is, to an absolute or a relative accumulation of excitation. One manifestation of this increased irritability seems to me to deserve special mention; I refer to auditory hyperaesthesia, to an oversensitiveness to noise - a symptom which is undoubtedly to be explained by the innate intimate relationship between auditory impressions and fright. Auditory hyperaesthesia frequently turns out to be a cause of sleeplessness, of which more than one form belongs to anxiety neurosis.

(2) Anxious expectation. I cannot better describe the condition I have in mind than by this name and by adding a few examples. A woman, for instance, who suffers from anxious expectation will think of influenzal pneumonia every time her husband coughs when he has a cold, and, in her mind’s eye, will see his funeral go past; if, when she is coming towards the house, she sees two people standing by her front door, she cannot avoid thinking that one of her children has fallen out of the window; when she hears the bell ring, it is someone bringing news of a death, and so on - while on all these occasions there has been no particular ground for exaggerating a mere possibility.

Anxious expectation, of course, shades off imperceptibly into normal anxiety, comprising all that is ordinarily spoken of as anxiousness - or a tendency to take a pessimistic view of things; but at every opportunity it goes beyond a plausible anxiousness of this kind, and it is frequently recognized by the patient himself as a kind of compulsion. For one form of anxious expectation - that relating to the subject’s own health - we may reserve the old term hypochondria. The height reached by the hypochondria is not always parallel with the general anxious expectation; it requires as a precondition the existence of paraesthesias and distressing bodily sensations. Thus hypochondria is the form favoured by genuine neurasthenics when, as often happens, they fall victims to anxiety neurosis.

A further expression of anxious expectation is no doubt to be found in the inclination to moral anxiety, to scrupulousness and pedantry - an inclination which is so often present in people with more than the usual amount of moral sensitiveness and which likewise varies from the normal to an exaggerated form in doubting mania.

Anxious expectation is the nuclear symptom of the neurosis. It openly reveals, too, a portion of the theory of the neurosis. We may perhaps say that here a quantum of anxiety in a freely floating state, which, where there is expectation, controls the choice of ideas and is always ready to link itself with any suitable ideational content.

(3) But anxiousness - which, though mostly latent as regards consciousness, is constantly lurking in the background - has other means of finding expression besides this. It can suddenly break through into consciousness without being aroused by a train of ideas, and thus provoke an anxiety attack. An anxiety attack of this sort may consist of the feeling of anxiety, alone, without any associated idea, or accompanied by the interpretation that is nearest to hand, such as ideas of the extinction of life, or of a stroke, or of a threat of madness; or else some kind of paraesthesia (similar to the hysterical aura) may be combined with the feeling of anxiety, or, finally, the feeling of anxiety may have linked to it a disturbance of one or more of the bodily functions - such as respiration, heart action, vasomotor innervation or glandular activity. From this combination the patient picks out in particular now one, now another, factor. He complains of ‘spasms of the heart’, ‘difficulty in breathing’, ‘outbreaks of sweating’, ‘ravenous hunger’, and such like; and, in his description, the feeling of anxiety often recedes into the background or is referred to quite unrecognizably as ‘being unwell’, ‘feeling uncomfortable’, and so on.

(4) Now it is an interesting fact, and an important one from a diagnostic point of view, that the proportion in which these elements are mixed in an anxiety attack varies to a remarkable degree, and that almost every accompanying symptom alone can constitute the attack just as well as can the anxiety itself. There are consequently rudimentary anxiety attacks and equivalents of anxiety attacks, all probably having the same significance, which exhibit a great wealth of forms that has as yet been little appreciated. A closer study of these larval anxiety-states (as Hecker calls them) and their diagnostic differentiation from other attacks should soon become a necessary task for neuropathologists.

I append here a list which includes only those forms of anxiety attack which are known to me:-

(a) Anxiety attacks accompanied by disturbances of the heart action, such as palpitation, either with transitory arrhythmia or with tachycardia of longer duration which may end in serious weakness of the heart and which is not always easily differentiated from organic heart affection; and, again, pseudo-angina pectoris - diagnostically a delicate subject!

(b) Anxiety attacks accompanied by disturbances of respiration, several forms of nervous dyspnoea, attacks resembling asthma, and the like. I would emphasize that even these attacks are not always accompanied by recognizable anxiety.

(c) Attacks of sweating, often at night.

(d) Attacks of tremor and shivering which are only too easily confused with hysterical attacks.

(e) Attacks of ravenous hunger, often accompanied by vertigo.

(f) Diarrhoea coming on in attacks.

(g) Attacks of locomotor vertigo.

(h) Attacks of what are known as congestions, including practically everything that has been termed vasomotor neurasthenia.

(i) Attacks of paraesthesias. (But these seldom occur without anxiety or a similar feeling of discomfort.)

(5) Waking up at night in a fright (the pavor nocturnus of adults), which is usually combined with anxiety, dyspnoea, sweating and so on, is very often nothing else than a variant of the anxiety attack. This disturbance is the determinant of a second form of sleeplessness within the field of anxiety neurosis. I have become convinced, moreover, that the pavor nocturnus of children, too, exhibits a form which belongs to anxiety neurosis. The streak of hysteria about it, the linking of the anxiety with the reproduction of an appropriate experience or a dream, causes the pavor nocturnus of children to appear as something special. But the pavor can also emerge in a pure form, without any dream or recurring hallucination.

(6) ‘Vertigo’ occupies a prominent place in the group of symptoms of anxiety neurosis. In its mildest form it is best described as ‘giddiness’; in its severer manifestations, as ‘attacks of vertigo’ (with or without anxiety), it must be classed among the gravest symptoms of the neurosis. The vertigo of anxiety neurosis is not rotatory nor does it especially affect certain planes or directions, like Meniere’s vertigo. It belongs to the class of locomotor or co-ordinatory vertigo, as does the vertigo in oculomotor paralysis. It consists in a specific state of discomfort, accompanied by sensations of the ground rocking, of the legs giving way and of its being impossible to stand up any more; while the legs feel as heavy as lead and tremble or the knees bend. This vertigo never leads to a fall. On the other hand, I should like to state that an attack of vertigo of this kind may have its place taken by a profound fainting fit. Other conditions in the nature of fainting occurring in anxiety neurosis appear to depend upon cardiac collapse.

Attacks of vertigo are not seldom accompanied by the worst sort of anxiety, often combined with cardiac and respiratory disturbances. According to my observations, vertigo produced by heights, mountains and precipices is also often present in anxiety neurosis. Furthermore, I am not sure whether it is not also right to recognize alongside of this a vertigo a stomacho laeso.

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