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OBSESSIVE-COMPULSIVE NEUROSIS
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Like the pure phobic states, a neurosis dominated by obsessions and compulsions is relatively rare, occurring in less than 5 percent of patients seeking help in a psychiatric outpatient clinic, but they can be extremely disabling Minor compulsions (for example, not stepping on cracks in the sidewalk), like minor phobias, are common in children, cause little or no distress, and tend to disappear in later life A few, such as rechecking a locked door or a gas stove, may persist throughout life Also, certain habits and rigid, obsessional ways of thinking, stubbornness, extreme punctuality, and excessive attention to detail are frequent and persistent but excite little attention medically unless they interfere with a diagnostic procedure or the treatment of a medical disease Obsessive-compulsive neurosis, or disorder, as it is now designated, begins, as do the other neuroses, in adolescence or early adult years, although treatment may not be sought until middle age is reached The two sexes are equally affected The onset is usually gradual and often cannot be accurately dated, but in some cases it is precipitated by a particular event in the patient s life, such as the death of a relative The family history often discloses a high incidence of obsessional or phobic personality in other members In some, but not all, instances, the obsessive-compulsive neurosis is engrafted onto a personality in which rigidity, in exibility, and lack of adaptability are prominent There is always a prevailing undercurrent of insecurity and anxiety Obsessions are de ned as imperative and distressing thoughts and impulses that persist in the patient s mind despite a desire to resist and to be rid of them They take various forms; the most common are intellectual obsessions, in which phrases, rhymes, ideas, or vivid images (these are often absurd, blasphemous, obscene, and sometimes frightening) constantly intrude into consciousness; impulsive obsessions, in which the mind is dominated by an impulse to kill oneself, to stab one s children, or to perform some other objectionable act; and inhibiting obsessions, in which every act must be ruminated upon and analyzed before it is carried out a state that was cleverly called doubting mania Every effort at distraction fails to rid the patient of the obsessive thought It engulfs the mind, rendering him miserable and inef cient Probably the most disturbing obsessions are the impulsive ones, in which patients constantly struggle with the fear that they will put some terrible thought into action Even as they tell of the obsession, they reveal a severe underlying anxiety and seek reassurance that they will not yield to it Fortunately, such patients rarely obey their pathologic impulses Phobias, as mentioned earlier, are considered
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PHOBIC NEUROSIS
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In this state, patients are overwhelmed by an intense and irrational fear of some animal, object, social situation, or disease Though acknowledging that there are no grounds for a particular fear (hence it is not a delusion) and that such provocative stimuli are for the most part innocuous, the patient is nonetheless powerless to suppress it This disorder was known to Hippocrates, who drew a distinction between normal and morbid fears Westphal in 1871 was the rst to give morbid fears the status of a disease Women are affected slightly more often than are men Unlike an anxiety attack, such a phobia always focuses on a speci c object or situation The patient is chronically fearful of a particular animal or situation and becomes extremely anxious or panic-stricken and incapacitated when placed in a situation that evokes the phobia These situations are avoided at all costs For example, it may be impossible for the patient to leave the house or neighborhood unaccompanied or at all, mingle in a crowd, walk across a bridge, or travel by air This fear of being in places or situations from which escape might be dif cult or extremely embarrassing is spoken of as agoraphobia (Agoraphobia, however, may be a secondary feature of other psychiatric disorders, the most frequent being anxiety with panic attacks as already mentioned) The most common phobia is probably claustrophobia (the fear of being con ned in a close space, such as an elevator or a magnetic resonance scanner) Other phobias, as remarked earlier, are those
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