OBSESSIONS AND ASSOCIATED CONDITIONS IN SO-CALLED PSYCHASTHENIA

BY JOHN E. DONLEY, M.D.
Physician for Nervous Diseases, St. Joseph's Hospital, Providence, R. I.

BY the term obsession I shall understand any recurring, extra-voluntary idea, feeling, or emotion which presents itself automatically in consciousness, either alone or in combination; and the clinical syndrome characterized essentially by such obsession and associated states, I shall, following many others, call psychasthenia. As psychotherapeutists we are interested in obsessions, not only as to their content, that is to say, the particular form and character they assume, but also and equally, if not indeed chiefly, as to their mechanism,—the manner in which they arise, the factors by which they are perpetuated, and the methods whereby they may be either alleviated or cured.

Approaching the subject, then, from this angle, we may set out with the observation that every obsession has its history just as truly as has a painting, a poem, or a symphony. Obsessions are not, therefore, as is so often apparently believed, discontinuous and uncaused mental experiences, arising nowhere and disappearing no whither; they are just as much products as are any other of the contents of consciousness; and only in this are they sui generis, that they are products of a very special and peculiar kind, whose genesis it may or may not be within our power to discover. To seek out the psychogenetic mechanism of obsessions is accordingly the first step toward a rational psychotherapy; for only if, and in so far as, a careful inquiry of this sort has been preliminary to any attempt at therapeusis, can the latter hope to be, in some manner and degree, successful.

The pursuit of this genetic method leads straight into the complexities and difficulties, sometimes, indeed, into the frustrations of normal and abnormal psychology. Yet, however difficult this domain may appear to be, to enter it is an absolute prerequisite to the progressive treatment of psychasthenia.

The most striking attribute of obsessive mental states is their more or less constantly recurring automatism. They do not appear as normal and harmonious elements within the conscious stream; on the contrary they are intruders whose constant entrance and exit disrupt the customary processes of mental life. In the language of abnormal psychology, they are said to arise as mental states or complexes which have been dissociated or split off from the main stream of the self-conscious personality. Whether an obsession appears in consciousness as a complex whose nucleus is an idea, a feeling, or an emotion, it is to be looked upon as having its origin in the same psychological mechanism, namely, dissociation. The psychological details of this dissociation may vary within comparatively wide limits in particular obsessions, but the general underlying principle would appear to be the same in all.

In the evolution of an obsession, dissociation is but one aspect of the process; for association comes to play an equally important role in the drama. Given a dissociated mental element, whether idea, feeling, or emotion, this mental element will not for long remain isolated and unattached, but in accordance with the laws of association will connect itself with some other conscious content to form a definite complex, upon the character of which will depend the type of obsession which appears in consciousness; for obsession is just another name for a particular, actively functionating complex.

Now this obsessive complex may be of multifarious composition; it may be composed chiefly of ideational feeling, or emotional constituents; it may be thick or thin, wide or narrow; it may contain many elements or few; as time goes on it may function in its original integrity or may become split, thus giving rise to curious and perplexing clinical manifestations; finally, the complex may be wholly or only partially conscious or subconscious; or to state it another way, the obsessed individual may be aware of much or of little concerning that which is really operative in the production of his abnormal mental condition.

We said a moment ago that association plays an equally important part with dissociation in the mechanism of obsessions. Obviously it is impossible here even to name the numberless associations that may occur between the conscious, subconscious, and co-conscious levels of mind, and the various obsessive complexes which may thus arise. One may point out, however, the important fact that these associations may be found to have taken place not only between ideas as such, but also between any and all of the other elements of consciousness, as well as between these latter and purely physiological processes, such as those mediated by the voluntary and involuntary musculature and by glands. Thus it may be seen that the variety of obsessions is coterminous with the possibilities of abnormal association and dissociation; hence also the impossibility of placing a limit to the patterns according to which obsessions may be formed.

When once an obsessive complex has been definitely established, it may be roused to future activity in a variety of ways. What I desire especially to call attention to here is the law of the substitution of stimulus, which may oftentimes explain the active functioning of an otherwise most puzzling obsession. Suppose the case where a person has had a painful and emotionally upsetting experience with a cat. Out of this experience may arise an obsessive complex, namely, fear of cats. In order to arouse this complex to activity, it is not necessary in the future to experience the actual presence of a cat. All that is required is some stimulus, e.g., the mere word cat, that has a symbolic relationship with the original experience. Or take the case of a patient of mine who overheard the doctors at a consultation remark that a certain pathological condition in her breast might be a carcinoma. As a matter of fact it turned out to be nothing of the sort, yet the obsessive fear of carcinoma of the breast remained with her for many months. In order to rouse her obsession it was necessary merely to present to her something having a direct or indirect symbolic relationship with the breast. On one occasion she was calling upon a friend who had recently given birth to a daughter. Out of the clear sky of conversation came something about the nursing of the child, when straightway an attack of obsession occurred which compelled her to terminate the visit. If we bear this fact of substitution of stimulus well in mind we may perhaps be able to explain an otherwise perplexing assault of obsessions.

Enough has now been said perhaps to give a reasonably clear idea of the psycho-genesis of obsessions,—their origin usually in some previous experience of the individual, which experience is either not remembered at all, or if so, is not recognized as being the point of departure for the obsession; their formation through dissociation of certain mental elements and the subsequent association of these elements with other contents of consciousness to form an obsessive complex; and finally the automatic and recurrent functioning of the complexes thus formed within the field of the conscious personality.

If now we approach the treatment of these psychasthenic obsessions we have at our disposal a variety of methods ranging from simple explanation and persuasion on one aide to hypnoidization and hypnosis upon the other. In order to render our discussion of these therapeutic measures as concrete as possible, I shall give a brief report of some cases actually treated, together with an account of what was done in each individual case.

Case II. A young married woman came under observation complaining of a very distressing type of obsession,—namely, the fear of losing control of her bladder. For nine years, with an interval of some six months, during which she was comparatively free, this imperative fear had dominated her mind, so that her life had been ordered with regard to the demands of her obsession. Not only did she have the mental fear, but also a distressing sensation in the bladder whenever her obsession was active. It is scarcely possible to describe the suffering which she had endured. She could not engage in the social functions which she enjoyed for fear of a humiliating accident. The theater was closed to her; she could not ride for any distance upon cars, nor accept invitations to visit any one save friends in whose houses she felt at ease. In her own home she experienced rather a different feeling,—not the fear of incontinence, which did not often occur, but the depressing idea that her life was to be circumscribed by a malady over which she had no control. On the theory that her trouble was due to cystitis, her bladder had been washed out with various solutions, among them boric acid and nitrate of silver, and she had swallowed a host of drugs like citrate of potassium, buchu, and oil of sandalwood. From a careful consideration of her history it seemed reasonable to suppose that her bladder sensations were secondary to her obsession, rather than that her obsession was consequent upon a real cystitis. An examination of her urine, which contained nothing abnormal, confirmed this view. Upon the principle that every obsession has a history, if only we can discover it, an attempt was made to determine the origin of this one. No special devices were employed other than a precise reconstruction of the clinical history. It then appeared that some nine years ago, a few days after the birth of her first child, she was troubled while in bed with a slight degree of cystitis and as a fact did lose control of her bladder. This made her, as she says, rather ashamed of herself, and struck her as being an unfortunate occurrence. Some few weeks later, while out walking, she suddenly felt a curious burning sensation in her bladder. Immediately she was seized with the fear that there was to be another loss of control; this, however, did not happen. Nevertheless the fear continued, and has persisted to within a very recent period. Here, then, was an obsession of disagreeable type, which had arisen upon the basis of a previous experience. The memory of an actual loss of bladder control plus a certain sensation referred to the bladder had become associated in a complex which functioned as an obsessive fear of incontinence. While the patient could recall perfectly her experiences as given above, she had no idea that they had anything to do with her present fear until this was pointed out to her, whereupon she acquiesced readily in this explanation. Before her treatment had progressed further than the second consultation, an opportunity presented itself of testing the truth of our hypothesis, namely, that her bladder symptoms were the tail to a mental kite. On this special occasion she was compelled to wait some little time, and when I began to talk to her it was very evident that her obsession was in full swing. An attempt was made then and there to disrupt her obsessive complex by forcibly replacing for the association represented by “bladder loss of control,” another association, “bladder full control.” This was accomplished by stating and restating very positively and in detail that she could certainly control her bladder, as the event would surely prove. For about twenty minutes her emotional agitation was intense, but finally subsided with the result that although she was anything but calm, her faith in her obsession had been somewhat diminished. By dint of subsequent and repeated persuasion her fear was finally removed, so that ultimately at the end of eight months she entered upon her social pleasures and duties with normal satisfaction. Untiring persuasion in the face of obstacles had succeeded in disrupting an obsessive complex which for nine years had proved rebellious to all other medical treatment.

Case III. A man, aged 32, presented a very interesting obsession, which was this: he could not get upon a street car whose number was odd. Cars with even numbers gave him no trouble, but if an odd numbered car came along he was compelled to let it pass no matter what his hurry might be. He could recall nothing which would shed light upon this curious obsession, but when placed in hypnosis he gave the following story: When about eighteen years old he was one day walking upon the street when he witnessed a street car strike and injure a child who unexpectedly ran out from behind a wagon. The sight of this accident gave him a very marked emotional shock, which upset him for several days thereafter. Standing near the scene of the accident he noticed that the car bore the number 213, and thought to himself, “Well, there is always ill-luck in l3.” Ever since the time of this experience he has had his strange aversion to riding upon cars bearing odd numbers, although his waking self could give no account of or even conjecture regarding the derivation of his obsession. During hypnosis it was suggested to him that the child whose accident he witnessed was not really injured and had recovered completely. Furthermore, he was told that odd numbers were quite the same as even numbers; that they would no longer cause him any trouble, and in fact would give him no concern whatever; and finally that like all other normal persons he would pay no attention to the number of the car he desired to ride upon. These hypnotic treatments were continued daily for eight days and resulted in the complete removal of the obsession, which, so far as I know, has not returned.

In the cases just described, one may observe the successful results that sometimes follow the use of hypnosis, hypnoidization, and persuasion, in the treatment of psychasthenic obsessions. I would not, however, wish to convey the impression that every case which clinically manifests itself by psychasthenic symptoms is treated with equally great success. Some of them are extremely obscure as to their genesis, and equally difficult in the way of successful treatment. In conclusion, I wish to describe such a case, which was characterized by obsessions, feelings of unreality, incompleteness, and strangeness, and to some extent by depersonalization.

Case V. Mr. X., by occupation a postman, complained that from the time he was about seventeen years of age he had been afflicted with feelings of incompleteness, by obsessions of fear of insanity, and by the lack of emotional reaction to his environment, whether pleasurable or painful. Throughout his life, as long as he could remember, he had always been reticent, and as a boy found it difficult to associate with his playmates because of shyness. On one occasion, when at school, he attempted to give a recitation, but failed through an acute attack of stage fright. He got along tolerably well until he was seventeen, when he suffered an attack of typhoid fever, at which time the more troublesome symptoms of which he complains began. He says that he seems to lack the ability to feel pleasure or pain in what he does. At the theater, for example, he experiences no emotion, but sits there, as he says, “equally indifferent to whatever may be going on.” He sees the play and hears the actors, but cannot get in tune with them. In his daily work of delivering letters he finds no pleasure, except that it serves him as a means of occupation and a source of livelihood. Constantly throughout the day, more particularly when he is unoccupied, the thought flashes into his mind that he is going to become insane, or that his malady will terminate in complete despair. He used to enjoy the reading of poetry, but complains that now poems are to him merely so many words, and that while he understands what the poet is trying to convey, he derives no answering emotion from his reading. He states his feelings thus: “I seem to myself to be another person. It appears to me that there is a split between my emotional and my intellectual nature. I cannot get in tune with things, and the greatest good fortune or the greatest misfortune in the world would leave me, I believe, equally unaffected.”

Throughout several months the attempt has been made by psycho-analysis to uncover some source for the psychasthenic symptoms presented, but without success. His seems to be one of those cases wherein the psychasthenic feelings of incompleteness, insufficiency, and strangeness, together with obsessions, are so interwoven with the texture of the mind as to render their complete removal practically impossible. No matter what he attempts to do, there is a fundamental perversion of feeling and emotion, and so long as this is present, his obsessions of anxiety and despair arise and continue. By persuasion and frequent practice he has been enabled so to switch his obsessions into a corner of his mind as to enable him to pursue his daily work with a certain external and mechanical success. This, however, requires a constant effort on his part, because there is always a tendency for his psychasthenic symptoms to obtrude themselves. Hypnoidization and hypnosis have been of some value in the sense that after a treatment he experiences a certain relief for a time, but this never lasts more than two or three days, at the most. His treatment has extended over the greater part of a year, but it must be said that the psychasthenic substrata of mind continues virtually unchanged.

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