Obsessive neurosis: nosographic and conceptual evolution

The term obsessional neurosis , although officially no longer in use in current psychiatric nosography, is still used among mental and non-mental health professionals.

Deepening its evolution, it turns out that the diagnosis of Obsessive Neurosis has a long history behind it.

Historical excursus

As early as the 19th century, scholars such as Pinel (1809) and Esquirol (1838) had provided observations in line with the concept of obsession . They described patients besieged by a limited number of thought contents, who attempted to deal with such mental representations through a struggle made up of diversionary actions (Magnan, 1893).

Between the end of the nineteenth century and the early twentieth century, various authors, in particular Freud, identified a specific morbid entity characterized by so-called ” obsessive phenomena “. It was distinct from conversion hysteria and phobic neurosis, called Obsessive Neurosis .

Freud, who described its phenomenology in his famous case of “The Rat Man” (1909), outlined a picture characterized by ambivalence, a fight against “forbidden impulses”, a desperate need for emotional control, a recurrence of magical thinking. Freud’s studies that followed led to the definition of obsessional neurosis as characterized by specific defense mechanisms (such as, for example, displacement and reactive training), blocks from a drive point of view (maturational arrest and regression to the anal phase) and the presence of a sadistic super-ego.

Some authors, such as Kubie (1937), have emphasized the distinguishing features between obsessional neurosis and the already existing hysterical neurosis . They observed that the phantasy of “dirt” and the “system of duty” prevail in obsessional neurosis while the phantasy of “pain” and the “system of fear” prevail in hysteria.

It was then Anna Freud in 1965, at the Congress of the International Psychonalitic Association, who spoke about obsessional neurosis, reiterating – on the one hand – the centrality of the constitutional factors already supported by Freud, but also paying attention – on the other – to familiar elements. In particular, the educational methods and maternal unavailability would favor the defense mechanisms and arrests in the psycho-sexual development phases (in this case, the anal one).

The obsessional neurosis in psychiatric nosography

Within the international psychiatric nosography obsessional neurosis is described in a concise and non-specific way in both the first and second editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I, 1952; DSM-II, 1968).

Starting from the third edition (DSM III, 1980) the traditional distinction between psychosis and neurosis is abandoned and the term obsessional neurosis , used until the 1980s, gives way to the more recent diagnostic label of Obsessive-Compulsive Disorder (OCD) .

In the subsequent revised edition of the manual (DSM-III-R, 1987) the disorder is described in a specific way with precise diagnostic criteria that consider obsessions and compulsions separately and highlight their reciprocal relationships. In DSM-III-R, obsessions are defined as “persistent ideas, thoughts, impulses or images that are experienced at least initially as intrusive or meaningless. (…). The subject tries to ignore or suppress such thoughts or impulses or to neutralize them with other thoughts or actions ”. The compulsionsthey are defined as “repetitive behaviors, aimed and intentionally performed in response to an obsession, according to certain rules and in a stereotyped way. (…). The individual recognizes that his behavior is excessive or unreasonable ”.

The main elements of these definitions are therefore: the distinction of obsessive and compulsive phenomena; the functional links and the connection that can exist between these phenomena; the subject’s awareness of the senselessness or excessiveness of the symptoms.

The most recent classifications

The functional link between obsessions and compulsions also seems to inspire the DSM-IV (1994) which points out that 90% of compulsions are connected with obsessions. Furthermore, the DSM-IV and the subsequent revised edition (DSM-IV-TR, 2000) propose the specification “with poor insight”, allowing to include in the diagnosis all those cases in which the subject is not fully aware of the excess of symptoms.

Finally, the most recent version of the Manual (DSM-5; 2013) leaves the diagnostic criteria of the disorder fairly unchanged, also placing the accent on the use of the term “discomfort” (broader than “anxiety” alone) as an induced emotional reaction from obsessions. Not surprisingly, in the DSM-5 we have the OCD out of the category of anxiety disorders , which occupies its own separate nosography from other categories, placing itself within the group “ Obsessive-compulsive disorder and related disorders ”.

In terms of scientific research, the large amount of studies on OCD over the last 30-40 years has allowed us to identify and investigate the peculiarities of the specific symptomatological subtypes. Within the disorder there are in fact a wide range of emotional reactions ( anxiety , disgust , discomfort, fear), different mental contents of an obsessive type and the related functional links with compulsive manifestations very different from each other.

It follows that, even within evidence-based psychotherapeutic treatments, more and more specific intervention protocols are being developed for each subtype of Obsessive-Compulsive Disorder . This with the aim of increasing the efficacy of therapies aimed at a problem that, since the dawn of its identification as Obsessive Neurosis , has always been resistant to treatments and tends to be difficult for therapists.

 

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