The term obsessional neurosis (or compulsive neurosis) denotes a condition in which the patient's mind is intruded upon (against his or her will) by images, ideas, or words. The patient's consciousness nevertheless remains lucid and his or her power to reason remains intact. These uncontrollable obsessions are experienced as morbid inasmuch as they temporarily deprive the individual of freedom of thought and action. Sometimes the defenses can eliminate the anxiety and the symptoms, but at the price of displacing characteristics of primitive obsession (uncontrollability, compulsions) onto the defense mechanisms.
Sigmund Freud's view of obsessional neurosis appeared as early as 1894. In "The Neuro-Psychoses of Defence" (1894a) he broke with the conceptions of classical psychiatry and stipulated that the cause of obsessional neurosis lies in the existence of an intrapsychic conflict of sexual origin that mobilizes and blocks all flows of energy. He thus opposed the classical theory of degeneration and the idea of innate weakness of the ego that Pierre Janet used as the basis for his description of psychasthenia. Freud proposed a traumatic etiology for obsessional neurosis. An early sexual event occurs before puberty; however, in contrast to what happens in hysteria, this event is a source of pleasure to the child. The individual experiences strong feelings of guilt and is overcome by self-reproach. These feelings are repressed and then replaced by a primary system of symptoms and traits: scrupulousness, shame, mistrust of self. The success of these defenses allows the individual to go through an apparently healthy period. But eventually these defenses are exhausted and there is a return of the repressed memories with the outbreak of the illness and its attendant symptoms.
In "The Disposition to Obsessional Neurosis: A Contribution to the Problem of Choice of Neurosis" (1913i), Freud defended the idea that the choice of this neurosis is linked to developmental inhibitions, and he stressed the role of fixation and regression to the anal-sadistic stage. He suggested "the possibility that a chronological outstripping of libidinal development by ego development should be included in the disposition to obsessional neurosis. A precocity of this kind would necessitate the choice of an object under the influence of the ego-instincts, at a time when the sexual instincts had not yet assumed their final shape, and a fixation at the stage of the pregenital sexual organization would thus be left" (p. 325). Thus, in the object relation, hate will precede love and "obsessional neurotics have to develop a super-morality in order to protect their object-love from the hostility lurking behind it" (p. 325). This opposition between love and hate for the object was underscored by Freud in the case of the "Rat Man," related in "Notes upon a Case of Obsessional Neurosis" (1909d). He saw it as the source of the doubt, compulsions, and ambivalence that are characteristic of obsessional functioning.
In "Inhibitions, Symptoms and Anxiety," Freud described the two main defense mechanisms in obsessional neurosis that replace repression: undoing what has been done and isolation. The first of these, undoing (Ungeschehenmachen), means making something that has already happened "unhappen" by means of a symbolic motor action; it is also found in magical practices, folk customs, and religious rituals. The second, isolation, involves the motor sphere and consists in the fact that after an unpleasurable event there is a pause during which nothing further can happen, no perception is possible, and no action can take place. Motor isolation functions to guarantee a break in the connection of thoughts.
In the same way that the obsessional patient enacts the taboo against touching (because he fears that contact with the object will force him to face his unbound ambivalence between love and hate), the isolation of an impression or an activity, by means of a break in the chain of thoughts, symbolically indicates that he does not want to allow thoughts relating to it to "contaminate" other thoughts. This mechanism is present in normal people in their everyday mental activities involving concentration.
The fundamental rule of free association involves asking the ego to give up this defense. The patient suffering from obsessional neurosis finds it particularly difficult to follow this rule. This is why, paradoxically, psychoanalysis is both the most indicated treatment for these patients and at the same time the most difficult to implement.
Like Freud, the psychoanalysts who came after him always placed the accent on the obsessional structure rather than on symptoms. This poses problems of terminology. The term obsessional neurosis is not the exact equivalent of the German Zwangsneurose : Zwang refers not just to compulsive thought or obsessions (Zwangsvorstellungen), but also to compulsive acts (Zwangshandlungen) and compulsive affects (Zwangsaffekte). Certain French authors therefore prefer to use the term névrose de contrainte, and some American authors prefer the term compulsive neurosis. Obsessional functioning is the preferred term for the group of processes and defense mechanisms that characterize obsessional neurosis, but which are also present, to a lesser degree, in other patients, in the form of obsessive personality traits or a system of defenses put up as an alternative to a costlier mode of psychic functioning, psychotic functioning.
In this regard, let us note that because organized obsessional neuroses are sometimes extremely debilitating, the categorization of this pathology has been questioned and it has been compared with the psychoses. Several factors present in the former are lacking in the latter: self-recrimination by the ego, adherence to insistent preoccupations, and the deployment of elaborate defenses. In the obsessional patient, affective isolation allows the ego to cut itself off from desire, whereas in psychosis the ego is cut off from reality.
