Neurotic Disorders. Psychoanalysis of Compulsive Neurosis

The period of compulsive neurosis is acute or chronic. Acute cases are triggered by external circumstances. These circumstances are the same as that provoked other neuroses. They mobilize the repressed sexual conflicts of the infantile period, violate the existing up to that time balance between the preemptive and the repressed forces, produce a relative or absolute increase of rejected instincts or opposing anxiety.

Compulsive neurosis arises under the influence of precipitating factors in those who suffered in childhood anal-sadistic regression. This regression has absorbed, but only a small amount of libido, genital was saved and puberty proceeded without insurmountable difficulties. Nevertheless, once an infantile defense opted for the regression, otherwise there would not be possible in adulthood with disappointment, when Oedipus complex revived, it regresses to the anal-sadistic level. Much more often compulsive neurosis occurs chronically, from his youth almost continuously, sometimes external circumstances aggravate it.

Following the light compulsive symptoms related to the time of the Oedipus complex, in the latency period, when developing intellectual abilities, there are compulsive rituals. At puberty sexuality chooses a path similar to that passed in early childhood, and again there is regression to the anal-sadistic level. Superego comes into conflict with the new rush of the anal-sadistic sexual desires and is not itself able to avoid regression, becoming more sadistic and angry on the anal and sadistic impulses no less than before on genital needs.

Similarly, the anger of the superego is restless on proper phallic oedipal desires that branch along with recalcitrant anal-sadistic drives. Freud wrote: ”The conflict is exacerbated by compulsive neurosis for two reasons: the protection is becoming increasingly intolerant, it is necessary to protect against what is almost unbearable and both phenomena occur as a result of the regression of libido.”

The protracted fight on two fronts and adapting ego to the symptoms (secondary protective conflicts, counter-compulsion against compulsive symptoms, additional jetformation, changing the value of the protective function of symptoms for the pleasure) form a complication. Jet formation may give rise to secondary narcissistic gain. For example, the pride of a compulsive neurotic of his kindness, generosity, intelligence is often difficult to overcome resistance in psychoanalysis.
As in the case of phobias, the state in compulsive neuroses is relatively stable, when the defense is more or less successful, but the progression of the disease is possible. In the latter case there is a slight violation of the “compulsive equilibrium” with the obvious anxiety and depression (which is favorable for therapy), or malignant course with the threat of complete paralysis of will.

Let’s consider a simple example of increase of symptoms

Patient compulsively avoided the number three. This number meant for him sexuality and suggested castration. He usually did everything four times to make sure he escaped the cursed numbers. Somewhat later, the patient felt that four is too close to the three, for safety, he began to prefer the number five. But five is an odd number, so bad. It has been replaced by the number six. Six is two times three, seven – an odd number. The patient decided to stop at eight considered it beneficial and a number of years.

It is hard to say what factors determine stability or progression of the disease. Complications are possible even in mild cases and represent a breach of the above-mentioned relative equilibrium, which until then was supported by indemnity or other symptoms of compulsive ego restrictions.

Unrecorded accidents in the systems of the patient at times, suppress compulsive rigidity. ”Traumatic treatment” of compulsive nature is opposed to traumatic neurosis.
These developments demonstrate the link between compulsive symptoms, the initial actual-neurotic condition and anxiety: anxiety, “binds” a second time by the formation of obsessional compulsive symptoms. In the compulsive rituals, which involved pre-phobia, this anxiety is more or less colored by feelings of guilt. Anxiety and guilt that hid behind compulsive symptoms occur again when these symptoms are psycho-analysed. Due to the fact that passions habitually reject, they often find expression in somatic equivalents.

The concept of regression to the anal-sadistic level of organization of the libido allows to understand the differences between the formation of symptoms in compulsive neurosis and hysteria. In compulsive neurotic the denied impulses are phallic trends related to the Oedipus complex and at the same time the anal-sadistic nature. There is no contradiction. Initially, the protection is directed against the phallic Oedipus complex, resulting in the substitution of his anal sadism, and then sewn has been against the anal-sadistic intentions.

Most of the differences in the clinical picture of hysteria and compulsive neurosis stems from the fact that in hysteria as a protective mechanism is used only the displacement, whereas compulsive neurosis can be invoked reaction formation, annulment, isolation. The use of specific protective mechanisms is necessary because not the genitals are rejected, but the anal-sadistic desires.  The application of various protective mechanisms explains the unequal amount of consciousness for two neuroses.

The relatively late onset of compulsive neurosis is related to the factor of regression. Introjection of parental superego, in turn, explains the marked internalization of the conflict, as well as the prevalence of punishing and redemptive signs of symptoms, that give pleasure. Regression is responsible for the particularly harsh superego, unable to avoid the regressive slide into sadism. The fact that the damage of the whole person is much stronger than in hysteria, also must be attributed to the fundamental phenomenon of regression.

Psychoanalytic psychotherapy for compulsive neurosis

From the standpoint of psychoanalytic therapy compulsive neurosis is regarded as the second representative of the “transference neurosis” and the second extensive application of psychoanalysis. But psychoanalysis in compulsive neurosis, as the discussion of the mechanisms of this disease shows, is much harder than in hysteria. The difficulties are such that, in severe cases with a long history of suffering the psychiatrist must be very careful with the promises of cure. Often it must be satisfied with only modest success.

What are the challenges?

1.The specificity of anticathexis in compulsive neurosis makes it very difficult or almost impossible the patient’s consent to the basic rule of psychoanalysis. Censorship is not weakened for a moment and forces him to evade unsystematized free association into “rational” ideas.. Attempts to explain what is required of him, only contribute to refining obsessions. Manifesting as compensation excessive conscientiousness, the patient wants to do everything necessary, in this way are issued contradiction of conscious intentions and unconscious desires. Perhaps the main technical problem in psychoanalysis of compulsive neurosis is to teach the patient the method of free association, without engaging with them in the theoretical debate and not providing him new material for sterile philosophizing.

2. Internalization of conflict and the role of the superego is much a difficult task of analysis. Tantrums treat their symptoms as something alien to the ego, their ego enters into an alliance with the psychoanalyst in the fight against the neurosis. In the treatment of compulsive neurotics in which ego is split, the working atmosphere is far from this ideal. Psychoanalyst or psychologist can only rely on the part of the ego. The rest of the ego thinks of magic, not logic, and actually takes the side of resistance. Conscious of the individual is ready to cooperate, not at the same level to which it is isolated from the unconscious part of the magic. The most comprehensible interpretation, however, is useless, if this isolation is not eliminated.

3. The regression implies that psychoanalysis must penetrate to a deeper level than in hysteria.

4. The regression also indicates that the essence of object relations is changing. They are regulated by the anal-sadistic tendencies, particularly significant ambivalence and obstinacy, which are manifested in the transference. Mixed feelings of compulsive neurotics are expressed in the simultaneity of rebellious tendencies and effort to submit to a therapist. Each impulse in some way accompanies his antipode.
5. Isolation of the ideological content of the relevant emotion creates a specific problem. There is always the danger that patients will perceive psychoanalysis as a purely intellectual process. And therapy, of course, is useless until this attitude is not worked out psychoanalytically as the resistance of emotional experiences.

6.  The thinking and speaking of compulsive neurotics is sexualized. But thinking and talking are the tools of psychoanalysis. Therefore, in compulsive neurosis a peculiar situation develops: the patient should be treated with the functions that are affected by the disease.
One patient gave a precise comparison: “It was like I fell into the water with a towel in my hand, and then they tried to wipe me with this towel.”
This problem is unsolvable. However, if a conscious person assesses their behavior as irrational, undamaged part of it may begin to psychoanalysis in the hope that will revive the feeble part of the ego.

7. There are secondary benefits, of course, as in hysteria, but they are never so integrally woven into the personality as jet formations feeding the narcissism. In many cases psychoanalysis is unsuccessful as the analyst does not succeed in convincing the “noble” compulsive neurotic that some “corruption” in the process of psychoanalysis would benefit. Analyst not only represents the superego of the patient, it can also act as a seducer, agent, id intimidating, fighting for the patient which is natural.

8. The emergence of psychoanalysis in the process of anxiety and autonomic symptoms that represent anxiety, can cause severe complications in patients unaccustomed to affect, whose symptoms are usually confined to the mental sphere.

All these difficulties are surmountable, but they can not be underestimated, since they are accompanied by compulsive neurotic psycho-analysis of each and make the treatment longer. Acute compulsive neuroses are cured relatively quickly. Typically, analysts work with heavy patients suffering from compulsive neurosis with the latent period. The much-vaunted ”long” treatment is necessary in most cases. Nevertheless, long-lasting psychoanalysis and huge energy expenditure justify themselves, cure is achieved even in very long-standing cases.

Sometimes the only course of psychoanalysis creates a test of the extent of the difficulties outlined and helps in making the forecast. The least susceptible ”end state” bordering on the schizophrenic cases, developmental disorders, as well as the phallic stage is reached .Since other forms of psychotherapy in such cases in general are useless, every compulsive neurotic, when external circumstances allow, should get psychoanalytic treatment.